The machine that puts THE NURSES back into nursing
Mountainous paperwork was keeping them from their patients. So this Ohio hospital turned to automation for help. Now a unique network
“I NEVER SEE a nurse!" is a familiar complaint made by hospital patients, their relatives and their doctors. Roger Sherman, the administrator of the 260-bed Children's Hospital in Akron, Ohio, had been listening to it for years. Determined to remedy the problem, he began prowling through the wards to find out why it was that nurses didn’t spend more of their time at the bedside of patients. Sherman soon discovered that most of his nursing staff spent a phenomenal proportion of their time at the ward nursing stations, deeply immersed in mountains of clerical work.
The proliferation of paperwork has become the bane of evers large modern hospital. As medicine becomes more complex and more specific, so does medical bookkeeping and recordkeeping. Nurses and other trained staff members are swamped under a sea of charts, graphs, forms, labels, reports and doctors' instructions regarding drugs, X rays, special diets, laboratory tests and various procedures. "My skilled staff were wasting a lot of valuable time in writing and typing things.’’ says Sherman. He appealed to his staff to devise a way of getting the nurses back to the patients.
Sherman's challenge w'as enthusiastically taken up by his assistant. Charles Campbell, a cherubic, thirty-
seven - year - old honors graduate in English, who had drifted into the field of hospital administration after the Korean War. Because all the business transactions of the hospital -— payroll, patients' invoicing, payment of accounts — had already been automated w ith a great saving in money and staff time, it was logical for Campbell to look to the computer to rescue the nursing staff from such a voluminous mass of paperwork. He hastily assembled a planning staff consisting of four of his colleagues — George Fowler. George Kenny, Randall Hagerman (Hagerman is a hospital-administration graduate from the University of Toronto and Toronto Western Hospital) and James De Marco, the director of nursing — together with two industrial engineers on loan from the Goodyear Tire And Rubber Company in Akron, and seven experts from the International Business Machines Corporation.
That was four years ago. Today, the Akron Children’s Hospital is the first hospital in the w'orld with the clerical work of its nursing staff automated. The new system is known as HIS — Hospital Information System. It consists of a master computer on the third floor of the hospital which is linked with fourteen smaller computers, or "terminals," situated in the various nursing stations and departments throughout the building. HIS now performs dozens of chores formerly done by hospital personnel. It assigns staff members to their jobs each day: it orders drugs, X rays, lab tests and special diets for patients; it
smoothly schedules appointments in the operating rooms and other departments to avoid needless waiting; it keeps track of the patients who, unexpectedly. come streaming into the out - patients and emergency departments: and it immediately provides the doctors with an up-to-the-minute record of the progress of their patients. On the less serious side, HIS never forgets to punch out birthday greetings to staff members, and it can play a game of blackjack with anyone who has a few idle moments to pass. "We’re proving.” says Campbell proudly, "that the efficient, scientific administrative techniques used to make rubber tires or steel can be applied to the modern hospital."
In the four years during which HIS was incubated, even vacations did not interrupt the work. Many preliminary planning sessions were carried on at the “Akron Colony" on Otter Lake, near Parry Sound, Ont., where several of the hospital staff own summer cottages. At the hospital the industrial engineers sought precise answers to questions that had never been asked before: What does a nurse do when she isn’t nursing? What nonessential chores engage her time? What actually happens after a physician issues an order on behalf of a patient? What skills are really needed? Who needs what information and why? How do we retrieve this information? Are medical records, in their present form, really needed?
Night and day, for several weeks, with notebooks and stop watches, the engineers shadowed the nurses as they went about their duties. Each movement was carefully observed and timed. They combed through wastepaper baskets to see what records were being
thrown away. They prepared elaborate flow charts to show' what happened, step by step, after an order was received at the nursing station. All of this information, carefully analyzed and summarized, was contained in a report to the hospital board and administration.
"It proved to our satisfaction," says Campbell, "that traditional hospital w'ork methods were scandalously inefficient and archaic." The ablest bedside women — the head nurses, registered nurses and student registered nurses — expended forty-one percent of their time doing paperwork. The licensed practical nurse and student practical nurse actually provided fourteen percent more nursing care than the RN group.
Why so much clerical work? The engineers found that it took thirteen distinct written steps from the time the doctor wrote his prescription until the pill went into the patient's mouth. This included waiting seven different records, which were stored in six locations throughout the hospital — all of the records deemed essential. Similarly. an order for a single X ray led to fifteen pieces of writing, including the final report on the film. A grave danger in this clumsy system, as noted by the engineers, was that each additional writing step increased the possi-
bility of error. The engineers’ report also emphasized the massive volume of written work demanded from the staff. In one two-week period at the Akron hospital, 375 doctors admitted 585 patients and issued ten thousand orders on their behalf, indicating that in the course of the year the nursing staff was required to turn out millions of individual pieces of paperwork.
Numerous other deficiencies in the system were described by the engineers. Two nursing supervisors were spending sixteen hours a day assigning the staff of two hundred and fifty to their jobs. Even so, at times some services were overstaffed, others understaffed. Traffic was not always running smoothly through the operating rooms, X-ray rooms and other services. At times these departments were relatively idle; at other times patients had to endure the inconvenience of waiting several hours. Patients coming into the emergency and outpatients’ departments, it was noted, were sometimes “lost” for several hours because of crude admission methods. With hundreds of patients to handle a day, a patient’s completed admission form would be placed on a doctor’s desk and get lost in the shuffle.
“We were bowled over by the industrial engineers’ report,” says Campbell. “We felt that the time had now come to stop talking and to start work at streamlining our administration.” The
master electronic brain — the IBM 1710 central processor — was installed on the third floor. Smaller machines, known as “terminals” were placed in the nursing stations and in the various departments. Each terminal is about two times the size of a typewriter and contains a few knobs and a keyboard with twelve rows of horizontal and nine rows of vertical numbered buttons. It also contains an automatic typing device that translates into ordinary language, incoming messages that have been transmitted in code. The same device also immediately types out the coded information fed into the terminal so that the operator can check it for accuracy before sending it. All information sent or received is stored in the system. Thus, the entire hospital has been linked together by an integrated communication service that possesses a memory.
The next step was to feed millions of pieces of information into the master brain. Every patient, every staff member, every staff doctor was assigned a code number. Every possible type of material or service required by patients has been “programmed” into the system. For example, the Drug Index lists forty-five hundred items, all coded; the Laboratory Index has nine hundred possible tests; the Dietary Index contains two hundred and twenty-six different diets; the Central Supply Index catalogues over a thousand items, ranging from pelvic traction belts to typewriter ribbons.
One of the first jobs handed over to HIS was to assign staff members
to their daily jobs. The master brain is fed up-to-the-minute information on the patient population in each ward, the daily work load in each department and what staff members are off duty or away because of illness or vacation. When the proper code is punched, the brain disgorges a duty list, instructing each person by name, where to report. It will state, for example, “DOROTHY BROWN IS AWAY BECAUSE OF ILLNESS, SO ANN ANDERSON IS TRANSFERRED TO WARD TWO, SECOND SHIFT.” The job of staffing which formerly occupied two nursing supervisors for sixteen hours a day, is now performed by the machine in seven minutes.
Physicians are finding the computers a valuable timesaver. Upon his arrival at the hospital in the morning, a doctor has only to punch his code number and out will come a list of his patients, their location and a summary of treatments and progress since his last visit. Again, information about the patient's condition is relayed to the switchboard so that telephone operators can intelligently reply to queries from friends and relatives.
Much of the computer’s time is spent dispensing drugs to patients, swiftly and safely. A nurse at Station Two, for example, receives a doctor’s prescription calling for penicillin for Peter Matthews, an eight-year-old patient. She converts the prescription into a series of coded numbers. The code contains the patient’s name, age, weight, condition, the type of drug he requires, the dosage, frequency of medication and the duration of treatment. She punches out the order on her terminal. A second later it is typed out on the machine so she can check all the details. Once verified, she
presses the "Go” button and the computer takes over. The order is now stored in the system. It also comes rattling out on the terminal in the pharmacy. The paper it is typed on can also be used as a bottle label. Fifteen minutes before Peter Matthews is to receive his medication, the terminal at Station Two punches out a reminder, containing all the details. If the nurse fails to respond to it, the machine will repeat the reminder every fifteen minutes.
Automation is particularly valuable in dispensing drugs because of the built-in safety factors. A patient receives the drug ordered, at the time specified, without fail. It is not possible, through error, to administer the same drug twice. Furthermore, the danger of overdosing has been largely eliminated. Stored in the back of the computer’s mind is the knowledge of what constitutes a safe dose of a drug for a person of given age and weight. If the dosage prescribed goes beyond the safe range, the machine will question the order, and the nurse or doctor must then confirm that an unusually large dose has been ordered because of special circumstances.
As a next step, it is planned to eliminate the ordering of drugs for patients by a doctor’s handwritten prescription.
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This will be done by having the doctor himself order the drug by punching the appropriate code on the terminal keyboard. The illegible handwriting of doctors has become one of the significant hazards of modern chemotherapy. For years this has been the subject of endless jokes. But in the present era of powerful medicines, sloppy handwriting is no laughing matter. An indecipherable prescription can lead to dire consequences for patients. In one hospital, for example, a physician prescribed a tranquilizer for a young woman. Because of poor handwriting, she was given penicillin instead — a drug that promptly sent her into a severe state of shock because she was sensitive to it.
Bad medical handwriting today has reached epidemic proportions, perhaps a reflection of the busyness of doctors. At the Pennsylvania School of Nursing, handwriting samples of fifty-eight doctors were chosen at random. A committee of five experienced nurses concluded that thirty-two of them were indecipherable. In a worldfamous eastern American hospital, within a seven-month period, there were one hundred and seventy-nine difficulties involving patients and the administration of drugs, most of them due to careless writing. At New York’s Mount Sinai Hospital an extra telephone had to be installed in the pharmacy for the sole purpose of getting in touch with doctors to “translate” prescriptions they had written into readable words. These difficulties will vanish w"hen the doctors feed their prescriptions directly into a computer system.
When HIS was being planned, many people expressed the fear that automation would “dehumanize” the individual patient by reducing him to a coded series of numbers. Exactly the opposite has happened. Nurses now have more time for personal service to the patients. Furthermore, the computers make it possible for a staff member, coming fresh to a ward, to learn immediately a great deal about any individual child. By pressing the correct buttons on the terminal, they receive a patient’s “profile.” This gives a fast resumé of his background and physical peculiarities. If the child has a favorite nickname, it is mentioned. Preschool youngsters often have a language of their own and this too is noted. Because it’s possible, by automation, efficiently to schedule appointments in the X-ray and other departments, patients no longer suffer the feelings of frustration and neglect that come when — as it sometimes has happened — they have to wait an hour or two for a service.
To the nonscientist, the “intelligence” of the HIS master computer in the Akron hospital is rather awesome. It makes decisions on its own and then “tells” you about them via automatic typewriter. For example, at two in the morning, when the flow of messages regarding patient care is somewhat slack, the machine an-
nounces, “I AM NOW SWITCHING OVER TO PAYROLL.” It will then rattle off the pay list, interrupting the chore only if there's a demand for its services from the nursing stations. It also monitors the entire system for mechanical efficiency. While I was there, it typed out a message that “THE TERMINAL ON NURSING STATION THREE HAS DEVELOPED FAULTS; I AM THEREFORE SWITCHING ITS LOAD OVER TO STATION TWO.” On another occasion it pointed out that a nurse on Station One was not pressing down heavily enough on a certain button on her terminal’s keyboard.
Without doubt the most exciting and valuable long-range benefits of hospital automation will be in the field of medical research. For the first time in history there will be available thousands of clinical case histories neatly stored on small cards or on magnetic tape. It will be possible quickly to come to conclusions about the causes, the progress and the most effective treatment for various diseases and conditions. At present this kind of epidemiological investigation is laborious, time-consuming and expensive. We will be able to add to our store of knowledge as to the best way to use drugs and their possible adverse effects. “The future possibilities are dazzling,” says Campbell. “Supposing in twenty years you have five thousand hospitals throughout the world keeping automated records. You’ll quickly be able to analyze as many as a half million clinical cases of any given disease.” The Akron Children’s Hospital has already received dozens of inquiries from curious and eager medical researchers throughout the world.
Revolution has just begun
Charles Campbell and his colleagues regard HIS, in its present form, as only the first phase in the revolution to automate hospital administration and patient care. It is now possible to monitor a patient’s pulse, blood pressure and temperature by remote control. IBM is developing a computer-based system that automatically performs fifty blood tests at a time and forwards the results to the ward nursing stations. At present, lab technicians are spending about a third of their time on routine clerical work. Scientists at Tulane University, in New Orleans, have automated the reading of X-ray films. A computer converts light density into digits, and, by glancing at a few rows of figures it is possible immediately to identify abnormal areas of tissue.
At the last meeting of the American Psychiatric Association in Los Angeles an entire session was devoted to the use of computers in psychiatry. The Mayo Clinic in Rochester, Minnesota, uses electronic equipment to score the Minnesota Multiphasic Personality Inventory (MMPI) test which is administered to most patients. The MMPI, most widely used of all tests, assesses personality by asking the subject to respond to about six hundred questions with true or
false answers. The machine analyzes the responses and assigns the subject to one of about seventy possible personality types. Only recently the U. S. Public Health Service has recommended that a national psychiatric registry be established for all patients seen in mental - health clinics. No matter where the patient moved, reference to a single card would give the physician a complete run-down on his medical history.
The mechanical brains have been called on to straighten out the present hodgepodge in medical terminology. At present, confusion arises because of hundreds of archaic terms and redundancies. The American Medical Association, using computers, is weeding out the useless terms. It has already published several editions of Current Medical Terminology.
A much vaster computer-based project is the establishment of a National Inventory Of Scientific Journals. Some fifty thousand scientific journals are now being published, with an additional five thousand new ones coming into existence each year. It is now impossible for a doctor to keep abreast of all that’s published in his particular field. It has been suggested that all current scientific literature be digested, categorized and stored in a central place on magnetic tape, probably Washington. A scientist in Chicago or Montreal, say, who wants information in a particular field, has only to go to his local scientific library, punch a code on the console located there and the information comes to him. Dr. Stafford L. Warren, a special assistant to President Johnson, is studying the project.
With present skills it is now possible to introduce more advanced techniques. But the Akron Children’s Hospital has demonstrated that a good place to start is by streamlining the paperwork in the local hospital. Charles Campbell firmly believes that HIS — which costs an estimated one hundred thousand dollars a year — will bring hospital costs down and provide better and safer care for patients as well as an effective answer to the eternal complaint, “I never see a nurse.” ★