A look back at information management reveals huge gains in the past 20 years

The rise of digital technology has revolutionized the medical workplace.

It is a typical day in the year 1982. Mrs. Jones calls your receptionist because she forgot the date and time of her next appointment. The information is looked up in a large handwritten appointment book, taking about 10 minutes. Mrs. Jones decides the appointment time is not good for her, so she asks to reschedule. Your receptionist uses a pencil eraser to remove her name from its current page and then pencils it in somewhere else. Meanwhile, your insurance clerk is completing the stack of insurance claim forms by hand that she has been working on all morning. Your office manager is calculating the payroll figures and writing the paychecks by hand.

On your way to work, your pager goes off. You have to stop at a pay phone and call your answering service to retrieve the message and return the call.

At the office, you pick up a handheld mini-tape recorder to dictate a consult note to a referring physician about the patient you just examined. You then have to call the local lab to get the results of some blood work you ordered for a patient who recently came in with recurrent anterior uveitis. Another patient comes in on some systemic medicine you never heard of, so you get down that heavy PDR and spend 5 minutes looking it up.

At lunch, you read through a stack of ophthalmology journals and publications, your main source of new information. You also spend time reading letters mailed to you from your colleagues. Replying is time-consuming, so many of the letters are placed in the often-not-done stack.

After work, you agree to take your son to the local library so he can do 3 hours of research for a term paper that is due tomorrow.

2002: computers everywhere

Now jump to the year 2002. Look at how far our information management technology has come. Computers are no longer big monsters confined to large rooms in university and government buildings. They are nearly as common as television sets and telephones. Microsoft’s Bill Gates’ vision of “a computer on every desk” is almost fully realized in the United States. We have all types of information at our fingertips nearly everywhere we go, thanks to widespread use of the Internet.

Computer literacy is no longer an option; it is a necessity for almost all of us, especially those in the health care industry. Thanks to advances in computer design and usability, the learning curve for “newbies” is now much shorter, though still not as perfect as we would like.

Data storage capacities have grown tremendously over the past 20 years. If you happened to be an early adapter or computer enthusiast in 1982 and had an IBM Personal Computer (invented in 1981) or one of its clones, you could store 360 kilobytes of data on a 5¼-inch floppy disk.

Hard disk drives didn’t really exist for personal computers back then. When they first became available, they were expensive, could hold only 5 to 10 megabytes of data and were not very reliable. None of us back then could imagine being able to buy an 80-gigabyte disk drive for only $189.

The technology that developed for information management did so at an astonishing rate while continuing to decrease in price. In 1982, $3,000 bought a 4.77-MHz single-tasking PC with 64K of memory, no hard drive and a small monochrome monitor. Twenty years later, for half the money you can get a much faster processor, 2,000 times the memory, 300,000 times the storage space and an incredible high-resolution large color display.

Now, thanks to this widely available technology, nearly all ophthalmology practices in the United States use computers at least to some degree for office management. Such tasks include appointment scheduling, claims filing, patient billing, accounts receivable and payable, banking tasks and word processing.

And thanks to small personal digital assistants (PDAs), we can carry a tiny computer in our shirt pocket that can give us instant access to all our contact information and even allow us to quickly look up important current information about pharmaceuticals.

1982: done by hand

I can easily remember how, 20 years ago, most of us did not place a long distance phone call unless we had to (for a special occasion or something important). It was just too expensive. Now, long distance service is cheap, reliable and always available within only a few feet of wherever most of us happen to be standing. In fact, many of us now enjoy “free” nationwide long distance service with our cell phone plans. It no longer matters if we are calling our next-door neighbor or our parents who live across the country.

Twenty years ago, I wasn’t even in practice, but I was beginning my ophthalmology residency training. We had no computerized scheduling, billing or digitized records. Fax machines were slow and not widely available. Cell phones didn’t exist. My “talkie” pager wasn’t digital; instead, it was a bulky, heavy device that needed recharging nightly. And the Internet? What was that? How did we ever survive?

Patient appointments were “penciled” into a large date book. If a patient called to ask the date and time of a forgotten appointment, the receptionist had to thumb through the book, page after page, looking for the information. Now such a task can be done with a quick computer search.

Filing medical claims with health insurance companies was all done by hand, often resulting in delayed payments due to simple clerical errors, not to mention the amount of time needed to handwrite each claim. Most of us now file claims electronically.

Appointment reminders were handwritten on a postcard. These are now accurately generated, addressed and mailed by our office computers each month.

When we needed lab results or other clinical data from outside sources, we had to make a telephone call to request the information. We now receive such information via fax or a computer-generated report as soon as it becomes available.

Internet, e-mail

Twenty years ago, information exchange was much more limited than it is today. Our sources of news regarding clinical research, new drugs, surgical techniques and other breakthroughs were primarily obtained through print journals and newsletters. Now we use the Internet both at work and at home to instantly locate the latest facts. Looking up drug information involved pulling the huge PDR off the shelf and flipping through pages. Now we can use handheld PDA applications like e-Pocrates to quickly find just what we need to know about a certain drug.

Continuing medical education courses can be completed online. Teleconferencing is becoming more common, allowing ophthalmologists separated by great distances to have a virtual meeting without leaving the comfort of their home or office. This saves money on travel expenses, too.

Getting in touch with our colleagues was much more difficult 20 years ago. Our choices were limited (phone or mail). But now we can send e-mails whenever we want, and our colleagues can reply at their convenience. We can reach most people quickly by calling their cell phone, no matter where they happen to be located. And if they don’t answer, leaving a voice message is a simple matter.

New technology, new science

Advances in information technology and management affected nearly all aspects of science and health care. Last year, the Human Genome Project and the biotech firm Celera published a first draft of the genome sequence. This was made possible by using high-performance cluster computing, which enables supercomputer performance at a fraction of the cost.

Celera used 800 interconnected Compaq AlphaServers to compare fragments of sequenced DNA and determine where on the genome they belong. Each machine can zip through more than 250 billion sequence comparisons per hour. These advances enabled scientists to sequence the genome years earlier than originally expected.

IBM’s Blue Gene project will try to tackle the protein folding problem, where the number of possible shapes for the average-size protein is greater than the number of atoms in the universe. The system will perform 1 quadrillion operations per second. Calculating the folding process of even a small protein on today’s most powerful computer would take 300 years. Even Blue Gene will take a year to crunch the same numbers, once completed in 2005.

A new Cornell project called Pathogen Tracker enables researchers and students around the world to upload the DNA fingerprint of a bacteria sample and have it compared via pattern-recognition software with all others in the system’s database for instant identification.

But knowledge can have a sinister side as well. For instance, if we know the shape of a protein that triggers Alzheimer’s and we are able to read your genome and accurately predict that you will develop this dreaded disease sometime in the future, how would you react to this news? Would your fiancé still want to marry you? How should we manage and apply the information that science offers us about ourselves?

The solution is up to us, as we continue to be fascinated by great discoveries and struggle with their implications.

A look ahead

Where will we be in another 20 years? What great advances in information management technology will we accomplish? How will they affect the way we practice medicine and how will our patients benefit from these advances?

By then, we might have a small “information capsule” that can be permanently implanted under the skin of patients at an early age. All medical information can be stored in and retrieved from the device by any qualified health care professional simply by waving a wand over it. Patients will no longer have to remember details about their medical history, drug regimen, allergies and previous surgeries. This will greatly speed up patient evaluation and treatment.

We may have a truly usable paperless medical records system in 20 years, once we finally figure out how to efficiently enter clinical data into a secure digital record system. All of our diagnostic instruments will have tiny cameras and data sensors built into them. They will be connected back to a central computer system via a wireless network, where their data can be permanently captured and stored.

Patients might have an inexpensive diagnostic device in their homes that can instantly send very high quality images and other data about their current state of health to their physician, allowing treatment decisions to be made without the patient having to visit the physician’s office. As for ophthalmologists, such machines might be able to send high-resolution 3-D images to us, along with data such as IOP, muscle balance, color vision, visual acuity and refractive error, all after the patient simply looks into the machine and follows a few simple commands.

I look forward to watching the ongoing progress that information technology will be making over the next 20 years. We have many hurdles to overcome, such as inexpensive, widespread high bandwidth data connections; faster microprocessors; cheaper, faster and larger data storage devices; and improved software. We must also find ways to securely maintain this information so it will be safe from hackers and other unauthorized persons. But if history is a teacher, we can expect to see fantastic technical discoveries that we cannot even dream of today.

For Your Information:

• Jeffrey R. Brant, MD, can be reached at Altoona Eye Institute, 962 JF Harris Parkway SE, Suite 201, Cartersville, Georgia 30120-2142; (770) 382-3598; fax: (770) 382-4892; e-mail: topdoc@mindspring.com.