Robert Scott Stall, M.D.
April 22, 1987
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Note: I wrote
the following paper in 1987 shortly after I went on-line via my SUNY--
If you have any comments or questions, my current
address is:
Robert S. Stall MD, Geriatrician
Phone: (716)
636-7531
FAX: (888)
387-1238
Email: drstall@stallgeriatrics.com
Educational web:
geridoc.net
Business web: stallgeriatrics.com
This article Copyright 1987 Robert S. Stall, M.D.
All Rights Reserved.
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GOAL
The following is a
description of the possible uses for such a system, methods of implementation,
and consideration of several practical issues.
AREAS OF USE
The scope of use will be at
various hierarchical levels:
Organizational
At this level,
Of particular interest to the
geriatric community,
Finally, such a network could
minimize the delays inherent in publication of journal articles and could also
help to speed and optimize the match between fellowship candidates and their
intended programs (14).
Personal
Individual practitioners could
contact each other quickly and easily to discuss problems (15) (e.g. on-line medical
consultations). Access to existing
informational databases could easily be incorporated (16) (e.g. access to MEDLINE
information), as could access to expert systems (17)(e.g. INTERNIST), patient
care documentation (18) (e.g. patient information pamphlets that may be distributed to a
given practitioner's patient population), and patient clinical databases (19)
(e.g. current medications, problem lists, and progress notes).
In addition, linkages could
be developed between individual practitioners and ancillary health care
personnel (20) to facilitate the implementation of a comprehensive treatment
plan for patients who require specific therapies or health education (21).
On-line informal
communication between individual practitioners could eliminate the delays
inherent in telephone communication (22) (e.g. busy signals, a practitioner
being temporarily unavailable to come to the phone, etc.).
A question/answer bulletin
board could be established to provide a forum for solving management dilemmas
and other patient care issues (23). Home
monitoring and emergency lines can be provided to high-risk patients by
monitoring analog and alarm signals generated by the patient at home (24).
Interlaboratory
On-line communications
between researchers could facilitate collaboratory
efforts on specific research projects (25).
In addition, it would establish a forum to discuss questions pertinent
to research issues.
Laboratories could be linked
to laboratory supply companies, instrumentation companies, and a variety of
consultants to provide technical assistance when necessary during the course of
research (26).
Interdepartmental
In house telecommunications,
similar to that available at the NIH, could obviate the need for written memos,
messages, and mailings. These functions
would be similar to person-person interaction except performed on a
departmental level.
IMPLEMENTATION
Prototype System
The
A directory of users would be
published both on-line and in written form to provide the network
"addresses" by which an organization, laboratory, or individual could
be reached within the network (38).
Guidelines for usage must be
established (39). System etiquette must
be defined (40), confidentiality issues addressed (41), and communication
priorities set. Maintaining
professionalism, protecting user privacy and patient data, and determining a
priority system for various levels of communication (e.g. official notices
having transmission priority over informal communications) are all crucial
implementation issues that must be addressed.
Specific initial applications
are GECNET and FELLOWNET, networks to facilitate communication between
Centralized Mail/Document Facility
To alleviate the burden of
processing
Users could transmit on-line
lists of addressee(s) and a list of the on-line files to be sent. Hard copy of these files would be produced
and written mail sent to the addressee(s).
It is likely that this process could be largely automated to increase
the efficiency of producing mailings and reduce the burden of manual handling
of written documents. Off line
documents/pamphlets would be available for mailing when the central facility is
provided with the addressee list. Non
users could have a catalog of documentation that is available for general use
and could issue written or telephone requests for the information. Non -user addressee lists could be maintained
on-line to facilitate future mailing requests.
Hardware
The hardware required to
implement the system is described below.
All equipment is currently available and is in widespread use. Hardware considerations must also anticipate
differences in software (e.g. file formatting, system commands) but systems in
current use are in general highly compatible.
Peripheral User Sites
Minimum computer hardware
requirements for peripheral sites would be a computer terminal with modem
(<$1000). Addition of a personal
computer (e.g. IBM PC or compatible) with printer would be the basic
requirements for a truly useful system, allowing file storage and production of
hard copy. Multiuser
systems would be necessary for larger offices (e.g. group practices) and local
mainframes necessary to coordinate communication from large organizations.
Central Computer Facility
For the prototype system, the
existing BITNET mainframes could be used, at no cost currently to
university-affiliated personnel or not-for-profit community organizations. In addition, for-profit agencies may get
accounts for a nominal fee ($500-$1000/year) plus usage costs (at rates much
less than those commercially available).
These mainframes are IBM, VAX, and other brand multiuser
machines capable of efficiently supporting approximately 100 users
simultaneously.
Eventually a dedicated
mainframe(s) would be desirable to provide a truly central focus for the
network using a uniform dial-in number to ease access to the system. It will also allow for future system planning
and alleviate the load an extensive system would place on the existing network. It would allow for greater syntax uniformity
in specification of system commands and file designation.
State-of-the-art technology
could be incorporated and developed through consultation with computer systems
vendors (e.g. IBM) and electronic research laboratories (e.g. Bell
Laboratories). Facsimile transmission
and telephone conferencing are currently available and could be incorporated
into the system. Remote medical
consultations could be performed via videophone terminals. Laser disk technology could be utilized for
Computer Aided Instruction (CAI) of medical students, practitioners, and
patients.
Additional system linkages
could be established with existing computer networks (e.g. Veterans
Administration computer system) via system-system modem communication to allow
direct in-hospital access to the network.
The utility of a network such as this in crisis situations can be
explored.
Practical Considerations
Real-time rate of data
transfer should be the goal to maintain optimum user satisfaction and appropriate
computer systems used to fulfill this goal and anticipate future system
needs. Security and confidentiality
issues must be addressed. Database
backup is crucial as is hardware maintenance and repair. A network structure should be devised and
tested (e.g. invisible
or visible substructures, routing and priority of information transfer, and
archiving). Development of a software package that would ease user access (i.e.
user friendly) will be critical in order to gain general acceptance of the system. Manpower issues must be addressed as must
cost analysis and funding sources.
Legal, accounting, contracting, and publicity input will be necessary. Possible affiliations and parallel networks
should be explored (e.g. linkage to the world-wide community). Finally, existing products that are used for
networking (both hardware and software) should be investigated.
System Requirements (estimate)
Anticipating a throughput of
100,000 users @ 1000 transmissions/day/user (average length 1 kilobyte, 9600
baud), approximately 100,000 system seconds/day would be required at the
input/output (I/O) ports. This
translates to approximately 1000 systems days/day as the time spent
transmitting at the I/O ports.
Therefore, at least 1000 parallel I/O lines would be required to enter
information into the processor, assuming 100% efficiency. A more realistic 25% efficiency would
necessitate at least 4000 parallel lines.
Depending on the existing technology, this would determine the number of
mainframes required to support the system.
However, within three months laser optic telecommunication lines will be
operational throughout the network and will make internode
communication virtually instantaneous (1.9 megabits/sec or about 1000 times
faster than a 1200 baud modem).
Data storage requirements
must also be determined. An average of
100-10,000 megabytes/user should be allocated.
For 100,000 users this would translate to 10-1000 gigabytes (10-1000
trillion bytes) that would have to be maintained. Some of this burden may be
alleviated at the peripheral sites (e.g.
100,000 users @ 20 Meg/user=2 Gb
with current personal computer technology).
All hardware requirements
appear to be currently available.
PROMOTING USE
The system, once established,
must recruit users. Person-to-person
recruitment, journal advertising, and conferences (e.g. Geriatric Education
Center National Conference, Buffalo, NY 4/27-4/28, International Symposium on
Research and the Ageing Population, Bethesda, MD 5/1, American Geriatric Society
Annual Meeting, New Orleans, LA 5/14-5/17, and The Gerontologic
Society of America National Conference, 11/87) are all possible forums to
promote the system. It is conceivable
that in the future familiarity with the network would be a prerequisite to licensing
and a means to assure continuing medical education. Training courses and usage manuals must be
developed to explain how to use the system.
SUMMARY
Overall, it seems that the
potentials of a computerized medical telecommunication network (
For additional information
please contact:
Robert Stall, M.D.
Division of
Geriatrics/Gerontology
(716) 831-3097
UB VAX userid/node: DRSTALL@UBVMS
4/14/87 revisions: Home monitoring and emergency services added
to "Personal" on p.2, "in general highly" instead of
"remarkably" on p. 4, correction of calculation of "System
requirements" from "1200 baud" to "9600 baud" on p. 5,
and addition of "For additional information..." on p. 6.
4/15/87: "from" inserted after
"diversity of input than..." on p. 1, paragraph 1 under the
"Personal" section reworded p. 2, paragraph 1 under "Centralized
Mail..." section reworded p. 3, paragraph 1 under "Central
Computer..." section reworded p. 4, misspellings and condensation of
paragraphs p. 4, "audiovisual" changed to "videophone" p.
4, thoughts about software and commercial products added to "Practical
Considerations" section p. 5, 1.9 megabit/sec fiber optic lines described
under "System Requirements" p. 5.
4/16/87: "correlates well" replaced by
"would foster" p. 1, "for practitioners" removed p.2,
"The other benefits of..." replaced by "These functions would
be..." p. 2, "as well as private couriers" replaced by "in
the actual delivery..." p. 3.
Beginning of new paragraphs eliminated for "Non-users..." and
"Non-user..." p. 4, "In addition, for-profit agencies..."
inserted after "...not-for-profit community organizations." p.4,
"currently" changed to "current" near end of p. 5,
"The Gerontologic Society of America,
11/87" inserted after "...5 14-5/17" p. 6.
4/22/87: superscripts represent words and phrases to
be annotated at a later date, name changed to GERINE11.DOC" as updated
footnote, related document "PILOT1.DOC" describes nine pilot studies
under way.