Electronic Health Records: Then, Now, and in the Future.

OBJECTIVES: Describe the state of Electronic Health Records (EHRs) in 1992 and their evolution by 2015 and where EHRs are expected to be in 25 years. Further to discuss the expectations for EHRs in 1992 and explore which of them were realized and what events accelerated or disrupted/derailed how EHRs evolved. METHODS: Literature search based on "Electronic Health Record", "Medical Record", and "Medical Chart" using Medline, Google, Wikipedia Medical, and Cochrane Libraries resulted in an initial review of 2,356 abstracts and other information in papers and books. Additional papers and books were identified through the review of references cited in the initial review. RESULTS: By 1992, hardware had become more affordable, powerful, and compact and the use of personal computers, local area networks, and the Internet provided faster and easier access to medical information. EHRs were initially developed and used at academic medical facilities but since most have been replaced by large vendor EHRs. While EHR use has increased and clinicians are being prepared to practice in an EHR-mediated world, technical issues have been overshadowed by procedural, professional, social, political, and especially ethical issues as well as the need for compliance with standards and information security. There have been enormous advancements that have taken place, but many of the early expectations for EHRs have not been realized and current EHRs still do not meet the needs of today's rapidly changing healthcare environment. CONCLUSION: The current use of EHRs initiated by new technology would have been hard to foresee. Current and new EHR technology will help to provide international standards for interoperable applications that use health, social, economic, behavioral, and environmental data to communicate, interpret, and act intelligently upon complex healthcare information to foster precision medicine and a learning health system.

Managing the technological edge: the UNESCO International Computation Centre and the limits to the transfer of computer technology, 1946-61.

The spread of the modern computer is assumed to have been a smooth process of technology transfer. This view relies on an assessment of the open circulation of knowledge ensured by the US and British governments in the early post-war years. This article presents new historical evidence that question this view. At the centre of the article lies the ill-fated establishment of the UNESCO International Computation Centre. The project was initially conceived in 1946 to provide advanced computation capabilities to scientists of all nations. It soon became a prize sought by Western European countries like The Netherlands and Italy seeking to speed up their own national research programs. Nonetheless, as the article explains, the US government's limitations on the research function of the future centre resulted in the withdrawal of European support for the project. These limitations illustrate the extent to which US foreign science policy could operate as (stealth) industrial policy to secure a competitive technological advantage and the prospects of US manufacturers in a future European market.

A four-phase model of the evolution of clinical decision support architectures.

BACKGROUND: A large body of evidence over many years suggests that clinical decision support systems can be helpful in improving both clinical outcomes and adherence to evidence-based guidelines. However, to this day, clinical decision support systems are not widely used outside of a small number of sites. One reason why decision support systems are not widely used is the relative difficulty of integrating such systems into clinical workflows and computer systems. PURPOSE: To review and synthesize the history of clinical decision support systems, and to propose a model of various architectures for integrating clinical decision support systems with clinical systems. METHODS: The authors conducted an extensive review of the clinical decision support literature since 1959, sequenced the systems and developed a model. RESULTS: The model developed consists of four phases: standalone decision support systems, decision support integrated into clinical systems, standards for sharing clinical decision support content and service models for decision support. These four phases have not heretofore been identified, but they track remarkably well with the chronological history of clinical decision support, and show evolving and increasingly sophisticated attempts to ease integrating decision support systems into clinical workflows and other clinical systems. CONCLUSIONS: Each of the four evolutionary approaches to decision support architecture has unique advantages and disadvantages. A key lesson was that there were common limitations that almost all the approaches faced, and no single approach has been able to entirely surmount: (1) fixed knowledge representation systems inherently circumscribe the type of knowledge that can be represented in them, (2) there are serious terminological issues, (3) patient data may be spread across several sources with no single source having a complete view of the patient, and (4) major difficulties exist in transferring successful interventions from one site to another.

[Dutch computer domestication, 1975-1990]. / De domesticatie van de computer in Nederland 1975-1990.

A computer seems an indispensable tool among twenty-first century households. Computers however, did not come as manna from heaven. The domestication and appropriation of computers in Dutch households was a result of activities by various intermediary actors. Computers became household commodities only gradually. Technophile computer hobbyists imported the first computers into the Netherlands from the USA, and started small businesses from 1975 onwards. They developed a social network in which computer technology was made available for use by individuals. This network extended itself via shops, clubs, magazines, and other means of acquiring and exchanging computer hard- and software. Hobbyist culture established the software-copying habits of private computer users as well as their ambivalence to commercial software. They also made the computer into a game machine. Under the impulse of a national policy that aimed at transforming society into an 'Information Society', clubs and other actors extended their activities and tailored them to this new agenda. Hobby clubs presented themselves as consumer organizations and transformed into intermediary actors that filled the gap between suppliers and a growing group of users. They worked hard to give meaning to (proper) use of computers. A second impulse to the increasing use of computers in the household came from so-called 'private-PC' projects in the late 1980s. In these projects employers financially aided employees in purchasing their own private PCs'. The initially important intermediary actors such as hobby clubs lost control and the agenda for personal computers was shifted to interoperability with office equipment. IBM compatible PC's flooded the households. In the household the new equipment blended with the established uses, such as gaming. The copying habits together with the PC standard created a risky combination in which computer viruses could spread easily. New roles arose for intermediary actors in guiding and educating computer users. The activities of intermediaries had a lasting influence on contemporary computer use and user preferences. Technical choices and the nature of Dutch computer use in households can be explained by analyzing the historical developments of intermediaries and users.

LINC: biology's revolutionary little computer.

The 1963 LINC (Laboratory INstrument Computer) stands at the center of two stories: the computerization of the biologist's laboratory and the advent of small-scale computing. The brainchild of Wesley Clark, 'the most brilliant computer designer of his generation', LINC was developed specifically to address the failure of biologists to adopt computer technology. To meet their unique needs, Clark built a machine the radical design of which defied and subverted the then dominant conventions of computer architecture.

Computers in the ICU: where we started and where we are now.

The first use of computers in critical care units were described in the mid 1960s. They reported the use of very large mainframe computers that filled entire rooms yet had very limited memory and processing capacities by today's standards. These were limited to only a few institutions until microprocessors were developed increasing computation speed and expanding memory capacity by many magnitudes. This allowed smaller more affordable stand alone systems to be developed and the inclusion of microprocessors into bedside devices. As the capacity expanded uses broadened. Simple results review developed into a more complete electronic medical record. Databases were created allowing population analysis for research and systems quality improvement activities. Decision support started as simple alerting of potential errors and dangers and expanded into more sophisticated clinical decision-making support. With this came problems that needed solutions. As the amount of information became overwhelming to the bedside clinician, methods to filter and display data made it more useful. Security and confidentiality became major concerns. Data input solutions had to be found including interfaces between computers, bedside devices and instruments designed to automate data input like scanners, bar coders, and other devices. The biggest issue of all however, was developing acceptance among clinicians and creating the cultural change required for successful implementation of electronic medical records. This paper will explore these issues.

Small bits to big bites.

The Department of Clinical Neurophysiology in Uppsala, Sweden, has reached a high degree of computerization. Patient booking, administration, recording equipment, reporting, and telemedicine are linked components forming an integrated laboratory. Today's configuration is a result of the continuous development and implementation of new technologies. During the 1960s and 1970s, the focus was set on the development of signal analysis procedures. The introduction of personal computers and a local network was the main interest during the 1980s. The 1990s were devoted to the Internet and the development of Keypoint electromyography/evoked potential equipment.

The statistical big bang of 1911: ideology, technological innovation and the production of medical statistics.

This paper examines the relationship between intellectual debate, technologies for analysing information, and the production of statistics in the General Register Office (GRO) in London in the early twentieth century. It argues that controversy between eugenicists and public health officials respecting the cause and effect of class-specific variations in fertility led to the introduction of questions in the 1911 census on marital fertility. The increasing complexity of the census necessitated a shift from manual to mechanised forms of data processing within the GRO. The subsequent increase in processing power allowed the GRO to make important changes to the medical and demographic statistics it published in the annual Reports of the Registrar General. These included substituting administrative sanitary districts for registration districts as units of analysis, consistently transferring deaths in institutions back to place of residence, and abstracting deaths according to the International List of Causes of Death.

The CCL conferences revisited.

The history of the ten conferences on Computing in Clinical Laboratories (CCL) since the first one in Birmingham, UK, 1975, mirrors the developments in medical laboratory computing during nearly twenty years.