Back when he worked in Silicon Valley, Paul Tang, M.D., believed that the greatest test of medical information systems lay in how they handled outpatient care.
Now, in his fourth year as medical director for information systems at Northwestern Memorial Hospital in Chicago, Tang is putting the kind of computer programs he once designed to the test. Tang is in charge of implementing a $20 million patient-records system at Northwestern, which was launched in conjunction with a $580 million construction project that includes a new, 2 million-square-foot inpatient and outpatient center. The records system has been installed over the past two years in two physician-group offices; the scheduled six-year rollout for the hospital, 1,200 affiliated physicians and an affiliated diagnostic center won't be complete for at least another three years.
Tang, 44, isn't in charge of the hands-on tweaking of the nuts and bolts of the system; for that he reports to a chief technology officer who has technical but not clinical training. Tang's job is to work with doctors, other medical staff and the software vendor creating Northwestern's system to ensure that electronic records actually work as a clinical tool. The first step, he says, is not to assume doctors know all the things a computer can do.
"Say you're in the horse-and-buggy era, and some person out of the blue says, 'What would you like in a car?' " Tang says. "But you don't even have a clue what a car is.
"I found long ago that you can't develop a new product by saying, 'What do you like,' and find the information reliable. We didn't ask, 'What do you like in a computerized record.' We studied what people did with the information."
Tang has a staff of seven clinical consultants, mostly nurses, who study the kind of information physicians gather, and how it is transferred from person to person. From there, Tang worked with Epic, the Madison, Wis.-based software company that is programming the records system, to come up with a design that can be tailored to individual physicians or practices.
For example, an affiliated, six-physician internal medicine practice is increasing the flu immunization rate for patients age 65 and older, thanks to a computer-generated reminder that appears on patient charts. Northwestern's flu immunization rate for the 1996-1997 winter season was 49%, less than the national average of 53%. Through the end of December of the 1997-98 season, that rate was up to 75%.
"We know through controlled studies that the simple action of giving flu vaccine will decrease mortality and morbidity of patients from pneumonia," Tang says. "You can reduce the number of admissions by half if you give flu vaccines, and the cost (of care) by one-third.
Meanwhile, Tang is running an experiment with 35 internal medicine-practitioner faculty members to see exactly what differences in care are attributable to using electronic records. Twenty are still using paper for their charts, while the other 15 have been using a computerized system since 1996. Tang says he expects to have results from the research this summer.
Tang's background prepared him well for such research projects. He received his master's degree in electrical engineering, with a specific interest in bio-engineering, from Stanford University in 1976. Then he went to work at IBM Corp.'s Boca Raton, Fla., research laboratory to help develop the first multimillion-bit-memory disk drive for the company's minicomputer. His work predated by a few years the development of IBM's personal computer in the same research lab.
Tang says he took the job at IBM because he was applying to medical school and had to wait a year to find out whether he would get in. He did, at the University of California-San Francisco, and graduated in 1981. He followed that up with a three-year residency at Stanford.
Tang was considering taking a fellowship to study cardiology at that time, but technology beckoned. He joined Hewlett-Packard's Palo Alto, Calif., research laboratory, helping to develop the company's first patient information system. Called CareView, the software was designed for intensive-care units, which were Hewlett-Packard's biggest medical customers at that time.
While at Hewlett-Packard, Tang says he closely followed the development of managed care and realized its demand for financial and clinical measurement information would be a boon for patient-records software. Comparing 1 billion outpatient visits per year with 35 million hospital admissions, Tang figured ambulatory care would present the greatest need for high technology.
However, hospitals have to play the key role in deciding whether outpatient-care records are computerized, because hospitals have the most capital available to invest in information systems, Tang says. Physician practice management companies make the same argument when they recruit doctors.
"It's the hospital and health system that has the capital," Tang says. "The physicians need to use the tools to help them take care of patients."