DATA MANAGEMENT IN A HOSPITAL ENVIRONMENT. THE USE OF A MINICOMPUTER.

An interim solution to our need for data management of medical information was to design under FORTRAN IV on a PDP-10 a relatively flexible data management program to handle specialized areas. More recently our work has shifted in the direction of creating a language with functions similar to those used in Massachusetts General Hospital's language "MUMPS". Our approach has been to develop this as a new version of FOCAL. FOCAL-11 has been incorporated on a PDP-11/4 0 under RSX-ll/D and is being modified to permit multi-terminal access, string manipulation and access to the data management facilities of RSX-ll/D. Work is underway in creating flexible data management routines callable by FOCAL and FORTRAN and on a report generator sublanguage. Examples of the work which we have already completed include:

An interim solution to our need for data management of medical information was to design under FORTRAN IV on a PDP-10 a relatively flexible data management program to handle specialized areas. More recently our work has shifted in the direction of creating a language with functions similar to those used in Massachusetts General Hospital's language "MUMPS". Our approach has been to develop this as a new version of FOCAL.  has been incorporated on a PDP-11/4 0 under RSX-ll/D and is being modified to permit multi-terminal access, string manipulation and access to the data management facilities of RSX-ll/D. Work is underway in creating flexible data management routines callable by FOCAL and FORTRAN and on a report generator sublanguage. Examples of the work which we have already completed include: an Admitting program, a storage and retrieval system for treatment evaluation, and a report generation system for opticalmark check-list patient records.
(Une solution temporaire \ notre besoin de donnees d' administration de renseignements medicaux £tait de preparer sous FORTRAN IV sur un PDP-10 un programme de donnees administratives plus ou moins flexible afin de 1) 2) reduction in the clerical work of filing and cross referencing and re-recording information reducing the storage space required by maintaining a single copy of the record in the computer, which is easily accessed by different departments the provision of fast information retrieval and communication easily available and easily used statistical and arithmetic computation facilities test and examination interpretation and, report generation, reducing typing and retyping of reports.
services. They are: 1) I A huge amount of information has to be kept for hospital administration, medical records and research, and hospital By using computers, some advantages are foreseeable. des routines flexibles de donnees en >ar FOCAL ou FORTRAN, aussi sur generateur de rapport sublingual. nous avons Un programme Today's health care delivery systems face a major problem: the cost of health care is rising uncontrollably. This is not only because of the rising cost of facilities, communication and staff, but also because of increasingly complex medical procedures, greater demands for better medical care, and the sheer burden of information handling. One way to quickly and substantially increase the efficiency with which the health services can handle information is the intelligent application of any available computer resources to handle health care data. This should increase the capacity of the system to meet the current demand. creer administratives que 1'on peut mettre action p un r z --Des exemples du travail que deja termine comprennent: d'admission, un systeme d1emmagasinage et de retablissement pour 1*Evaluation de traitement, et un systeme de rapport gen^rateur pour marques-optiques liste de controle des rapports sur les malades.) To achieve such goals, several computer programs have already been written by the Medical Development Group a University Hospital, London, Ontario. An Admitting rog reduces clerical work and provides information retrieval ana maintainence on patients being booked, admitted and dischargea . A Respiratory Function program calculates routin respiratory parameters and prints out results in a report form  . A Psychological Test Battery scores and interpre psychological tests of the following types (presently) WAIS-Clarke Vocabulary Test Raven Progressive Matrices it must be flexible.
The amount and type of information collected varies from one patient to another, handle variable length patient records.

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In the hospital, reports are used as the tool for communication between and among the medical care peronnel, the administration, and referring and following physicians. Any adequate DMS should be able to produce and communicate reports to the appropriate departments and individuals requiring information. x_ . . * requiring information. A statistical package providing continuous monitoring of treatment and activities would be useful for evaluating, for example, the result of treatment with drugs or the level of use of a particular service.
The system should be able to -. Deletion and appendage of information to a record should be easily accomplished by the system.
In order to make the system accessable by all professionals in the hospital, the feature of on-line enquiry A medical data management system must be able to meet the variety of requirements exemplified by the studies mentioned above: it must be flexible. Flexibility in medicine means the ability to structure files according to the specific needs of a group or department. A truly useful data management system must incorporate a sublanguage accessible by higher level languages, which creates files and allows user programs to interact with them without programmer knowledge of the disc structure. There must exist adequate facilities to map one structure into another as the needs of an area change. Needless to say, this must be accomplished without major reprogramming. Very few minicomputer system provide resources of this type. A Report Generator creates reports from a psychiatric admitting record for patients admitted to the psychiatric ward.
A batch-oriented data management program stores information and provides reports for a study which is intended to evaluate the cost and effectiveness of an out patient in-community novel treatment program. Programs are also available or in the final stages of development to create reports from our Psycho-physiology laboratory and to handle nursing schedules and departmental finances.
All of the above basically require a flexible data management system.
We have, to date, developed all of our applications in FORTRAN IV, but the facilities required for data management are not easily created in FORTRAN • Thus a data management system (DMS) using a data management sublanguage is proposed to fill the need. This will run on a PDP-11 type processor.

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must be included and must be simple to use. Error diagnostics given by the system should be clear and errors should be recoverable.
Presently, the two most active programs running on our PDP-11/4 0 system are the Admitting and Respiratory Function programs. They are written in FORTRAN and have a few FORTRAN callable assembly language routines. FORTRAN and MACRO were chosen because: both FORTRAN and MACRO come with the RSX-ll/D monitor which we are running FORTRAN is good for arithmetic computation needed by the Respiratory Function program FORTRAN is machine independent most programmers are familiar with FORTRAN, and the assembly language is flexible and is required for implementing special features not supported by FORTRAN, for instance, file management.
Under the RSX-ll/D system, the editor, the FORTRAN compiler and MACRO assembler are single-user programs. This significantly reduces the access to the machine for program development. This is, however, to be overcome in an upcoming revision of the operating system. To install a program, the time consuming process of creating (editing) , compiling and linking must be followed. Once an error is found in the program, the whole procedure of editing, compiling and task building must be repeated. MACRO is an assembly language requiring sophisticated programmer. ' " of FOCAL programs suited for many applications can be easily converted and run under RSX-ll/D. An interpretive language is chosen because a typical program written in it occupies less core than the object code generated by a similar program written in a compiler or assembler language.
In addition, as long as the interpreter is reentrant, all programs written in that language can share the same utility routines which also effectively reduces the memory required.
An interpretative language is more popular and can be used by much less sophisticated programmers.
Several limiations also exist in FOCAL.
Programs are not directly transportable, is only implemented on computers manufactured by Digital Equipment Corporation (DEC). the DMS is written in FOCAL, it can only be on DEC machines. Slower Speed Compared to a Compiler Language. It is recognized that the execution speed of interpretive program is slower than corresponding code generated by a compiler or assembly language system. Smaller Instruction Set. FOCAL has a relatively small instruction set compared to BASIC or FORTRAN. It does not have the capability of matrix operation as in BASIC. Also, it is not nearly as sophisticated as FORTRAN for scientific applications.
Since, however, FOCAL is only one of the languages which have access to the data management sublanguage, languages may be selected suited for a particular application. The ease of programming in FOCAL and its flexible input/output features make it still a very attractive language for implementation in a medical DMS.
BASIC was preferred to FOCAL, but was not chosen because the single-user FOCAL has been easier to modify and BASIC was not available to run under the RSX-ll/D Executive. We did not create a language of our own since it is much easier to build the DMS by adding new features to an existing program rather than to start from the very beginning. On the other hand, the DMS implemented in FOCAL is just a proto-type system in a long-term project. Other languages will be used wherever has been implemented under RSX-ll/D. String manipulation and to a data management sublanguage are being added at FOCAL has a simple and easily learned instruction Since it is an interpreter, program creation, modification, . ► A large library It Should Operate in a Multi-task Environment 1.

Stand-Arithmetic
In the field of medical research, arithmetic computation plays an important part. Most of the routines in the Respiratory Function Program involve arithmetic computation.
Surveys of patients* records, inventory control, and treatment method requires a fast and flexible arithmetic package.

REASONS FOR WRITING OUR OWN DMS
There are quite a few data management systems available on the market, for example: TOTAL, GIS, IMS, MUMPS, IMAGE and so on. Most of them are for industrial applications (TOTAL, GIS, IMS), are stand-alone systems, and are expensive. Most require large-scale hardware. The only two data base systems available from the computer manufacturers for (Hewlett-Packard) and MUMPS (Digital IMAGE is a multi-user system on In order to make the DMS flexible and useful, access to this system via callable routines must be available. It must be callable by any language. The user should be able to incorporate the data management features in the language of his choice without having to develop his own access methods. MUMPS is a multi-user, medical oriented (Gabrieli 1970) , single language, data base management system.
It is a alone system and runs on PDP-11 and PDP-15 computers. calculation in MUMPS is poor, and modification of the language itself is difficult. Also, MUMPS has no capability of handling real-time tasks simultaneously with data base management.

PROPOSED FEATURES OF OUR DMS
In hospitals, different departments and different projects often share the same resource, for instance, a PDP-11. Data management does not require full-time use of that resource. For example, the Admitting and Respiratory Function programs are running concurrently on our system now. The Admitting Program is used whenever a patient is booked for admission or admitted to the hospital, and the Respiratory Function program is used throughout the day after routine respiratory analysis. We cannot afford to have a data base system that supports these activities but which does not allow real-time tasks, for instance, our Psycho-physiology laboratory to run concurrently (Covvey 1975).
necessary. The language chosen will depend on the function of the routine. It is also possible to write programs under a compiler and to call them in FOCAL through a call statement.

Access
CONCLUSION Although development will continue over Information in the system should be secure. Only authorized personnel should be allowed to update and obtain information.
The system should be designed to handle many users simultaneously.
When one user is doing the updating, the record being updated should be protected from access by other users, while the condition of deadlock should be prevented.
Adequate data base management in the medical area is relatively new, especially on smaller machines in the dis tributed environment.
Since it is difficult to specify its exact requirements in its application to such a huge area, the system should be easily modified and added to and flexible enough to allow many implementations, for example, of different storage methodologies.
The system should function in both on-line and batch modes .
The on-line mode provides interactive response to the user and is good for query functions. Using batch mode for large scale information updating reduces the input/ output time required. Also, batch mode is essential for inputting mark-sense forms.
The system must be designed to be used by hospital personnel.
Few know what a computer is, let alone know about the concept of data management. Hence, access to the system should be easy and in natural language format. Operations of insertion, deletion, replacement and so on have to be simple and described in simple terms, enquiry-level implementation.
Multi-user FOCAL-11 is now running under the RSX-ll/D Executive at our centre. The features of string manipulation and file management are being added to FOCAL. The u -sea e development of the data management sublanguage was begun m January 197 5 and portions will shortly be operational. a long period of time, a basic system will be operational in late spring, early summer 1975.