The first integrated circuit was as- sembled in 1958, leading to the development of the mi- croprocessor by Apple in 1976 and the IBM personal computer in 1981 ...
Pediatr Cardiol 21:324–327, 2000 DOI: 10.1007/s002460010073
Pediatric Cardiology © Springer-Verlag New York Inc. 2000
Original Articles The Impact of Information Technology on Pediatric Cardiology: Present, Past, and Future V. Grech Pediatric Department, St. Luke’s Hospital, Guardamangia—Malta
Abstract. Inexorable progress in information technology has been the driving force behind much of the progress that has been achieved in the fields of pediatric cardiology and cardiac surgery since the inception of these two subspecialities during the middle of the 20th century. This article outlines the influences of the digital age and speculates on likely future developments in these two subspecialities. Key words: Heart defects, congenital — Information systems — Databases, factual
Information technology refers to any equipment or interconnected system or subsystem of equipment that is used in the automatic acquisition, storage, manipulation, management, movement, control, display, switching, interchange, transmission, or reception of data or information by the executive agency. The term “information technology” includes computer, ancillary equipment, software, firmware, and similar procedures, services (including support services), and related resources. Information technology, as we know it today, originated approximately 50 years ago. At the beginning of the 20th century, slide rules were used extensively in order to perform complicated calculations. In 1944, the first mechanical calculating device, “Mark I,” was constructed. In 1946, ENIAC, the first electronic calculating machine, was built. The first integrated circuit was assembled in 1958, leading to the development of the microprocessor by Apple in 1976 and the IBM personal computer in 1981, thus paving the way for the electronic computers of today. Unceasing progress in microprocessor technology has led to ever-increasing computing power, both at the institutional level and at the individual level. These changes have been paralleled by a reduction in computer size. I briefly detail hardware upgrades that have occurred over the years. Computing power is a function of several
factors. The speed of the central processing unit (CPU) is crucial. During the past 12 years, CPUs have undergone many generational leaps, from 8086/8088 processors to (80)286, (80)386, (80)486, Pentium, Pentium II, and Pentium III. Each generation has resulted in a significant increase in processing power. A 286 personal computer (PC) 10 years ago typically ran at a clock speed of 16 MHz. A new PC will now run at about 850 MHz, a 30-fold increase. However, the actual increase in computing power is far greater than 30-fold because the number of calculations that can be carried out per unit time (i.e., during each clock cycle) is at least four times greater. This increase in computing power has held true since 1965, when Gordon Moore, then the head of research at Fairchild Semiconductor Corporation, noted that computing power was doubling, at a constant cost, every 12 to 18 months. He predicted that this trend would continue for another decade. Moore’s estimate was conservative in that this phenomenon has held true for the past 30 years and has made electronics the world’s biggest industry and Moore’s next company, Intel Corporation, the world’s richest chip maker. On-board memory [random access memory (RAM)] has also undergone several generational leaps in terms of speed of operation. In addition, the price of RAM has also decreased. This has resulted in an increase in the amount of RAM available on a typical PC. Ten years ago, the typical amount of RAM was on the order of 2 MB. Now, the typical amount on a new PC is on the order of 128 MB, a 64-fold increase. Hard disks have also become faster and of larger capacity. The typical capacity on a PC 10 years ago was approximately 40 MB. A new PC will typically have a 10-GB hard disk, a 250-fold increase. The massive increases in speed and capacity of hardware and the reduction in size have allowed the development of ever more sophisticated and user-friendly software. The latter encourages the purchase of entire systems for home use. Increased volume of sales results in decreased unit manufacturing costs, and competition between hardware and software manufacturers further
Grech: Information Technology and Pediatric Cardiology
decreases prices for the end user, whether at the institutional or individual level. These features have influenced the practice of pediatric cardiology and cardiac surgery in several ways.
Imaging Pediatric cardiology, by its very nature, is very imaging intensive. Since the heart is a continually moving object, dynamic forms of imaging are crucial. Cardiac catheterization pressure tracings and angiography were the only dynamic forms of imaging prior to the advent of digital technology. The availability of cheap computing power has allowed imaging to expand dramatically. Echocardiography machines are completely reliant on real-time electronic processing of ultrasound reflections, and computing advances were reflected in the capabilities of successive echocardiography machines. Abilities progressed from M-mode only, to two-dimensional images, pulse and continuous-wave Doppler, color Doppler, and to 3-dimensional echocardiography [9]. The latter allows reconstruction of structure(s) in a rotatable matrix, onscreen, from a series of two-dimensional images. In this way, novel views of structures can be created. Real-time volumetric images of the heart also allow assessment of ventricular volumes, function, and muscle mass. Newer echocardiography machines routinely have the capability of saving images not only in analog format (i.e., to videotape or hard copies) but also in digital format to disk, as single images or as cine loops. The standardization of saved image formats permits the exchange of images between clinicians in different centers [8]. Other imaging techniques used in pediatric cardiology that were not possible prior to the advent of digital processing include computerized axial tomography, magnetic resonance imaging, and digital subtraction angiography [15]. Analog investigations have also benefited from digital techniques. Electrocardiogram machines have become smaller and can also produce digital output. X-ray machines can save images directly in digital form by receiving radiation onto sensors rather than photographic film. Similarly, angiography is a purely analog technique which relies entirely on the sequential recording of images onto photographic film. Modern catheter laboratory equipment can save sequential images in digital format rather than to film or tape [21].
Patient Records Databases have many advantages. Foremost is the saving of time, with instant access to a patient’s record, and summarization of key information on-screen [12]. Databases also save time in audits and when patients with
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particular characteristics need to be identified for research purposes. Data can be output directly to a spreadsheet or a statistical package for the purposes of audit or statistical analysis or for the direct production of graphs and tables which summarize data and are inherently easier to understand [12]. Databases also make it easier to exchange information between centers. If sufficient information is gathered for each patient, databases can also be used to generate patient summaries [12].
The World Wide Web Cyberspace has much to offer to health care professionals. Medline and related literature databases, formerly available only on CD, are now available on-line [2]. Similarly, electronic versions of journals are also available on-line. Some journals publish partly conventionally and partly on-line (e.g., Pediatrics), others duplicate the conventional journal on-line (e.g., British Medical Journal), whereas others publish exclusively on-line (e.g., Images in Paediatric Cardiology, which can be found at http://www.magnet.mt/health/impaedcard), with subsequent saving in publishing costs [1, 3]. Many sites dealing with various aspects of pediatric cardiology are also available. Most are aimed at the lay public, but some sites dedicated exclusively to medical professionals can also be found. One prime example is PediHeart [4]. PediHeart is defined by its creators as “a mailing list on the Internet. The purpose of PediHeart is to provide a means of communication for health care professionals involved in the care of children with heart disease.” The system was launched in 1994 and currently boasts approximately 1000 members worldwide. Queries or comments aimed at the pediatric cardiology community are e-mailed to the listserver, and all the members receive the messages and replies/comments to said messages. The Internet also allows cheap and instantaneous connectivity between health care professionals through e-mail. Moreover, digital copies of images can be exchanged as e-mail attachments.
Telemedicine Telemedicine is defined as the “delivery of health care and sharing of medical knowledge over a distance using telecommunication systems” [20]. Telemedicine links are becoming widely available and imply the creation of dedicated channels which are used for the transfer of patient information from one health care professional to another. Such systems can function over the Internet or can use dedicated integrated services digital network telephone lines that allow users to simultaneously transfer voice, video, and data at speeds much faster than
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today’s fastest conventional modems. Telemedicine can be used for teaching purposes and for giving advice about medical management of patients, even under battlefield conditions [22]. Telemedicine is most widely used in the field of radiology, followed by cardiology [20]. A remote observer may use this technology to advise regarding a patient. For example, a cardiologist may give advice to a peripheral hospital by viewing a patient by means of a video camera and by discussing electrocardiograms and x-rays which may be viewed via a video camera or scanned and e-mailed. Alternatively, if a highbandwidth link is available, an echocardiogram performed at the peripheral hospital may be reviewed by the cardiologist in real time and appropriate advice given.
Intensive Care Settings Monitoring equipment has decreased substantially in size due to the use of integrated circuits and liquid crystal displays. In intensive care units, monitors, equipment, and pumps can be digitally linked to a central computer that not only monitors and displays ongoing activity and trends but also can be used to control active functions, such as pump infusion rates, from a central point [11]. On-line references to therapeutic information can be very useful, and spreadsheets can be designed to calculate dosages of drugs and fluids by weight.
Mathematical Modeling Engineers can help to design mathematical models of operations conceived by surgeons. Such models allow surgeons to not only assess the effects of an intervention on the circulation but also to incorporate improvements which may be suggested by such models [7].
Likely Future Developments Computer-based expert systems will develop further. Algorithms will be available as computer programs that will help clinicians to establish diagnosis by entering the results of a logical sequence of signs and simple investigations if access to a human expert pediatric cardiologist is not readily available [10, 13]. At the individual level, data-entry level will become easier. Existing voice recognition programs can be used to enter data or type letters into various software packages. Some programs also allow the user to access menus on the active program. For individuals who find writing easier than talking to a computer, optical character recognition software will continue to improve in accuracy and will also be able to recognize ordinary handwriting [16].
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Telemedicine links will continue to evolve and will allow not only remote advice regarding diagnosis and management but also actual interventions to be carried out on patients by means of remote manipulators, a process known as telepresence surgery [5, 6, 14, 17]. Telepresence surgery may eventually be applied in the field of pediatric cardiac surgery, although the size of patients and the criticality of such operations makes this difficult. Expansion of the bandwidth on the Internet will allow larger quantities of data to be transferred between medical staff in different centers in shorter periods of time. This will facilitate, for example, the transfer of echocardiography and angiography loops. Video conferencing will become commonplace. It will also be possible for a patient’s individual record to be held on a single disk, a copy of which could also be kept by the patient. This disk may contain not only textual information such as case notes but also imaging information in the form of static images, such as x-rays or electrocardiograms, or dynamic images, such as echocardiography or angiography loops [18]. The establishment of the DICOM common standard allows different centers to view the same compressed imaging loops [8]. Formats for data storage will evolve from standard CD-ROM to DVD-ROM. DVD-ROM has 20 times the capacity of CD-ROM, allowing literally hours of film, such as angiograms and echocardiograms, to be stored. Should an international pediatric cardiology database format be agreed upon, access to patient records, including imaging information, could be further simplified. Such records could potentially be entered into a single central database, in which global results for epidemiology, diagnostics, surgery, and outcome could be readily studied. Training for surgeons may be assisted by virtual reality equipment, including visor and gloves with force feedback. Such equipment would allow the operator to practice procedures before actually performing them [19]. Who knows, we may even reach the stage of the true paperless office. References 1. Abdulla R (1997) Pediatric cardiology and the electronic literature. Pediatr Cardiol 18:321–322 2. Benson M, Kjellmer I, Rosberg S, Billig H (1997) Can pediatricians benefit from the Internet? Arch Dis Child 77:179–182 3. Bingham C, Coleman R (1996) Enter the Web: an experiment in electronic research peer review. Med J Aust 164:8–9 4. Birek A, Jue K, Kimura YF, Moazamipour H (1997) PediHeart: pediatric cardiology and cardiac surgery on the Internet. Pediatr Cardiol 18:323–325 5. Bowersox JC, Cordts PR, LaPorta AJ (1998) Use of an intuitive telemanipulator system for remote trauma surgery: an experimental study. J Am Coll Surg 186:615–621
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6. Corker K, Lyman JH, Sheredos S (1979) A preliminary evaluation of remote medical manipulators. Bull Prosthet Res 16:107–134 7. de Leval MR, Dubini G, Migliavacca F, et al (1996) Use of computational fluid dynamics in the design of surgical procedures: application to the study of competitive flows in cavo-pulmonary connections. J Thorac Cardiovasc Surg 111:502–513 8. Elion JL (1995) DICOM media interchange standards for cardiology: initial interoperability demonstration. Proc Annu Symp Comput Appl Med Care 6:591–595 9. Fiegenbaum H (1996) Evolution of echocardiography. Circulation 93:1321–1327 10. Franklin RC, Spiegelhalter DJ, Macartney FJ, Bull K (1991) Evaluation of a diagnostic algorithm for heart disease in neonates. Br Med J 302:935–939 11. Friesdorf W, Gross-Alltag F, Konichezky S, et al (1994) Lessons learned while building an integrated ICU workstation. Int J Clin Monit Comput 11:89–97 12. Grech V, Pace J (1999) Automation of follow-up and data analysis of pediatric heart disease in Malta. Int J Cardiol 68:145–149 13. Habashi MS, Abdel-Bary MA (1991) Disturbances of impulse formation: an expert system for ECG interpretation. Med Inform (London) 16:29–41
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14. Kassell NF, Downs JH III, Graves BS (1997) Telepresence in neurosurgery: the integrated remote neurosurgical system. Stud Health Technol Inform 39:411–419 15. Longmore D, Forbat S (1992) Studies of the heart using magnetic resonance. J Cardiovasc Pharmacol 19(Suppl 5):S87–S111 16. Massengill SP (1992) Image-based document management systems for medical records. Topics Health Rec Manage 12:40–48 17. Rininsland HH (1993) Basics of robotics and manipulators in endoscopic surgery. Endosc Surg Allied Technol 1:154–159 18. Ripley RC (1995) Cooperative efforts between tertiary-care centers and outlying hospitals boost imaging services and transfer technologies. J Cardiovasc Manage 6:24–26 19. Satava RM (1995) Medical applications of virtual reality. J Med Syst 19:275–280 20. Thrall JH, Boland G (1998) Telemedicine in practice. Sem Nucl Med 28:145–157 21. Van Meurs BF (1995) Information management in the cardiology department. An analysis of current options for replacing cinefilm. Int J Cardiol Imaging 11(Suppl 3):159–163 22. Vassallo DJ, Buxton PJ, Kilbey JH, Trasler M (1998) The first telemedicine link for the British Forces. J R Army Med Corps 144:125–130
