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Strategic Planning for IAIMS: Prototyping as a Catalyst for Change John A. Paton, Ph. D., Jeffrey I. Clyman, M.D., Patrick Lynch, M.S. Perry L. Miller, M.D., Ph.D., Dean F. Sittig, Ph. D., Bella Z. Berson, M.A.L.S. Yale School of Medicine, New Haven, CT 06510
Abstract
Yale School of Medicine
Yale School of Medicine has developed a prototype integrated computing and information environment as part of its strategic IAIMS planning. The prototype consists of a menu system and underlying network communications programs and networks to access a variety of medical information resources at Yale and elsewhere. This prototype has been useful in testing user needs, in designing a technical architecture, in exploring related institutional issues, and as a basis for research in integrated access to medical information using UMLS tools and concepts.
Yale School of Medicine is a leading center for biomedical research, a training ground for over 1000 medical and graduate students, and a provider of patient care through its own Faculty Practice Plan and the facilities of its partner institution, the Yale New Haven Hospital. The School is closely associated with Yale School of Nursing, and the School of Epidemiology & Public Health which are also located on the Medical Center campus. The School has access to a heterogeneous collection of computing resources including supercomputers, mainframes, minicomputers, workstations and personal computers; and all of these can be linked by campuswide high speed networks (ethernet) or low speed switching systems. The predominant form of computing within the school - in terms of capital costs, computing power and personal access - is through personal computers (over 350 Apple Macintosh computers and over 1400 IBM personal computers or clones). Members of the Medical Center community use an equally diverse set of computer-based information resources induding an online catalog of Yale Library resources (based on the NOTIS system), MiniMEDLINE (from Georgetown), an online version of Current Contents (mounted under BASIS), and molecular biology databases and tools (Wisconsin Molecular Biology Resources).
Introduction The National Library of Medicine has provided a vision of "information when and where it is needed" and has supported this vision through its Integrated Academic Information Management Systems or LAIMS program [1]. Yale School of Medicine is in the midst of strategic planning to find a version of the IAIMS vision which fits its institutional missions, resources, and character. As part of this planning we are developing a prototype information environment to explore and refine key issues in creating an integrated computing environment which will support IAIMS. This prototyping has been invaluable in converting an abstract vision into concrete form and thus has been a very effective tool for planning. In the rest of this paper we describe our prototype and how it has been used (1) in iteratively determining what users of information need, (2) in developing an overall technical architecture, (3) in exploring institutional policy and infrastructure required to foster IAIMS, and (4) as a basis for research in conjunction with the Unified Medical Language System (UMLS) project [2]. Our emphasis throughout will be on issues raised by IAIMS; the prototype exemplifies still experimental but promising answers to certain of these issues.
0195-4210/90/0000/0709$01.00 © 1990 SCAMC, Inc.
Prototyping User Requirements To rephrase the IAIMS vision of "information when and where it is needed" our overall goal is to increase access to information by lowering physical, economic, administrative, and educational barriers to its use. We also begin with two basic assumptions: (1) that present and future access should build on the established base of personal computers and personal computer expertise, and (2) that information services should be provided from a variety of sources, both within & without Yale. Thus a major technical challenge is to integrate a small number of standard
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services simultaneously (multiple open telnet sessions) and of passing information directly between services. In this future scenario it should be possible to search for bibliographic references in Current Contents and then check to see whether the journal issue has been received by the library; or to review a patient's lab results and ask for a critique of proposed treatment - all without reentering information or returning to the menu. In summary, our working understanding of user requirements are as follows. From a user perspective the personal computer on the desktop is a window on the world and that world emphasizes services rather than computers and networks. Information services appear as if they were personal computer programs and thus can be integrated with other familiar programs and utilities within the personal computer system. The NetMenu contains extensive descriptions of the information services and help files for use of the NetMenu. Secondary menus and multiple access paths provide levels of power and a sense of depth to the environment. These features of NetMenu as well as the users' familiarity with the personal computer all contribute to lowering the educational barriers to use of medical information.
devices for access (at present Apple Macintosh computers and IBM or similar personal computers), and a changing and potentially unlimited number of information resources. Our initial prototype environment is based on a menu of information services (NetMenu) which resides on a Mac (Figure 1). Beyond the NetMenu front-end are underlying communications programs which use local and national networks (Internet, Telenet) and phone lines to reach local and remote information resources. In a typical scenario a user turns on a personal computer, is asked for personal identification, and is then shown a menu of information services. Electronic mail, one of the basic underlying communications services, can be selected by clicking a mouse on the electronic mail icon at the bottom of the menu. When the user leaves the mail program, or any other service accessed through the menu, the menu reappears. Other information services are reached through pull-down menus under categories such as Library Services, Bulletin Boards, Education, Patient Care, Research Databases, and Administrative Affairs. Services which the user is authorized to use are shown in black; others are greyed out. The same services can be reached indirectly by clicking on the names of the categories to obtain descriptions of the information services. The descriptions can be used to "shop" for the most relevant sources of information. The description screens also have buttons to access the service described. Finally the same description screens can be reached from a comprehensive index of services, obtained by clicking an icon in the lower right corner of the menu screen. The variety of paths to access services is intended to reduce the frustration of "only one right way" and to meet the needs of users with different levels of experience. The primary menu is augmented by a banner menu at the top of the screen with items for (1) help with the NetMenu use or configuration, (2) direct access to computers rather than services, and (3) institutional information such as emergency phone numbers or campus maps. The banner menu items provide another level of power and complexity to accommodate users with more expertise. A key concept of IAIMS is integration. The initial NetMenu prototype provides basic connectivity, that is, access to a variety of information sources from a single familiar device. At a second level the operating system and utilities allow "cut and paste" mechanisms so that queries or results can be stored and readily reused from within NetMenu or the services it accesses. The present NetMenu accesses services sequentially; we are exploring means of connecting to
Technical Architecture and Issues The basic architecture of the prototype environment consists of personal computers on local networks, connected to University and national networks, and information resources available through these networks. The desktop level of the initial prototype is a HyperCard program running on an Apple Macintosh computer (Mac). This program calls communications programs through documents which contain configuration information and procedures (scripts) for automatically connecting and disconnecting from information services. Both high and low speed data communications media are used. The Mac is connected to a LocalTalk network which has a modem server for low speed communications. The LocalTalk network is connected to a campus-wide ethernet by a gateway which supports both AppleTalk and Internet protocols. The campus ethernet has gateways from Internet protocols to DECnet, and electronic mail gateways from the Mac electronic mail system (Quickmail from CE Software) to Internet mail, and from Internet mail to BITNET mail. The campus network is connected to the BITNET and Intemet national networks. Thus electronic mail can be sent and received from the Mac without ever logging on to another computer. Grateful Med (from the NLM) and Tincan (from Yale University) are the terminal emulation programs
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laboratory results. In the future we envision a network-based identification server similar to the Kerberos authentication server from MIT [3]. In summary, we have been able to construct a reasonable working prototype from existing software, and computing, and will use this prototype this fall in at least one duster of computers within the Computer Resource Laboratory of the Harvey Cushing/John Hay Whitney Medical Library. Some additional programming effort will be needed before distributing NetMenu more widely. In particular better scripting functions are needed to automate the use of communications programs. Furthermore Hypercard has been a productive environment for prototyping, but it may be necessary to move to a more powerful programming environment to accomplish some of the more research-oriented goals described below. We also need to provide similar connectivity for IBM personal computers. This appears feasible based on the existence of analogous tools and applications for IBM personal computers (indcuding Hyperpad from Brightbill & Roberts, NCSA Telnet for IBM personal computers, Grateful Med and Yale University's Yterm terminal emulator).
used to log onto to services over the modem server on the LocalTalk network. Versions of telnet and TN3270 from the National Center for Supercomputer Applications (NCSA) and Brown University are used to log onto text-based services over the Internet. MacX from Apple Computer is used to access remote services such as Prophet (Bolt, Beranek & Newman; Boston) which have user interfaces with windows, graphics, and mouse control. To automate logon procedures and thus lower educational and administrative barriers, we have relied on scripting. Grateful Med, Tincan and NCSA Telnet all have scripting and configuration features; we have used a separate macro utility (AutomacH) to provide scripting for TN3270. Further scripting improvements are needed to reach our goal of a single dick of the mouse to logon or logoff. Our initial collection of over thirty different information resources indudes communications services such as electronic mail and NetNews, traditional bibliographic and reference databases such as miniMEDLINE and Current Contents, decision support systems such as HT-ADVLSOR and LIPIDADVISOR, and a variety of educational programs. These services are provided either by logging on to remote programs, or by setting up a client/server relationship such as exists in X-window systems, or by sending requests to a server via electronic mail messages, or by using remote computers as remote file systems. Of the mechanisms we have tested, the client/server model appears to have the most promise for the future, in that the capacity of the personal computer is used for interactive tasks, servers are relieved of load, and the user interacts in familiar ways - for example point and click, or cut and paste - with services. One unresolved issue which we are still exploring is security. We must have a robust yet simple mechanism for identifying users and managing their access to services they are authorized to use. This requirement affects our technical environment at all levels from the desktop to remote services, and it also has implications for institutional policy. On a technical level traditional security depends on identifying users by passwords or physical keys, and determining access sites. The latter conflicts with the IAIMS concept of information "where it is needed", and thus identifying users may need to be more stringent. The NetMenu program provides access to multiple services which may each require identification. In the near term these requirements might be met (1) by having each user carry passwords on a key disk; (2) by using the same password for all services; or (3) by encrypting passwords so that they can only be used if the user presents the key for decrypting (a master password). More stringent identification might rely on password generating cards which are being tested in Yale New Haven Hospital for access to
Institutional Issues Many of the administrative and economic barriers to the use of information must be solved at the institutional level. The two issues which have most affected our prototype have been the related issues of creating infrastructure to support the environment, and developing a fiscally sound economic model. We have very little experience yet with support issues other than to say that there are clearly economies of scale at the desktop, and that a system which relies on so many pieces will require substantial support. One obvious element in providing support will be to use the network itself as much as possible. We are exploring the use of file servers to provide standard copies of software, configuration, and help files. The network might also be used to provide remote access to personal computers from a support center. The one aspect of IAIMS which is essential for its dissemination is an economic model consistent not with pilot experiments but with incorporation of information services into the basic fabric of academic medical centers. At one extreme information can be given away, however this can fuel a level of demand which cannot be met. At the other extreme, use of resources can be accounted for scrupulously, creating administrative barriers, overhead and financial disincentives to use. The model which we are using to charge for services tries to deal with these potential problems by
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creating three different cost recovery models for different categories of information resources. First any computer connected to the campus network is charged a monthly fee comparable to the cost of a telephone or low speed data line. For this fee the owner of the computer receives basic communications services (electronic mail, public file servers, file transfer, bulletin boards), access to institutional information (directories, calendars, course catalogs), and essential library services (Orbis, the NOTIS-based catalog of Yale resources), all of which are typically useful to Library all members of the community. Other services which are only useful to a subset of the community, which have a high but fixed cost, and whose use is selflimiting, are available for a fixed subscription cost. An example of this is a personal subscription to MiniMEDLINE and Current Contents search services for a yearly fee of $300. The third category of charges is for those services whose use of resources is not limited other than by charging for amount of resources used, for example DNA sequence comparisons, program development, private file servers, or genetic linkage analysis calculations. Most services provided outside of Yale conform to this last cost recovery scheme if not for the same reasons. It should be noted that our technical architecture and economic model lend themselves to management of costs and services because services should naturally follow demand, and because alternative means of providing services can be readily interchanged. Low use services may be provided initially by remote commercial services, then as usage increases they may be mounted locally on CD-ROM based servers, and later still mounted on minicomputer systems with faster disks, and yet all three versions may have been accessed from the same item on the NetMenu.
Prototyping as a Planning Tool: Final Comments Having spent months learning about IAIMS environments and prototypes being developed at other institutions such as Georgetown University [5] and Columbia University [6], and many more months discussing the issues involved in creating an IAIMS environment of our own, we have been pleasantly at how effective prototyping has been in surprisedour defining vision and in gaining institutionalof the support. It has also forced us to focus on many issues necessary to make our plans a reality, including user needs, an architecture for our technical environment, and institutional policies. It has been our experience that each of these areas individually and collectively contribute to lowering physical, economic, administrative, and educational barriers to the use of medical information and thus help foster the IAIMS vision.
Acknowledgements encouragement from our prototype. We who have reviewed of those many would particularly like to thank Carl Jaffe for his and support. This work has been ongoing interest in by NIH Grant T15 LM07056 and NIH supported part Contract N01 LM63524 from the National Library of Medicine. We have received advice and
References 1. West R. The National Library of Medicine's IAIMS Grant Program: Experiences and Futures. J. Am. Soc. Info. Sci. 1988;39(2):142-145. 2. Humphreys B, Lindberg D. Building the Unified Medical Language System. SCAMC 13, Washington, DC: IEEE Computer Society Press, 1989: 475-480. 3. Steiner J, Neuman C, Schiller J. Kerberos: an authentication service for open network systems. 1988: 191-202. 4. Clyman J, Miller P. An environment for testing advice-giving systems in medicine. SCAMC 14, Washington, DC: IEEE Computer Society Press, 1990: in press. 5. Broering, N. Strategic Planning: An IAIMS at Georgetown University Medical Center. Washington, DC: Georgetown University Medical Center, 1986. 6. Anderson, R. and P.D. Clayton. IAIMS at Columbia-Presbyterian Implementation Medical Center. New York, NY: ColumbiaPresbyterian Medical Center, 1988.
Related UMLS Research NetMenu has separate modules for menu access to services and for descriptions of services. We are presently using these descriptions and the information in our configuration and script files to produce, in collaboration with the UMLS project of the National Library of Medicine, a prototype Information Sources Map (ISM) . This ISM will then be integrated with our original NetMenu and used to select and access relevant information resources. We intend to use the resulting NetMenu/ISM to explore dynamic linking between applications programs, such as clinical decision support systems and other information resources. In particular, we are planning to use LIPID-ADVISOR [4] as a test case for both automated linking to LIPID-ADVISOR from other programs via the ISM; and for retrieval of information from diverse sources from within LIPID-ADVISOR, also guided by the ISM.
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