Computers, health care, and medical information science.

The clinical laboratory is examined as a microcosm of the entire health care delivery system. The introduction of computers into the clinical laboratory raises issues that are difficult to resolve by the methods of information science or medical science applied in isolation. The melding of these two disciplines, together with the contributions of other disciplines, has created a new field of study called medical information science. The emergence of this new discipline and some specific problem-solving approaches used in its application in the clinical laboratory are examined.

Dual parameter flow cytometry studies in human lymphomas.

Dual parameter flow cytometry studies using Coulter volume and cell DNA content were carried out in monodisperse cell suspensions of 64 samples of human lymphoma, chronic lymphocytic leukemia, hairy cell leukemia, and benign lymphoid proliferations. Differences in mean Coulter volume among the lymphomas were due both to the intrinsic differences in mean G1 cell Coulter volume and to the presence of increased fractions of larger S and G2 cells, especially among the large B cell lymphomas. However, the relative contribution of large non-G1 cells to the overall population Coulter volume distribution was a relatively minor one; the presence of cells in S did not increase mean Coulter volume by more than 10%, even in samples with high S fractions. There was a good correlation between mean G1 cell Coulter volume and the log of the fraction of cells in S among the B cell lymphomas (r = 0.55). Evidence is presented that within individual samples, large cells proliferate more rapidly than small cells. This was seen in every case, both in the normal samples and in the lymphomas, and in the T cell lymphomas as well as in the B cell lymphomas. Aneuploidy was detected by flow cytometry in 11 cases; in 7 cases the aneuploid cell component could be analyzed separately from the diploid cell component on the basis of cell Coulter volume differences. The aneuploid components of diploid-aneuploid mixtures had higher S fractions than the diploid components in six of seven cases (0.16 +/- 0.04 [SE] vs. 0.08 +/- 0.02). These findings are considered in relation to the histopathological classification of the lymphomas, and in relation to the concept of clonal selection and clonal evolution of tumors.

Integrated expert systems and videodisc in surgical pathology: an overview.

We present an overview of our 6-year experience in the design of expert systems for anatomic pathology. Our practical goal is to help practicing pathologists with learning, teaching, and the task of diagnosis by providing them with dynamic expert knowledge by means of a personal computer. This project could only be undertaken by first addressing a scientific goal: to characterize the problem-solving strategies that expert pathologists use in making a diagnosis and to state them in the logical terms of computer science. Our approach has been to build systems first for experimentation and then for use. The result of our work is an integrated computer-based approach that handles expert knowledge as formal relationships and morphologic images and that uses a number of logical strategies to provide multiple perspectives on diagnostic tasks. Configured as a pathologist's workstation, this approach can be expected to enhance the performance of trained general pathologists and pathologists in training. Lymph node pathology has been used as the prototype domain for this research, but care has been taken to seek a generalized authoring and inference structure that can be applied to other areas of pathology by changing the contents but not the structure itself. Excursions into various surgical pathology specialties suggest that the ways the system is constructed and exercised is fundamentally robust. Such computer-based expert systems can be expected to generate a new standard in the practice of pathology--based on the "gold standard" of classical morphology, but including the coordinated use of new methods from immunology and molecular biology in a multidisciplinary approach to diagnosis when these techniques are relevant. The benefits from this technology can be expected to be widespread with the evolution, refinement, and diffusion of these systems.

Clinical laboratories are laboratories for re-engineering.

The concept of re-engineering rests on computer coordination of information. As a management tool, it has been tested and found to be ambiguous. At best it sharpens laboratory objectives, but at worst it fragments skills and threatens the community attitudes needed for teamwork. Experience with its most fruitful components has long been a part of laboratory management.

Programming languages.

This article focuses on the strengths and shortcomings of application languages as they are used in general purpose computers, on the strategies for their use, and on how they impact laboratory and medical systems. The author describes the reason why we are where we are at the present stage of computer languages and suggests where we might expect to be in the foreseeable future.

Re-engineering the clinical laboratory. An overview.

This article provides an overview of processes involved in re-thinking the clinical laboratory. The author, also the Guest Editor of the issue, alludes to the work of the other authors in this issue and provides his own views on this increasingly important subject.

Acquiring a laboratory computer system. Understanding the issues.

This article reviews the issues involved in introducing or upgrading computer automation in the clinical laboratory. The strengths and weaknesses of computers and computer systems are discussed. Information on selecting and educating the laboratory team who will use the computer and analyzing the needs of a particular laboratory is included.

Acquiring a laboratory computer system. Vendor selection and contracting.

The steps involved in acquiring a computer system, from writing the request for a proposal to signing the contract, are discussed. Guidelines for selecting a system include information on the merits of different hardware and software available for use in the laboratory.

Preventing postlaminectomy adhesion. A new experimental model.

STUDY DESIGN: The efficacy of various interpositional membranes for prevention of extradural adhesion was investigated by a new animal model that quantified the biomechanical effect of scar formation. Twenty-one dogs were treated with autologous free fat graft, hyaluronic acid or no interpositional membrane after undergoing two-level laminotomy, nerve root exploration, and disk injury. An additional 11 dogs that did not undergo spine surgeries served as control animals. OBJECTIVES: Inter-animal variability in inherent propensity to form scar was first measured before any spine surgery. Twelve weeks after spine surgery, the lumbosacral spine of each dog was harvested en bloc for biomechanical testing of extradural adhesion ultimate load. Scar stiffness coefficient was also calculated. SUMMARY OF BACKGROUND DATA: Adhesion ultimate load was significantly less in the nonoperative control group when compared with the fat graft and no interpositional membrane group, but not when compared with the hyaluronic acid group. A beneficial effect of hyaluronic acid in lowering adhesion ultimate load was demonstrated, although a statistically significant difference from the fat graft and no interpositional membrane groups was not reached. No difference in scar stiffness coefficient was found between the four groups. METHODS: A new experimental model allowing objective biomechanical quantification of the effect of postoperative scar was described. Ultimate load of adhesions to both nerve roots and dura was measured. A biochemical assay that determined collagen content was also used to assess inter-animal propensity to form scar after a standardized surgical insult. Results were compared with other relevant studies. RESULTS: Findings suggest a beneficial effect of hyaluronic acid in decreasing the biomechanical strength of extradural adhesions following laminotomy, nerve root exploration, and disk injury when compared with use of fat graft or no interpositional membrane. These results support other recent investigations that study the use of hyaluronic acid treatment in a laminectomy model. The adverse consequence of intraoperative epidural bleeding was also demonstrated. CONCLUSIONS: The new experimental model described in the current study was reproducible and permitted objective quantification of the effect of postoperative adhesion rather than measuring its mere presence. A beneficial effect of hyaluronic acid treatment and a lack of such beneficial effect of free fat graft interpositional membrane was suggested. The importance of avoiding active epidural bleeding was also evident.

Global healthcare and the flux of technology.

For Medinfo '98, as an exercise in technological forecasting and analysis, we volunteered to project the direction of healthcare informatics into the next century. This paper is an extended discussion of that presentation. We open with the observation that healthcare informatics is merely one of the many endeavors that is following a turbulent but nearly inescapable path into a digital future. Our objective is to describe as best we can the overall geography of the general path we appear to be on, to anticipate some of our future checkpoints along the way, to identify some of the roughest transitional passages as they apply to healthcare, and to present this as one guide among many to those who have offered to do the steering into this exciting, electronic unknown. Emphasis is placed on the growing importance of information networks, the particular nature of complexity as applied to healthcare communications and healthcare itself, and the impact of the rising costs of what is medically possible in a technological age. Certain evident recent changes in computing technology are singled out for their present and expected importance. The whole is considered from a broader organizational perspective to better understand the turbulence of present times, and what medical informatics might address to ameliorate the most onerous healthcare issues.

Global healthcare and the flux of technology.

We begin with the inescapable observation that healthcare informatics is merely one of the many endeavors that is following a turbulent but nearly inescapable path into a digital future. Our objective in this paper is to describe as best we can the overall geography of the general path we appear to be on, to anticipate some of our future checkpoints along the way, to identify some of the roughest transitional passages, and to offer this as one guide among many to those who have volunteered to do the steering into this exciting, electronic unknown.

Using information tools to improve hospital productivity.

Because of the new reimbursement incentives placed on healthcare institutions, the efficient and effective use of resources is being emphasized more than ever before. In this new environment, decisions must be made with skill and insight, supported by information tools that analyze and manage productivity. By integrating advanced information technology into hospitals' existing information systems, productivity can become a powerful tool to achieve and maintain a competitive advantage.