iiiiiiiiii *EOOL I CARE,@@ EARINGS,,, BIMFO E TH 19 ]m BCOMMITTEE ON INTERNATIONAL@.'- $CIENTIFIC ON MMITT TECHNOLOGY CE,-AND. O'l E VES!@ FIF'RH CO. M Y 9,-10,/AND 11 the,,use of the@@, ttee-, Tqe#no 3 6?3 Mr. SCHEUER. Perhaps you would just care to chat with us for 10 That has not been smooth even within HEW. I think one possible approach to it is to include the National Bureau of Standards, or 12 minutes and then we could have some questions. which is certainly the most academically oriented within the De- Dr. LINDBERG. I would be delighted to and I thank you for the partment of Com-merce. It has in fact involved itself very positively opportunity of being here. and significantly in medical computing in the past. TESTIMONY OF DR. DONALD A. B. LINDBERG, DIRECTOR, Mr. ScREuER. That's the first rve heard of that. HEALTH CARE TECHNOLOGY CENTER, UNIVERSITY OF MIS. Dr. @BERG. Both through a series of very careful studies on privacy which resulted in the definitive documents Gn the subject SOURI, COLUMBIA, MO. of medical privacy. Also they are participating with the three Dr. LINDBERG. I agree with many of the things I have heard both armed services with the development of TRIMS, the triservice today and the day before. I won't resay them because many of medical information system. them are in my printed statement. I think there are many aspects of the medical computing prob- I would like to make three points to commence with. Firstly: I do lem. Certainly it is not the primary responsibility of a commerce want to urge that one believes that computers have a great contri- agency, but on the other hand subparts of the problem are very bution to make to health care and biomedical research. This prob- relevant, and NBS has been very interested in it. ably would hinge upon their function in medical recordkeeping in Let me stress, if you will permit, one aspect that has not been the first place, and a second major emphasis, mainly the represen- directly talked about in the last 2 days-I was not in New York, tation of medical knowledge. but I mean the 2 days in Washington and that is the National Second: You had asked in your letter about the Federal Govern- Library of Medicine. Their primary mission in the Federal Govern- ment's policy with respect to support of research in computers and ment is to store, access, and disseminate biomedical information. medicine, what it is and what it might be. I would like to say that Naturally this has taken the form of books and documents over if it has a policy, it is a "fall through" option. It is ad hocism as these many centuries. But in this modern computer age it is possi- you referred to, and it is totally unsatisfactory. ble and reasonable to represent much knowledge in a machine Mr. &muER. What is totally unsatisfactory? form. Indeed, no computer system can do anything until the knowl- Dr. LINDBERG. If the Federal Government has a policy it is an edge is represented in machine form. unsatisfactory one and it is not a cohesive policy. It is subject to That is an area of research which can have a number of names the criticism of on-again, off-again fimding. but "artificial intelligence in medicine" is one of the keys to that Mr. ScHEuER. Are you @g about HEW? area. Dr. LINDBERG. Yes. There are now a number of systems in which this representation Third: This can be corrected. I do think that the statements that has been successful and in which they do a day-to-day realistic job. Ms. Hanft has made are pointed in exactly the right direction. It is no longer a pie-in-the-sky business. People in th@t field are no They say that there will be a cohesive policy and there will be an longer making robots and chess-playing games. They are making office which draws together the problems of support in this field. treatment selection games and antibiotic drug selection functions, I question if it is possible to do all of that within HEW and I et cetera. recommend that the committee consider an interagency strategy. Now, that is in the mainstream of the National Library mission Mr. ScHEim. If there is anything more unwieldy than a Govern- and also in the mainstream is a series of training grants. NLM is, ment agency capability it is an interagency capability. Our record so far as I know, the'only agency in Government that supports with interagency coordinating mechanisms has generally been a medical information science and medical computer science training disaster. It usually doesn't work. But anyway- grants. The only place. Dr. LINDBERG. I would have to disclaim any intimate knwoledge I would like to take issue with-maybe it's a difference in our of how the Government should really be organized and perform phraseology-the previous testimony of the AMA, I will read with internally, but I think the issue of- extreme interest the statement that tells me the number of medi- Mr. ScHEuER. One of the basic principles down here is when the cal schools which have programed teaching medical students about subject is everybody's data it is nobody's data, and when you have computers in medicine because I strongly suspect that the count six or eight agencies coordinating something and nobody has exclu- would be zero. sive responsibility, everbody does their own thing. It not only falls Mr. SCHEUER. Look, they're right here. Why don't we find out. between two chairs but it falls between four, five, or eight chairs. Mr. PoLu. Let me only make the point ihat in fact when I We just don't seem to know how to make interagency coordinat- visited Dallas, Tex., to attend the annual convention, not in 1977 ing bodies work. Everybody is concerned that they are not going to but in 1976'they have a policy of permitting medical students in get the credit, and if it isn't part of their turf nobody cares. That's the area to come in for a nominal fee, if anything at all, and they just a fact of life. And whatever you put on the organization chart, had a booth and I met a student who was very upset, a medical no matter what, very little seems to flow from these efforts. That student from the University of Texas. He was very concerned. Why has been our experience i3myway. was he learning basic Fortran when he should really be learning Dr. LINDBERG. It is a :serious problem that I think you and the applications in that area? We commiserated for a while and I laid staff pointed to, for HEA' to work with industry on computer work. a (I out a pro6-i-am and I told him to go back to the director and say, impediments, and think about the roadblocks." Her instinctive re- "Sir, I talked to some people in this area and here is how we action was to recognize all of the things that were combining to should m@ a program that exists right now for teaching medi- defeat any progress in this area. cal students @bout computer technology and getting away from the Of course, she is right. Those are the roadblocks out there, so any hard bolts iiown into the specific application and practices." So the progress that is made is something that is encouraging. It's not only thing I can comment on is that I have one counterexample. going to be easy. I take great hope from the attitude that I have Dr. LiND13ERG. I don't think it's a counterexample. Is he a medi- heard from the three AMA representatives this morning. After all, cal student and is it a required curricular course? they probably have as much to do about the mindset of the future Mr. PoLu. The answer to the two questions is, he was a medical generation of doctors in this country as any other institution, per- student and it was a required course. haps apart from the medical schools themselves. If my senses tell Dr. LINDBERG. I will read it with great interest. me anything, it is that the AMA is taking a very creative and Mr. ScHEuER. You will give us a list, to the best of your ability, forthcoming approach about the involvement of the computer in of the schools who are integrating computer training into their health care. medical training. Maybe I am naive and maybe I am missing all kinds of signals Dr. LINDBERG. That is certainly a desirable aim. And that is but this is what I am picking. But I think this is a good augury of exactly what the National Library of Medicine training grants are things to come and I hope they will be having some communication trying to stimulate. There are only 10 schools and I have visited and impact on the State and county medical organizations. The them. I think in each case there is nothing approaching this sub- Governments itself is not organized to do this either within HEW ject. I think there should be. I in no way underemphabize mecii- or among all of the other agencies involved. Neither are we orga- cine's need for a whole lot of other professional participation in the nized particularly well in the classic sector. There is the problem of way of bioengineering and computer science and so forth. But I physician resistance and a feeling that he is threatened by all of think it is key to get medical students trained in this techology this technology and that it sort of demeans his ability to play his early in the game when they are young and malleable so that they fine art for the practice of medicine. But there are good things will retain that understanding the rest of their lives. moving too. As I say, we have heard from the AMA people and I I was surprised somewhat to note how greatly you were interest- think their attitude bespeaks hope for the future. ed, @, in the presentation of Dr. Brandt, and I'm very pleased that Dr. LINDBERG. I have been installing computer systems since .he and you talked about it. Well, I was surprised. 1961 and I have almost never heard a negative attitude from the Mr. ScHEuER. Why were you surprised? medical people. They may be "from Missouri" and need to be Dr. LINDBERG. I had expected you would be more concerned with shown. Ileir attitude is neutral to positive, but I have not found hospital systems and their direct application to health care and the resistance that Mr. Gallagher referred to. I think it is mytho- their effect on hospital per them charges. logical. I think it is reasonable skepticism about systems that have Mr. ScHEuER. We are interested in that, too. not yet come to full flower. Dr. LINDBERG. I was happy that you understood immediately that Mr. ScHEuER. Well, that's healthy. change in the per them is not the way to evaluate a system and Dr. LINDBERG. That is very healthy. I don't think a major.obsta- that its effect on societal health care cost is really the way to cle is the M.D.'s resisting the computer applications. evaluate it. Mr. SCHEUER. What d6 you think the major obstacle is? Mr. ScHEuER. The thing that @ed me is an implication from Dr. LINDBERG. Technology transfer. Nobody is in charge of seeing Dr. Weed's suggestion that at the end of the year you can evaluate that it goes from innovation to development, to demonstration and what a doctor has really accomplished. The prospect of applying then out to the end where it gets into industry. We have operated that kind of a computer system to Congressmen-our constituents as ff NIH Support will terminate once a research problem is suc- being able to figure out at the end of the year what we have cessfully pursued. Once a system works, NIH support stops and it accomplished-is something that I think 535 Members of this body is extremely difficult for those systems ever to get over that chasm would feel a little threatened by. But seriously I think the mem- to the National Center for Health Services Research where the bers of this committee who have participated in these hearings funds are now being sharply limited, and then from there to indus- have really had an eye-opening and mind-openmg experience. try. It almost never happens. Yet, it is that full spectrum of tech- Dr. LINDBERG. I think you should realize that, in spite of the nology development which really'should be at the center of Gov- assurances everything will be smooth in government with respect ernment inter-est. In other words, it knows how, through NU-I, to to computers in medicine, that the perception one has from outside buy creativity but it does not know how to get that creativity the Government is really different. transferred over so that the hospital administrator can ultimately Mr. SCREUER. I don't think anything is really going to be smooth. buy it. He cannot buy devel oi)ment. He can only buy from a This mornmg, you heard Ruth Hanft, who is one of the truly great vendor, and the technology hai to get over to industry before he people in goverrunent; every time I asked her a question about how can benefit from that. Much of it never does get that far. could this be done or how that could be done, she would say, "Yes; Mr. SCHEUEP.. Dr. Wells suggested I may have been overly skepti- it's a great idea but just think about the barriers, think about the cal about the possibilities of- improved interagency cooperation. Why don't you describe to us the kind of interagency cooperation I humbly express my inability to know how the Government you perceive taking place? should be run. I think anybody can see an intuitive weakness in Dr. LINDBERG. I think, Mr. Scheuer, the relevance of i National the strategy of interagency anything. But on the other hand, I Center for Health Services Research is very obvious, and that think the present Policy is @ weak one. It is not one which I would subject has been addressed a number of times today arid the day put my faith in. I think we have been issued a bunch of promissory before. In the same way, the relevance of the National IrLstitutes of notes. Health and their role in sponsoring basic research and innovation Mr. SCHE:UER. That's exactly right. Right now there is very little is quite clear. Everybody in this field knows that for a development going on and what ' gomg on is not being coordinated. Ruth Hanft "S at NIH to get to implementation and demonstration in a national is si!nply giving us a projection of things to come, hopes, and ideas. center is extremely difficult. Most developments just simply do not I take some hope from the fact that Peter Bourne seems to be make it and it is certainly the case that nobody is in charge of interested in this area. He is a close confidant and adviser to the seeing to that transition. That just doesn't happen. And then President on health affairs. beyond that is the issue of getting the development into industry. Certainly, an effective coordination could come from him ff he So I see the most logical industry representation being from Com- wills it. He' is an enormously talented individual. There seems to be merce and the National Bureau of Standards, who, in fact, have a a certain amount of ferment and there seems to be, ff I judge Ms. computer science institute. I see the NIH side being represented by Hanft's remarks, a certain understanding that the potential is the National Library of Medicine whose prime task it is to deal there and they are taking advantage of it. There is a certain with knowledge representation. I think NLM could very logically amount of movement going on. New responsibilities are being cre- serve as a lead agency, because I think they have strong credibility ated. Of course, the question is how will they work. and ties with the academic community. They have good manage- Dr. LINDBERG. It really does look to the outside person, the ment and are currently proposing to commit themselves to a major university researcher, as though this whole field has ground to a computers-in-medicine program. halt in front of a brick wall. The Study Section on Computers and Also, strengths on the National Institutes of Health side certain- Biomathematics at NIH war, abolished last June. The program for ly include the Division of Computer Research and Technology, Dr. support of computers in medicine at the National Center has, I Pratt's organization, which I guess is for service within the NIH. think, adopted a smart strategy. It has decided that it doesn't have There is also the biotechnology resource branch which has spon- very much money to put into this field, so it has put most of it in sored at least two major good systems in this area, and CLINFO, the PROAUS sys7tem. Whether that is the right system or not, of which is a computer record system. In the case of CLINFO, the course, is a matter of personal and professional judgment. But I y did attempt this technology transfer I spoke of. They attempted to think the strategy is wise. They probably in fact cannot support use Federal funds to get a competitive contract which was won by very much. I think you ought not derive the impression that Rand Corp. to supervise the situation of 3 years to put the systems PROMIS is an example of many systems being funded. That jr, the in at Baylor and Oklahoma and then to carry it further. SO it Will 100-percent sample. That is it. That's where the money is going. So, now, I believe, move out into industry and be marketed by Date it appears extremely difficult to conceive of starting a new system General Corp. So BRB has attempted in their own shop to make now. that entire transition happen. They also sponsor among other re- The Government seems, from the outside, to be in a phase of sources the Stanford SUMEX facility. It is tied on the east coast to evaluating what already exists. That is very discouraging from the Rutgers, which is the other major mode in the network. So there is Point of view of a researcher. That doesn't seem like the proper a good bit of expertise and real competence in government, n outlook. question about it. I really think the problem, Sir, is that nobody ios Dr. Wum. Dr. Lindberg, the proposal that you are suggesting on in charge of the transition. NIH is in charge of the creativity and pages 30 and 31 of your testimony, the interagency strategy which the National Center seems to have placed itself in charge of evalu- you were just discussing with the chairman our previous reviews in ation and assessment, but nobody is in charge of the transition. the hearings last fall on Computers in education, would, I think, The industry is not represented in either of those two health tend to Support your notion. We found that a great deal of the agencies. So the combination is a very powerful interagency com- expertise and knowledge about computers in education resided in mittee. It is known that the VA offers the opportunity for imple- Department of Defense, of all places. Some of the key witn mentation at 160 hospitals, and they have created a research insti- and the key suggestions came from Department of De-fense. They tute. turned out to hold a veritable gold mine of experience. So I do Mr. SCHEURR. The VA has. believe that your suggestion is worthy for us to consider. I do @e Dr. LINDBERG. Yes; in fact, they fund centers in parallel with the it that you do not offer this as a specific coordinating body and National Center for Health Services Research. In other words, your listing of various entities is illustrative. Do I understand it where there is one funded by HEW's Health Resources Administra- correctly that way? It is a conceptual approach. tion, there will be a Health Resources Center funded by VA. There Dr. 1,4NDBERG. It is a conceptual approach, prefa ed by my con- c are a lot of other relevant parts in Government, but I think those fessmg,'that in no way is my expertise in Political science or gov- are the key parts. emment operations. But I Would stick with that list, and now idso 375 add ADAMHA which has the alcohol and drug abuse programs. We recommend creation of a National Institute of Health Computing within HEW They are highly relevant. whose function would be to plan, (*ordinate and undertake in health a broad series One tends also to forget the great successes of medical informa- of research, development, dffuBion and evaluation activities related to the use of computing information science an(i telecommuni tions in health. Currently, Feder- tion systems and mental health. In fact, it is one of the exceptions al funding m health adivity is cbspersed with-incathe HEW bureaucracy, et cetera. in which funding has been relatively consistent and the outcome has been very favorable. The Rockland State System which is It expands on that point. MSIS, Multi-State Information System, got a total of about $10 In summary, there is no coordination of Federal efforts and relatively small suraB million of Federal ftmdinl- over a period of 6 or 7 years and is a of money have been invested to explore the potential offered by computer technol- ogy as an extremely powerful tool There is no institutions memory for bang-up succem. It is said to serve some 1300 different hospitals l@ns learned in the past. and mental health c@es and centers. At one time at its high water mark I think there were 11 different States involved. It Dr. LINDBERG. That's all true. Is that actually an OTA recom- changes, of course, from month to month. But, it was, ' mendation? m TY event, a very successful program; one the Government and the ventors Dr. Wrr.T-g. No; this is an Ohio State recommendation. can be quite proud of. I think it is the case that the alcmohol and Dr. @BERG. As I said, I am not an expert on Government mental health agencies change in the way the Government is operations. organized from time to time and I'm not sure where they are-if Dr. W@. From the concept of having an institute which would they are properly called HRA or not-but whereve the a e theZ pull together, as thFy suggest, this rather broad capability, how do t r y r ctua you view that as having a more centralized focus, at least for are pretty big and they are pretty important and hey have a HEW. IY made some technological successes. I think I gave you a good list. Dr. LMDBERG. Let me try to say it a different way. I had the Dr. WELM. Yesterday Dr. Cramblett and Dr. Pengov from Ohio privilege of visiting Japan last April and I saw there a'model that I State suggested that one orL-anizational entity that could be consid- want to bring your attention. There are many things admirable ered would be a new institute for computer science research with about the way they do their medicine and science. One of the specific relevance to the health care system. things is an outfit called the Medical Information Systems Develop- One of our questions which then followed is: Would it be possible ment Center whose mission is precisely what has been specified in to consider this ar, an umbrella institute in which you would look the @nnony you just read and'in fact, what I want and what at education also, since there are many commonalities where com- many of us want; namely, a known center to go to with an inte- puters are affecting various facets of society? If you take some of grated responsibility to see developments through from their incep- the testimony of these hearings and eliminate the words "health tion until their implementation, including evaluation. A total re- care" and put in "education" you will see many of the same things sponsib.Uity. In Japan it is jointly ftmded by MM which is the we heard last fall being repeated. So the commonalities appear to Ministry of Industry and Technology and the Ministry of Health on be very evident. more or less a @50 basis. What is your reaction, @, to this notion of a special institute I met with the assistant administrator of A= and he showed devoted to computer sciences in the health care area without speci- me the budget for the last 4 years and for this year and for the fying where it would be located as an entity and, second, the notion next 5 years, a very orderly progress. They know that things don't of it being an umbrera-type of institute. How does that relate to happen in 18 months and that 6-month @rogress reports are not your sensible if we're about building bij systems. But also, there Dr. the testimony and haven't read was an interesting coordination of the need for industrial develop- it, so adequately, but it strikes me that ment in which the aim is marketable products and the coun@r the ed was m no way an arbitrary aims of the Ministry of Health, whose desires are improved health list. key actors in the medical computer care and controlling health care cost and access, the game as ours. area a lot of competence within its A very interesting and creative environment has been set up there. organization and a lot of rnip-gion experience and adequate funding. I don't think that any project in the United States has ever had The reason that thev all need to be involved is that none is funding from Commerce and HEW. I don't know what OAM would Ss ever do if it heard of such a thing. Yet, intellectually. it makes adequate by itself. So I @e I would worry a little bit. In a way it great sense. I think that any institute will have to relate to the would be wonderful if there were such an institute as you spoke of. scholarship of academia and the knowledge representation, because It would face the same problems the Government faces right now; that is where creativity is in our country. It will have to relate to namely, if it is on the NIH side, it will be strong in scholar-ship but will not have any tradition of strong contacts with industry nor industry, because otherwise there won't be a marketable roduct with health care delivery. and that is wh regard. It has tpo have enough contact world, in other words, In other words, the same weaknesses might actually be a prob- real hospitals, i reality of the tests and lem for iL field trials in t. are the ultimate Dr. Wam. Let me read the recommendations specifically. market and recipient d technology developed. Giebink has surveyed clinical data processing in the Veterans' It is flat out impossible to develop any of the medical information Administration at La Jolla. Your prepared statement will be print- systems or medical applications of computers to medicine without ed in the record at this point, so perhaps you may want to chat those. with us for 10 or 12 minutes. So the institute hypothesized would somehow need to touch those [The prepared statement of Mr. Gerald Giebink is as foeows:] three legs of the tripod, or it couldn't succeed. And if it did touch those three, and it had adequate dollars and years, then it probably PR"@ STA@ Or G@ A. GmBmK could achieve its goals. These hearings are an example of the increasing public interest in computer use Dr. WrT.T--,. Thank you very much, D.-. Lindberg. in health care. I assume that prior testimony has provided the Subcommittee with Dr. MURRAY. I would like to just comment that your progress some understanding of the diversity of computer applications in health care and their potential benefits. My observations and opinions are derived from ten years Of report to the National Academy of Sciences is the first written call experience in medical computing research, development and evaluation, and I be- that I have seen for a comprehensive treatment or for a national lieve they represent a perspective balance between research interests and practical policy for a coordinated program to support computer technology experience. I would like to acknowledge the assistance and involvement of my colleague, Leonard H@, in the preparation of this statement. for uses in health care. I wish to concentrate first on three fundamental problem areas which require Your position in the order of testimony this morning and the further work and investigation prior to the development and implementation of a ensuing questions and answers do not reflect that adequately, and I comprehensive national policy: wished to make sure that that was in the record. For that we are (1) As a prerequisite to establishing a national policy, "computers in health" concepts and vocabularies should be clearly defmed. very grateful. I personally wish to cite you for an insight which is (2) Preliminary policy should be aimed -at thorough synthesis and classification of most valuable. you. the wide range and variety of ways that computers can be used in health cm. Dr. LINDBERG. I appreciate the opportunity to be here. Thank (3) Policy should be aimed at establishing a cooperative and unduphcated research and development effort. you. Dr. Lindberg, have you discussed with any of the Finally, implementing options are discussed for the preliminary work which Mr. SAL should precede establishment of a comprehensive national policy. agencies that you have mentioned whether or not they could un- dertake, or whether their mission allows them to undetake, the @@AL PROBLEM efforts that you propose? (1) As a prerequisite to establishing a national licy, "computers in health" Dr. LMDBERG. I haven't presumed to go and discuss it in detail. I concepts and Vocabulary should be clearly deftif The absence of a 9="H vocabulary and clear concepts and definitions is an obstacle confronting those do know in detail the mission of the National Library of Medicine investigating national policies. For example, a recent study by the Office of Technol- @use I serve as a member of their study section, and Dr. Cum- 09Y ment I set forth some definitions useful for ing policy. The study mings is good enough to meet with the study section three or four ad the difference between medical information systems and health datiL times a year. I also know that they have initiated a study of their @ms de@ a medical information system "as a computer-based system that receives data normally recorded about patients, creates and maintains from these own extramural research programs through an outside review data a computerized m- edical record for every patient, and makes the data available group and, in fact, that outside review group has strongly recom- for the following @: patient care, administrative and business management, moni- mended a computers-in-medicine philosophy for them and they are tor* and evaluating medical care services, epidemiological and clinical research, and planning of medical care resources." Health data systems were defined as favorably disposed toward that. collections of data organized for a variety of purposes including reimbursement of Beyond that I have not presumed to go. health services, utffiwtion review, ass@g quality of care, and p monitor- Mr. SAL . Particularly the group called Computer Science ing, or evaluating medical care services." The study excluded h@th data systems Institute of the National Bureau of Standards. and also excludes computer applications such as automated clinical laboratories, pharmacy systems, intensive cam monitoring systems, and financial systems which Dr. LwDBmG. I have not discussed this matter with them, but benefit particular areas of clinical care or @tutional management. Much addi- again through professional contacts with them I have firsthand tional work is required to develop definitions so that appropriate definition and knowledge of the goodness of their work in connection with the boundaries can be placed on national @h and development policies. A related TRMS activity. Problem is the need for development of a vocabulary in which computers in health care, as a topic, can be clearly discussed and communicated among individuals in Mr. SAL So you are not aware of whether they could under- federal agencies and industry. take or would undertake any other items on page 25 and page 26, Conceptual c@ty is also needed. An understanding of the use of computers in items 1 through 6, beginning the formulation and evaluation of health care is a prerequisite to adopting or implementing a national policy regard- criteria, et cetpxa? ing @h and development. For example, computers can be seen as both an instrument used to achieve an end and as an end in themselves. Three areas of Dr. LrNDBMtG. No; I have not tried to negotiate with them. I computer application are described below, each illustrating where national policy thought it was well to give some examples. might or might not focus: Mr. SAL . Thank you very much. A. Education of health professionals Mr. ScHEumL Dr. Lindberg, I have appreciated your testimony Although differing in content, the education of health professionals = be viewed very much. I share your concerns. I guess we will have to wait and as similar to educating lawyers; educators, or engineers. A cfrtain body of knowl- see what the outcome is. you very much for your testimony. edge and the methods of applying that knowledge must be transmitted t'o a group of Dr. LiNDBEw. I am pleased to be here and I thank you for the motivated people who are interested in becoming doctors or other providers of privilege. Mr. ScHEuEL We will now have our last witness, Mr. Gerald 'Policy ImplicationB of Med:@ information S@ms, November 1977, Office of Technology ment, Co of the Uni@ Sta@. Giebink, director of Health Care Management Systems, Inc. Mr.