We begin with a bird's eye view of the history and evolution of medicine and related enabling technologies. We then turn our attention to existing 'tried and true' clinical information technologies that help to manage and streamline data obtained from clinical activities such as imaging and monitoring. A discussion of emerging technologies and their capacity to enhance human interactions in health care will come in a second report.

A Brief History

From 450 BC to 300 AD, most people believed that diseases were sent as a punishment from the gods. Treatments were aimed at pleasing the gods so that the disease would be cured. Hippocrates went against this conventional thinking and looked on the body as having a balance between four humors: blood, phlegm, black bile, and yellow bile. If a person was ill, it meant that there was an imbalance in their humors and so it would take a treatment to return the balance back to normal. This often included bleeding or induced vomiting. This radical approach took medicine out of the spiritual world and the four humors formed the basis of medical treatments well into medieval times.

Naturally, tools were required to carry out these treatments and with the development of crude instruments the age of 'clinical technology' was born. The term 'technology' includes the "processes by which human beings fashion tools and machines to increase their control and understanding of the material environment," in this case the human body. Earliest physicians crafted everyday objects such as thorns and shark’s teeth into rudimentary surgical tools used in bloodletting to cleanse the body of impurities and excess fluid. The physician's arsenal evolved to include lancets and fleams for therapeutic purposes such as incising veins, the most common method of bloodletting at the time. Today, syringes and needles serve as indispensable tools for phlebotomy, transfusion and many common diagnostic investigations.

The Evolution of Clinical Information Technology

The evolution of clinical interactions, information sources and technologies (Table 1) paralleled the developing field of medicine. As Dr. Seigworth points out, "the physician and his treatment must be judged in the light of the contemporary theory of disease." Progression from a tool-centric to technology-based society can be illustrated by tracing our description of early bloodletting tools through to modern interventional radiology, where the goal is to access blood vessels not to purge "imbalanced humors," but to insert through tiny openings an assortment of X-ray guided tubes, wires, balloons, coils, glue and plastic particles for the therapeutic benefit of the patient. In fact, the history of interventional radiology is a fascinating look at innovative pioneers who changed the delivery of medicine and greatly improved the quality of patients' lives through minimally invasive procedures.

As Robert Sanders points out, "medical technology has embedded itself in our culture and has been a positive and powerful force in the improvement of life for millions of people." Case in point: in 1901, the average life expectancy in the United Kingdom was 47 years. By the year 2000 it had risen to 77 years. This 64% increase in life expectancy was due in large part to new technologies including medicines and medical techniques as well as improved air quality and better public hygiene.

Table 1. Evolution of domains that have shaped medicine across history.

In recent years, clinical information technologies have come alongside other clinical tools to augment benefits to providers, clinicians and patients. Clinical information technology encompasses the software and hardware environments needed to effectively capture, store, manipulate and disseminate clinical data and information resulting from clinical encounters. These activities fall under the purview of the Clinical Informatics field, which Choong describes as a rapidly expanding and vital sub-specialty that has permeated through all fields in medicine and surgery.

Many information-based medical devices are already or rapidly becoming well established, familiar and unquestioned in their value as part of routine patient care. Computerized pumps, electrocardiograms, and magnetic resonance imaging (MRI) machines are but a few. The following summaries of Picture Archiving and Communications Systems (PACS) and intensive care monitoring / point-of care testing mechanisms demonstrate the valuable benefits of clinical information technology.

Picture Archiving and Communications Systems (PACS)

X-rays, among the first major 'high tech' devices used in medicine, reveal an interesting and productive history since their discovery by Wilhelm Röntgen in 1895. Standard x-rays have progressed to include ultrasound, computerized tomography (CAT), magnetic resonance imaging (MRI) and positive emission tomography (PET), to name a few. Until recently, film was the exclusive media for viewing, sharing and archiving images. Radiology departments have gone through enormous changes. Instead of light boxes we now have computer monitors. And instead of dusty file rooms, we now press buttons on a keyboard to view images. All this technology has also made it easier and quicker to find the images clinicians require.

In fact, this new way of working has been realized through the growing adoption of Picture Archiving and Communication Systems (PACS) across many healthcare centers and regions. Fast becoming a "must-have" for healthcare providers, PACS is an electronic diagnostic imaging system that captures, transmits and stores images in digital form, making them available remotely and simultaneously, often through a secure web browser. This efficiency offers significant time and cost savings in the delivery of care from a system that in one recent installation is expected to pay for itself in 10 years, in part due to the elimination of the £1.1 million annual cost of medical imaging film.

Imaging technicians are no longer required to handle dangerous chemicals used to process images on film. In addition, the quality and versatility of digital images far exceed that of film. The dramatic reduction in wait times to process images and obtain diagnostic consultations and reports, (e.g., from 7-10 days down to 24 hours at the Irvine Medical Center in California) minimizes the need to transfer patients between sites or physicians between cities. Instead of moving patients and healthcare providers, PACS is moving information. Time savings increase patient and physician satisfaction and improve health outcomes by enhancing diagnostic accuracy and by reducing duplication, wait times and lengths of stay. The benefits are summed up by the slogan for the British Columbia Canada Fraser Health Authority's PACS, one of the largest such projects in North America: "Any Image, Anywhere, Any Time."

Intensive Care Units: Monitoring and Testing

Similarly, patient monitoring of vital signs and other physiological data has progressed dramatically from early temperature tracking with a thermometer in the 1700s. Automatic artificial ventilation of the lungs during chest surgery has been performed since 1896, around the time that Harvey Cushing and Amory Codman developed the 'ether chart.' This enabled monitoring of pulse, respiration and temperature during surgery and led to a significant reduction in mortality rate from anaesthesia.

Eventually the realization that separating patients with acute, life-threatening illness or injury could improve care led to the establishment of intensive care units (ICU) in the early to mid 20th century. The development of ICUs has made the care for more seriously sick patients possible. It allowed the utilization of more technically oriented tools to monitor and get information instantly about any changes of the patient’s physiological parameters and developed new strategies to save life. Modern ICUs support an array of equipment such as ventilators to assist breathing, intravenous (IV) lines for fluids, medications and nutrition, and a multitude of monitors, most of them controlled by a small but powerful computer. Widespread utilization of non-invasive patient monitoring has further reduced the cost and medical/nursing complications associated with the care of critically ill patients.

Neil McIntosh describes monitoring as an essential component of beneficial care for critically ill patients through the timely recognition of patterns across physiological data. Recognizing these patterns is challenging given the many distractions in addition to information overload in an ICU. Furthermore, it is difficult to discriminate both short-term and long-term trends for different physiological states simultaneously across different monitors. McIntosh and his colleagues devised a computer decision-support technique that resulted in a reduction in false positive alarms and in the time required for correct diagnosis of a life-threatening condition in ICU infants (from 127 minutes down to 10-15 minutes).

Point-of-care laboratory testing is another advance that helps shrink time intervals and enable essential interventions sooner in the ICU. Gupta and Bhattacharya point out that testing performed in a central hospital laboratory may lead to long delays in obtaining results; while in the mean time the condition of a critically ill patient can change significantly. In contrast, computer supported point-of-care testing offers real-time results at the bedside and "is a major force in the future evolution of hospital care, with prospects for even greater expansion of accessibility, speed, and also, hopefully, accuracy of results."

An increasing number of hospitals are taking efficiency in monitoring and testing to the next level through the coordination and connectivity of data in different formats from a variety of equipment. Eliminating these 'islands of information' can help improve clinical decision-support and clinician productivity as well as reduce medical errors from duplicate data entry. Medical device connectivity specialists help to solve the problem by providing systems that translate medical device data into industry standard formats that can communicate with modern clinical information systems.

Realizing the Benefits of Clinical Information Technology

Clinical information technologies are indispensable to the optimal care of patients that includes a deliberate focus on patient safety, quality and clinical accountability. Advances like PACS and new monitoring methods facilitate quicker, more accurate and less invasive responses to clinical needs. According to David Feinbloom, information technology is the enabler for handling the "explosion in the complexity and volume of information that must be mastered and easily retrieved at the point of care"—yet healthcare lags dramatically behind other industries when it comes to integrating information technology into daily practice. In comparison to the European average of 0.55%, the United Kingdom spent only 0.36% of its gross domestic product on medical technology (according to a recent report by the House of Commons Health Committee). Susan Mayor reports that what is needed is a coordinated approach to technology adoption and spending that emphasizes long-term advantages for patients as opposed to short-term financial savings.

PACS is vital to service improvement and the delivery of the NHS Connecting for Health Programme. As Roy Male, Chief Executive Officer of Blackpool Victoria Hospital, contends "Putting all the technical and other benefits of going filmless aside, to my mind the true impact of PACS and its related IT [information technology] is that it has demonstrated real benefit to clinicians in their day to day work."

Smooth integration of information technologies into clinical workflow (see earlier World View vignette entitled "The Benefits of Computer Technology Can Only Be Realised When Systems of Work Are Changed") is indeed pivotal to their rate of adoption and success, which goes hand in hand with ongoing high-quality training and evaluation. This reality underscores the fact that people drive change; technology simply enables change. As Patricia Fripp, award-winning speaker asserts: "Technology does not run an enterprise, relationships do." This means that in order to realize the full benefits of clinical information technology in the accountable and transparent world of healthcare in the new millennium, advancement will be driven not by technology itself, but by the needs of patients, clinicians and healthcare organizations as they work together to design the future.

References

• American Institute for Medical and Biological Engineering. AIMBE 2005 Hall of Fame.
• Choong A. Editorial: Medicine For The 21st Century And Beyond. The Internet Journal of Medical Technology. Vol. 1, No. 1, 2003.
• IDC. U.S. Picture Archiving and Communications Systems (PACS) Forecast, 2003-2007: How Cedars-Sinai Medical Center Delivers Better Patient Care with PACS.
• Enersen O. Harvey Williams Cushing. 2001.
• Feinbloom D. Information Technology for Quality Improvement and Patient Safety. Medscape 2005.
• Fraser Health Authority. Fact Sheet. January 19, 2003.
• Fujifilm Medical Systems USA. Power of PACS Benefits Pediatric Oncology Research. November 28, 2004.
• Gupta S and Bhattacharya A. Point-of-care Testing In Anaesthesiology and Intensive Care: An Overview. Indian Journal of Anaesthesia. Vol 48, No. 4, 2004.
• Kalisky LD. A Knotty Problem. E-Health Insider. March 31, 2005.
• Lauzier F. Web-based PACS Drives Efficiency and Improvements Throughout the Enterprise. University of California, Irvine.
• Mayor S. NHS is Failing to Reap Benefit of New Technologies, MPs Say. British Medical Journal. Vol. 330, 2005:861.
• McBride G. Medical Breakthroughs: High-Tech 'Surgery.' Consumers Digest Magazine. January/February 1999.
• McIntosh N. Intensive Care Monitoring: Past, Present and Future. Clinical Medicine. Vol. 2, No. 4, July/August 2002.
• Merritt R. Technology. Microsoft® Encarta® Online Encyclopedia 2005.
• NHS Modernisation Agency. PACS Benefits Realisation and Service Redesign Opportunities.
• Prince Edward Island Health and Social Services. PACS Goes Live, Island-Wide. February 12, 2003.
• Promedica Clinical Information Technology.
• Sanders R. Medical Technology: A Critical Perspective. The Internet Journal of Medical Technology. Vol. 2, No. 1, 2004.
• School Science and Curriculum Online, UK. The History of Medicine. 450 BC to 300 AD.
• Schwartz L. Just the PACS. Medscape. Dec 2000.
• Seigworth G. A Brief History of Bloodletting: Bloodletting over the Centuries.
• Society of Critical Care Medicine. Patient and Family Resources: History of Critical Care.
• Society of Interventional Radiology. Interventional Radiology History.
• Sollid L. Calgary Health Region. PACS: An Investment in New Technology Improves Patient Care.
• Takrouri M. Intensive Care Unit. The Internet Journal of Health. Vol. 3, No. 2, 2004.
• Weatherburn G, Bryan S, Nicholas A, Cocks R. The Effect of a Picture Archiving and Communications System (PACS) on Diagnostic Performance in the Accident and Emergency Department. Journal of Accident and Emergency Medicine. Vol. 17, 2000:180-184.