a TI FL PL GN Is CA UL MISSOURI MEDICINE 50,1953-- ST. LOUIS MO CONTINUES JOURNAL OF THE MISSO 0026-6620 W1 MI878 M39000000 URI STATE MEDICAL ASSOCIATION 719 Reprinted from pages 719 to 758 of the September, 1968 Missount Mevicine issourt Medicine JOURNAL OF THE MISSOURI STATE MEDICAL ASSOCIATION Copynicnt, 1968 ny Missount Stare Mepicax Association. Aun Ricuts REserven. VERNON E. WILSON, M.D., Columbia Vice-President for Academic Affairs University of Missouri Missouri Regional Medical Program An Overview DURING THE LAST YEAR AND A HALF numerous articles have appeared attempting to explain the role of the Missouri Regional Medical Program and its rel The most recent appeared in Missouri Family Doctor in April and M for detailed statements of goals and philosophies. The purpose of the present p ationship to the physicians in the state. ay and are recommended aper is to clarify those points which seem to be most often misunderstood and to propose a basis for productive en- deavors during the next several years. In its future development, the Missouri Regional Medical Program is expected to continue its goal to facilitate communications between the physician who cares for patients and the sources of information that can help him provide the best possible care for those patients. Elsewhere in this issue the various projects which are presently underway in the Regional Medical program are identified. All but two of the projects which have been operational during the past year are so-called “core activity proj- ects.” These were designed to provide assistance to any physician who desires them, anywhere in the state. Their purpose is to assist the physician in selecting from the great array of scientific ad- vances, which continue to become available, those parts most applicable to his pat{ents in his community. The Smithville and Springfield projects are demonstrations of this approach in action. All new projects for which applications have been at least tentatively approved are similarly com- munity-based. In every instance, the project capitalizes on close communication with the Uni- versity and the central staff of the RMP ‘pro- gram. A comprehensive description of the Mis- souri Regional Medical Program, its pur- pose, its community-based projects and its goals for the future. Doctor Wilson speaks of the University’s involvement in and atti- tudes toward the Program and this unique effort to facilitate communications between the physician and the vast sources of in- formation now available to assist him in pro- viding best possible patient care in the area of heart disease, cancer, stroke and related diseases. He states that the ultimate. suc- cess of the Program depends entirely upon the initiative of the physicians of the state and their response to this challenge to par- ticipate in the design of improved health care patterns for the future. 720 MISSOURI REGIONAL MEDICAL PROGRAM—WILSON Perhaps a good subtitle for this article might be “This Is Your Life,” borrowing from the re- cently-popular radio and television program. Re- gional Medical Programs are a congressionally- implemented, but physician-guided, national ex- pression of the growing public demand to have the advantages of the latest technologies brought to the community, wherever its location. More importantly, however, it is the one Jarge, clearly visible and genuine effort on a nationwide basis to place the responsibility for health planning squarely in the community with the physician in the key leadership role. It has as a running mate the comprehensive health planning en- deavor, which, at least in Missouri, thus far has had minimal participation by the medical pro- fession in the design of its policy or in the im- plementation of early planning. Comprehensive health planning here has been structured to give the consumer and the supporting groups the major role in the design of health care. This difference in posture and plan is of crucial im- portance. Regional Medical Programs at present are by far the most favorably financed for planning and demonstration. Nevertheless, MRMP will fail or succeed as a result of the support it receives from the practicing profession rather than the amount of finances poured into it. Insofar as MRMP activities are the result of initiative taken by local physicians who exert their interest and energies in their behalf, they will fulfill the dreams of those who brought this program into being. If this is misunderstood, opposed or sim- ply ignored, the program will play into the hands of those who have always believed that improvement must come from a central. direc- tion for the enlightment of those on the pe- riphery. Competition of ideologies is always a sound basis upon which to initiate change. The ideology of RMP is clear, namely, that the medi- cal profession has been in a leadership role and deserves to continue in that role. From the beginning, the Missouri Regional Medical Program has been based upon grass roots participation. Its Advisory Council is com- posed of citizens from outside full-time state di- visions and the University and includes six phy- sicians. Members of the Council are appointed by the Governor, serve rotating terms and for- mulate the policy. upon which the program is based. Their continued insistence has been that all projects undertaken at the community level should ultimately develop economic self-suffi- ciency and that any changes. in the health care system should be of an evolutionary nature. This Missounr MrpicixE Serremmrn, 1968 is in accord with the original intent of the na- tional act. The presently-operative programs are. dedi- cated to a number of relatively simple objectives utilizing known but too infrequently applied principles. First, they are based upon the as- sumption that there is a considerable body: of health care need as yet undiscovered by the formal health care system. The Regional Medical Program within heart, stroke and. cancer con- cerns has dedicated itself to finding an improved. way to get paticnts to physicians and into proper and ethical health-care systems. Secondly, these projects are directed toward finding was of improving resources available to the physician. These range from a handbook of resources to development of new techniques and distribution of new methodologies. They in- clude improved training for ancillary groups and some types of “automated consultation.” The latter involves back-up for physicians in communities which do not have access to up-to- date or comprehensive medical center resources. Such techniques include “dial-a-lecture” series, automated computer interpretation of clectro- cardiograms and the computer fact bank. Each is designed to provide for any individual with a telephone the opportunity to obtain pertinent information immediately. While such “auto- mated consultation” is still a research endeavor, its enthusiastic reception suggests an active fu- ture. In general, these kinds of activities first will be tested internally and then with medical students and faculty of The University of Mis- souri Medical Center. Following this they will be tested in hospitals affiliated with the Uni- versity’s School of Medicine. Afterwards, such programs can be tested in the offices of precep- tors throughout the state and in demonstration areas, such as Smithville and Springfield. They then will be available for those who have an interest in trying such devices “on the firing line” without the protection of prearrangement. We believe that this type of assistance will be par- ticularly useful in such places as poison control centers, but that it also has applicability far be- yond such highly specialized needs. Other resources which will be made available to physicians include improved postgraduate education programs through leased telephone- teaching circuits originating at the University of Missouri Medical Center. The “dial-a-lecture” program will be designed to provide immediate and direct response to needs as defined by local medical staffs. Initial lectures will be developed around questions asked most often. While this is Voitume 65 NuMBER 9 a more traditional approach, by its very nature it is more easily handled and helps to fill in the spectrum of aids which are easily accessible for the physician’s continuing education. One might appropriately ask why a university and its medical center should have this kind of involvement in improvement of health care. Cer- tainly those of you who are acquainted with the tradition of land-grant colleges will have no diff- culty in perceiving the relationship between this kind of medical experiment station and the types of activities conducted for many years in the agricultural and engineering experiment sta- tions. These stations have been established to respond to needs as perceived by the communi- ty. Their purpose is to rapidly translate tech- niques and research results, available through the university, into action in behalf of communi- ties in the state. In the medical experiment sta- tion concept, as conceived through the Missouri Regional Medical Program, the intent is to pro- vide similar assistance primarily through the practicing physician, giving to him these ad- vantages and hopefully helping him to under- stand at the earliest possible date the potential of newly discovered techniques. One of the responsibilities agriculture and en- gineering have always had in relationship to these activities now shared by Regional Medical Programs is that of measuring and demonstrat- ing the positive or negative impact of these ac- tivities. While no one as yet has measured nor, in fact, defined “good health,” a substantial effort in the Missouri Regional Program is dedicated toward evolving such a definition so objective measurement can be carried out in a manner helpful to all concerned. Meanwhile, traditional approaches are being utilized to help set up standards that can mea- sure to some degree the impact of changes now being proposed and tested. One such activity is “Operation Icepick,” which was initiated by the Missouri Hospital Association in cooperation with the Division of Health and is now co- sponsored by MRMP. This program provides for the collection of statistical information from hos- pitals throughout the state and will make pos- sible compilation of baseline data. In terms of disease incidence, it will indicate how many people receive care, for what reasons and where they receive that care. Other basic quantitative information about the state’s population and present health patterns and habits is being ob- tained through surveys conducted by the Popu- lation Study Group of MRMP. Perhaps the most troublesome responsibility MISSOURI REGIONAL MEDICAL PROGRAM—WILSON 721 of Missouri Regional Medical Program has been its effort to achieve a balance between resources dedicated to central or supporting facilities and those used for field activities, as in Springfield and Smithville. A few principles of approach re- garding this division have now been accepted and implemented. The University provides only those service activities which cannot be per- formed by others or those in need of immediate and intimate research which can be carried out only in the University with its multiplicity of faculty and facilities. Each time the University takes on a service activity, it does so with the intent of working itself out of business so far as service is concerned. However, a strong central resource unit is im- portant for a number of reasons. It can provide unique assistance, such as prompt access to in- formation not otherwise available, research ca- pability in problems of interest to those in the field and coordination of effort which cannot be provided from the periphery. This kind of unit also furnishes highly sophisticated equipment and personnel, which are needed only rarely but can be found in a university community because their time can be divided between several depart- ments, The unit also serves as a link between the local regional medical program and similar pro- grams being conducted in conjunction with uni- versities elsewhere in every section of the U.S. Obviously, the most important activities in the Missouri Regional Medical Program are. those which take place at the bedside or in the physi- cian’s office in Smithville, Springfield and_ the many other communities to be included in these activities in the future. Quite as important will be the maintenance of some kind of central ser- vice and coordination so each of the projects can proceed with full knowledge of lessons learned elsewhere and of new information being assembled. Certainly, at the present time, no one would claim to have discovered what the optimum balance will prove to be. It is our in- tent, however, to continue the majority of activi- ties at the bedside, while maintaining strong central services at a level necessary to provide response to needs found in the field, and to pro- vide a stable and desirable basis for communica- tion between the field and the University, as well as between the several units within the field. SUMMARY We have attempted to answer two or three issues now before the medical profession and to (Continued on page 727) 722 GEORGE E. WAKERLIN, M.D., Columbia Director for Planning, MRMP Planning for the Missouri Regional Medical Program (MRMP) Tne primary coaL of the Missouri Regional Medical Program (MRMP) is to facilitate ful- fillment of the promises of modern medicine for all people of the Missouri Region with particular reference to bringing the newest and most com- petent services in heart disease, cancer, stroke and related diseases as geographically close to the patient as possible. The final focus is on optimum health for the individual citizen of the Missouri Region with emphasis on assistance to the local practicing physician who is strategical- ly situated to provide medical care and health guidance to his patients and to the community. Planning for MRMP is directed by the Ad- visory Council and its committees and by Ar- thur E. Rikli, M.D., MRMP Program Coordina- tor. It is staffed by the MRMP Planning Divi- sion. Doctor Wilson, formerly Coordinator and now Vice-President for Academic Affairs for the University of Missouri, still maintains an active interest. MRMP is one of the responsibilities of his new office. ; The Planning Division Staff of MRMP in- cludes the Director; Warren P. Sights, M.D. and Yeu-Tsu N. Lee, M.D. of Columbia, Associate Directors; Richardson K. Noback, M.D. and Mr. Albert P. Mauro, Associate Director and Assist- ant Director for Planning, respectively, in met- ropolitan Kansas City; Stanley S. Peterson, M.D. and Mr. Bacil Steed of Springfield, Consultant and Administrative Assistant, respectively, for Southwest Missouri; and Mr. Lee G. Cochran of Jackson, Consultant for Southeast Missouri. The Program Evaluation Center of the Uni- versity of Missouri School of Medicine, directed by David J. Jones, M.D., is responsible for gath- ering data regarding health and health-related resources of the Missouri Region and for devel- oping methods for evaluating the effectiveness of MRMP in achieving its goals and objectives. An overall Plan for MRMP was prepared in 1967 and thoroughly revised in early 1968. The Plan was approved by the MRMP Advisory Council and its Committees with the under- standing that it will be continually revised and updated. Copies of the Plan have been sent to the Division of Regional Medical Programs and distributed to the coordinators of all RMPs. The essentials of this document, as summarized be- low, describe the current state of planning for MRMP. CoorERATIVE ARRANGEMENTS In keeping with one of the prime purposes of the RMP Law, MRMP has effected cooperative arrangements among the University of Missouri School of Medicine, other University of Missouri schools and colleges, other educational and re- search institutions of the Missouri Region, hos- pitals (including community hospitals), practic- ing physicians, health profession organizations, appropriate voluntary health agencies, official health agencies and consumer groups. Through representation on the MRMP Project Review and Liaison Committees, 30 Missouri organiza- tions, institutions and agencies have an active role in the MRMP planning and operation. MRMP leadership and staff regard coopera- tive arrangements as a long term, continuing re- sponsibility and a sine qua non for success of the Program. Heatty Resources AnD NEEDS In order to facilitate planning and later evalu- ation of the Missouri Regional Medical Program, the Program Evaluation Center is gathering in- formation regarding health and health-related resources of the Missouri Region, as well as mor- bidity and mortality figures for heart disease, cancer, stroke and related diseases. Moreover, five MRMP pilot projects now in operation will directly produce important information relative to health resources and needs of the Missou- ri Region and, at least, five other projects will tangentially supply helpful information. As more data become available, MRMP will be able to plan, implement and evaluate on an increasingly firmer basis. VoituME 65 NumsBer 9 PRIORITIES Since the primary focus of MRMP is on the delivery of optimum health care to the patient as close to home as possible, top priority is given to pilot projects which will directly strengthen the health care system of the Missouri Region. Prevention and early detection, continuing edu- cation and public education-information may be looked upon as parts of the health care system. They also are given high priority by MRMP. Increasing attention is given to rehabilitation, ambulance services, school health, home care and rheumatic fever prevention as well as to manpower, health careers and emergency medi- cal and dental services. Indeed, when they are part of a proposed comprehensive health care project, they are given high priority by MRMP. MRMFP leadership holds all areas of concern under continual scrutiny and subject to change in priority as the Program unfolds. ConTInuInG EDUCATION The University of Missouri Medical Center recently initiated an MRMP-supported telelec- ture project for continuing education of physi- cians and allied health professions. MRMP also encourages other organizations active in these fields to submit project proposals, particularly ones involving cooperative effort. One MRMP project now under way—the Computer Fact Bank—is primarily concerned with continuing education for physicians, and eight other opera- tional projects include important continuing ed- ucation components for physicians. Continuing education for the allied health profession must parallel in coverage and effec- tiveness programs for physicians. Six pilot proj- ects now in operation provide important contin- uing education for nursing and other allied health professions. MRMP encourages continuing education proj- ect proposals for physicians based in community hospitals, as well as similar efforts for the allied health professions. MRMP also encourages proj- ect proposals for the retraining of allied health professionals reentering the health field MRMP projects are ordinarily of a develop- mental and experimental nature and, therefore, supported for a limited period of years with the understanding that those proving successful will be continued under local or other funding and, hopefully, implemented in other communities. Prevention AND Earty DETECTION As biomedical knowledge advances, primary prevention of the various forms of heart disease, PLANNING FOR THE MRMP—WAKERLIN 723 In summarizing the overall Plan for MRMP as prepared in 1967 and revised early this year, Doctor Wakerlin explains the need for and development of cooperative ar- rangements with involved groups through- out the state, the priorities extended when considering new project proposals and the guidelines that have been developed to as- sist local physicians and groups in submit- ting proposals to MRMP. He also discusses such pertinent subjects as planning for the future; MRMP and continuing education; prevention and early detection of heart dis- ease, cancer and stroke; community health services; and public education and informa- tion. cancer and stroke will become increasingly effec- tive. In the meantime, increased prevention and early detection require more continuing educa- tion for physicians and allied health professions and more public education. Thus, in the Mis- souri Region, full application of present knowl- edge would mean a yearly saving of 250 lives from death by rheumatic heart disease, 1,000 from cancer, possibly as many as 2,000 from cor- onary heart disease and an undetermined num- ber from stroke and from hypertension. Early detection of heart disease, cancer and stroke will be facilitated by the findings of six MRM? pilot projects now under way. MRMP will assist communities of the Region in developing screening project proposals when requested by local physicians and other health leaders. Such project proposals should prefer- ably include a new or unusual feature such as custom-designed screening or an innovative ap- proach to more effective follow-up. Ultimately, every physician’s office should be- come, in part, a prevention and early detection center for heart disease, cancer and stroke. Heart Disease There is need for wider application of knowl- edge about the surgical correction of congenital heart disease, rheumatic heart disease, periph- eral vascular disease and cerebrovascular insufli- ciency due to extracranial arterial disease, as well as for knowledge relative to diagnosis and treatment of hypertension and follow-up of con- gestive heart failure patients. An estimated 1,000 lives could be saved per year in the Missouri Region by prompt application of cardiopulmo- 724 PLANNING FOR THE MRMP—WAKERLIN nary resuscitation and by making intensive cardi- ovascular care or coronary care units available in community hospitals for all heart attack pa- tients in need of such care. Accordingly, MRMP emphasizes the need for additional intensive cardiovascular care and/or coronary care units in Missouri Region hospitals including community hospitals, as well as for establishing training centers for such units. At least ten MRMP projects now under way relate to the care of heart disease patients. They in- clude an intensive cardiovascular care unit in one community hospital (Springfield), a coro- nary care unit in another (Smithville) and a coronary care unit at the University of Missouri Medical Center. MRMP also is authorized to initiate a programmed cardiovascular care unit at Kansas City General Hospital and Medical Center (KCGHMC). Three of these also will serve as training centers. STROKE The great majority of strokes involve either hypertensive cardiovascular disease or athero- sclerosis or both, but data are still imprecise and more long term studies of etiology and patho- genesis are needed. Identification of the stroke- prone individual offers increasing promise, but much remains to be done. The MRMP Bio- engineering project and the Ultrasound-Radiol- ogy project offer prospect of detecting altered blood flow patterns. The MRMP-sponsored In- tensive Care Stroke Unit at the University of Missouri Medical Center is concerned with im- proved diagnosis and treatment of stroke and will provide training for the staffs of other medi- cal centers and hospitals. The Northeast Missou- ri Cooperative Stroke Project centered at Kirks- ville emphasizes rehabilitation and its early im- plementation. A number of other MRMP pilot projects also assist in providing better care for stroke patients. MRMP encourages the submission of project proposals for two or three innovative communi- ty stroke programs. The programs may be hos- pital-centered, based on home care or traveling clinics or a combination of these as determined locally and should give appropriate emphasis to long term treatment. CANCER The Missouri Cooperative Tumor Registries project is supported jointly by the Bi-State (St. Louis-Southern Ilinois) RMP and MRMP. The project will provide centralized information about cancer patients from hospitals and clinics Missournr MEpIcINE SEPTEMBER, 1968 which diagnose and treat such patients in Mis- souri. Elimination of cigarette smoking will signifi- cantly reduce the incidence of lung cancer. The effectiveness of public education toward this ob- jective is expected to be advanced by MRMP Communications Research Unit project findings and by increased utilization of University Exten- sion Division facilities, including 4H clubs. Early detection of cancer will be facilitated by such MRMP pilot projects as Multiphasic Testing, Mass Screening-Radiology and Auto- mated Patient History, as well as several project proposals jnow under consideration (if imple- mented). MRMP places strong emphasis on more effec- tive prevention of early detection of cancer in the Missouri Region and pledges wholehearted cooperation with efforts directed toward this ob- jective. ComPrEHENSIVE HeattH CARE The most important MRMP project involving comprehensive health planning now in opera- tion is the Comprehensive Health Services Pro- gram at Smithville, since it exemplifies in micro- cosm the essential aims of MRMP for communi- ties of the Missouri Region and of all RMPs for communities of the United States. MRMP encourages the development and im- plementation of a comprehensive health services program in two or three other communities of the Missouri Region. As steps in this direction, MRMP also encourages project proposals for (a) further improvement in the care of heart disease, stroke and/or cancer patients, (b) com- munity health centers (preferably associated with community hospitals) and (c) coronary care unit demonstrations pointed toward solu- tion of the problem of such units in smaller com- munity hospitals. All MRMP projects now under way ultimately relate to comprehensive health care and several involve collaboration with the Smithville project. RELATED DisEASES The Regional Medical Program Law specifies heart disease, cancer, stroke and related dis- eases. MRMP interprets the last to include dia- betes mellitus, renal disease, precancerous con- ditions and pulmonary diseases producing cor pulmonale. During its regular 1968 session, the Missouri Legislature voted an appropriation of $100,000 to be utilized by MRMP during 1968-1969 for the development of a chronic renal disease-renal Votume 65 NumsEn 9 dialysis program. This is the first appropriation by a state legislature to an RMP for operational purposes. At a special meeting on July 1, 1968, the MRMP Advisory Council approved an award of $60,000 to the Kansas City General Hospital Medical Center to help finance its chronic renal disease program. The remaining $40,000 will be allocated at a later time. Project proposals aimed at the foregoing “re- lated diseases” are invited by MRMP. Community Heactu SERVICES Community health services considered in this section include rehabilitation, ambulance ser- vices, school health, home care and rheumatic fever prevention. There is need in the Missouri Region for sev- eral demonstration rehabilitation units in appro- priate community hospitals. When necessary, every physician in the Region should be able to refer his cardiac patients to a reasonably acces- sible work evaluation unit. Also, the benefits of rehabilitation for heart, stroke and cancer pa- tients must be repeatedly emphasized by con- tinuing education of the health professions and by health education of the public. One community of the Missouri Region is de- veloping an ambulance service project proposal which may well serve as a model for other urban-rural areas. With reference to school health, the Missouri Heart Association has submitted a pilot project proposal involving early detection of heart dis- ease in school children. Home care services need strengthening in metropolitan areas of the Missouri Region, but especially in rural areas. Such programs are best developed in relation to community hospitals. Home care also is an important component of several current and pending MRMP projects. Rheumatic fever prevention and the need for more continuing education of physicians and other health professions as well as more public education have already been emphasized. Re- cently, the Missouri Heart Association imple- mented a pilot project which will enhance rheu- matic fever prevention in the Missouri Region. Pusuic Epucation AND INFORMATION Despite the excellent efforts of the Missouri Division of the American Cancer Society, Mis- souri Heart Association, Missouri Tuberculosis and Respiratory Disease Association, Missouri Society for Crippled Children and Adults, Mis- souri Division of Health, Missouri State Medical PLANNING FOR THE MRMP—WAKERLIN 725 Association and Missouri Interagency Council on Smoking and Health, much remains to be done through public education toward achieving max- imum application of existing knowledge regard- ing prevention, early detection and care of heart disease, cancer and stroke. Thus, one third of current cancer deaths could be prevented if the seven danger signals of early cancer were better known and heeded promptly. The public needs to be more aware of the importance of self- examination of the breast, Papanicolaou smear and other procedures for early cancer detection. Likewise, the carcinogenic effects of cigarette smoking, especially for lung cancer, require con- tinued emphasis. There also is great need for more public knowledge of the benefits of rheu- matic fever prophylaxis, stroke prevention, con- trol of asymptomatic hypertension and reduc- tion of the risk factors of coronary heart disease. Indeed, reduction of these risk factors (dietary saturated fat, obesity, cigarette smoking, physi- cal inactivity and hypertension) has more po- tential for reducing morbidity and mortality in the United States than any other health mea- sure now available. To facilitate cooperation of official, voluntary and professional organizations active in public education-information in the Missouri Region, MRMP established a Public Education Commit- tee consisting of representatives of these organi- zations which recommended that initial health education emphasis through University Exten- sion be given to smoking and health. MRMP now supports a Communications Re- search Unit-School of Journalism pilot project which aims to increase the effectiveness of health education materials and procedures. For many years, the University of Missouri Extension Division has emphasized nutrition and home economics and one of the 4Hs is “Health” The Extension Division and MRMP look forward to significant collaboration in pi- oneering effective health education about heart disease, cancer and stroke via Extension facili- ties. MRMP. welcomes health education project proposals particularly when they involve collab- oration of voluntary, professional and official Missouri agencies already active in this field. MANPOWER The subject of Health Manpower is signifi- cantly related to every phase of MRMP. There will always be a relative shortage of health per- sonnel which precludes waste of this resource due to insufficient information or lack of under- 726 PLANNING FOR THE MRMP—WAKERLIN standing of the skills and abilities of professional groups. MRMP, through the Program Evaluation Cen- ter, has begun a Health Manpower Study which should continue throughout the life of the Pro- gram. Material from previous studies is being collated to provide a baseline upon which to build a new methodology for the approach to health manpower data. Such data stored on magnetic tape will be essential in establishing a continual. communication network with the vari- ous health professional groups. MRMP encourages the development of train- ing courses and programs for all levels of health care and public health management personnel and would cooperate with academic public health and medical care administration pro- grams of the University of Missouri and other graduate schools by serving as one of the in- service training sites for such programs. Hesttu CAREERS The Missouri Council on Health Careers, Mis- souri Hospital Association, Missouri State Medi- cal. Association, Missouri Nurses Association, Missouri League for Nursing, Future Nurses of Missouri, Women’s Clubs and Rotary are active in recruitment for health careers in the Missouri Region. The Missouri Health Council has pre- pared a Manual on Health Careers in Missouri under MRMP auspices. The Missouri Council on Health Careers and Missouri Hospital Associa- tion are developing a recruitment project pro- posal for MRMP consideration. ‘ MRMP encourages all organizations of the Missouri Region with health careers potential, including the University Extension Division, to strengthen their efforts and collaboration in re- cruitment of young men and women. EMERGENCY MEDICAL SERVICES Heart attack, stroke and motor accident pa- tients are most acutely in need of emergency medical services. Hence, the concern of MRMP for such services. INFORMING THE HEALTH PROFESSIONS AND THE PuBLIC All but four county medical societies of the Missouri Region have been directly informed of MRMP. The remaining societies will be in- formed during the fall of 1968. Osteopathic phy- sicians have been informed, as have members of the nursing profession. All health professions, health related agencies and interested lay or- ganizations of the Missouri Region not yet in- Missovrat MEDICINE SEPTEMBER, 1968 formed are invited to request. speakers from MRMP. This information task is open-ended since, once the health professions and the public are informed about MRMP, they must be kept ap- praised of progress to stimulate development of new pilot projects and to insure understanding and full utilization of health care advances cat- alyzed by MRMP. INTERREGIONAL COOPERATION The Kansas RMP and MRMP already are en- gaged in joint planning and operation with re- gard to Mctropolitan Kansas City, as well as on Regional bases. Appropriate interrelations have been developed with the Memphis Region- al Medical Program and the Arkansas RMP, and cooperative arrangements are under way with the BiState (St. Louis-Southern Illinois) Program. Negotiations are in process for more active cooperation with a number of other RMPs, particularly the remaining six RMPs bor- dering on the Missouri Region. DEVELOPMENT AND SUBMISSION OF Pitot Proyect Proposars MRMP believes that all health and health re- lated institutions, agencies, organizations and leaders of the Missouri Region should be aware of their opportunity to develop and propose projects to MRMP for the benefit of their re- spective communities. Guidelines have been prepared to provide communities, organizations, institutions and oth- er groups with information concerning bench- marks used by the MRMP Advisory Council and its committees in judging the merits of pro- posed pilot projects and determining priorities for transmittal to the Division of Regional Medi- cal Programs. Inquiries:‘may be addressed to Dr. George E. Wakerlin, Director for Planning, Missouri Re- gional Medical Program, Lewis Hall, 406 Tur- ner Ave., Columbia, Mo. 65201. The MRMP Planning Division Staff will be pleased to advise with reference to the preparation of project pro- posals. Indeed, early involvement of the Staff in project planning is likely to facilitate develop- ment of the project proposal and formal submis- sion to MRMP. Inquiries from Metropolitan Kansas City, Southwest Missouri or Southeast Missouri may be addressed respectively to Dr. Richardson K. Noback, Medical Director, Kansas City General Hospital and Medical Center, 24th and Cherry Kansas City, Mo. 64108; Dr. Stanley S. Peter- Voutume 65 Nustser 9 son, 1835 South Stewart, Suite 105, Springfield, Mo. 65804; and Mr. Lee G. Cochran, Jackson, Mo. 63755. Furure The national climate is increasingly favorable to RMP. Thus, in January, 1967, Charles L. Hudson, M.D., now a Past-President of the American Medical Association, urged practicing physician concern with prevention and early de- tection, health team leadership, community health services and community health plan- ning.’ In January, 1968, Dwight L. Wilbur, M.D., now President of the AMA, stated that RMP “can make a real contribution to personal health services if it continues to pursue what ap- PLANNING FOR THE MRMP—WAKERLIN 727 pears to be its main thrust today—to serve as catalyst for and to facilitate those winds of change which blow in the right direction.”* Achievement of the primary goal of MRMP over the next decade (as stated in the first para- graph) will require continued and effective co- operation and participation of the medical and other health professions, laymen and consumer groups, health and health related organizations and institutions, government agencies and com- munities of the Missouri Region. Brs.ioGRAPHy 1, Hudson, Charles L.: The Changing Medical Climate of America, Missouri Medicine 64:965-969, 1967. 9. Wilbur, Dwight L.: Quality and Availability of Health Care Under Regional Medical Programs. JAMA 203:945-949, 1968. Missouri Regional Medical Program ( Cont'd) delineate the challenge which appears to exist. We believe that the University should be in- volved and that it has a specific and unique contribution to make in assisting the physician with the problems which confront him in his particular practice. We believe that the Regional Medical Program stands alone in offering the profession both the opportunity and the chal- lenge to participate in the design of improved health care patterns for the future, even though the present area of activity is categorically limited to heart, stroke, cancer and related dis- eases. While we do not maintain that we have found the perfect balance between supporting service and peripheral activities, these relation- ships are unde constant study and will be sub- ject to continual revision as a great variety of in- dividuals assisting us throughout the state bring to bear their advice, consultation and construc- tive criticism. The success of Missouri Regional Medical Program activities is totally dependent upon the initiative and the response of physi- cians in the state. This, we believe, is exactly as it should be. The Advisory Council of the Missouri Regional Medical Program has award- ed $60,000 to the Kansas City General Hospital Medical Center to help finance its chronic renal disease program. These funds are part of the $100,000 appropriated by the Missouri Legisla- ture last March to MRMP to initiate patient care and research in kidney disease in the state. The remaining $40,000 will be allocated at a later time, according to Nathan J. Stark, Council Chairman of Kansas City. The Kansas City Program began its second year of decreasing Federal support on July 1. The U. S. Public Health Service is providing $287,000 of a $359,000 total budget for the program of the remaining $72,000, KCGHMC is providing $12,000 and the balancg was made up by action of the MRMP Council. ~] Ww ow ARTHUR E. RIKLI, M.D., Columbia Director for Operations, MRMP Operational Program for Missouri Regional Medical Program (MRMP) The Operations Division of MRMP is responsible for implementing more than 20 projects developed by the Planning Divi- sion. Doctor Rikli reports that the three basic types are (1) projects that define heart, cancer and stroke problems and eval- uate impact of MRMP; (2) projects that assist in preventing or detecting these dis- eases; and (3) projects that aid physicians in providing diagnoses, therapy and _pre- ventive measures. Tue Mussournt RecionAL MEpICAL PRocRAM seeks to provide optimum health for the greatest number of people by accelerating the applica- tion of effective preventive and therapeutic measures for heart, stroke and cancer patients or those with related diseases. The Missouri Regional Medical Program Op- erations Division is responsible for implementing those activities that have been developed by the Planning Division through the Missouri Regional Medical Program review groups and is given fi- nancial support by the Regional Medical Pro- gram National Advisory Council. These financially-supported projects may be divided into the following three groups: 1. Projects that define the nature of the heart, stroke and cancer problems and the effect of the Missouri Regional Medical Program. 2, Projects that aid in bringing heart, stroke and cancer suspects into the health delivery sys- tem. 3. Projects that aid physicians in providing effective diagnostic, therapeutic or preventive measures to those who need them. It is the Missouri Regional Medical Program plan to help close the time gap between discov- ery and application by introducing innovations into the Missouri health delivery. system on a demonstration basis and, in this way, aid heart, stroke and cancer patients in receiving better di- agnostic and therapeutic measures from their traditional sources of health services. DEFINING AND MEASURING The first group of projects defines the nature of heart, stroke and cancer problems in Missouri and seeks to measure the effect of the Missouri Regional Medical Program upon these problems. For any health program to be effective, it is es- sential to know who has or is prone to have a disease. In what kind of an environment are they living, what health services do they need and which ones are they demanding and receiv- ing? The “Population Study Group Surveys” rep- resents Missouri Regional Medical Program's effort to determine the nature of the heart, stroke and cancer problem in this region. This project will be supplemented by the “Automated Hos- pital Patient Survey” when we find appropriate staff to assist Missouri hospitals in assessing the services used by heart, stroke and cancer patients. The physician’s office is where most patients gain access to the services of health workers and related resources that make up the health de- livery system. Analysis of this system to aid in determining rational innovation is the responsi- bility of the “Operations Research and Systems Design” project. This project is using its skills to analyze the forces at play within the Missouri Regional Medical Program and is proposing more effective use of resources. As we acquire information germane either to a specific problem or to a solution, we attempt to simulate the anticipated effort through model development and testing. This work ‘is carried out by the “Data Evaluation and Computer Sim- ulation” project. The most difficult task in introducing an in- novation into the health delivery system is to foretell the effect or value of the innovation. To- day’s health delivery system is the product of in- numerable variables that have been introduced VOLUME 65 NuMBER 9 by both the consumers and producers of health services. Most changes have been made upon an empirical basis rather than upon a carefully cal- culated cost-benefit basis. As therapeutic mea- sures develop (such as renal dialysis and organ transplants which can prolong a productive life at costs that no individual or his family can afford), there arises a critical need for method- ologies to evaluate the practice of such extraor- dinary measures. This is one of the responsibili- ties of the “Program Evaluation Center” project. The “Communications Research Unit” has set out to determine and measure the elusive factors in communication which cause people to react or not to react under varying circumstances. The medical profession has had little real success in “selling” the principles of well-being to the pub- lic. Our “Communications Research Unit,” for the first time, is delving deeply into this crucial problem on a scientific and closely controlled basis. DETECTING OR PREDICTING The second group of projects involves our ini- tial efforts to determine the most effective meth- ods for detecting persons who either have or are prone to have heart disease, stroke or cancer. Although there are many forces that influence the ways by which a person may gain access to the health delivery system, the Missouri Region- al Medical Program is directing its primary effort toward means of detecting signs of disease. The names of three of these projects are self-explana- tory. They are, (1) Multiphasic Testing, (2) Mass Screening-Radiology and (3) Automated Patient History. The fourth project, “Bioengineering,” provides support to several projects through the develop- ment of new or different kinds of electronic and mechanical “packages.” One such development, for example, has involved the design and build- ing of a “diagnostic chair” that looks like an ordi- nary, comfortable reclining chair. In less than two minutes and without the need for attached terminals however, it can produce three-lead electrocardiograms. Other measuring devices are being built into it at present. Cuosinc a Gap The third group of projects {tends to stimu- late the flow of information from its research source to the physician who needs it in order to provide the best possible diagnostic or therapeu- tic services to his heart, stroke or cancer patients. Modern information storage and retrieval OPERATIONAL PROGRAM FOR MRMP—RIKLI 729 methods are being, blended so that they will be readily accessible to the inquirer as he considers various diagnostic possibilities suggested by signs and symptoms in a patient. Physicians now may acquire answers to such questions by time- consuming inquiry into the medical literature. It is the mission of the “Computer Fact Bank” to provide this information much more rapidly and pertinently than would be available in any other way. The second project in this group, and one of the best models reflecting the use of modern in- formation-handling devices to serve the health needs of persons with heart disease, is the “Auto- mated Electrocardiography” project. It is pro- viding physicians with computer interpretation of electrocardiograms at six different locations. The system has been developed during the past ten years and is now being field tested by the Missouri Regional Medical Program. It is antici- pated that, in the near future, computer inter- pretation of electrocardiograms will be as readily available to physicians in Missouri as their tele- phones. This method could be used with phono- cardiograms, electroencephalograms and many other diagnostic signs. Computers are finding their place in the practice of medicine as a diag- nostic aid to a physician. Computers, however, are merely tools for helping the diagnostician or the practicing phy- sician. They neither can, nor probably ever will, supplant the basically vital “doctor-patient” re- lationship that is the keystone of effective medi- cal practice. What we do with these machines, or, indeed, with any of the products of medical research is being studied with utmost care, and their appli- cations are being introduced into Missouri's health delivery system with careful restraint. We look upon all such activities as critical ex- periments and we are carrying them out in two carefully selected communities under limited, controlled conditions and only with the closest collaboration with professional and administra- tive personnel in those communities. We are proceeding with caution because we believe that the future of the Missouri Regional Medical Pro- gram depends upon our ability to learn how to carry out experiments like the “Smithville” proj- ect and the “Comprehensive Cardiovascular Care Unit” in Springfield in a way that will re- sult in the heart, stroke, and cancer patients in these communities enjoying an improvement in their health services after these projects are com- pleted. (Continued on page 733) 730 GAIL BANK, M.S. and WILLIAM D. MAYER, M.D., Columbia* Associate Project Director and Project Director, MRMP Continuing Education for the Health Professions ALTHOUGH THE LEVEL OF HEALTH CARE in the United States is considerably higher than that in many other nations, it has a potential of being even higher. How rapidly we approach this po- tential level will depend to some degree upon the extent to which provisions are made by edu- cational institutions for continuing education for physicians and other health professionals. Even more important is the extent to which those cur- rently in the health professions and those who will enter the professions will involve themselves in the process of continuing study of each other’s professions throughout their years of practice. In these days of rapid growth in bio- medical knowledge, continuing education be- comes the bridge between what is known and what is applied. It is estimated that knowledge currently ap- plicable in medicine is twice as great as it was a decade ago and that it will double again in an- other decade. This staggering volume of infor- mation makes it impossible for a physician to learn during his professional education every- thing necessary for a lifetime of practice. Elim- inating or even slowing down the development of new knowledge or lengthening the time re- quirements for professional school education are impractical alternatives. Thus, it becomes im- perative for those in the health professions to take increasing responsibility for continuing study in their career lines and for educational institutions to provide increased opportunities for continual learning. Since its beginning, the University of Missou- ri Medical Center has supported the view that continuing education needs to be an integral part of the day-to-day, week-to-week practice of health professionals. Present and future activ- ities are directed toward making appropriate contributions to a totally integrated system of *Mr, Bank is Executive Director of Continuing Medical Edu- cation and Associate Professor of Extension Education and Doctor Mayer is Dean and. Director of the University of Missouri School of Medicine. education based upon the premise that learning should be a lifelong activity, the ultimate goal being the improvement of health care. This con- cept envisions a time when health professionals will have at their disposal mechanisms with which to engage in learning activity at any time, at any place and at whatever breadth or depth desired for their own self-learning and for the needs of their patients. To help accomplish this, access to great libraries, other clinicians, researchers, teachers, consultants, teaching- learning materials and all manner of pertinent data and information will be immediately avail- able. In this concept, continuing education is both a means to an end and an end in itself. The concept of lifelong learning has brought about changes in educational activities for prac- ticing professionals and also has been an in- fluence upon the teaching programs within pro- fessional schools. There has been a shift from emphasis upon the acquisition of information to selection, organization and evaluation of infor- mation. At the Medical Center, for example, multidisciplinary laboratories and__ teaching- learning centers are being introduced. These fa- cilities will make it possible for students to inter- act with the basic material and, also, with many additional sources of information. Students, thus, can progress as rapidly as they wish with the aid of texts, recorded lectures, films, video tapes, computers and other devices. Developing self-learning habits early in the students’ profes- sional education better equips them to direct their own continuing education activities follow- ing entry into practice. There also has been a shift from isolated pro- grams for different health professions to bring- ing the professions together in patient-oriented education activities. This reflects an increasing interdependency among the professions in the delivery of health care. It also prepares them for future participation in interdisciplinary con- tinuing education activities. Votume 65 Number 9 The University Medical Center, recognizing these needs, established an office of Continuing Medical Education to develop and carry out various educational programs. Faculty supervi- sion is provided through the Committee on Con- tinuing Medical Education and includes repre- sentatives from the clinical departments of the Medical Center, the basic science departments, and nursing, medical technology, physical ther- apy and other health professions. Liaison and advisory arrangements with various professional groups are actively maintained. Thus, the edu- cational needs of many health professions are coordinated and the interrelationships of the various health professions are incorporated in the educational activities. Many educational opportunities have been developed for different health professions. Con- ferences and workshops have been presented at the Medical Center, as well as at various loca- tions in the state. Efforts are made to involve the audience in each of the conferences rather than to rely on lectures alone. Panel discussions, with opportunity for audience questions, are frequently employed. Other techniques include small group discussions; live case presentations; presentations directly from the clinical areas via closed circuit television with direct questioning from the audience; workshops in which the pro- fessional learns skills and techniques; extensive use of audio-visuals; and presentation of sum- mary materials, bibliographies and_ reference materials. Recognizing the difficulty professionals in the health care fields have in leaving their practices to engage in scientific programs at distant points, the Medical Center has helped to pro- vide scientific programming at hospital staff meetings, at meetings of medical societies and other professional associations. This is accom- plished through a Speakers’. Bureau. Programs for meetings arranged through this service usu- ally take the form of a single presentation with subsequent discussion about the materials pre- sented. During the guest speaker's visit, he often provides consultation, makes rounds or discusses various facets of a particular problem with local professionals. As important and extensive as these activities are, they fall short of involving health profes- sionals in educational activities associated with day-to-day, week-to-week patient responsibili- ties. Since the majority of health care is pro- vided locally, local health care facilities need to incorporate an educational function in their re- sponsibilities. It can be the source of education- CONTINUING EDUCATION—BANK AND MAYER 731 Continuing education contributes to the elevation of health care by reducing the time between biomedical discovery and its application. The authors also state that it should be an integral part of the day-to-day practice of health professionals who have educational linkage to practitioners in of- fices, clinics and other local settings through local health care facilities. They tell how, through appropriate cooperative arrange- ments, the Missouri University Medical Cen- ter can assist and support the educational function of local health care facilities. al linkages with practitioners in offices, clinics or other local settings, and the Medical Center can assist and support the educational function of local health care facilities. An important start has been made in this di- rection. Regularly scheduled, illustrated lectures and discussions via amplified two-way tele- phones to a few hospitals in Missouri are being made on a test basis. Presentations are by Med- ical Center faculty and various practitioners in the state. The speaker is heard simultaneously at widely separated locations and his slides and other visual materials are projected locally for instantaneous viewing. Questions can be asked and answered, and discussion from many dis- tant geographic points is possible. Programming is arranged at hours when most physicians are normally at the hospital and are not required to absent themselves from their patients and prac- tice. Telephone activities to date represent only a beginning in the development of this tech- nique’s potential activity. While programming has been limited to only a modest number of physicians, requests from physicians at other hospitals and from other health professions far exceed our current ability to respond. The ma- jor deterrent to expanding this technique to more hospitals and to other professions is the lack of funds. - Involvement of educational institutions in continuing education activities requires more than a recognition by individual faculty mem- bers of the value of continuing education in the process of health care delivery. It also requires a philosophical commitment and a demon- strated capacity of the institution to be of edu- cational service to society. The University of Missouri has a long history 732 CONTINUING EDUCATION-—-BANK AND MAYER of commitment to this educational philosophy as well as to educational service beyond the cam- pus. The roots of this philosophical commitment " go back to discussions prior to the establishment of the University in 1839. Further ideas stem- ming from this philosophy spring from the es- tablishment of the University as the land grant institution immediately following the Civil War, the establishment of the Agricultural Experi- ment Station in the late 1800’s to do research and devise ways of improving the state’s econ- omy and the establishment of the cooperative extension service in 1914 to help disseminate re- search findings. The extension of the educational resources of the University from the campus to the citizens of the state is known as the Extension function of the University. This responsibility is now of such importance it warrants administrative re- sponsibility by a vice-president of the Universi- ty. The extent of the University’s commitment to this educational function also may be judged by the fact that more than 700 persons are en- gaged in discharging this responsibility. There is at least one University Extension representative in each county. No single organization has a corner on educa- tional. expertise or has sufficient resources to meet the continuing education needs of the present, much less the needs of the future. How- ever, the necessary expertise can be made avail- able by tapping the health manpower pool of the state. Financial resources are potentially available through federal legislation which cre- ated the Regional Medical Programs. Regional Medical Programs originally were conceived as a means of providing health ser- vices through a system of complexes including regional centers and diagnostic and treatment facilities. Services grown out of recent research findings were to be made available to patients through these complexes. The original concept, however, was drastically modified to eliminate the regional center concept. Legislation finally enacted (PL 89-239) calls for “regional cooper- ative arrangements among medical schools, re- search institutions and hospitals for research and training (including continuing education) and for related demonstrations of patient care in the fields of heart disease, cancer, stroke and re- lated diseases.” Thus, continuing education be- came an important component of the law estab- lishing the Regional Medical Programs; it as- sumes that same importance in the eyes of those implementing the Law at the national level. At the local level, the framework of coopera- Missourt MEDICINE SEPTEMBER, 1968 tive arrangements now established by the Mis- souri Regional Medical Program among the Uni- versity, state professional societies, state health agencies, voluntary health agencies, the hospi- tals in the state and individual practicing physi- cians does, indeed, offer a superb base of inter- relationships upon which to build meaningful programs in continuing education. What edugational opportunities might be pos- sible through the University, Missouri Regional Medical Programs and other agencies if neces- sary cooperative and funding arrangements are made? The potentialities are impressive and ex- citing. Only a few of the ideas under discussion will be mentioned here. The telephone lecture service is being ex- panded with MRMP support to include more hospital locations and educational programming in nursing, physical therapy, medical technol- ogy and other health professions. Presentations can be made by practicing professionals, Medi- cal Center faculty and faculty of other institu- tions. The format can be extended to include case presentations, journal clubs, seminars and other activities. Programming might be pre- sented in a time span so that health profession- als on different work shifts can participate. Slides and other visual materials used in presen- tations and a tape recording of the presentations might be made available to each receiving point as a library resource. This initial educational communications network might well be the fore- runner of more sophisticated systems involving FM broadcasting and two-way television. The latter system offers the potentiality of presenting patients for immediate consultation. Establishing an educational communications system will enhance the capabilities of data transmission, rapid transmission of EKG’s and their interpretations, access into vast medical li- brary resources, rapid transmission of library materials and access to computers with their multitude of medical applications. Regular teaching situations in hospitals, using local patients as teaching materials, might be arranged. Through this device, which is compa- rable to the “clinical clerkship” in medical schools, members of different health professions become directly involved in learning situations concerning their patients. Opportunities might be provided whereby members of different health professions can re- turn to a professional school to study some par- ticular aspect of his or her profession in greater depth than possible locally. Instruction would be under the tutelage of a faculty member; pre- VotumeE 65 Number 9 sentation of materials to be covered would be worked into a time schedule compatible with the time schedule of the health professional. To the greatest extent possible, the health professional would be assimilated into the daily teaching and patient care activities of his faculty preceptor. The possibility of providing “locum tenens” cov- erage for the local practice should not be ex- cluded. Continuing education for the health profes- sions is many faceted. The skills, energies, imag- inations and financial resources of many indi- viduals, agencies and organizations are needed to provide necessary opportunities for continu- ing education. However, dedication on the part of health professionals to continually learn and Operational Program (Cont‘d) At Smithville, which is, in effect, our “pilot” community, we are considering the whole per- son and the several factors which may have brought him to the condition of apparent illness at the time he seeks his doctor's help. Health care does not begin when a patient enters a doc- tor’s office or a hospital, nor does total health care end when he is discharged. We need to be concerned with such matters as how to keep from becoming ill, the best care for a person who is ill and how to best readjust to normal living after medication has ended. At Springfield, through the energetic efforts of a number of highly motivated physicians, the Missouri Regional Medical Program is acting as CONTINUING EDUCATION—BANK AND MAYER 733 study during their years of professional activity also is required. The combination of adequate resources for continuing education and increased involvement of health professionals in the processes of contin- uing education can only result in the constant elevation of levels of health care. The University of Missouri Medical Center has been and con- tinues to be committed to significant efforts in continuing education. The framework of coop- erative interrelationships of all the professions, agencies and _ institutions provided for by MRMP can only enhance the effectiveness of all as we strive to increase the quality and quantity of continuing education for all health professions in Missouri. a powerful catalytic force in developing an ideal comprehensive cardiovascular care program. To this end, a model “cardiac hall” has been de- veloped at St. John’s Hospital where an entire area is devoted entirely to intensive, intermedi- ate and recuperative care of heart patients. A “Manual of Services,” prepared by a Mis- souri Regional Medical Program team of re- searchers in cooperation with the Missouri Health Council, provides the first list and thor- ough description of all medical and paramedical services in the state. It soon will be available to every physician in the state, as well as to many other persons who are concerned with the well- being of our people. Dr. Robert Q. Marston has been appointed to succeed Dr. James A. Shannon as director of the National Institutes of Health. He has been administrator of the NIH’s Health Services and Mental Health Administration since April 1. Dr. Marston joined the NIH in 1966 as the first administrator of the Heart Disease, Cancer and Stroke Regional Medical Programs. In accepting his new post, he listed knowledge and then money and manpower as the key factors in future improvements in the health of Americans. 734 LAWRENCE C. KINGSLAND, JR., M.D., Columbia* Project Director, MRMP The Computer Fact Bank THE PHILOSOPHY, PLANS AND CURRENT ACTIVITIES in developing a pilot-scale operational Computer Fact Bank designed to assist physicians through- out the state in their daily practice are described in this article, In the smallest towns, as well as in the larger population centers, physicians would like to have almost immediate, carefully considered, concise answers to any one of millions of com- plex medical questions on diagnosis and treat- ment; this is almost impossible in today’s world. Versatile communications networks linking large computer-based informational systems and hundreds of remote display devices are becom- ing commonplace in the business world where individual items of information tend to be far simpler and answers more clear cut. In medi- cine, the bottleneck is not devices, but the prim- itive state of definition, standardization and syn- thesis of the medical knowledge and logic in- volved, plus the need for systems and programs tailored to meet specific medical needs. “Wall-to-wall” money, in volumes to which the military and space industries have become ac- customed, only could begin to make a dent in the formidable informational, logical and logistic problems involved in furnishing “instant medical A progress report on the developing Com- puter Fact Bank, which is an open-ended collection of biomedical information equiva- lent to several hundred thousand text pages. It will be rapidly accessible to physicians, medical students and other health profes- sionals by means of local and remote termi- nals linked to a central computer and by microforms available through computer-ori- ented, automatic retrieval and display de- vices. Doctor Kingsland also discusses the Missouri University Medical Center’s CON- SIDER programs to which the Fact Bank continually adds current biomedical content. ® Doctor Kingsland is Associate Professor, Department of Com- munity Health and Medical Practice, University of Missouri School of Medicine. This investigation was supported in part by Public Health Service Research Grant GM 09907-03. \ wisdom” upon request. Even large, in-depth teams of medical and surgical specialists work- ing in shifts around the clock, 365 days a year, would require versatile communication systems and an elaborate, continuously updated Platform of Organized Knowledge or Data Bank with most of the features of our pilot model from which to furnish instant expert advice. Moreover, most physicians, lacking detailed knowledge of other physicians’ exact medical background and understanding of the patient’s manifestations and problems, know that furnishing what amounts to “medical consultations” at a distance would be fraught with danger to all concerned. Furnishing “informational consultation” on de- mand, however, is another matter. The busy physician wants specific answers, not long sets of bibliographic references. He knows from sad experience that the articles and texts he seeks, even if theoretically “available” in his vicinity, often will be “out on loan,” “at the bindery” or lurking in some benighted faculty member's desk drawer or briefcase. The Missouri Regional Medical Program’s Fact Bank is designed to al- low the user to enter the system with his own chosen words and concepts and to help him to “negotiate his own” request for information. Re- quests can be made locally or on remote tele- processing terminals. Some terminals will have cathode ray tube (“television-like”) display fea- tures. The Fact Bank is an open-ended collection of all kinds of biomedical information, equivalent to several hundred thousand text pages, and se- lected to contain appropriate current facts, defi- nitions, basic science, clinical and research in- formation. A small but exceedingly. important and increasing proportion (now about 2,000 pages) of the Fact Bank will be in machine- readable form, i.e., on magnetic tape. The vast majority of the collection (now about 150,000 pages) is journal, monograph and_ textbook material on 16 mm microfilm in cartridges and on microfiche. Any one of these pages or any item in the machine-readable portion of the file can be displayed automatically within a half a VotumE 65 Numser 9 COMPUTER FACT BANK—KINGSLAND on.clinical research projects. Dr. Burgess Gordon of the American Medica ES, ADAPTED numbers when available. One ment. ‘CONSIDER’ PROGRAMS DEVELOPED BY THE STAFF OF THE UNIVERSITY OF MISSOURI MEDICAL CENTER COMPUTER PROGRAM The name “CONSIDER” was chosen for the program, or system, since it implies that if a patient has certain input findings, ie., signs, symptoms, x-ray findings and so on, his physician should con- sider the possibility that his patient may be suffering from one or more of the diagnoses suggested d on the IBM 1410 with printer and punch card outputs in early versions, and CDC or IBM 2260 cathode ray tube outputs in later (IBM 360-50) versions. During the past three years, both stude SIDER programs: students especially during the end of their second year when they are most ac- tive in learning varied clinical terminology or when studying unusual patients on the ward; faculty when seeking exhaustive suggestions for consideration in clinical-pathological conferences and even by the program. The original programs were use nts and faculty alike frequently have used CON- 1 Association Editorial Staff deserves great credit d clinical information concerning several thousand diseases and conditions found in the present 1966 Third Edition of Current Medical Terminology (CMT) published by the American Medical Association. The entire 500 pages of text also are kept in machine-readable form on magnetic tape. A tape version constitutes the data base upon which, with certain additions, all University of Missouri Medical Center CONSIDER programs operate. A new, larger and much improved fourth edition of CMT is due early in 1969. CONSIDER programs accept sets. of signs and symptoms (e.g., pain or tenderness in various re- gions of the abdomen), X-ray findings (e.g., gaseous distention or changes in intravenous pyelog- raphy), or laboratory findings (e.g., increased white count or urinary changes). They then display or print out lists of diseases consistent with the input items, plus STANDARD NOMENCLATURE OF DISEASES AND OPERATIONS and INTERNATIONAL CLASSIFICATION OF DISEAS- begins to appreciate the potential importance of such programs for clinical diagnosis and medical education generally when “Porphyria, Acute, In- termittent” and “Pancreatitis, Interstitial, Acute” “Pyelitis, Acute” or “Appendicitis, Acute” in response to input items. Much, of course, remains to be done in improving definitions, obtaining better synonym control, extending the medical content and improving the logic and arrangement. However, the system, as is, is highly useful.+ An interim program, available for use on IBM 360 systems, produces remote cathode ray tube displays on 2260 terminals and also has teleprocessing (IBM 1053) typeout capability. A much more elaborate and far faster program called EXPANDED CONSIDER is under active develop- for developing the unique collection of condense appear along with the more usual diagnoses, minute by means of existing programs and equipment. The key that unlocks the wealth of detail in the Fact Bank is the unique Depth Index or Thesaurus. Now under construction, the Depth Index will be kept entirely in machine-readable form. The Depth Index is based on the National Library of Medicine’s MEDLARS Subject Heading Authority Lists merged with the Col- lege of American Pathologists’ Systematized No- menclature of Pathology and the Indexes and Tables of Contents of several representative im- portant textbooks and monographs. It retains all important semantic and hierarchical relation- ships and eventually will total more than 100,000 clinically or biomedically important key words and concepts. The user will enter the Fact Bank via the Depth Index with the key word or concept of his choice. He will be led rapidly to the pre- ferred terms in the system and, in some cases, will be shown their definitions and the present word association map or “universe of discourse” now centering around these terms. This process will give him direct reference numbers to ap- propriate machine-readable output or, where this is not yet available, to selected relevant lit- erature on microfilm. Alternatively, the user may have access to condensed machine-readable clinical informa- tion via “CONSIDER” Programs developed by the staff of the University of Missouri Medical Center Computer Program under the direction of Dr. D. A. B. Lindberg. Messrs. Larry Row- land, Manager of Advanced Systems Planning; Charles Buck, Manager of Systems; Joseph Schroeder, Senior Systems Analyst; William (Continued on page 737) 736 HUBERT J. VAN PEENEN, M.D. and JAMES B. FILES, M.D., Columbia* Project Director and Associate Project Director, MRMP Laboratory Multiphasic Testing Today AT THIS MOMENT, laboratory multiphasic testing is limited to 12 clinical chemistry tests and four hematology tests that can be performed on Technicon Corporation Sequential Multiple An- alyzers. The tests are serum glucose, urea nitro- gen, uric acid, total protein, albumin, calcium, inorganic phosphorus, total bilirubin, alkaline phosphatase, glutamic oxalacetic acid, lactic de- hydrogenase, cholesterol and whole blood hem- atocrit, hemoglobin, white count and red count. The Analyzers make it practicable to do all these tests as a routine hospital admission bat- tery. By making available sooner some of the The MRMP Multiphasic Testing Project is concerned with making available in- formation that is useful clinically. The au- thors show that it has become practical to do a large battery of clinical chemistry tests as a screening device for the detection of disease. They state that with a computer even normal results can be interrelated mathematically and may offer clues to fu- ture disease before symptoms appear. results that would ordinarily be requested dur- ing hospitalization, it would be possible to dis- charge patients earlier to justify the extra cost of testing by decreasing total hospital cost. The test battery also should be useful in office practice! and as a health screening device in dis- covering unsuspected disease in patients who have not consulted a physician. As such, it serves to introduce patients into the health care system. The multiphasic testing project of the Missouri Regional Medical Program is concerned with evaluating the presently available test battery for its diagnostic value, for deciding which tests should be excluded and which new ones added and for determining the interrelationships of test ® Doctor Van Peenen is Associate Professor of Pathology and Doctor Files is Resident Physician at the University of Missouri School of Medicine. This investigation is supported in part by USPHS Grant CD-00235. values which may be more meaningful than any one normal or abnormal test value by itself. Test Barreny Fixvincs in Missouri To date, two Missouri subpopulations have been tested with a battery of tests similar to that performed by the Sequential Multiple Analyzers. The first consists of newly-admitted inpatients at the University of Missouri Medical Center and the second consists of long term inpatients of Missouri State Psychiatric Hospitals. The first group demonstrates the abnormalities caused by overt disease. The second group is supposedly free of serious organic disease but, nevertheless, harbors many patients who either have or are developing the degenerative diseases with which the Regional Medical Program is primarily con- cerned. More than 3,000 patients from each group have been tested to date. In the near future, a third population is to be added. It will consist of outpatients seen by the physicians of a representative Missouri community. Preliminary results from patients of the State Psychiatric Hospitals were recently published in this journal.? Preliminary results from the inpa- tient UMMC population are now being proc- essed. Our results and those from many other groups*° confirm that a large number of ob- viously abnormal laboratory results can be found by screening supposedly healthy persons, espe- cially those more than 40 years of age. Ninety percent or more of the abnormal tests are de- rived from only five tests in the 16 test battery. The five tests are serum glucose, urea, uric acid, cholesterol and hemoglobin. Characteristically, of course, a reduction in hematocrit and red count accompanies a reduction in hemoglobin. CoMMENT Although only five tests provide most of the abnormal results, with the equipment available today it is actually easier and cheaper to do all 16 than only the five. Furthermore, interrela- tionships of the other “normal” values may prove VotuME 65 NUMBER 9 to be diagnostically useful in the future, Progress in instrumentation is rapid, and it is very prob- able that it will be easier to add new tests as they prove useful than. to eliminate old ones. Our concern is no longer that of providing large amounts of information about a patient. It is to make the information provided clinically useful. Laboratory data is now available. Soon, many parameters of physiological testing being studied in other projects of the Missouri Re- gional Medical Program also will be available, yet it has not been proven that the discovery of abnormal results in any way benefits the pa- tient. Hopefully, demonstration of abnormalities can and will lead to preventive treatment. Studies under way in this project coupled with the resources of the computer-based fact bank of the Missouri Regional Medical Program should make it possible to more specifically interpret normal and abnormal laboratory findings and so aid the physician in maintaining the good health of his patient. Conclusive studies along these lines will take many years but are in progress. SuMMARY. It has become practical to do a large battery Computer Fact Bank (Cont'd) Morse, Systems Analyst; and Mrs. Susan Morse, Programmer, are among others who helped de- velop the CONSIDER Systems Programs. In summary, the Fact Bank and associated Depth Index will enable the User (1) to choose material hopefully containing answers to his spe- cific questions at the time of his greatest interest and clinical need; (2) to become aware, at the same time, of the availability of additional new information, some of which, perhaps, he was not consciously seeking; and (3) to reestablish ac- tive contact with an ongoing information system designed to challenge him and promote habits of lifelong learning in his chosen profession. Due to the categorical nature of our grant, we are concentrating on heart disease, gancer, stroke MULTIPHASIC TESTING—VAN PEENEN AND FILES 737 of clinical chemistry tests as a screening device for the detection of disease. A third of the tests yield most of the abnormalities, but interrela- tionships of normal values obtained for the others may prove diagnostically useful in the future. BisLioGRAPHY 1, Rardin, T., E.: Laboratory Profile Screening in the Physi- cian’s Office. JAMA 198:1253, 1966. 2. Van Peenen, H. J., Files, j. B. and Wood; M. J.:_Bio- chemical Screening in Missouri Psychiatric Hospitals: Preliminary Results. Mo. Med. 65:367, 1968 3, Mikkelsen, W. M., Dodge, H. J. and Valkenburg, H.: Distribution of Serum Uric Acid Values in Population Unselected as to Gout or Hyperuricemia. Tecumseh, Michigan 1959-60. Am. J. Med, 39:242, 1965. 4. Berkowitz, D.: Blood Lipid and Uric Acid Interrelation- ships. JAMA 190.856, 1964. 5, O'Sullivan, J. B. and Mahan, C. M.: Blood Sugar Levels, Glycosuria and Body Weight Related _to Development of Diabetes: The Oxford Study Seventeen Years Later. JAMA 194:587, 1965. 6. Schilling, F. J., etal: Studies of Serum Cholesterol in 4,244 Men and Women, an Epidemiologic and Pathogenetic Interpreta- tion, Am. J. Public Health 54:461, 1964. 7. Dawber, T. R., Kannel, Ww. B. and Lyell, L. P.; An Ap- proach to Longitudinal Studies in a Community. The Framing- ham Study, Ann. N. Y. Acad. Sci. 107:546, 1963. 8. Bryan, D. J. et al: Profile of Admission Chemical Data by Multichannel Automation, An Evaluative Experiment. Clin. Chem. 12:137, 1966. 9. Epstein, F. H., ef al: Prevalence of Chronic Diseases and Distribution of Selected Physiological Variables in a Total Com- munity. Tecumseh, Michigan. Amer, J. Epidemiol. 81:307, 1965. 10. Collen, M. F.: Periodic Health Examination Using an Automated Multitest Laboratory. JAMA 195;830, 1966. and related diseases, but, also, are including much additional material of direct interest to physicians everywhere. This fall, we begin our first real-life trials of the system on medical students, friendly col- leagues and captive audiences. When suitable feedbacks have been received and evaluations, necessary revisions and improvements have been made, we will be ready “to go on the air” throughout the state. Meanwhile, we will be glad to demonstrate the system as it evolves to interested physicians and would welcome their comments and suggestions. BIBLIOGRAPHY 1, Lindberg, Donald A. B., M.D. Computer Routine “Consider”: pp. 135-141, in The Computer and Medical Care (Charles C Thomas, Pub., Springfield, Mlinois, 1968, 67-25712, 210 p.). 738 PETER L. REICHERTZ, M.D., Columbia* Project Director, HRMP Mass Screening Radiology This MRMP Project aims at developing radiological techniques for mass screening and at improving the accuracy of radiolog- ical diagnosis for heart disease, cancer and stroke. Doctor Reichtertz explains how com- puter-assisted diagnosis is being made avail- able to hospitals in Missouri as well as in the University of Missouri Medical Center. He indicates that ultrasound techniques and thermography also are being investigated as a means of detecting arteriosclerotic disease and cancer. Tue opjectives of the Mass Screening Radiology Project are to develop radiological techniques for mass screening and to improve the accuracy of radiologic diagnosis in the areas of heart disease, cancer and stroke by making computer-assisted diagnosis available to other hospitals as well as to the University of Missouri Medical Center. Furthermore, ultrasound techniques and _ther- mography are being investigated in order to pro- vide a means for the early detection of arterio- sclerotic disease and cancer, with special empha- sis on cerebral circulation and brain tumors. In order to attain these goals, the acceptability and efficiency of various electronic communica- tion media are being tested, Previously de- veloped techniques of computer-aided diagnosis are being expanded and perfected. The full range of application of ultrasound in the diag- nosis of neoplastic and vascular diseases has to be determined, and techniques must be de- veloped to apply ultrasound and thermography to mass screening situations. “RADIATE” is a computer-oriented part of the project. A system has been developed for the synthesis, standardization, formatting, cod- ing and transmission of radiology reports. The radiologist using the system to describe his find- ings is interfaced with the computer by means of television-type terminals on which are dis- ® Doctor Reichertz is Association Professor of Radiology Science and Director of Radiology Computer Research at the University of Missouri School of Medicine. \ played queries to which he responds by typing in code letters on a keyboard similar to that of a typewriter. Information previously fed into the computer may be retrieved by the same term- inals. When the report is finished, it will be stored in the computer, will become part of the patient’s record and will be transmitted to the ward or, eventually, to other hospitals or the of- fice of a physician. If the radiologist seeks diag- nostic aid, a number of questions will be dis- played to which he answers according to his own findings. When he has answered all the questions, the computer calculates and displays the possible diagnoses. At the moment, RADIATE is operational in the Department of Radiology of the University of Missouri Medical Center. The system is based on the investigations of Doctor Templeton and co-workers.!-3 Numerous programming problems had to be solved.*-* Extensive studies were done to determine standard terminology for the type of radiological examination, the anatomic sites to be described and the radiological diagnosis. This standardized terminology is stored on mag- netic disks. Each term can be retrieved by radiologists using RADIATE by specifying the first four letters of any word in the pertaining description. When several applicable descrip- tions are stored, all are displayed and the radi- ologist may choose the most accurate term. This may enhance the accuracy of the report. Further- more, the user may be guided through the dif- ferent anatomic sites pertaining to a certain type of examination. This is intended to be a teach- ing feature for residents. Fig. 1 shows the initial display by which RADIATE introduces itself to the radiologist, Fig. 2 gives an example of the display of diag- nostic terms retrieved by the keyword “ULCE.” Modifiers to the description (such as acute, healing, left, right, etc.) may be added. Fig. 3 gives an example of a report generated in the described fashion. Each time the radiologist specifies a diagnosis, he has to assign a proba- bility estimate of accuracy (confidence level 1-9). Free text comments may be added and precoded standard reports may be generated by specifying a code number. NoLeMe 6° MASS SCREENING RADIOLOGY—REICHERTZ 739 Number 9 TCADTATE? . c YN wANT TO START BEADING FILMS, GEPPESS SHIFT AND ENTER KEYS DEVELMOED RY t o ARC 1o4, TEMOLETONMDcy GHELYY So LODWICKsM.0e, PETER Le PETCHERTZsMeDas JAMES Le LEYR4.3., fe DAGUET 4.06 - SYSTE4S DESIGN: PETE2 Le FETCHES ITZ» 4.Dey JAMES Le LEHR M.D. PONSQAMMING: SEOANCIS Te SCOTT; %eSeo JANES Ly LEHPsM.0., PETER Le REICHERTZ»NeDey KEN CAGEY ERITH BIQINIEKS pAabs wo ar by geile SAE iat Fig. 1 Introductory display of “RADIATE.” It instructs the radiologist how to proceed in order to have access to the system. = ULCER MARGINAL we “| K= ULCER CUSHING'S = ULCER PENETRATING ~~ we ULCER POSTBULBAR ULCERATION SOFT TISSUE ULCER FPITHELIZED CRATER LESTON ULCERATING COLITIS ULCEP ATIVE: = ULCER GIANT fis ULCER DIAGNOSIS KEYWORO IS ULCE.ENTER CODE TN SELECT ENTRY» ADD X FOR MODIFIER. ve NIER 1 OF THESE. Y-NEW KEYWGRD »Z-RELIST, W- 3 LET COMP, U-UPDATE. . Bx a Fig, 2 Display of the diagnostic terms that are retrieved from the information stored on magnetic storage de- vices by the keyword “ULCE.” In this case, the physician has chosen the term “Penetrating Ulcer” and has speci- fied that he wants to add modifiers (such as acute, chronic, etc.) to the description. IGATIAN NAwE JOMN 9. 104 56 DATE OF ADMISSION (12 30 66 AGS Sh DATE OF EXAMINATION 3.23. 67 RACE GAUICAS TAM AED : : SEX MALE AOMLTTING DIAGNOSIS OEFERRED TYPE OF SXAMUNATION: AKRATOMIC DYAGHOSTS: # Pal. SETCHEPR TZ Fig. 3 Report generated by “RADIATE.” Fig. 4 Display of the cur- rently implemented diagnostic routines. Whenever a number SELECT MPTAGNCSTIC ROUTINE of questions has been an- \ swered, the most probable di- agnoses will be displayed. The specified symptoms may be re- displayed (option: display level chosen). and symptom descrip- tions may be changed in or- der to come to a better diag- - nosis. PPEVARY PRME TUMABS COMGENITAL HEART DISEASES SULTTARY LUNG MODULES GASTSPS ULCERS THYR ATA DESSUNC TION APTSPLAY LEVELS CHOSEN (CHECK GNES TO BE CHANGED) sTne 740 At the present time, computer-aided diagnosis is available for primary bone tumors, congenital heart diseases, solitary Jung nodules, gastric ulcers (differentiation between malignant and benign ulcers) and thyroid disfunction. Fig. 4 shows the display from which the physician may make this choice. The diagnostic programs are based upon the investigations of Doctor Lod- wick and co-workers.7™ At the present time, the system is ready for application in several hospitals connected by a computer network. Ultimately, private physicians might participate. RADIATE’s use will result in the acceleration of report transmission, the im- provement of diagnostic accuracy and the central storage of findings. The work in “Ultrasound and Thermography” is being carried out by Dr. P. Wollschlaeger. Ultrasound techniques to improve the detection of intracranial masses and cerebral displacement are being explored, as well as methods to eval- uate cerebral perfusion. Ultrasound methods are being tested in order to provide means for the detection of vascular lesions by measuring fre- quency alterations due to the Doppler effect. Plans are to develop techniques to detect and visualize areas of vascular malfunctions, espe- cially in the cerebral systems, by means of ther- mography. This method is based on the measure- ment of emission of infrared (heat) waves. The MASS SCREENING RADIOLOGY-—-REICHERTZ MiussounL MEDICINE SEPTEMBER, 1968 emission spectrum is influenced by vascular le- sions and underlying tumors. Early tests have vielded_ satifactory results, but engineering changes of existing equipment have to be made in order to provide more effective means for mass screening. This is being done in coopera- tion with the Bioengineering Project of the Mis- souri Regional Medical Program. BIBLIOGRAPHY 1. Templeton, A. W. et al: RADIATE—Updated and Re- Designed for Multiple Cathode Ray Tube Terminals; Radiology, in press. 2, Templeton, A. W. and Sides, §. D.: RADIATE—A Radiology (and Hospital)’ Computer Oriented Communicating System. Na- tional Conference on Computer Applications in Radiology, April, 1967, Columbia, Mo. 3. Templeton, A. W., Lodwick, G. S. and Turner, A. H.: RA- DIATE—-A New Concept for Computer Coding, Transmitting, Storing and Retrieving Radiological Data. Radiology 85:811 (Nov.) 1965. . 4. Reichertz, P. L., Templeton, A. W. and DeLurgio, L. J.: A FORTRAN Compatible Multi-terminal System for Physician- Computer-Interfacing (FCMTS). Sixth Annual Symposium on Bio-Mathematics and Computer Science in the Life Science, Hous- ton, Tex. (Mar.) 1968. 3. Reichertz, P. L., Templeton, A. W. and DeLurgio, L. G.: A Multi-terminal Cathode-Ray Tube System for Man Machine Inter- facing Method. Inform, Med., in_press. . 6. Reichertz, P. L.:; PCI (Physician-Computer-Interfacing)— Example of RADIATE and Diagnosis of Primary Bone Tumor. Bio-Engineering Conference on Computers in Medicine, Oct., 1967, Columbia, Mo. 7. Lodwick, G. S.: A. Probabilistic Approach to Diagnosis of a Tumors. Radiologic Clinics of North America 3:487-497, De 8. Lodwick, G. S.: Solitary Malignant Tumors of Bone—The Application of Predictor Variables in Diagnosis. Seminars in Ro- entgenology 1:293-313, 1966. 9. Templeton, A. W., Lehr, J, L. and Simmons, C.: The Computer Evaluation and Diagnosis of Congenital Heart Disease Using Roentgenographic Findings. Radiology 87:658 (Oct.) 1966, 10. Templeton, A. W. et al: Solitary Pulmonary Lesions— Computer-Aided Differential Diagnosis and Evaluation of Mathe- matical Methods. Radiology 89:605 (Oct.) 1967. ll. Wilson, W. J. et al: The Computer Analysis of Gastric Uleers. Radiology 85:1065-1073, 1965, A special progress report on Federal Health Programs published by the Na- tional Health Education Committee includes the following items: —The death rate in the U. S. is now as low as it has ever been in history. It is 3% lower than it was in 1963. Cancer, the “number two killer of Americans,” claimed 300,000 lives in this country last year. But one cancer patient in three is now being saved, against one in four just a few years ago. —Our infant death rate has declined 13% since 1963 to a record low of 22 deaths per 1000 live births in 1967. —tThere’s been a 19% decline in rheumatic fever and chronic rheumatic heart disease deaths since 1963; a 22% decline in the same period for hypertensive heart disease fatalities; a 21.6% decline in chronic and unspecified nephritis and other renal sclero- sis deaths; and a 5% decrease in mortality from vascular lesions affecting the central nervous system. (strokes). In explaining various federal programs that are helping to bring about these striking improvements, the Report discusses the Regional Medical Programs and; among them, singles out “the Missouri Region (which) is pioneering new serv- ices to enable doctors and patients anywhere in the area to use computer-assist- ed X-ray diagnosis and other advanced techniques.” The Coronary Care Unit as a concept for local and community hospitals is also credited for helping bring about these reductions. 741 JOHN C. LYSEN, Ph.D.* and ALLEN PURDY, M.S., Columbia Project Director and Deputy Project Director, M RMP Bioengineering in MRMP BIOENGINEERING IN MRMP is perhaps a misno- mer. A more appropriate name in this case might be medical engineering. If this calls to mind a man in white coat with a stethoscope hanging out of one pocket and a slide rule stick- ing out of the other and surrounded by numer- ous wires, tubes, pumps, transistors and IBM cards, then the image is correct. The human body, as viewed through the bio- engineer's eyes, is the most exquisite machine of all. Where else can one find every known principle of engineering (and unknown, too) in one bundle, topped by a computer unrivaled by artificial means? The relationship of bioengineering to MRMP springs from the object of MRMP, ie., to de- liver the best possible medical care to as many people as possible. To this end, we seek to assist and extend the hands, eyes, ears and, presump- tuously, the wisdom of the physician. In real terms, this takes several forms: A. Sensing and quantitation of physiological information with the use of all available engi- neering sophistication needed for that task. This means searching for or originating designs and the actual construction of prototypes to that end. B. Signal Conversion. Sensing (or transduc- ing) of information usually results in electrical analog signals. These signals must be converted to meaningful numbers or language for the phy- sician. This takes the form of analog to digital conversion, digital computing and a read out system. Bioengineering shares this function with the engineering computer team. C. Advisory Service. The physician and medi- cal researcher are often faced with the problem of matching different brands of equipment or the selection of equipment to work in a given environment. To assist with this problem, we have amassed an extensive file of the latest com- mercial equipment available. Fukther, we are able to recommend modifications for a successful installation.. Bioengineering also maintains con- tact with the Midwest Research Institute for the retrieval of medical research information. One of the major efforts of the bioengineering ® Doctor Lysen is Director of the Engineering Experiment Station at the University of Missouri. The team of bioengineers of MRMP as- sist the Program by testing, measuring and developing devices and equipment that will aid the physician in diagnoses and treat- ment of patients. The authors report that the results of their efforts include the de- velopment of a diagnostic chair, a cerebro- spinal fluid pressure monitor and a thera- peutic current generator for the rapid heal- ing of decubitus ulcers. group is directed toward multiphasic screening The diagnostic chair is an outgrowth of these efforts. The diagnostic chair records spirometry, pulse wave velocity, automated blood pressure, heart sounds (including vibrations) and auto- mated EKG. A working model of the chair has been built and is capable of transducing pulse waves, heart acoustics and three lead electro- cardiograms. In addition, the commercial appa- ratus used in conjunction with the chair will al- low the taking of spirograms and automatic blood pressure. At the present time, this infor- mation can be gathered in less than three min- utes. We currently are involved in computer analysis of this information as well as improve- ment of the apparatus. In addition to assisting in the evaluation of the above data, computer analysis will calculate cardiac output (90% cor- relation with the Fick Method). To help achieve the MRMP goals, a number of other projects have evolved from without and within our group. A cross-section showing the widely variable character of these bioengineer- ing projects is as follows: —A cerebrospinal fluid pressure monitor. This unit gives a continual readout of CSF pressure. —A therapeutic current generator for the rapid healing of decubitus ulcers. —Application of ultrasound to organ location and possible atherosclerosis diagnosis. —A simple rapid method of damping cardi- ac catheters for maximum frequency response (Continued on page 745) DONALD A. B. LINDBERG, M.D. and P. RUDOLPH AMLINGER, M.D., Columbia* Project Director and Deputy Project Director, MRMP Automated Analysis of the Electrocardiogram Focusing on a technique of computer processing of electrocardiograms developed by the U. S. Public Health Service, the authors are seeking to develop a working system in Missouri using telephone lines to link outlying areas with a central computer at the University Medical Center for rapid and accurate reading and interpreting of EKGs. They discuss their efforts in detail and report that the system is now in daily operation in the offices of six collaborating physicians or groups of physicians. Ir 1s OUR INTENT to start with a system for com- puter processing of electrocardiograms which was designed and produced by Cesar Caceres, M.D. and his colleagues at the Instrumentation Field Station of the Heart Disease Control Pro- gram of the United States Public Health Service. We wish to make this system available, so far as we are able, to a large group of physicians in a number of communities within and, also, eventually outside the Missouri Region to assist them in interpreting their patients’ electrocardio- grams. Selection of the Caceres system for im- plementation as a Missouri Regional Medical Program project followed a very careful study and evaluation of all alternative systems. We wish to provide for collaborating physi- cians in medical settings outside of Columbia the appropriate “data acquisition carts” and re- lated equipment so that they can make record- ings of their patients in the usual fashion, pro- duce a traditional paper tracing for their inspec- tion and, also, transmit a magnetically-recorded version of the same examination via telephone © Doctor Lindberg is Associate Professor of Pathology and Di- rector of the Medical Computer Center and Doctor Anilinger is Associate Director of Physiological Monitoring of the Medical Computer Center at the University of Missouri School of Medi- cine. This investigation is supported by USPHS grant 3-503-RM- 8009. \ lines to Columbia for parallel computer inter- pretation. Existing “dial up” telephone lines are being used, along with a Wide Area Telephone Service . (WATS) billing arrangement. No special private or leased lines will be employed unless it can be shown that the telephone connections truly limit the operation of the system. We will be selecting additional collaborators (through an appropriate advisory committee) primarily with the objective in mind of testing our system in a large number of different medical settings. Only the collaborating physicians in those communities can tell the profession about the true contribution to care or to saving of physician time contributed by operation of the system. Our ultimate objective, should all preliminary testing phases end satisfactorily, is to provide 24- hour-a-day computer service via telephone with reasonably short “turn around time.” Within the present project, cardiographic signals will be recorded on high quality tape in Columbia and batch processed by the computer. The results will be returned to a teletype printer in the col- laborating physician's office as soon as possible. An important issue for us to resolve in this set- ting is one familiar both to physicians and com- puter men, namely, how to balance the economic advantages of batch processing against the con- venience of immediate processing. An objective for future study is to determine the medical worth of simple automation of the interpretation of the electrocardiographic signal as opposed to all of the other benefits ordinarily derived from consultation with a cardiologist. Systems DEsIGN Fig. 1 presents the arrangement of necessary equipment. Fig. 2 reproduces an actual inter- pretation as it was received in the collaborator’s . private office. Fig. 3 presents a portion of the criteria by which the computer program judges the electrocardiogram. VotuME 65 NumBen 9 STATUS OF THE INVESTIGATION Data acquisition carts and telephone data sets have been installed in the offices of six collabo- rating physicians or groups of physicians. They include Cecil Auner, M.D., Springfield; C. L. Clark, M.D., Trenton; Wallace D. English, M.D., Cardwell; P. Hill, M.D., Kansas City; Jack M. Mart, M.D., Columbia; and B. M. Stuart, M.D., Boonville. The system is in daily operation, except for the expected delays associated with malfunction- ing new equipment. Breakdowns of the data acquisition carts in the doctors’ offices have been relatively more common than we originally ex- pected. The computer operates from 8 am to midnight on Monday through Friday and from 8 am to 5 PM on Saturday. During those hours, we are able to assure collaborators of immediate (10-20 minutes) processing of any examination they classify as a medical emergency. The re- mainder are getting out on a “same day” basis. Our present collaborators are testing the sys- tem in the following different medical settings: a University medical center; the heart station of a community hospital with cardiologists; a community hospital without cardiologists; a city hospital emergency room; the office of a private physician in solo general practice in a small com- ELECTROCARDIOGRAM—LINDBERG AND AMLINGER . 743 ANY DATA 2 Receiving RECEIVING PHONE e Data Phones TELETYPE 6038 and Direct Channet 6509 DATA FMF ML IF. BYPASS WATS LINE CART for ape jtape |tape| TAPE DECKS celek receivi Fl | #2 | #3 A/D CONVERTER PROG, TAPE (i) | Baga paper tape | TELETYPE DIGITAL TAPE Fig. 1 MRMP automated EKG project system’s blockdiagram. 1 © ° 4 WPOSDURT ALS]OHAL MECTCAL PROGRAK = EXE PROUECT u Ho UNIVERESTY CF HO,» COHPUTER PROGRAM e ConPutEr PAOCESELO CLECTROCARDIOORAR rs : 7 AROWELL ° i wane BOC EECNO «991800586 ; munace eoooeze tare os06. 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Ti. ah oft ja see ee TE GED AE Tea e ji + Aulein 9 ors f &@ R 8 STO ANGLE IN CROREESe. ST. ONS-T } q@ _drenees 38 -Ho Tas 09 280. 188 oo 182 e Ef s e i ° QaTs ateptcac ona on antiracy S EXCLUDE VENTRICULAR PC : i : Hl © «-AITT PRoLONeES PR TnYEaval < Pina? OLEREE A-¥ BLOCK e Gat ens of} See; terningy one & LEFT BUNDLE BRANCH BLOCK ow e Leethakor GhOAG R VSH8 : ef SSTY ORG AXTE AaweE ~To fo -$4 © LEFT AXIS OEVIATION Le? e an a 8 744 ELECTROCARDIOGRAM—LINDBERG AND AMLINGER MYOCARDIAL INFARCTS Diagnostic Statement Criteria Poor R progression V Jeads. Consider old infarct or fibro- sis Atypical Q V2 or V3. Con- sider old infarct or fibrosis Small R2 Leads V2-V5. Pos- sible old infarct—anterior or fibrosis Absent R2 leads V2-5. Con- sistent with old infarct—an- terior Small or absent R and nega- tive T 2 leads V2-5. Consist- ent. with age undetermined infarct—anterior Small or absent R and ele- vated ST 2 leads V2-5. Con- sistent with acute infarct— anterior Questionable @ 2 leads 1, AVL, V5-6. Possible old in- farct—anteriolateral R < 0.15 MV both V2 and V3, or either V4 or V5 Q = 0.07 MV in V2 or V3 R < 0.10 MV in 2 leads V2-V5 R Absent 2 Jeads V2-5 Either of preceding 2 R criteria and T or T’ 2 — 0.10 MV in 2 leads V2-5 R Wave criteria as above and STO > 0.15 MV in 3 leads VI-5 ORS peak to peak must be => 0.20 MV 1) Q at least 0.048 C and ¥ R amplitude 2) Another Q at least 0.03 (OR) % R amplitude 3) ORS peak to peak at least 0.20 MV 2 leads 1, AVL, V5-6 NOTE: < means equal to or less than; 2 Means equal to or greater than, Fig. 3 Examples from the computer program de- veloped by the Medical Systems Development Labora- tory of USPHS: Version of Jan. 31, 1968. munity; and a medical group in a medium-size town. Daily operation has revealed several classes of problems which were largely unex- pected by us. Solutions, so far, have been satis- factory. Additional data carts have been ordered and additional medical settings are being exam- ined, Brief experience with the system so far con- firms Caceres’ previous claims.1 Specifically, the system is 100% correct when it classifies a tracing as “normal.” It is incorrect less than 15% of the time in its abnormal interpretation. Many (about 5%) of these instances constitute minor and/or insignificant deviations from the interpretation of reference cardiologists. The simple provision of an electrocardiogram Missournr MEDICINE SEPTEMBER, 1968 interpretation has so far seemed worthwhile. In addition, we are creating prerecorded audio messages related directly to the computer in- terpretations for a “dial up” telephone medical lecture system.? We believe this system will par- tially relieve the absence from the computer/ EKG system of true cardiologie consultation. Collaborators in the preparation of the audio lec- tures include Drs. Allen Bures, Cesar Caceres and Frank Brand. Comparisox Witn Oruer Systems Fig. 4 presents a comparison of salient fea- tures of some of the major computer/EKG sys- tems. We have made arrangements for parallel interpretation of selected tracings with other computer systems throughout the next two years in order to be able to recommend the very best system for this region. Future PLANS We would hope to serve a maximum number of communities. To do this, it may be necessary to reprogram the existing system in order to use more efficient, more modern computers.’ Alter- natively, collaborators may be able to work with us and Doctor Caceres to improve and render the existing system more efficient. Caceres is per- sonally investigating the possibility of produc- tion by private industry of small, special purpose computers to be dedicated only to interpretation of the electrocardiogram. If these prove to be sufficiently inexpensive, we may be able to test them in selected communities which would then be totally independent of the Columbia com- puter center. Amlinger and Carlson* are testing a preproc- essing circuit which may be able to reliably classify a tracing as “normal” or “abnormal” without use of an expensive general purpose computer. This would radically reduce the cost of processing and increase the number of com- munities we could serve. Engineering collaborators in the Missouri Re- gional Medical Program are exploring the prob- lem of mass screening data acquisition devices. Cox at Washington University, working inde- pendently, has been investigating the use of a special computer for on-line processing of vari- ous physiological signals, including the electro- caridogram. This work has focused on the prob- lem of the intensive care facility. All present systems fail to provide for a large data file to store concisely the results of previous electrocardiographic signals and interpretations. We plan during future years to be able to con- Voutume 65 Numper 9 ELECTROCARDIOGRAM—LINDBERG AND AMLINGER 745 PHS-Caceres - Mayo Clinic/IBM* Mt. Sinai Hospital Queens Univ. Does MD get Yes Yes Yes Yes 12 lead tracing Computer interpretation Yes No Yes Yes based upon 12-lead scalar system Computer based on 3-lead No Yes No Planned vector system Computers utilized CDC 8090, or CDC IBM 1800 (IBM 1401) PDP-8 and IBM 160A IBM 360/40 360/50 Published medical evalua- See note 1 See note 2 See note 3 Not yet completed tion Data Carts cICc IBM (Computer Instru- Marquette Experimental cic ments Corporation) Electronics Private leased line In-house connections Undetermined Hartford Hosp: Private leased line Missouri: ordinary “dial up” Telephone connections Data Console ® Dr, Robert A. Stratbucker of the University of Nebraska also is utilizing the Mayo/IBM System. Note 1. Computers, Electrocardiography and Public Health, A report of Recent Studies From the Instrumentation Field Station, Heart Disease Control Program, Div. of Chronic Diseases, U. S. Public Health Service, Dept. of Health, Education and Welfare, Wash- ington, D. Cc. Note. 2. Smith, R. E. and Hyde, C. M.: A Computer System for Electrocardiographic Analysis, Third Annual Rocky Mountain Bio-Engineering Symposium, Univ. of Colorado, Boulder, Colorado, May 2-3, . Note 3. Pordy, M. D. et al: Computer Aanalysis of the Electrocardiogram. Journal of the Mount Sinai Hospital, Vol. XXIV, No. 1, January, 1967. Fig. 4 Features of selected systems for interpretation of electrocardiograms by computer. tribute this feature and, also (with collabora- tors), to encode the requisite rules for compar- ing within the computer new and old tracings from the same patient. All of these efforts have been based upon “the expert cardiologist” as the reference against which any new system is measured. In the mean- time, other groups of mathematicians and bio- statisticians are looking toward new techniques with which a computer system could extract from the electrocardiogram information which the hu- man viewer cannot see by present methods of Bioengineering (Cont'd) and minimum artefact. ~—A rapid portable system of pbtaining six EKG leads simultaneously. As might be expected, serendipity is bound to occur. In the case of bioengineering, we have stumbled onto an electrostatic wave surround- ing the human body with up to five times the voltage of an EKG signal. It pulses at the heart rate with its own peculiar wave form. We don’t know the origin or method of modulation of the inspection. This is an exciting time. The next five years will see major changes and improvements in electrocardiography. BIBLIOGRAPHY 1, Dobrow, Robert J., Caceres, Cesar A. et al: Transmission of Electrocardiograms From a Community Hospital for Remote ‘oe ‘Analysis. The Amer. J. of Card, 21:687-689 (May) 2, Lindberg, D. A. B., Rowland, Larry and Morrison, G, E.: Automatic Message Center. In preparation. 3. Lindberg, D. B.: Pattern Recognition, Chapter XII, in The Computer and Medical Care. Springfield, Ill: Charles C Thomas, Publisher, 1968. 4, Amlinger, P. R. and Carlson, A. J.: Proposal to Develop an eee EKG Pre-Processing Device. Submitted to MRMP, ec. . wave, but only that it is there. One suggested use of the phenomenon is monitoring without at- tachment of gadgetry to patient. We are prepared to dream and to imagine, - but we are prepared through basic knowledge in medicine and engineering to convert dreams and imagination into useful hardware and sys- tems of an advanced nature to provide more ac- curate, reliable, durable, economical and simple- to-use equipment for patient care. GLENN O. TURNER, M.D., Springfield* Project Director, MSMP The Community Approach to Reduction of Cardiovascular Deaths A preliminary summarization of the unit recommendation of the Project Staff of the MRMP Comprehensive Cardiovascular Care Unit in Springfield as expressed by Doctor Turner in collaboration with Dr. Cecil R. Auner, Associate Director and Dr. John J. McKinsey, Advisory Committee Chairman. The author details the need for and the development of a community-supported Comprehensive Cardiovascular Care Unit with specific reference to his experience in Springfield, where such a unit is well under- way under the aegis of MRMP. WovuLp you BELIEVE that there is within our grasp a medical advance, the most important in a decade, that could save as many lives per year as were lost each year of World Wars I and II? Corday? draws this comparison, even if only half of the 100,000 potential reported by Wakerlin? is actually achieved. The means to this end is the application of the Coronary Care Unit Con- cept in all our hospitals. Fox? reported that 350,000 of the nearly 600,- 000 who die annually in this country from heart attacks arrive at the hospital alive (250,000 die without benefit of hospitalization). The Coronary Care Unit can reduce the inhospital death rate from approximately 30% to about 20%, resulting in the saving of roughly one third of the 350,000 who are still alive upon arrival. Using these figures, Corday’s estimate of a possible 50,000 lives saved per year is, indeed, modest. Fox reports that, as of June, 1967, only 300 of the nation’s 7,000 hospitals had coronary care units in operation. Even doubling or tripling this number of units during the past year would have left more than 6,000 hospitals without such mod- ernized service. Extending this improved care into these remaining hospitals presents the great- est challenge the American health team has yet faced, Preservation of future earnings of this one © Doctor Tumer is in the private practice of medicine. third of hearf attack admissions who were saved justifies a major community expenditure in im- proving coronary care. Add to this the potential lifesaving from bringing about, by earlier recog- nition of and attention to warning signs, hospital admission of some of the 250,000 who now die each year at home or at work, and one is even more impressed. Heart damage and deaths in those admitted also can be reduced by earlier entry of all coronary patients. Additionally, ap- plving intensive treatment methods to other high risk cardiovascular patients will swell the total of lives saved. Ultimately, actual prevention of heart disease through attention to “Risk Factors” is now foreseeable. The Project Staff of the Ozarks Regional Comprehensive Cardiovascular Care Unit in Springfield is undertaking these objectives on a regional basis under a grant from Missouri Re- gional Medical Program. Incomplete, capsulized results of the first year of this study are as fol- lows: 1. Promptness of recognition and hospital ad- mission of heart attack suspects is the prime con- sideration. In the Ozarks an initial effort to teach the people the early warning signs by the Greene County Division of the Missouri Heart Associa- tion by mass media communications led to a pro- posal for a pilot public information program un- der Missouri Regional Medical Program. Such a program also should stimulate physicians to re- spond more promptly and more definitively to early heart attack manifestations. Pain in the sub- sternal region, back, jaws, arms or combinations of these areas and otherwise unexplained dyspnea or sweating frequently can be interpreted accu- rately enough by telephone to justify immediate admission as a heart attack suspect and, often, to permit by-passing outpatient facilities. Systems of more rapid ambulance transport of patients with emergency care capability en route should be developed. 2. Bed needs for the establishment of a cardio- vascular care unit can be determined most simply by a patient count and classification of the entire hospital population. This can be done Votume 65 Nusmer 9 by one physician in less than a day and can be repeated on other days by other physicians for confirmation. The Springfield group feels that all high risk cardiovascular patients should be tallied for probable inclusion in a specially staffed and equipped cardiovascular division. These include proved or suspected acute myo- cardial ischemia and infarction, congestive fail- ure, arrhythmias, pulmonary embolism, thrombo- phlebitis, hypertension, cardiacs with other medi- cal and possibly surgical problems and, perhaps, acute strokes. Pulmonary insufficiency also de- serves similar care. Not only can this grouping reduce the number of emergencies that arise, but resuscitation efforts also can be enhanced by doing away with the “galloping exercise that ends in failure.” In February, 1965, the initial such count in St. John’s Hospital showed 75 of the total 450 patients to be in such a high risk cardiovascular category. This one count alone led to the restriction of an entire 40 bed hall, by rigid admitting policy, to these patients. Validity of the count was immediately shown by the inadequacy of this number of beds in meet- ing the needs as reflected by requests of staff REDUCTION OF CARDIOVASCULAR DEATHS—TURNER 747 physicians for admission of their patients to this newly-created division. This count (Fig. 1) can be carried out in any hospital with the anticipa- tion that roughly 10% to 25% could be classified as benefitting from grouped, specialized care. 3. A progressive care system with three zones, acute, intermediate and convalescent should be provided in one common area. The acute zone ~ should include intensive and “observation” beds. ‘The ratio of beds needed in these areas can be determined from the patient tally. Underestima- tion of needs as utilization increases was one of the most common deficiencies noted elsewhere by Springfield teams. 4, A cardiovascular hall or division, including an intensive unit, can be established in almost any hospital to accommodate these patients, once bed requirements are ascertained. Existing construction usually can be used. One device for provision of intensive care is to knock out por- tions of walls between rooms and to install a door and large windows extending down to or below bed level to give easy access and full visibility. 5. Subdivision of the intensive care unit into “quiet” and “noisy” areas will permit reception CARDIOVASCULAR DISEASE CENSUS, ST. JOHN'S HOSPITAL, BY DIVISION FEBRUARY 5, 1965 4n__ INT O5W 1, Acute Myocardial Infarction and/or ischemia Chronic Coronary Disease Congestive Failure Stroke Seizures, miscellaneous . Chronic Cor Pulmonale 1 Pulmonary Embolism a) Complicating leg fracture b) Complicating abdominal surgery i c) Complicating Phlebitis, without surgery Total Pulmonary Emboli sO uN & Wb oo. ee WIT NIT TOS elole 4a BWW GW HE O3E OE OPTUS TOTAL 1 2 1 21 6 3 1 i 11 8 4 3 an tet tefl Hehe N 8. Arrhythmias, acute 9. Arrhythmias, chronic bate tt 10.. Hypertension 11. . Congenital Heart Disease 12. Acute Rheumatic Fever ‘ 13. Pericarditis 4 14. Bleeding Esophageal Varices _1 15.. Ruptured CNS Aneurism — 1 16. Chronic Coronary Disease, in for Surgery 1 Total 18 2 8 e eel loft] [polo aA 1 1 2 11 0 4 9 6 6 5 6 75 Fig. 1 Patient Survey. This rough tabulation of high risk cardiovascular patients in St. John’s Hospital on Feb. 5, 1965, led to establishment of pilot 40-bed comprehensive cardiovascular care unit. 748 PASSAGE SPACE ING GL&SS o: open I gw of oe RB SCALED . i, + 2 * FG Tt & Fig. 2 Model Room Floor Plan. Floor plan of “saw- tooth” design of one of 14 rooms in round unit for ob- servation of less complicated acute patients (six-bed intensive unit is separate). ‘ of patients of varied requirements. This arrange- ment also lends itself to a combination with general medical-surgical I.C.U, Staffing problems will be less with this comprehensive grouping than with permitting these zones to be scattered throughout the hospital. Nurse instruction is simplified and there is better back-up for any overloaded component. Patients can be shifted within the division with ease as they improve or worsen. In new construction, one can incorporate into the “observation” or uncomplicated acute care area the following desirable features (Figs. 2 and 3): Ln i. 7 l Fig. 3 Medel Room. Photo of room represented by floor plan sketch in Fig. 2. Over-the-bed auto-headlight- type, recessed reading light and oxygen-and-suction out- lets have not been installed. REDUCTION OF CARDIOVASCULAR DEATHS—TURNER Missounr MEDICINE SEPTEMBER, 1968 a. Direct visual surveillance, In addition to electronic. b. Recessing of gruesome monitors and other gear. c. Outside windows with low sills. d. Bathrooms, which do away with that mon- strosity, the commode. A couple of steps into the bathroom is surely less stressful than the commode or bedpan. e. Carpeting and acoustical ceilings for noise control, f. Power drape operation—cost is about $70 per room. g. An abundance of electrical outlets, includ- ing at least one 220 volt line. 6. Bedside defibrillator provision for each pa- tient is ideal. Saving the life or brain function of just one wage earner by this means of cutting off that precious fraction of a minute would pay for numerous defibrillators. 7. The following ancillary services ideally should be in or near the cardiovascular division: a, Department of electrocardiography, bearing in mind possible later application of central recording and of computerization. b. Inhalation therapy department. ce, Cardiopulmonary laboratory, including blood gas analysis, where feasible. d. Procedure room for cardioversion and pace- maker placement. e. Exercise tolerance evaluation. 8. Radiographic service should be intensified. The Springfield group agrees with Meltzer* that congestive failure, the second most death- dealing complication of acute myocardial in- farction, can be treated more effectively if recog- nized earlier through frequent chest x-raying. Furthermore, even low output portable equip- ment can be successfully used by well-trained technicians to obtain six foot sitting PA films for determination of heart size and pulmonary vascularity (Fig. 4). Radiologists are urged to routinely record heart size on films and re- ports in cardiac roentgenography. A difference of one cm. or less may be significant on serial study. Also, there should be a greater index of suspicion in looking for early increases in vascu- larity. 9. Telephone EKG transmission, preferably utilizing bedside magnetic tape recording which permits sending a number of tracings with one phone call, will give same-day reporting and will, eliminate one of the most serious deficiencies in hospitals without an electrocardiographer. 10. Radio telemetry will expand EKG surveil- Voutume 65 Numper 9 Z Pe uae - ConvenTeatau: 2G FoatT Séc. EX POSURE REDUCTION OF CARDIOVASCULAR DEATHS—TURNER 749 3 [2] RR Pak 0 That oy FO SB ae pos ae Choo PA PORTABLE ees ; Fig. 4 X-Ray Photo. Comparison of conventional versus ICU portable techniques to show significant altera- tion in heart size and pulmonary vascularity (latter is more obvious on original films). Monitor needle electrodes are in place. lance into intermediate and convalescent zones. Length of stay in the acute care zone can be diminished, perhaps, by this means. 11. Financing of instrumentation and possibly meeting other costs should be actively sought through civic groups, particularly hospital ladies’ auxiliaries. This can reduce daily rates by several dollars. 12. Nursing staff, relatives’ lounges and teach- ing and conference rooms should be better planned. 13. LPN and nurse aide utilization can be very effective in cardiovascular care units, in- cluding reading monitor scopes. In addition to holding costs down, they permit expansion of services into the areas of RN shortage. 14. Defibrillation by nurses is mandatory for maximum service to the patient. Not providing this capability may soon be legally indefensible. Specialized cardiovascular training for nurses must be expanded. Under Missouri Regional Medical Program and other interested groups and agencies, an early objective should be the provision of training facilities to enable each hospital in the Missouri Region to have one or more such specially trained nurses. These nurses, under continued guidance of nursing instructors and with time for travel to community hospitals, can organize local teaching programs. Instituting this system of consultation in Missouri is the ambition of the Springfield group. These nurses are the key to the entire program and must be given special recognition and encouragement. Physicians will find that they can learn a great deal in the specifics of cardiovascular unit opera- tion from them and also will be stimulated in their own study. 15. Physician education will accelerate as the potential and mechanics of the entire program are made more clear. Workshops and confer- ences designed for the community hospital, ideally cosponsored by Regional Medical Pro- grams and the Heart Association, will best ac- complish this goal. The Springfield MRMP Project Staff and the Missouri Heart Association are now planning such a workshop for October, 1968 to be offered statewide. | 16. Hospital administrator. and governing board participation in unit development is an obvious necessity. The latter serves as represen- tation of the taxpayer and of the purchaser and consumer of health services. 17. Alliance with health agencies, both gov- . (Continued on page 753) 750 The Smithville Project ! An Evaluation The SxurHvitte Project of the Missouri Region- al Medical Program attempts to measure the as- sumption that if comprehensive care were made available to the people of a given medical service area, the people of this area would (a) profit from the extended medical knowledge available to them, (b) demonstrate acceptance of compre- hensive medical care which would be meaning- ful in their lives, (c) exhibit less ambivalence in cooperating with the physicians’ directives, (d) develop an innate motivation toward in- creasing their own productivity and lowering their own morbidity and, in addition, that (e) the comprehensive care, having been made avail- able to a medical service area, will inculcate within the consumers of this care the type of discipline which makes the care most effective. The Smithville Project also set out to measure the degree to which physicians in practice with- in the given medical service area would avail themselves of the totality of comprehensive care. It also attempted to measure the extent to which physicians, given an appropriate time for learn- ing and for familiarization with comprehensive care, would accept it as a way of medical prac- tice. The purpose of the Smithville Project was, therefore, to determine and to focus upon those inadequacies of current practice of which the physicians were aware. Once these inadequacies had been determined, the purpose was to supply the equipment and the necessary backup per- sonnel so that inadequacies would no longer exist. The aim of. the Smithville Project was, consequently, to shorten in one dimension, namely, time, the progress which physicians in the area were currently making toward provid- ing their patients with a total kind of care to which they were receptive. It is important to point out that the Smithville Project did not set out to provide comprehen- ® Doctor Hardwicke is Assistant Professor of Physical Medicine and Rehabilitation at the University of Missouri School of Medi- cine, HENRY M. HARDWICKE, M.D., Columbia* Project Director, MRMP sive care to a community. It did not set out to direct the doctors in the manner in which they were to provide medical care to their patients, nor did it set out primarily to lower morbidity or mortality or absenteeism within the medical service area chosen. The Smithville Project did set out to prove what we believe to be a valid assumption—if physicians were given the equipment and_ the backup personnel which, for financial reasons, they currently did not have available but which they felt were needed, these same physicians would proceed to give the very best quality medical care that they were capable of giving in the most comprehensive manner that their patients would accept. SELECTION OF THE MEDICAL SERVICE AREA Smithville appeared to be ideally structured for conducting research of this type. The Smith- ville Hospital, an economically self-sufficient unit serving approximately 75,000 people and staffed with some 38 doctors, was curently providing the best medical care that equipment, training and time permitted. Smithville, as a medical service area, also was unique in that Dr. Arch E. Spelman had founded the hospital, had developed a clinic adjacent to it and had acted as Medical Director of the Hos- pital and the Clinic without being so named. His personality was dynamic, his knowledge of medicine tremendous, his interest in people un- ending. For many years prior to the initiation of the Smithville Project, Doctor Spelman had been interested in studying the complexities of a pa- tient’s illness. He was acutely aware of the role that environment, economics and emotional sta- bility played in the well-being of his patients. He also was aware of and had studied rather intensely the effects that sudden illness had up- ~ on the stability of an entire family. He, in short, had developed the habit of practicing medicine in depth. His work and his records will prove of Vouume 65 Numsen 9 great value when the final story of the Smith- ville Project is written. Smithville is a “ruralpolitan” area. The medi- cal service area contains both well-established agrarian families whose roots are deep in the soil and whose mores and traditions are strong ‘and a large number of suburbanites who had moved into the Smithville medical service area from Kansas City where they still maintain em- ployment. This area, therefore, offered an inter- esting cross-section of the American scene. The interplay of social forces are inevitable under these circumstances. INITIATION OF THE PROJECT The scope and intent of the Smithville Project were presented to the Board of Directors of the Smithville Community Hospital at their regular monthly meeting in February, 1967. After a per- ceptive discussion of the proposed project by the Board, it voted unanimously to submit the Project to the staff for its approval. The Board further voted that if the staff approved the Proj- ect, the Board would endorse and support the Project. Two meetings were arranged with the active staff. The first took place within the first week of March, 1967. The meeting, interestingly, was held at a hotel in Kansas City, the place of the meeting being established by the active staff. At the first meeting with the staff, the Project was presented for their comments and consider- ation. This meeting was devoted, for the most part, to a discussion by the staff of their deep feelings concerning federal funds being brought into the practice of medicine. It could well have been classified as a psychotherapeutic group meeting. It was our feeling that a great deal was achieved since the foundations for an honest exchange of views were well laid. It was evi- dent, however, at the end of the meeting that a second meeting to discuss the Project itself would be in order. A second meeting was held with the active members of the staff in the latter part of March. With some expressed reservations, the staff at this time agreed to participate to the extent that they felt their patients would benefit from the Project. Their reservations all related to the fact that they anticipated that once they had suc- cumbed and become part of the Project, repre- sentatives of the federal government would then move in and begin to dictate in what fashion they should practice medicine. They were as- sured that this would never happen. They also were reminded at this second meeting that the THE SMITHVILLE PROJECT--HARDWICKE 751 This evaluation of progress made during the first year at the MRMP project in Smith- ville includes a review of the basis for se- lecting this medical service area, the initia- tion of the project and the implementation of the program. The author emphasizes that the MRMP is not attempting to change the practice of medicine in Smithville. The goal is to establish a model which, having been developed by the physicans practicing in that community, may be utilized with effec- tiveness in other interested areas. Project was self-limited; that at the end of two and half years all financial support for person- nel or additional equipment would be with- drawn; and that equipment purchased for the Smithville Hospital, which had been used suf- ficiently to justify its continued existence, would be left there. At the end of the second meeting, the staff voted to recommend to the Board that it accept the Smithville Project. IMPLEMENTATION OF THE PROGRAM Implementation of the Smithville Project has been extremely difficult. Personnel had to be found in all areas that were lacking within the Smithville medical community. Research-ori- ented individuals were needed to implement the repeated necessary surveys of the community. These surveys were designed to continually test, on a random sampling basis, the people's atti- tudes about medicine, their willingness to utilize the medical resources of their community, their mores or traditions that might interfere with their appropriate utilization of medical science. As time went on, surveys would remeasure these same things so that changes for the better or for the worse might be recorded. Personnel had to be found who would offer expert services in the fields of physical therapy, medical social work, home care nursing, rehabil- itation nursing and intensive coronary care nurs- ing. From a purely professional level, resources which were not then present in Smithville had to be recruited in the fields of psychiatry, in- ternal medicine and physical medicine. It also was necessary to set up administrative devices which made it possible to cost-count the operation of the extended care facility which was to be developed within the existing hospi- tal, of any home care program which was to be started, and of all other programs to be initiated for the physicians in their use of the extended care program. 752 Slowly, but steadily, administrative mechanisms were developed and personnel were recruited in the several areas. It was impossible to recruit ‘trained intensive coronary care nurses, so it was necessary to recruit nurses who would be willing to leave for training at recognized training cen- ters. Professional personnel are difficult to recruit at best. When they are recruited under special conditions and at salaries usually lower than those paid by hospitals less than 15 miles away, recruiting becomes extremely difficult. It was possible by June 1 to maintain in the hospital 15 beds which were devoted to ex- tended care. It was possible to recruit and train a rehabilitation head nurse who was responsible for the training of aides and other nurses on her ward. It also was possible to recruit a physical therapist who was registered and had had experi- ence in professional physical therapy. After great difficulty, the services of two well qualified in- ternists and two physiatrists were made avail- able to the group at Smithville. Things were moving ahead in accordance with schedule. Suddenly, on Oct. 7, 1967, Dr. Arch Spelman, the prime mover of the program, the prime sup- porter of comprehensive care in the Smithville area and the founder, builder and developer of the program, died of a coronary. An immediate hiatus of no small magnitude ensued. The staff was disoriented and without leadership; the ad- ministrator found himself somewhat inadequate to the many tasks that fell upon him. The mem- bers of the University of Missouri Medical Cen- ter faculty, who were assigned to Smithville to assist, felt it incumbent upon them to remain aloof. from the organizational problems that ex- isted. Any direct participation by members of the team from the University of Missouri prob- ably would have delayed the final resolution of these problems and might well have placed a- bias upon the whole study which could not have been. tolerated. There actually ensued a period of approximately four to five months in which no real concentrated work was done on the pro- gram by the members of the active staff of the Hospital. All the related work was done indi- rectly by representatives from the Missouri Re- gional Medical Program. Their task was to main- tain as much cohesion and progress as possible under the circumstances. This was an unexpected complication which, in the long run, probably will move the entire project to quicker consummation than otherwise could have been achieved. The staff has learned to relate to each other THE SMITHVILLE PROJECT—UARDWICKE Missournt MEDICINE SEPTEMBER, 1968 since the death of Dr. Spelman six months ago. Interestingly, the quality of care has not deteri- orated, the patient load in the hospital has not decreased and the attention which physicians pay to their patients and their dedication to their patients’ welfare has not been altered. A new staff organization has begun to emerge, the strong have begun to take leadership, the pieces of the puzzle have begun to fall into place and the Smithville Project has begun to move ahead. A new administrator is being ac- tively sought by the Board of Directors. Cost accounting systems which are meaningful are being inaugurated. The management of the Hospital is beginning to assume more definite shape and pattern. A new extended care pavilion containing 50 beds and a large rehabilitation and occupational therapy area is under construction. Plans already are on the drafting board for a 250-bed acute hospital which will serve as an addition to the present hospital. The nursing home, which was partly finished when the Project began, will now be finished; funds have been raised for its com- pletion. Plans have been altered so that the home will be more usable than its original design would have permitted. It now appears that the Smithville hospital will begin to assume its proper responsibility for the personnel provided by the Regional Medical Program. Six months later than anticipated, the pattern is reassumed and the program continues. There has been a growing acceptance by local physicians of the role that intensive coronary care facilities and rehabilitation and extended care can play in the lives of their patients. An in- creasing number of physicians are not only ad- mitting patients to both services, but are super- vising their medical care after they are ad- mitted. Consultation is requested only when the physicians feel they honestly need it and not as a matter of routine. The home care program is growing quite rapidly and very satisfactorily. There is evidence now that each of these pro- grams will be self-supporting in the near future. It is probably true that the one aspect of the program that offers the greatest difficulty from a financial point of view is the intensive coronary care unit. It is the most expensive to operate, the one least frequently covered by third party carriers, and the one which those who do not have insurance are least able to afford. It would appear that the research unit has done its work quite well. An original survey rep- resentative of the entire 75,000 people in the medical service area has been completed. The Votume 65 NuMBER 9 THE SMITHVILLE PROJECT—HARDWICKE 753 second survey is now underway to measure, if possible, any change in attitude on the part of the recipients of medical care in the area during the past year. Physicians on the staff are now plamning actively to become part of a lay edu- cational program and to conduct lay educational meetings. PartTICIPATION OF HEALTH AGENCIES Concentrated efforts have been made to uti- lize the public health department and voluntary health agencies located within the medical ser- vice area. Efforts to inform these groups will be continued as opportunity permits. EVALUATION It is hoped that by the end of 1968 it will be possible to institute a retrospective study of those patients who have come under the influ- ence of the extended comprehensive program offered through the Missouri Regional Medical Program conducted by the physicians in prac- tice, and to compare this progress with patients who have not come under the same influences. Community Approach (Cont‘d) ernmental and volunteer, provides broadly based support and vast resources of skill and expe- rience. There should be better utilization of USPHS systems development. Partnership with the Heart Association is a key factor. 18. Local medical society approval can pro- vide cooperation of all physicians in the com- munity extending beyond any one hospital staff. 19. News media involvement, through sharing of plans and objectives from the outset, will probably assure unprecedented public interest and support, as exemplified in Springfield. 20. Limitations of units will vary with the hospitals and must be stressed. If full profession- al and hardware capability is not at hand, prompt referral or consultation when needed is obligatory. This particularly applies to pacing catheter placement, to management of serious By the end of 1968, there should be a sufficient number of people in both categories to make such a study meaningful. Within the next six months, it is hoped that the home care program will prove self-sufficient both economically and from the service point of view. It also is hoped that the intensive coro- nary care unit will prove to be self-supporting during this same period of time. The balance of the programs appear to be moving in this direc- tion quite rapidly. SuMMARY In spite of unexpected difficulties, unexpected sorrows and the expected antipathy and distrust of the practicing physicians toward any program connected to possible federal control, the Smith- ville Program has moved along in satisfactory fashion. A great deal of work has gone into the Program, both by people interested locally and by those representing the Missouri Regional Medical Program. This work seems to be well justified at this time. We are hopeful that the outcome will be especially rewarding to the re- cipients of medical care in the Smithville area. arrhythmias, unresponsive congestive failure and intractable pain and to uncertainty of diagnosis. SUMMARY The Missouri Regional Medical Program has provided in the Ozarks the best mechanism yet available to meet the greatest health challenge ever faced here by creating a forum for as- sembling a vast array of people and resources to bring about a reduction in cardiovascular death and disability. BisLioGRAPHY 1, Corday, Eliot: Address, National Coronary Care Unit Plan- ning Conference, Washington, D. C., June 24-25, 1967. 2. Wakerlin, George E.: Address, Annual Meeting, Missouri Heart Association, Columbia, Ma., May 18, 1964. 3. Fox, Samuel M., II: Address, National Coronary Care Unit Planning Conference, Washington, D. C., June 24-25, 1967. 4, Meltzer, Lawrence E.: Panel Discussion on “Congestive Heart Failure,’ National Coronary Care Unit Planning Con- ference, Washington, D, C., June 24-25, 1967. 754 WILLIAM STEPHENSON, Ph.D., Columbia* Project Director, MRMP Communication Research By “pre-testing” the impact of health pamphlets, posters, brochures, films and ra- dio-TV spots being developed, the Commu- nication Research Unit of MRMP is able to improve their effectiveness before general distribution to the public. Doctor Stephen- son shows how “pre-testing” and “facilita- tors” applied to medical publications on preventive health measures result in “changing behavior directly” and facilitat- ing desired action and response. Tue Communication ResearcH Unit (CRU) has as its objective the development of communi- cation which serves not merely to inform, but to bring about immediate change. Its concepts are communication-facilitation, | communication-ac- tion and the like; its affinities are with advertis- ing and public relations programming rather than with education and information dissemina- tion. First, CRU has devised methods for “copy- testing” news releases, pamphlets, radio and tel- evision spots, posters, documentary films and movies and any or all of the materials produced for public consumption. It is important to be able to do this because few, if any, of these ma- terials are “pre-tested” today. Costly films are produced and pamphlets published without pri- or copy-testing to find out how far people identi- fy with them. The result is that many are doing more harm than good. One pamphlet on cancer, for example, is calculated to alarm women and not at all to assuage their anxieties about. can- cer. Copy-testing shows that women react highly negatively to this kind of leaflet, in spite of the happy-looking graphics. It is not merely that they dislike having their attention drawn to the grave consequences of leukemia. What disturbs the women is the triteness of the treatment— the scrappy bit of paper for so grave a matter is totally out of place. As one woman said, “It’s like printing the Bible in a comic book.” Serious ® Doctor Stephenson is a Distinguished Research Professor of Journalism at the University of Missouri. topics, somehow, have an intrinsic “demand” character of their own, and this throw-away bit of paper in no way satisfies it. Many examples of this kind could be given in which good inten- tions, fine photography and expensive films make serious communication mistakes which could have been obviated by prior copy-testing. Second, CRU adds to pre-tested materials certain “facilitators” which aim at changing be- havior not by “persuasion,” “education” or “in- junction” (Stop Smoking!), but in some sense directly. The best analogy here is “programmed learn- ing” by which materials can be learned very effectively when each step in the learning is “rewarded.” Children will learn very effectively and happily if they are paid to do it. Poor wom- en will readily Iook at a television program on birth control if paid to do so. Mass advertising for consumer goods wouldn’t be successful with- out the facilitation of supermarkets where housewives who are shopping can see again the items they saw on television and, thus, be re- minded to act. Each of us, upon hearing some news about which we feel strongly, may intend to write to the editor or to one’s congressman, but how often do we do so? CRU sets out to facilitate action. Given pre-tested materials, how does one cause people to act? An example of CRU at work in this matter is seen in connection with the Smithville Project of MRMP. Can women be persuaded to exam- ine themselves regularly for early signs of breast cancer? CRU studies show that women are worried about cancer. As one physician has said, “There are two major diseases today, cancer and worry about cancer.” How, then, assuage the anxiety and, at the same time, get women to examine themselves? First, cancer experts devised the self-examination procedures. Next, CRU under- took some outstanding photography to illustrate the self-examination by using a beautiful model with restrained, dignified poses (Fig. 1). An ex- pensive-looking pamphlet was then written and designed by a creative advertising expert whose work had won many awards for excellence na- tionally and at the 12th Festival International VotuME 65 Numer 9 t pr a, Fig. 1 This model was used for the many photo- graphs required for the pamphlet. Note the restrained, quict dignity. du Film Publicitaire in Cannes (1965). All of this material is copy-tested. Men like looking at it as much as their wives. Finally, comes the fa- cilitator. The responsibility for putting the pamphlet into the hands of women in Smithville rests, of course, with their physicians. Once it is in the homes, however, will the women under- take the monthly examination following men- struation as advised in the pamphlet? How can this be facilitated? CRU hit upon the idea of asking the women to hang the pamphlet in the bathroom, just:as cookbooks are kept in kitchens. So, this medical booklet has to find a place in a bathroom. People read there. The booklet is ex- pensive-looking and worth keeping; it is pro- vided with a silk loop so that it can be hung from a hook, A newspaper campaign is used to impress upon women the idea of keeping the booklet (and other MRMP “do it yourself” book- lets) hanging near a seat in the bathroom. Such is a facilitator. It is scarcely necessary to add that husbands act as facilitators, too, in the above case. Put a copy of Playboy in a man’s hands and his in- terest in breasts is obvious. The pamphlet on “How to Make a Self-Examination” interests men as well as women, and husbands influence their wives in the matter of regular self-examina- tion. The beauty, the elegance of the production is anxiety-reducing—a matter CRU puts to test. Consider cigarette smoking. Everybody knows that lung cancer and cigarette smoking are linked. Smokers, however, meet the situation with reactive indifference. How, then, can we change their behavior? Current advertising campaigns by the Ameri- can Cancer Society stress the risks run by smokers and call on smokers to stop smoking. CRU offers no such categorical injunction. Fol- COMMUNICATION RESEARCH—STEPHENSON 755 lowing basic principles, CRU doesn’t seek to persuade, enjoin or inform anyone (although these benefits may occur incidentally). Instead, the object is to change behavior directly. Again, resort has been made to a pamphlet written from the standpoint of a “do-it-yourself” kit. It doesn’t tell anyone to stop smoking. It merely says that if you want to quit smoking, there is a scientific way to do it by “switching” the smoking habit for another habit. The meth- od is based upon a modern learning theory (re- inforcement of a low probability habit by a high probability habit). If you want to switch “chewing gum” for “smoking,” the trick is to re- inforce the one at the expense of the other. Thus, the reader finds that the next time he wants to smoke, he “chews gum” for five min- utes and then has a smoke. The latter begins to reinforce the former. Soon he finds himself en- joying the gum, and forgetting the smoking. It sounds like expecting a snake to eat itself tail- end inwards, but it works. Again, the pamphlet on “How to Cope With Cigarette Smoking” (Fig. 2), is expertly produced. It tells no one not to smoke. CRU tests how far behavior is changed this way. The attitudes, no doubt, change pari passt. Fig. 2 This poster, through graphics alone, alerts high school students to the dangers of smoking. The above-mentioned folder explains how they may then handle their smoking prob- lem. They will find copies in the school library. It should be clear, then, that CRU is directed to changing behavior by communication, and not simply to communicating information to peo- ple. Where information is involved, it is inci- dental to the main purpose. In particular, it is nowhere assumed that “educating” or informing people leads ipso facto to desired actions, nor is it anywhere assumed that messages themselves may be “persuasive” and that they induce be- havior on that account. Instead, action requires action. This is the basis of CRU’s work. Is it not interesting that where matters of opinion arise, CRU may have a place? This fol- lows from the body of theory at issue.’ When one thinks of theory in the communication fields, 756 COMMUNICATION RESEARCH—STEPHENSON one thinks of it in relation to information science (such as enters into library science, cybernetics and computerized networks generally) and to mass communication, mterpersonal communica- tion and organizational networks and so on. There can be little doubt, however, that what is common to these areas, upon which so much effort is being expended in the applied sciences today, is information theory in the Shannon and Weaver sense.? The concern is with signal trans- mission expressed as entropy, redundancy, net- works, noise, coupling, channel capacity and the like. From this standpoint a regional medical program is a network involving the lay public, hospitals, general practitioners and MRMP re- search and development projects. One would study, from this standpoint, which parts of the network have the greatest information input, output and couplings. One might inquire about channel capacities. If information is fed to the public at increasing rates and volume, is there a maximum capacity for its absorption? What of the couplings between lay public and_practi- tioners, public and MRMP and practitioners and MRMP? Who channels what information in these couplings? What is the fidelity of the mes- sages they receive? What distortions occur? Who passes on what to whom? How repetitious (re- dundant) do messages have to be in order to communicate? Is terse and simple writing the best for information flow? These and similar questions illustrate very well to what informa- tion theory leads. The questions, no doubt, are all important ones requiring answers by scien- tific means. The concern, however, is with in- formation and the afore-mentioned flow, cou- plings, networks, redundancy, entropy, channels and the like. All enter, no doubt, into mass, in- terpersonal and organizational communication, but none leads to action as such. Indeed, there is an assumption in information theory that mo- tivation is either nonexistent or of maximum and constant impact upon the systems under consideration. CRU can accept no such assump- tion. On the contrary, it sets out to study these motivations in the form of operant behavior, first as attitudes (whether before or after events) and, then, as changed behavior. This in no way denies importance to information theory. We use it in CRU whenever necessary to get at facts. At first, perhaps, it is a little difficult to grasp _, Missouri MEvICINE SEPTEMBER, 1968 what operant communication (which is CRU’s principle concern) really is. However, examples can help. Consider, for example, how CRU might enter into multiphasic testing. Where does opinion enter here? No doubt, there may be differences of opinion among biomedical re- searchers about this or that in the multiphasic test battery. Ordinarily, this would not become a problem for CRU unless these scientific differ- ences took on considerable, almost ideological proportions. Or if automated multiphasic testing can drastically reduce costs for tests in general hospitals, there might be diffcrences of opinion regarding the desirability of instituting these re- ductions, at least until hospitals have. found a way to recoup themselves for loss of income that this more efficient testing would occasion. Again, it is unlikely that CRU would find much of a problem here that wouldn't be solved more easily in other ways. What of the public’s body of opinion about such testing, such as attends the Kaiser Foundation Health Plan in California, compared with the wider medical profession’s standpoint? It is here that CRU can find its problems. One could illustrate the matter for every proj- ect of every regional medical program. Enough has been said, it is hoped, to introduce the pur- pose of CRU. Nothing has been said about the technical resources it has at its command, such as in depth-type interviewing, Q-sorting, “copy- testing” pamphlets, television spots, posters and in programmed factor analysis and the like. Its staff are journalists with behavioral-science (as well as information theory) perspectives and in- cludes Communications Director, William Ste- phenson, Ph.D.; Associate Director, Normand DuBeau; Associate, Donald J. Brenner, Ph.D.; Technical Consultant, Terrill Rees, Jr.; Adminis- trative Assistant, Elvera Scroggs; and Research Assistants, Cathryn Buesseler, Richard Carlson, Thomas Drese, Robert Dunham, William Ingen- thron, Leah Krawetz and Arlene Stewart. BisLioGRAPHY 1. Stephenson, W.: Definition of Opinion, Attitude, and Belief. The Psychological Record XV: 281-288, 1965. 2. Stephenson, W.: Application of Q-method to the Measure- sei of Public Opinion. The Psychological Record XIV: 265-273, 1 . 3. Stephenson, W.: Evaluation of Public Relations Programs, to be published in Rivista Internazionale de Scienze Economiche e Commerciali, Milan (1968). (Copies of the paper are available on request to the author.) 4. Shannon, E. E. and Weaver, W.: The Mathematical Theory of Communication, Urbana, The University. of Illinois Press, 1949. 757 CHESTER G. STARR, Columbia* Project Director, MRMP Manual of Medical and Paramedical Services in Missouri For A NUMBER OF YEARS in Missouri, a demand for a statewide directory or manual of the vari- ous health facilities and personnel has been ex- pressed at meetings and conferences of physi- cians, nurses, hospitals, nursing home staffs and public health, welfare and voluntary health or- ganization personnel. The Health and Welfare Council of Greater St. Louis and the Regional Health and Welfare Council of Kansas City have published directories for their areas. Also, nu- merous voluntary health associations. have pub- lished special booklets and brochures on the spe- cific diseases in which they are interested. At the inception of planning for the Missouri Regional Medical Program, the Missouri Health Council, a federation of some 35 statewide and regional health organizations, presented a proj- ect to collect and arrange information concern- ing the entire state and to make this information available through publication. The project was approved by the National Advisory Council for MRMP and the Missouri Health Council as- sumed responsibility for its implementation. As the project progressed, it appeared that two publications would be more useful. As a re- sult, one was developed on facilities and ser- vices and the other on the health manpower situation in Missouri. Tue MANUAL This publication is a book consisting of more than 400 pages with particular emphasis on the health facilities and services available in every county in Missouri. They include hospitals, nurs- ing homes, medical laboratories, clinics, treat- ment centers, pharmacies, public health services, permanent local offices of voluntary health as- sociations and societies, field representatives of various health organizations and local clubs or groups that furnish some type of medical or paramedical service. The official health agencies of the Division of Health, Division of Welfare, Division of Mental Diseases, Vocational Rehabilitation of the De- ® Mr. Starr is Secretary of the Missouri Health Council. A description of The Manual of Medical and Paramedical Services in Missouri which consists of two volumes and was developed by MRMP in response to the demand for a statewide directory of various health facili- ties and personnel in Missouri. The first vol- ume offers a county-by-county breakdown of all health facilities and services. The second is a supplementary report on all as- pects of employment and training of health | manpower in Missouri. The author discusses distribution of the books and invites inter- ested persons to send for copies. partment of Education and the State Crippled. Children’s Service are described in regard to functions, district or area territories, hospitals, treatment centers, clinics and other health ser- vices. The principal professional health organi- zations are listed with location, permanent branch offices, officers, membership and other pertinent information. The voluntary health or- ganizations are included with location of prin- cipal and branch offices, field representatives, executive directors and the services offered. HeaLtH MANpower IN Missouri The supplementary report on health man- power in Missouri is a much smaller publica- tion of approximately 60 pages. Current em- ployment or practice of the various principal health professions, current needs in the various disciplines, the number of specialists in medi- cine, dentistry and nursing, salary ranges and schools for education and training are presented on a statewide basis and, also, for each county in the state. The counties are represented in a series of charts that are self-explanatory. Each discipline is described and schools are listed with location, admission requirements, length of study, costs and degrees given. Twenty-two health disciplines are represented in the book. The Health Manpower in Missouri Report is 758 especially adapted for use by the disciplines in recruiting young persons for health careers. DisTRIBUTION The circulation of the two books will reach personnel of the Division of Health, Division of Welfare and Division of Mental Diseases. The voluntary health organizations plan distribution to their county and area districts. The Missouri State Medical Association and the Missouri As- PARAMEDICAL SERVICES IN MISSOURI—STARR Missourt MEDICINE Serpremper, 1968 sociation of: Osteopathic Physicians and Sur- geons plan to distribute copies to all of their county and district societies and organizations. The Missouri Dental Association is placing copies in each of its area districts. Many hospi- tals and nursing homes have requested copies also. Any person who is interested in the informa- tion contained in the books may secure copies from the Missouri Regional Medical Program, Lewis Hall, Columbia, Mo. 65201 National Manpower Conference To Be Held in Columbia One of the most urgent problems facing the nation’s health care systems is the critical and ever-growing need for health manpower—the right numbers and kinds of people in the right places. About 2.8 million people were employed in health occupations in 1966; estimates are that another million will be needed by 1975. In order to help meet this serious challenge, the Missouri Regional Medical Program and the University of Missouri Medical Center has announced that a national conference will be held on Sept. 25, 1968 at the Medical Center Auditorium to discuss “Manpower: Does Health Get Its Share?” The one-day conference will include presentations by Dr. Vernon E. Wilson, Vice-President of the University of Missouri for Academic Affairs, Dr. Leonard Fenninger, Director of the Bureau of Health Manpower, NIH, Bethesda, Md.; Dr. William L. Kissick, Executive Director of the National Advisory Commis- sion on Health Facilities, Washington, D. C.; Dr. James P. Dixon, President of Antioch College, Ohio; and other prominent figures from across the nation who are deeply involved in health care planning. The conference will be unique in considering manpower needs, supply and re- cruitment for the health and competing professions, such as law, engineering, finance, industry, etc. Key officials from Regional Medical Programs from all over the U. S. are being invited to attend and participate in the conference and panel discussion which will follow, as well as representatives of medical schools, educational institutions, hospitals, health professional organizations, voluntary health agencies, official health agencies and consumer groups. Health manpower needs are a national challenge, and a nationwide sharing of ideas is needed to find solutions.