Computer Development and
Health Care Information Systems
1950 to Present

Decade

Computers

Healthcare

1950s

In 1952 after analyzing only 5% of the tallied vote, the Univac I predicted that Eisenhower would defeat Stevenson in the presidential election (Shelly, & Cashman, 1980). Remembering the 1948 election in which the East Coast newspapers, based on a faulty survey, erroneously predicted that Dewey was the winner, CBS withheld the information until it was confirmed by the actual vote. To this point computers had been developing out of the public's eye in university laboratories. This incident brought the computer into the mainstream, however the public's vision was of "giant brains" which would out think humans and eliminate their jobs.(World Impact of the Integrated Circuit, 1995).

In some institutions, automation of the financial and accounting functions began in the mid 1950's. These systems were transaction or process oriented systems.

1956

Second generation computers, based on the transistor are developed. These computers are smaller, faster, more reliable and more energy-efficient than first generation computers. The second generation lasted until 1963.

1958

The integrated circuit (IC) is developed by Jack Kilby, an engineer with Texas Instruments. The IC is the foundation of all microchip technology (Texas Instruments, 1997).

1960s

Douglas Engelbart, while working at Stanford Research Institute invents the mouse. At that time the device was ignored because computers were so big and expensive that it never occurred to anyone that a computer could be used by one individual. Later in his career he developed video-conferencing, multiple-window screens and hypertext (Inventor of the Mouse Wins $500,000 Prize, 1997). The mouse was first introduced to the general public with the Macintosh computer, but did not become standard in MS-DOS products until the introduction of Windows™ in the late 1980's.

A number of second generation computers are in use by businesses, government and universities (Computers: History and Development, 1997).

Some health care institutions begin to include patient care applications in their computer systems (Saba, Johnson, & Simpson, 1994).

1964

The third generation of computers were introduced. What distinguished them from the second generation was the use of the integrated circuit. They had operating systems which allowed them to run many different programs at once by providing a central program to monitor and coordinate the computer's memory (Computers: History and Development, 1997.)

Computers become smaller as more components are squeezed onto the IC.

By the mid 1960's the abilities of computers had been recognized by some health care institutions. In 1965 the US Congress amended the Social Security Act to include Medicare and Medicaid. To qualify for reimbursement, nurses were required to provide data to document care delivered US Department of Health and Human Services, 1983). This proved to be a great impetus to the development of nursing information systems.

By this time shared data-processing centers were providing some hospitals with business and financial system processing Ball, Hannah, 1988).

A Burroughs third generation computer provided one of the earliest hospital information systems in Charlotte, NC (Saba, & McCormick, 1986). El Camino Hospital in Mountain View, CA started working with the Lockheed Corporation on a hospital information system (Buchanan, 1980). Hospitals, however, trailed government and industry in installation of computers because the hospital market was not well understood by computer manufacturers (Ball, & Hannah, 1988).

Work begins on SNOP by the American College of Pathology to systematize the language of pathology. Will eventually become SNOMED

By the late 1960's some hospital information systems include patient diagnoses and other patient information, and care plans based on physician and nursing orders (Saba, Johnson, & Simpson, 1994).

1969

The concept of a Uniform Minimum Health Data Set (UMHDS) was formulated in an effort to develop national health data standards and guidelines (Werley, Devine, & Zorn, 1998)

An ambulatory care system, Computer Stored Ambulatory Record (COSTAR) system is developed in the late 1960's at Massachusetts General Hospital for the prepaid Harvard Community Health Plan. Patient care data was computerized to meet providers' medical, financial, and administrative needs (Saba & McCormick, 1986).

Bell Aerospace Company designs a health care system for the Papagoe Indian Reservation in Tuscon, AZ. The centralized database contained all the medical records. All health care providers in this system with access to a computer terminal had access to these records Saba & McCormick, 1986).

In late 1960's and early 1970's health departments and other community health organizations developed or contracted with vendors to develop systems to provide the statistical reports required by local, state and federal governmental agencies (Saba & McCormick, 1986).

1970s

Fourth Generation Computers are seen. Intel develops a chip that locates ALL the components of a computer on a single chip. This enabled the same microprocessor to be programmed for many needs. Household items such as microwave ovens, television sets and automobiles with fuel injection were able to incorporate microprocessors.

1971 - microprocessors lay the groundwork for hobbyists to start building "home computers," or microcomputers, as they are first called.

Taking advantage of third generation computers, in 1968 development of the PRoblem Oriented Medical Information System (PROMIS*) was begun by Dr. Lawrence Weed at the University Medical Center in Burlington, VT (McNeill, 1979). The importance of this system lies in the fact that it was the first attempt to provide a total, integrated system that included all aspects of health care including patient treatment. It used as its framework the problem-oriented medical record (POMR*). The system was patient, not health care oriented. It was originally implemented on a gynecology unit in 1971, then completely redeveloped for use on a medical unit.

PROMIS provided a wide array of information to all professions involved in health care including the cost of procedures and laboratory tests. Documentation was focused on the problem list and all disciplines recorded their observations and plans on this list breaking down barriers between disciplines. The PROMIS system also made it possible to see the relationship between conditions, treatments, costs, and outcomes. This system did not have wide acceptance. To accept it meant a change in the power structure, something that did not begin to happen until the 1990's when the advent of managed care in all its variations reinvigorated a push towards patient centered information systems.

1972

The Uniform Hospital Discharge Set is adopted. (UHDS)

1973

The Division of Nursing, U. S. Public Health Service, Department of Health, Education and Welfare funds the first invitational conference on management information systems for public and community health agencies under the auspices of the National League for Nursing (NLN) (Saba & McCormick, 1986). This conference was followed by five workshops held around the country designed to teach community health nurses how to implement computerized management systems in their agencies. The participants were shown how systems could be used for statistical reporting, cost analysis, and agency administration.

The first meeting of the National Group for the Classification of Nursing Diagnosis was held.

1976

SNOP enlarged to include medical terms and becomes known as the Systematized Nomenclature of Medicine (SNOMED). Development continued with the goal of using it in electronic records.

1977

1977 - The first Apple II is delivered. Although weak by today's standards, it had the ability to do color graphics and shipped with a form of the Basic Programming language as part of the computer. It used the Motorola 6502 chip. The original had 4 K of RAM and an 8 bit bus.

Rockland County (NY) Health Department attempts to computerize the patient progress methodology to develop a patient care classification and nurse staffing system for local community health nursing agencies. Funding and technological limitations keep it from ever being functional (Saba & McCormick, 1986).

The State of New York at Buffalo attempts to computerize a standardized patient assessment form. The computer technology, however, is not advanced enough to process the numerous variables and it is never computerized (Saba & McCormick, 1986).

Another project that was never completed was the attempt in the early 1970's to establish criteria for predicting care requirements by the Community Nursing Services of Philadelphia. The goal was to develop a system to evaluate the process of patient care. (Saba & McCormick, 1986).

The New Jersey Department of Health implemented a home visiting management information system to provide statewide information on home visiting services. The processing, however, was so slow that by the time the information was received by agency directors it was outdated (Saba & McCormick, 1986).

Early in the 1970's the Omaha VNA started development of a clinical database capable of being included in a fully integrated, automated management information system. This became known as the Omaha System. It is still in use today in an expanded format.

In the late 1970's, hospital information systems other than large teaching medical centers started to use online data communications technology to provide instant access to computerized data bases.

1980s

IBM realizes that they need to build a smaller, stand alone computer. Bill Gates convinces them to use a larger chip (16 bit) and more RAM than originally planned (64 K instead of 16 K). He also convinces them to license the Microsoft Operating System (the famous DOS, rhymes with boss) as the operating system and contracts to write software for this machine.

1981

In 1981 IBM ships its first Personal Computer (PC). It uses a 4.77-MHz Intel 8088 chip and has 64 kilobytes RAM, one 5.25-inch floppy diskette drive and PC-DOS 1.0 (Microsoft's MS-DOS). Color graphics were extra. The entrance of IBM into the PC market legitimized the PC and established the preeminence of the Intel 8086-family of chips and the Microsoft MS-DOS operating

1982

The price of PCs drops as"clones" appear on the scene. Although the term clone is used, these computers were not an exact duplicate of the IBM PC. In computers, the term clone means that a computer allows one to run the same programs, or software. For the first 10 years after the introduction of the IBM PC these clones were generally referred to as being "IBM compatible." Later the term heard more often was MS-DOS™ computers. Today the terms used is generally a PC or Windows Computers meaning they run an operating system produced by Microsoft™.

The first International Medical Informatics Association Working Conference on the Impact of Computers on Nursing is held in London, England. This was followed in 1985 by another international nursing informatics conference in Calgary, Alberta, Canada. These are now held every three years.

1984

Apple Computer introduces the first Macintosh with 8-MHz 32-bit Motorola 68000 chip, built-in 9-inch B/W screen, graphics, a 400 KB 3.5-inch floppy disk drive, a mouse, and 128 KB RAM. The Macintosh introduced the graphical user interface (GUI) which was a revolutionary change in the computing environment. Instead of typing in a command, or giving a combination of keystrokes, users moved the mouse pointer to the icon representing their choice and clicked on their mouse. It quickly became popular with users who found it easier to use than the IBM PC type computers.

IBM ships the short-lived IBM PC Jr. It was an attempt to reduce the cost of owning a computer, but had too little power to satisfy most potential computer owners.

Microsoft tries unsuccessfully to get IBM interested in its GUI, Windows™.

1985

Microsoft releases Windows 1.0. Although gaining some converts, it was about five years before it became popular.

The Intel 386 is introduced by Intel and the first PCs based on the 386 chip are produced.

Middle to late 80's, Saba and the research staff of the Home Health Care Classification Project at Georgetown University develop a method for classifying home health Medicare patients for the purpose of predicting resource requirements and measuring outcomes (Saba, O'Hare, Zuckerman, Boondas, & Oatway, 1991). Known as the Home Health Care Classification it is still in use today.

1986

The First Freenet, in Cleveland, OH comes on line on July 16. It included access to nurses and doctors for information on health related questions (Zakon, 1996).

ANA House of Delegates adopts a resolution identifying the need for nurses to use information systems to collect essential data for clinical practice, management of nursing care and nursing resources, education, administration, and research (Milholland, 1997). They also recommended that the Nursing Minimum Data set be tested and implemented at local, regional and national levels.

1987

Apple Computer introduces the open architecture Macintosh featuring a plug-and-play architecture for expansion cards.

ANA House of Delegates approved policies to promote the classification of nursing practice in the categories of assessment, diagnosis, interventions and outcomes (Milholland, 1997).

Work begins on the Nursing Interventions Classifications by nurse researchers at the University of Iowa. This system is in use today, known by its acronym of NIC.

1981

Microsoft ships Windows 2.1 for PCs based on the 286 and 386 Intel chip.

1989

Intel announces the 25-MHz 486 microprocessor at Spring Comdex in Chicago, Illinois.

ANA Steering Committee on Databases to Support Clinical Nursing Practice was first convened. Today this committee is known as the Committee for Nursing Practice Information Infrastructure.

1990s

1990 - Intel introduces the 33-MHz 486 microprocessor.

Windows 3.0 is introduced by Microsoft.

ANA House of Delegates directed ANA to pursue collaborative efforts to develop essential minimum data elements for determining cost and quality of nursing care and to provide leadership in developing uniform classification systems (Milholland, 1997).

A shift from the retrospective, process oriented systems towards patient-centered outcome-oriented systems.

Focus of automation in hospital information systems becomes quality of patient care (Guide to Effective Health Care Clinical Systems, 1996)

1991

Creative Labs introduces the Sound Blaster Pro Deluxe, the first stereo PC sound card.

Increased clinician usage by developing better user interfaces is a goal of information systems (Guide to Effective Health Care Clinical Systems, 1996).

1992

Apple Computer chairman John Sculley coins the term Personal Digital Assistant, referring to handheld computers that typically operate via a stylus on a LCD display.

ANA establishes nursing informatics as a nursing specialty (Milholland,1997).

Cost becomes the major driver of computerization, surpassing quality of care (Guide to Effective Health Care Clinical Systems, 1996).

Mosby publishes the first edition of the Nursing Outcomes Classifications (NOC), a system still in use.

Work begins on the Patient Care Data Set at the University of Virginia. Still in use.

1993

Apple Computer introduces a personal digital assistant (PDA), the Newton MessagePad. It runs on four AAA batteries.

Intel introduces the Pentium processor.

Controlling costs are still important, but the 1992 recession slows the budget growth for systems (Guide to Effective Health Care Clinical Systems, 1996).

1994

Microsoft releases Microsoft Windows 3.11.

Dr. Nicely reports his discovery of the Pentium floating point bug to Intel, and his report is made public on CompuServe.

Outcomes become a prominent focus for automation (Guide to Effective Health Care Clinical Systems, 1996).

LOINC system initiated by the Regenstrief Institute and developed by Regenstrief and the LOINC committee as a response to the demand for electronic movement of clinical data from laboratories that produce the data to hospitals, physician's offices, and payers who use the data for clinical care and management purposes. (LOINC background, n.d.) Is in use today.

1995

Intel announces the Pentium Pro microprocessor, if numbered it would be a 686. The processor uses 5.5 million transistors.

Keeping costs down still prevails, but focus now moves to improving patient outcomes. Capturing data at the point of care becomes important (Guide to Effective Health Care Clinical Systems, 1996).

To operationalize point of care data capture PDAs start to appear in hospitals.

1996

Compaq Computer introduces the 180-MHz Pentium Pro-based Prolinea.

Advanced Micro Devices begins shipping the K5-PR100 microprocessor. It is a 100-MHz Pentium-compatible plug-in replacement. Price is US$84 each for 1000.

Managed care is driving increased computerization. There is increased interest in patient-centered computing environments (Guide to Effective Health Care Clinical Systems, 1996).

Health Insurance Portability and Accountability Act passed by Congress. Also known as the Kennedy-Kassenbaum Bill

1997

The Nightingale Tracker, a portable communication system utilizing a PDA that will allow nurses or students in the field to be in touch with instructors in an office, under development since 1994 goes into Beta Testing.

1999

SNOMED and the Read System are combined and become SNOMED-RT. Is recognized by the ANA.

There is much disagreement about when the fifth generation of computers began. Some say that putting the microprocessor on one chip introduced this generation in 1975 (Saba & McCormick, 1986), while others believe that fifth generation computers are now in their infancy and are dependent on parallel processing and superconductor technology (Computers: History and Development, 1997). Parallel processing involves making multiple computer processors work together to provide faster computing. Superconductors, are materials that are capable of conducting electricity without resistance. For them to be useful in computers they need to work at room temperature.

Some of the goals for this next generation are the improvement of the ability to recognize the spoken word and foreign language translation. Although these things look simple they are not. The spoken word has many accents and nuances from different regions of a country, or different countries, to those that occur when one has a cold. It is difficult to get a computer to recognize that the same word is being spoken when any of these are active. Language translation is also difficult. As anyone who has learned a second (or more) language knows, it is often a phrase and a context that give meaning, not individual words. Like chess, these tasks do have finite boundaries and will be solved.

2000

The Health Insurance Portability and Accountability Act (HIPAA), first passed by Congress in 1996 is getting the attention of health care agencies. The final rules and regulations are i being promulgated.

2002

Rules for privacy provisions for HIPAA are finalized.

Software for PDAs that allow clinicians to easily access reference material becomes popular.

SNOMED-CT is released.

National Alliance for Health Information Technology (Alliance), a non-governmental group of senior healthcare leaders from organizations associated with healthcare such as hospitals, ambulatory care providers, health-systems payers, technology vendors, and other healthcare stakeholders is established.

2003

Attention in PDAs turns to the portability aspect of this act. Attention is given to standardization of documentation.

2004

President Bush establishes the position of National Coordinator for Health Information Technology and the Office of the National Coordinator for Health Information Technology (ONC)

2005

American Health Informatics Consortium (AHIC) established. It was a federal advisory committee of public and private sector leaders.

Health Information Technology Standards Panel (HITSP) is established. They are responsible for designating standards that will be used in the structure and transmission of healthcare information, standards that will affect how nursing and others document care, including the nursing and other healthcare terminologies that will be acceptable

2007

2008

AHIC Successor, the public/private redesign of AHIC emerges as the National eHealth Collaborative.

2009

HITECH Act passed as part of the American Recovery and Reinvestment Act (ARRA). Provided for meaningful use, or a set of national priorities that, if focused on, would help health care performance-improvement efforts. Provided help for physicians to implement electronic medical records

2000s

The development of health information exchanges (HIEs), formerly called RHIOs (Regional Health Information Organization)

2010s

Meaninful use deadlines established, now being extended.