Abstract: This decade has brought great changes in social, moral, economic
and governmental attitudes toward public and personal health services and acceptable
procedures for their optimization. Along with these changed attitudes there
has developed a large body of transferable technology, particularly in the areas
of microcomputer application, automation, electronic communication, information
processing and education. “Personal participation” and “Do it yourself” are
heard everywhere as the costs of professional medical services soar and personal
concern for the patient diminishes. This may be a healthy and cost-effective
development that can be accelerated and facilitated by properly designed feasibility
demonstration projects, but it certainly has new and unfamiliar dangers that
need to be discovered and protected against. You will be asked to offer your
ideas and value judgments in developing and critiquing one four-stage scenario
for development in this arena emphasizing the role of modular dedicated home
medical instrumentation and computer-aided telecommunication with the necessary
paramedical education and possibly certification of participating patients and/or
their family “aides”.
Systems analysis has been talked about the considered in various contexts during the last few years until it became first a bandwagon to be climbed on, then a buzzword to be used mouthed by the elite who presumably understood it, Lately it has become a dubious idea, probably because it has shown so little demonstrable productivity. This low productivity is probably to be blamed more on the lack of solid data in a form suitable for analysis and a lack of understanding of the principles of technology transfer than on the methods of system analysis proper. Moreover, we are not aware of the fundamental lack of epidemiological data, especially in the health field, regarding health style preference given familiarity with available options.
What I am doing today is feeling my way into a feed-forward systems analysis synthesis of a projected medical-health care delivery life style or set of optional life styles to be examined deductively by feasibility tests and factorial analyses. In effect, the task is to create a scenario of a projected health system and then examine it by thought experiments, recruit new components by offering categories into which new bioengineering or adaptation of old can be fitten and then, if the results seem viable, consider doing the education, marketing and political facilitation to bring a new system into being.
I want to put together today such a scenario in three parts; a three act play
with each succeeding act less specific than the previous, but each backed by
firm, already existing transferable technology. You will notice that I have
provided forms for your convenient participation and I hope you will get into
the act as we go along, even though your participation may keep us from finishing
within the hour. The forms will give you a choice today or for later return
to assure your contributions or your warnings against ideas that might be proposed
by me or by others.
What I am going to propose is an implementation for progressively increasing technical participation of the individual and his or her immediate family in health care and even family medical procedures of preventive maintenance, diagnostic “how-goes-it” procedures, and therapeutic measures. Obviously this will create real concern about practicing medicine without a license, susceptibility to all sorts of fraudulent medical quackery and dangerous self medication - even encouragement of psychosomatic disease. These are legitimate problems, but problems that I believe can be solved and be worth solving. These problems we can take up later; for the present let us consider the feed forward principles on which the scenario is based so that you can examine the credentials of the underlying factors on which I base my design.
I would like to state these credentials in the form of declarations about the changing world in which we live and the expected further changes to become reality during the span of about fifteen years in which I predict we can bring about the beneficial optimization which I envision. Let us examine these individually.
1) Standard medical care via centralized medical facilities, e.g. HMO clinic, group practice, individual self-sufficient general practitioners, is outgrowing our ability to pay via individual, government supported, employee supported health insurance and subsidy. It's inflation rate is approaching twice the already alarming general inflation and GNP rate.
2) Individuals are, to a large extent, becoming critical of “doctors orders” passive acceptance of diagnoses and therapies based on brief impersonal visits with internist and ordered tests and specialist studies, They would welcome an opportunity to learn of individually available options with relative costs, necessary paramedic training and anticipated improvement in health satisfaction.
3) Do-it-yourself technology is on the upswing with sharp labor cost rise and restriction of labor supply to maintain income for professionals as with labor.
4) Microcomputers are becoming a household appliance and can be freely incorporated
into products in the $25 - $1000 range. The status symbol of the home computer
“A microcomputer lives here” is likely to rise rapidly for at least five more
years.
5) Taboos on discussion of bodily functions are rapidly disappearing and must not be expected to reappear in the near future, e.g. regular newspaper and TV discussion of sex and its mechanics, cathartics, tampons, abortion, AA, chemical dependence, even relative flatulence ratings for various types of beans, are becoming routine and are apparently accepted without major recoil.
6) A major portion of our population, including many with advanced informal and/or formal education, are disillusioned with the paternalistic articles of faith; God, interfaced by his local representatives, will take care of you automatically if you behave yourself: the government will take care of you if you behave yourself; your doctor will see that your health is well taken care of if you behave yourself and take his advice; the government will take care of providing an optimal health and medical environment.
7) An increasing and already large fraction of our population is becoming comfortable with using and interacting with sophisticated instrumentation including measurement equipment, control and processing equipment, telemetry equipment. Examples are a) microwave ovens with microcomputer control, b) computer remote terminals, e.g. school computer terminals, bank terminals, c) general aviation flying, d) word processing typewriters, e) computer programmed photocopy machines, f) 40 channel single side band CB transceiver and scanners, g) computerized cameras. This is especially true of a large segment of women who have in previous years “left those tricky things for the menfold”.
8) We are very slowly but definitely moving toward more intimate interaction with technically prosthetic devices that intrude into the previously sacred body functions, physiological (implanted pacers, pain alleviators, dialyzers, sphincter controls”, mental (biofeedback, speed reading, meditation, epilepsy therapy), diagnostic (CAT scan).
We cannot legitimately contemplate going into even phase 1 of this patient
participatory health era without giving great attention to controls and educational
procedures to prevent gross misuse of a new freedom, an encouragement to hypochondriacs
and those with mental aberrations. A new kind of consultative medicine will
need to he offered with some of it best conveyed by other technically skilled
personnel beside the physician. This we might reserve for discussion.
A particular feature that I consider especially important is notably absent in the medical and health area. This is the mini-certification or licensing training for a special technology. With the notable exception of daily insulin injections in millions of homes, we do not, in general, trust a non-medical individual to use a hypodermic syringe and needle. This is an easily taught set of procedures but one dangerous if done intuitively or thoughtlessly. Wound dressing of a particular kind is tricky but easily learned. Electrocardiographic interpretation for monitoring, especially in the case of a known disease condition, can be learned in a few hours. Graphical plotting of data and interpretation including an understanding of expected daily patterned variation can be understood by intelligent laymen. Speech therapy in stroke recovery, muscular rehabilitation, therapeutic massage, stethoscopic monitoring of chest sounds, basic clinical chemical tests on urine, even blood, can be easily learned as technical procedures not requiring insight into underlying biochemistry or physiology.
Each procedure can be the basis of a “minicourse” to be rewarded, upon successful completion and passing of a simple practical examination, with a dated certificate for limited practice with a refresher checkup after perhaps a year. Many individuals, after completing perhaps a dozen of these minicourses, will become valuable health aides and are likely to be unusually well prepared to cope with health emergencies at home and in the general environment.
State courses with certification of this type are very common in other areas
of technology. There are several classes of licenses for amateur and professional
radio operators. There are private pilot licenses in aviation with special provisions
for instrument flight, etc. Auto drivers licenses are familiar with special
truck or chauffeur classes. We could easily see a family of civilian medical
technology and nursing arise similar to the many small societies for hobby computers,
gourmet cooking, arts and crafts and the like.
Now we can begin to indulge our fancy in examination of some specifics. Who are the candidates for home medical participatory care and to what level should the care go? There is certainly the “how goes it?” family of tests that we should all do but which most of us neglect. Daily or weekly logging of even a few vital measures will give us alerting data; heart rate, blood pressure, weight, urine sugar, perhaps a dozen in all including even a subjective completion of a check list will often give assurance or an alert. We may even discover the real pattern of meaningful rhythms that are often disclosed by such measurement in contrast to the nonsensical but apparently intriguing biorhythms that are now being computed for millions of people.
Next those in the family of therapies and maintenance procedures such as metered exercise, not only muscular in the gross sense but correction of chronic disease, sensory exercises as with vision and digit manipulation and coordination, even my own pet - mental jogging.
Finally there is the investigative - tutorial family of procedures especially well implemented by the computer access to advice personnel and coded literature accessible by micro.
Let us now plunge into the possible gadgetry that could occupy stages 1 and
2 particularly. I have been impressed to see the value judgments regarding suggested
instrumentation. Some that I thought were sure things are considered doubtful;
some of what I considered far out are taken to quite fondly. Look at a few of
my first order lists and make your comments as we go.
1. Self-standing dedicated biomedical instrumentation privately affordable for purchase or lease.
2. Microcomputer supported modular system with special purpose modules plug gable into basic inexpensive home computer utility mainframe.
3. Dialup linkage of stage 2 microcomputer system to public data bases and HMO clinical facility or private priysician accessing technician, paramedic, physicians assist, probably utilizing sloscan video mode as well as ASCII.
4. Affinity networking of system 3 to educated short courses literature search, preparation of material for public TV access, lobbying and initiative -referendum actions.
1. Tremor meter
2. Skin temperature
3. Instant body (core) temperature
4. Card iotachometry
5. Electrocardiograph
6. Cardiorhythmometer
7. Pacemaker check
8. Perfusion meter
9. Jogging - exercise alarm
10. Blood pressure
11. Alcohol level meter
12. PVC monitor
13. Pregnancy detector
14. Sperm count - activity meter
15. Saliva analyzer
16. Breath expulsion meter
17. Muscle strength
18. Skin heat flaw
19. Fattiness meter
20. Urine analyzer
21. Pain threshold
22. Pulmonary impedance meter
23. Eye tester - accommodation
24. Ocular tonometer
25. Pupillometer
26. Breath analyzer
27. Environmental air quality monitor
28. Bruxis monitor
29. Audiometer
30. Blood drop analyzer
31. Pain threshold
32. Gastric acidity
33. Gastric motility
34. Hand - eye coordination
35. REM recorder
36. Infant heart beat, respiration, temperature
37. Wet diaper monitor
38. Epileptic monitor
39. Holter type monitor - multivariate
40. Circadian rhythm monitor
41. Pneumatic sequential massager
42. Skin temperature, heart rate, E~ biofeedback
43. VCRS pacer
1. Chronobiological sound competition for the “Biorhythxn” faddist
2. Should I go to the doctors?
3. Diet planner-evaluator
4. Paramedic packages
5. Exercise pacer with safeguard monitor
6. Diabetic evaluator, insulin recommender
7. Environmental evaluator-modulator: temperature, gases, humidity, air circulation, lighting, odors, background sound
8. Health data file and reminder - link to portable medical record
9. Mental jogging program
10. Certification program training
1. Status report for FY10 or physician's interactive conference, will immediately present key work-up data without preprocessing
2. Cardiovascular, infectious disease, psychiatric, etc. advisory and test programs - probably one memory package each
3. Hardwired interface to self-standing monitoring and. test instrumentation control and interpretation packages
4. Therapy control and advisory packages, probably containing vocalization sections
5. Literature look-up with personal consulting loop
6. Print up your more valuable data (with illustrations) for subsequent use, vocal interpolations available
1. Group conference meetings with tutorials
2. Group action meetings for initiative and referendum
3. Link to public TV programs
4. Emergency aid personal supervision with one or two way sloscan video
5. CB channel 9 link-up and mobile-marine auxiliary
6. Neighborhood paramedic intermediate facility