Being Digital.

The Media Laboratory at MIT was conceived by Professor Nicholas Negroponte and the then President of MIT in the late 1970s. It was completed in 1983 with funding from many philanthropies, corporations involved in multimedia communications, and private individuals. At the time, most faculty at MIT were involved in studying technologies for computer operating systems, programming languages, and disk drives. Negroponte predicts that all programming for television, radio, and cable TV; all information currently printed in newspapers, magazines, and books; all interactive entertainment in video games and personal computer software; and all personal communications by standard and cellular telephone service will convert to digital format and will merge into one digital stream that intimately incorporates the emerging personal computer as the translator and router. Producers of information proggramming will have many digital avenues for distribution of their products, but all of it will be in digital format and will flow through the successors to the personal computer to your attention. But being digital means much more than receiving the same type of information in a new, and transparent, format. It means receiving services and products hitherto impossible in the analog format. These new products and services will transform the ways we practice medicine and the ways we manage health care.

There are many differences between analog and digital communication, but two stand out in importance. Digital communication permits the recipient, or an automated agent, to interpret and edit a received bit stream before viewing what the bit stream brought. And digital communication fits comfortably in a smaller electromagnetic spectrum than analog signals require, meaning that senders of information can pack more information into the signals they use to convey information to customers. The consequences to us, in terms of new functions and services we will enjoy, of the powers of data correction and data compression on digital data flowing into our lives are not defined in most publications about the information age. Negroponte makes them very clear. He argues that they usher in the "post-information age," defined by our ability to act on, modify, and change the information streams coming to us and to make them uniquely suited to us. In the information age, we were washed by floods of mass-produced information that everyone received in the same format and at the same time. Again, the implications of these changes for patient care are profound. These technologies will free us of the homogenizing influence of so much mass media and give us our schedules and our preferences back.

When an analog television show is on, you must watch it then, or program a VCR to catch the show in analog format to watch later. The VCR is cumbersome to use, and only about two hours of programming fits on one tape. Most of us schedule our time in front of the "tube" to attend to programs we want to watch. We watch them passively, as countless social scientists have reminded us. We modify our schedules to fit the schedule of programs. Would it not satisfy us more if we could program our personal computers with our preferences for subject matter to watch at home, or in the office, and trust that agent to sift through the sports broadcasts for the sports and teams we follow, the news subjects of importance to us, the people whose lives we want to study, the scientific subjects about which we want to learn more, and the material we consider entertaining? Think of the thousands of hours you have "wasted" in front of television watching advertisements for products you will never buy and have no interest in. Think of the tens of thousands of hours your children will consume in the same way, until the bit streams into their homes are digital and they have intelligent agents, in the form of personal computers, screening out what they do not want to see, and having what bits they do want to save compressed and stored on rewriteable optical disk drives in those computers to be viewed and interacted with at their own time, on their own schedules.

The newspaper arrives in the morning looking the same at every home and office that receives it. Most of the information does not interest us. We skip it to find the few articles that may be of use, but we have to scan whole sections, and all the titles, to find the few we want to read. One morning newspaper arrives daily for hundreds of thousands, or millions of individuals in a metropolitan area. Think of the wasted type and paper and effort to deliver those papers to their destinations. And less than one hundredth of one percent of the articles, advertisements, and photographs are kept for posterity because they meant something special to some individuals. The newspaper is the hallmark of an analog communications medium meant to take advantage of mass production, with huge printing presses and large delivery trucks and mass marketing.

But think of all the magazines you receive with articles you don't want to read, and advertisements of no interest to you. By your subscription fees, and the prices you pay for the products and services advertised, you pay for the production and distribution of all the content that is not of interest to you. Think of the tens of thousands of articles published in medical journals every month. Most of us receive several, perhaps as many as 10, professional journals a month. Until our children are grown, we may be lucky to read one fifth of them. We may scan the index of each issue but have time to read relatively little, because we have to schedule ourselves to watch the evening news, or a sports event, when the broadcaster sends it. And we sit there wasting 20-30 percent of the time scheduled for the programming we want to watch consuming advertising of little interest to us. On the other hand, if I am considering the purchase of an automobile I might want to watch several hours of focused advertising on automobiles. But the automobile manufacturers have no way of identifying me with that sort of interest, so they must broadcast the same thirty seconds of glitzy advertisements to everyone, wasting the time of most everyone watching.

Wouldn't it be better if physician executives had an automated agent programmed, say, by the National Library of Medicine to operate searches of the literature retrospectively, sifting through incoming professional literature for materials of particular interest to us every month and producing for us our own listings of articles most likely to be of interest? Wouldn't it be better to call up on a home computer detailed engineering promotions of the latest automobiles when we are ready to purchase an automobile?

Our society is just beginning to convert from analog to digital distribution of public information to home and office. I say public because private information of corporations is almost entirely digital and is distributed between computers by local and wide area networks. But those are data on customers, sales figures, and production numbers. Annual reports are still broadcast in an analog brochure to every shareholder. Company newspapers and magazines still are mass produced and distributed to employees by analog mail (via interoffice mail or the postman). When we travel, our itinerary and reservations are held in digital format by airlines and hotels, but we read standard analog airline magazines and hotel visitor guides that are developed and printed with the average traveler in mind, not for you as an individual. In an analog world, mass production reduces the costs of producing each individual unit. In the digital world, we can interpret the streams of bits of information coming at us to select what we want to watch, and know about. And merchants, including airlines and hotels, can build up digital portraits of us, of our preferences and tastes, to deliver to us the products and services we most value.

What does it really mean for information to be digital? On one level, it simply means the words, or numbers, or images (moving or still), or sounds that were stored on paper, or on film, or on tape are stored as streams of bits on magnetic or optical disk drives and are moved from place to place as streams of electron$ or photons. But that misses the point, or, rather, two points. it means the information is stored electronically, in a weightless state, and can be moved anywhere in the world in seconds with very low incremental cost, instead of on relatively heavy paper that can only be moved with considerable effort, in trucks. Most important, it means the sender can afford to customize the packaging of information for individuals at far less cost than he would have to pay to customize the packaging of printed information, and the recipient can act on the incoming information to select only those subjects, programs, and topics of interest and to store them electronically for consumption at leisure.

What does this conversion from moving atoms of information to bits of information mean to physician clinicians, physician executives, and patients? Everything. The same opportunities to customize the timing and content of digital information apply for individual patients, their family members, and their physicians. Instead of managing care actuarially, where the unique characteristics of all patients are averaged into homogeneous age and sex cohorts and their costs of care are predicted en masse, we will be able to manage their care epidemiologically, with specific data on each patient gathered from health risk assessments, functional status surveys, and claims data, all used to predict accurately the likely ailments patients will suffer and their costs of care.

With accurate information on individuals, we will practice prospective medicine, with clinicians working with individuals to reduce their likelihood of suffering accidents and occurrence, or recurrence, of acute exacerbations of chronic illnesses. The concept of prospective medicine was first promoted more than 30 years ago, but digital data on individuals, and the personal computers to manipulate those data, have become available only recently. This will break the hegemony insurers have over providers, in that insurers keep datasets of claims but attempt to manage the care of populations in the old way, with gross actuarial predictions by large subpopulations.

Health care providers should welcome the dawning of the era when they can manage the health of populations far more precisely, managing each individual's care specifically, and before a person's health deteriorates and he or she appears in an emergency department. The key is the migration of the information about specific patients that is now stored in atoms of medical records to electrons of computer-based patient records shared by providers in organized delivery systems. Those electrons will permit providers to manage care surgically, predicting the likelihood of bad outcomes and intervening to prevent them for individuals.

Insurers do not have access to the medical record and cannot manage care epidemiologically. They can assemble summary medical records from claims, but they do not have clinicians' findings at history and physical examination, or from laboratory and radiology studies, to give them resolution into the real conditions of each patient. Providers can take back much of the control of their patients, which they feel they have lost to insurers, by investing in building organized delivery systems that they own, and control, and by investing in the electronic information processing infrastructures to produce the computer-based patient record-moving from atoms to electrons for the storage of their patients' records. Then computers can interact with those electrons to give physicians management possibilities they never had before. They can prescribe specific health promotion information, periodic risk screenings, diet and exercise training, advice about medications, and training to help patients take better care of themselves.

With medical records stored in electrons, manipulated by powerful computers, moved from place to place effortlessly by electronic telecommunication networks, and stored in large databases designed for retrospective health services and clinical research, physicians will have more tools with which to measure the outcomes of their patients, including the costs of their care, and more tools to gauge the practice habits of their peers in the organized delivery system than they ever dreamed possible. Manufacturers learned long ago that they needed to move the information in inventory, assembly, and warranty records into electrons, and analyze those data by computers to identify the suppliers of parts leading to the greatest warranty costs for them. Armed with specific data, they can approach suppliers and insist they improve their parts or face losing the opportunity to supply those parts.

Health care organizations need to learn the same lesson. Data and information stored in the atoms of paper do little good to the organization after the transactions they record have passed. They do not provide a resource for later retrospective analysis seeking opportunities for quality improvement and cost control. At least, they do not give up their secrets easily, not without expensive manual chart review. In health care, the same rules apply. Clinicians in any given specialty rarely know how physicians in their specialty practice, because they do not refer to physicians of the same specialty. Unless they cross-cover for one another, they do not see each other's patients. Yet clinical departments of physicians are expected to develop practice guidelines together and to work systematically to improve clinical care among themselves. This is wishful thinking, at best, until physicians are in the same economic unit, a group practice or capitated physician organization of some sort, and no longer face each other as courteous competitors.

Beyond the politics is the huge obstacle to continuous quality improvement of data about patients stored in atoms of paper. The discharge abstract of inpatients is available, but it only includes the services provided, diagnoses, and procedures for the patient. In the electronic discharge abstract are none of the findings of clinicians at history and physical examination or, laboratory study that explain their decisions for treatments. Pharmaceuticals are also not included in the discharge abstract. The medical record needs to be stored in electrons so that studies of the characteristics of patients and the clinical decisions of physicians can be made relatively effortlessly, by database analysis with statistics software.

When we think of computer-based records, we tend to think of computer terminals where we need to chart our notes, enter our orders, or look up results, as if the medical record were pasted on the computer screen the way text and number about patients are attached to paper. We may think of the computer keyboard with trepidation, or loathing, because it is harder for most of us to use than pen and ink. We know how to thumb through paper intuitively. We have more difficulty searching for specific data in cyberspace. These uneasy thoughts about computer-based patient records show we are thinking of the computer as a substitute for paper. We are not considering the new services, new functions, and additional actions we can take that empower us as clinicians to deliver much better clinical care than we ever could before, when the information about patients is transformed from atoms of paper to electrons in, and whizzing between, computers.

In subsequent articles in this column, I hope to elaborate on the implications of moving information about our health plan members, and our patients, from atoms to electrons. But right now, I want to urge you to enjoy Negroponte's new book.

HEALTH CARE BYTES

I've just finished reading an understated gem, Being Digital, by Nicholas Negroponte, Professor of Media Technology and Founding Director of the Media Lab at MIT. It is a small hardback, less than 250 pages, without a single arcane term and with no equations at all. Yet it presents the implications of our migration from analog to digital communication with humor, grace, and simple grandeur. He sums up our conversion from analog to digital with the disarmingly simple statement that we are converting from moving atoms of information to moving bits of information, and therein lies all the difference. It takes reflection during reading to appreciate the meaning of such a simple statement. But when you appreciate what he means, you'll thank yourself for taking the time to read what he wrote. This is a great book for a long airplane flight, or a weekend retreat, if you enjoy learning about science and technology by broad brush strokes of enthusiastic prose, full of import without technical detail.

Marshall Ruffin, MD, MPH, MBA, FACPE, is President and CEO of The Informatics Institute. Until he started the Institute, he was Clinical Information Officer, INOVA Health System, Falls Church, Va. He continues to consult to the Informatics Department of that organization.