Program Competition 97-03
|NOTE: From 1994-1998, the bulk of ATP funding was applied to specific focused program areasmulti-year efforts aimed at achieving specific technology and business goals as defined by industry. ATP revised its competition model in 1999 and opened Competitions to all areas of technology. For more information on previously funded ATP Focused Programs, visit our website at http://www.atp.nist.gov/atp/focusprg.htm.|
The U.S. healthcare industry stands at a critical juncture. While facing a significant increase in the number of customers who will need to be served, the industry is being tasked by the nation to increase quality of results, to ensure consistent quality between rural and urban providers, to be accountable for outcomes, to provide accurate measures of success, and to accomplish all of these with lower costs.
Information technology forms an important part of the solution. Accurate and up-to-date information is essential to continuous quality improvement in any organization, and particularly so in an area as complex as healthcare. However, information systems must enhance rather than hamper the role of healthcare providers. Furthermore, diverse information systems must be integrated across the healthcare enterprise.
The knowledge base in the medical field is large, complex, and growing rapidly. It includes scientific knowledge as well as familiarity with the day-to-day business of providing healthcare. Information scientists cannot hope to understand the medical users' complex needs in a short amount of time. Similarly, complicated information science techniques, such as rigorous requirements analysis techniques or systems which require a great deal of training, cannot be, and should not be, introduced into the already complex healthcare environment. With limited time and resources for both the nation and for individual participants, it is crucial to identify the processes in the healthcare sector that would most benefit from the support of information technology. A broad-brush approach could be extremely costly and could actually impede the progress of the healthcare industry.
Tools are needed to assist with broad and accurate knowledge acquisition from healthcare providers and to help determine the business case for reengineering and technology development. The tools produced by this program must help bridge the gap between the medical and administrative knowledge possessed by healthcare personnel and the information science knowledge possessed by technologists.
The Information Infrastructure for Healthcare focused program, managed by the National Institute of Standards and Technology's Advanced Technology Program (ATP), is based on advanced technology rather than on standards development; however, it will coordinate with and contribute to on-going standards development efforts related to healthcare and information science. The tools developed under this program will provide maximum flexibility for healthcare systems development. For example, the development of information brokers, which translate and transfer knowledge among many vocabularies, databases, and information systems, can enable interoperability of new and existing applications. This approach is based on defining common requirements, rather than imposing a common design. The subsequent utilization of the management tools developed under this program will help to define crucial areas where standards are needed, while eliminating the need for excessive standards development.
The program budget is estimated to be $185 million over 5 years. The private sector participants are expected to meet ATP matching fund and indirect cost requirements. Outyear funding is contingent on future appropriations.
The ATP healthcare program will develop automated tools to catalyze the development of the healthcare portion of the National Information Infrastructure (NII), referred to in this document as the National Healthcare Information Infrastructure (NHII). This infrastructure will enable enterprise-wide integration of information among all sectors of the healthcare industry.
Information infrastructure development involves both:
The ATP healthcare program will be accomplished with serial solicitations in each of three technology areas:
It is imperative that the infrastructure developed be driven by user requirements, rather than by the technology available. Experience in the software development industry has shown that purchasing hardware before considering how it will be used seldom satisfies real customer needs. In fact, one reason that automation has not been more widely accepted in the medical community is that its implementation often has been unwieldy.
This program enables technology development for an infrastructure in an area that is both critical to the nation and fraught with complexity. Both of these facts increase the risk of the venture, but also increase the expected contribution of a successful ATP program.
To establish the technologies for:
To gain the capability to develop products that will:
- shorten hospital stays; reduce outpatient visits per illness
- decrease needless duplication of records through reuse
- decrease duplicative and erroneous tests
- improve financial and management information handling
- faster and more accurate analysis of data
- faster delivery of treatment
- more accurate diagnosis
- reduced incidence of errors in tests ordered
- remote and widespread access to expert medical advice and advanced diagnostic and treatment tools
The rate-limiting step of information-related healthcare industry reform is integration and, right now, the industry is stymied at that step. Never before has an integration so massive and complex been attempted. Existing modeling tools, simulation tools, data management systems, search mechanisms and security measures cannot address a problem of the scope and breadth of the entire national healthcare industry. The ATP can provide critical leverage to develop the technology needed for an infrastructure that will meet or exceed user expectations.
The technical program encompasses three levels of technological advancement, as shown in Figure 1.
The development of the envisioned infrastructure will be driven by the healthcare-specific technologies. These are the systems that directly address the problems of the medical user community.
The user-interface and efficiency-enhancement technologies are those that enhance the usability of the healthcare-specific technologies.
The infrastructure-development technologies enable the capture and organization of user requirements and varying forms of user information repositories. These tools will be used to develop the prototype information infrastructure and to maintain and enhance its functions as user feedback is obtained.
Thus, the medical user:
- appreciates the results of the user-interface and efficiency-enhancement technologies, but is not directly involved with them, and
- is completely unaware of the infrastructure development technologies in the day-to-day providing of healthcare.
The medical user may have only an indirect interaction with the infrastructure development technologies. Information scientists will use the infrastructure development technologies to gain knowledge from and interact with a representative sample of healthcare users in modeling the healthcare enterprise. These tools will help validate the completeness and integrity of the model for the infrastructure.
Thus, the healthcare users will see the infrastructure pyramid from the top down. However, the infrastructure developers will build the pyramid from the bottom up. The infrastructure development technologies will help to capture and synthesize the basic user requirements. The user-interface and efficiency-enhancement technologies will then add value and ease-of-use to the basic infrastructure. Finally, the healthcare-specific technologies will actually implement the users' functions using the enhanced infrastructure.
The first solicitation (94-04) was held in 1994 and addressed the infrastructure development technologies. Technical challenges included:
- Total quality management techniques, needed to improve corporate performance, based on customer satisfaction
- Enterprise integration tools to translate information from multiple vocabularies and parts of the healthcare enterprise, to help users determine what information is needed, to facilitate information flow, and to enable electronic commerce
- Domain identification tools to help define criteria that truly identify a domain in a way that optimizes reuse, and domain analysis tools to acquire, organize, and model the knowledge about the processes in each domain and the rationale behind them
- Verification and validation tools
Sixteen awards were announced in October 1994 as a result of the first solicitation.
The second solicitation (95-10) focused on technologies and tools that will underlie and enable the development of applications for distributed, heterogeneous, multimedia-based healthcare systems. Projects funded as a result of this solicitation will expand the base of the infrastructure development technologies by providing the user interface to, or the efficiency enhancement of, the information infrastructure for healthcare. Projects fall into one or more of the following categories: (1) information access, transmission, storage, and retrieval technologies; (2) multimedia information technologies; (3) security and privacy technologies; (4) mobile and collaborative computing technologies. In addition to those types of projects listed in the middle section of the triangle in Figure 1, examples of specific advanced technology research topics included under each of the categories are as follows:
(1) Information access, transmission, storage, and retrieval
- Interfaces capable of adapting to user preferences, limitations, and behavior
- Mechanisms for effective information filtering
- Techniques for optimizing searches of large, mobile and distributed information resources, including capabilities for time-critical delivery of data and for handling conflicting responses or out-of-date data
- Digital libraries that support the above capabilities
(2) Multimedia information
- Representation of multimedia objects, including modeling of the relationships and coordination between multiple streams, and semantics-based compression schemes
- Information management systems that deliver multiple data streams in an integrated fashion with guaranteed time constraints and support content-based queries
(3) Security and privacy
- Methods for designing, building and maintaining scalable, secure systems
- Mechanisms for security management across network and enterprise boundaries
(4) Mobile and collaborative computing
- Universal connectivity, including concurrent communications and efficient information dissemination methods
- Robust security systems and compression technology for wireless transmission
- Low-cost, non-volatile storage with fast access, high data rates and low power requirements for geographically dispersed and mobile databases 
It is understood that some technologies funded may fall into more than one category. Also, this representative list is not meant to be exhaustive. Research proposed under this solicitation was tailored to the requirements of the healthcare information infrastructure but should be applicable to other infrastructure domains as well. Projects funded address relevant system requirements, including elicitation of user requirements, data integration, interoperability, scalability, security and privacy, system performance, and ease of use.
Ten awards were announced in September 1995 as a result of the second solicitation. Summary award data for the two solicitations held thus far is shown in the table below. A set of abstracts describing the twenty-six projects is included in this package.
An additional future solicitation, subsequent to the one addressed here, will request proposals in technologies such as those in the top tier of the triangle pictured in Figure 1, namely, healthcare-specific technology challenges including artificial intelligence and clinical decision support systems, clinical outcomes data analysis tools, and consumer health information and education systems. Demonstration projects will lead to integration and commercialization of the various technologies.
Many of the twenty-six projects funded through the first two competitions of this ATP focused program are still in their infancy. Nonetheless, some early trends and progress towards the building of an information infrastructure can be identified. These include:
To facilitate teaming and to maximize the benefit in such areas of progress as listed above, the Advanced Technology Program and individual projects engage in a variety of outreach efforts. A workshop was held in March 1995 for the awardees from the first solicitation in this focused program. More recently, a public meeting was held on October 9-10, 1996, to bring together all ATP project participants in the focused program, as well as other interested parties, to present overviews of the non-proprietary aspects of their research and development activities. The goals of the workshop were to:
The meeting featured formal presentations, there were demonstrations of early prototypes, open discussions, and ample opportunities for networking. The highly successful public meeting boasted an attendance of approximately 200 representatives from industry, academia, and government.
In addition, both the ATP and individual projects within this focused program are active in sponsoring sessions and giving presentations at relevant conferences, meetings, and tradeshows, as well as in publishing articles in the archival literature.
You are invited to visit the Advanced Technology Program's World Wide Web homepage
for up-to-date information on the Advanced Technology Program and the Information Infrastructure for Healthcare focused program. Similarly, many individual projects in this portfolio maintain their own homepages for dissemination of information.
Despite the many strides being made, healthcare today is still facing increased challenges. Some of these are summarized here:
Health awareness and information accessibility
Uniform, universal access
Moving towards managed care
Many of these issues are discussed elsewhere in this paper, and others are self-evident. For example, capability to develop products that will lead to a reduction of unit healthcare costs is one of the business goals of this program. That will not be reached with the number of healthcare administrators growing four times as fast as the number of healthcare providers.  Technologies that will lead to improved quality is another goal. Today, large and small employers alike are challenging healthcare entities to provide data on preventive and continuing care. For example, how many individuals diagnosed with diabetes have had an eye exam within the last year? How many two year olds have not completed the prescribed immunization schedule? Employers are using this data in negotiating healthcare policies for their employees. The need for such data by both businesses and consumers is evidenced by the emergence of a new database called Quality Compass, launched earlier this year to make available national information about healthcare quality. This database is produced by the National Committee for Quality Assurance, a leader in the development of measuring health plan performance and the main body responsible for accreditation of health maintenance organizations (HMOs). On the business side, there is increased consolidation, as well as an increase in the membership of HMOs. In 1995, almost 60 million individuals in the United States were members of HMOs, which in itself is an increase of fifteen percent over the number belonging to these plans in 1994. In the next six years, however, enrollment in HMOs is expected to double.  Finally, in planning for healthcare, the demographics and population must be taken into account. There are over 30 million people in the United States today over 65 years old, and that number is increasing by 3,500 a day.
The government-industry partnerships represented in this focused program have certainly made strides towards an open, interoperable infrastructure for healthcare. Nonetheless, one needs only to look at Table 2 below which shows the relatively small percentage of institutions adopting information technology and, in many cases, the lack of sophistication of that technology, to realize that there is still a long way to go.
Also, in addition to the changes in the mechanisms for the delivery of healthcare as discussed above, there have been dramatic changes in technology since the inception of this focused program. One needs only point to faster processing times, increased storage capabilities, health telematics, enhanced use of the Internet, and a myriad of World Wide Web capabilities, to name just a few. These reasons, coupled with the all-important fact that in the first two solicitations of the IIH focused program, far more excellent proposals were received than could be funded, lead to the conclusion that this current solicitation should have as its focus the lower two layers of the triangle as pictured in Figure 1 and as elaborated upon above. This decision was made after extensive input by industry and other interest parties, both at the October 9-10, 1996, public meeting and in subsequent verbal and written communication.
Technical challenges, therefore, in proposals submitted to this competition must be in the areas of infrastructure development technologies and user interface and efficiency-enhancement technologies. Examples of project areas that will be deemed in scope for this solicitation are illustrated in the pyramid in Figure 1 and are outlined in the section of this paper entitled "Technical Ideas, Plan and Program Structure." Proposals should clearly state which layer or layers of the triangle are being addressed and through what specific tools or technologies. In discussing how, when successful, the goals of the project will enhance and/or speed up the development of the information infrastructure for healthcare, detail should be provided on synergy with any on-going efforts, whether Federally or privately funded. Evidence should be provided of interface efforts and integration across projects, teams, technologies, and domains.
Attention should be given to the end user, the individual who needs to access the system to obtain the information sought, with insight to use by both large institutions and small, private users. Any inclusion by a proposed project of infrastructural tools, either currently in use or under development, should be included. Other areas of discussion should, when applicable, cover: the proposal's impact on any existing or developing standards efforts; issues related to security, privacy, and confidentiality; scalability; system requirements and performance; and relevance of the technology being suggested to related legislative and regulatory issues. Research proposed under this solicitation should be tailored to the requirements of the healthcare information infrastructure, but should be applicable to other domains as well.
With the number of challenges as well as pressures in the healthcare enterprise, along with the demands on technology that is made by healthcare providers and healthcare data, projects proposed in this solicitation have the potential to continue the strides being made and to give new and yet-unmined impetus to the dramatic vision of an information infrastructure for healthcare.
As discussed above under the section on "Technical Ideas, Plan and Program Structure," it is expected that this current solicitation is in addition to the three as originally outlined. We now visualize that this focused program will include four competitions, with the fourth addressing the top tier of the triangle to be held at a later date.
According to the Health Care Financing Administration, medical spending in 1994 exceeded $938 billion. That means that one out of every seven dollars spent in the United States is on healthcare. Only a few decades ago, health and education consumed equal amounts of the U.S. GDP; now the amount for healthcare is more than double that for education. There are 6,500 hospitals and 700,000 doctors in the U.S. When analyzing the workforce, we see that one in every 11 people is in the healthcare business. Take Pittsburgh, for example, where 25,000 work in the steel industry, but 106,000 work in medicine. Likewise in Houston, where 66,000 are employed by the oil industry, but 110,000 by the healthcare industry. 
Indeed, the healthcare industry has a pivotal role in the economic health of our country. The United States has long been the recognized leader in providing high quality innovative care. We have been the pioneers in life-saving advances such as bone marrow transplants and coronary artery bypass surgery. We have developed advanced diagnostics and therapeutic products, which in themselves form an important export industry with significant growth potential. (For example, U.S. exporters control half the world's $71 billion medical device market.) Medical technology is the fastest growing sector of American exports.  Nonetheless, we are all aware that runaway healthcare spending is slowly eroding the competitiveness of U.S. companies and straining the U.S. government. The industry has had difficulty in reducing operating costs and increasing productivity.
The healthcare industry is not integrated in its information management. Patient information is often inaccessible at the time healthcare decisions are made. Healthcare professionals spend valuable time looking for records, calling each other for basic information, or repeating tests because previous test results could not be found or obtained quickly. It has been estimated by the Parkview Episcopal Medical Center, Parkview, Colorado (July 1994) that physicians spend 35 percent of their time and nurses spend 50 percent of their time on paperwork. A recent study performed by Ira Magaziner, Senior Advisor to the President for Policy Development, confirmed that nurses are so burdened with administrative costs that they spend more time with paper than with patients. Data are not readily available to evaluate and compare alternative treatments and interventions on an ongoing basis.
According to Dr. William Tierney, Professor of Medicine at the Indiana University School of Medicine and one of the lead authors of several Journal of the American Medical Association cost/benefit studies, "This is the most expensive industry in the country, and everything is done on paper. We've got to get away from that."  Donna Ganzer of the American Hospital Association has described the industry's data collection mode as "collect many times, use once." It must move to "collect once, use many times." In addition to the healthcare provider, information is used by government agencies, payers, and researchers. These users must depend on a limited set of data, often not transmitted in electronic form, or wade through perhaps hundreds of pieces of paper to locate the key information required. This is not only unwieldy but raises confidentiality issues. Computerized access could make it easier to obtain the needed data while at the same time controlling release of what data is supplied to whom.
This program addresses the innovation and reengineering of the information technology related to the medical facility and delivery system. Today the infrastructure is fragmented, each institution having a unique set of diagnostic systems, internal data formats, patient record systems, and communication and computer networks. This lack of an adequately developed infrastructure is a cost barrier, discouraging commercial companies from advances in this area. There are also high technical risks in the systems engineering to ensure reliability, availability, maintainability, data integrity, and the high level of confidence needed to make data available for every patient 24 hours a day, 365 days a year. This program will provide evolutionary changes and advances in information technology applied to healthcare that will change and improve the delivery of care and will reduce care costs. With estimates that a minimum of 15 to 25 percent of today's healthcare costs are related to the processing of information, the economic benefit of such a program is clear. 
Although there are many barriers to collecting cost-benefit information, and it is difficult to obtain reliable figures to evaluate the overall cost-effectiveness of contemporary systems, evidence exists that shows partially automated systems can be cost effective. For example:
The above examples provide evaluations of specific systems. There have been a few attempts to estimate more broadly the costs and benefits of information technology advances in this area:
- faster and more efficient processing of the more than four billion claims, 90 percent of which are now processed as paper submissions ($6 billion savings)
- improved inventory management ($600 million savings) 
Healthcare is the fastest growing market in the computer field. Medical software systems have uses including the monitoring of patients, tracking financial information, and collecting and analyzing data from medical instrumentation. Sheldon I. Dorenfest & Associates, Ltd., estimates that hospitals will spend $6.7 billion a year on information systems in 1996, a 36.7 percent increase over 1993. Computer companies are taking note. Hewlett-Packard, the world's largest medical equipment maker, has established a healthcare group. Ben Holmes, manager of this group, expects the market for healthcare information systems to reach $13 billion by 1998.  Estimates for needed hardware for this industry also show growth. According to Dataquest, Inc., the worldwide market for computer systems dedicated to medical applications reached an estimated $610 million in 1993, an increase of nearly 10 percent over 1992. Assuming constant growth, it is reasonable to extrapolate that the 1994 market reached approximately $670 million. By 1996, worldwide sales are expected to reach more than $800 million.  An ATP program would accelerate the growth rate of both computer hardware and medical information systems used in the healthcare industry.
In addition to the economic benefits discussed above, there are qualitative benefits, including:
- more efficient patient care management (fewer lab tests, shorter hospital stays)
- dramatic improvements in productivity and job satisfaction within the healthcare industry
- education and preventive care (with major implications for cost reduction in billions of dollars)
A 1988 Rand study found that one out of every five patients admitted to a hospital is either wrongly diagnosed or treated. The Institute of Medicine reports that: 11 percent of laboratory tests must be re-ordered because of lost results; 30 percent of the time, the treatment ordered is not documented at all; 40 percent of the time a diagnosis is not recorded; 30 percent of the time a medical record is completely unavailable during patient visits. Better care can also lead to cost savings. For example, mistakes in prescribing medicines add $3 billion a year to the national health bill. Tests at the Latter-Day Saints Hospital in Utah showed that in determining appropriate medication, a doctor was 60 times more accurate when using a computer system than when only paper records were available. 
Today the healthcare community encompasses much more than hospitals, doctors, and the insurance industry. The healthcare industry impacts employers, communities, state governments, telecommunication operators, providers, patients, payers, service coordinators, financial services, regulators, and vendors. The healthcare community is at the threshold of spending billions of dollars on new information technologies. In the past two years, several large consortia have been formed to address parts of the long-term, national interoperability issues surrounding the development of an information infrastructure: the Computerized Patient Record Institute; MCC's Healthcare Open System Trials program; and the National Healthcare Industry Consortium. Participants in these consortia represent well over 50 percent of the healthcare community. Included are physician and dental organizations, nursing organizations, hospital organizations, health informatics organizations, medical record organizations, employers and businesses, managed care and insurance organizations, healthcare facilities, and vendors of technology. Activities of these consortia are funded through membership dues and newsletter subscriptions.
This ATP focused program is based on white paper submissions from approximately two dozen companies and consortia. On February 4, 1994, a steering group met at the National Institute of Standards and Technology (NIST) to plan an ATP-sponsored workshop in this program area. The steering group consisted of twelve industrial representatives who had submitted source documents and two representatives from other government agencies. At a workshop on February 23, 1994, industrial support was evidenced by an attendance of over 400 representatives.
Industry commitment is also evident from the funds presently being allocated. In 1993, hospitals and providers spent approximately $12 billion for research and programs related to the healthcare information infrastructure. Insurance companies, payers, and Health Maintenance Organizations also spend appreciable funds. Approximately $400 million to $500 million is expected to be spent on research and development in medical informatics a year.
In this program area, funding is needed to develop the foundation for a NHII, namely, to accomplish the development of a national reference architecture and some representative enabling technologies. Members of the consortia listed above have been and are willing to at least match funding for this technology development with the federal government.
The development of the technology needed to establish the long-term national vision of an interoperable, highly complex and dynamic information system is too costly and too risky for even a group of companies to fund. The technical resources needed to tackle the problem are diverse. Consortia are being formed, as discussed above. Industry has begun to build relationships with state and local governments. The health reform plans being discussed in many states call for powerful information solutions. These groups need the information technology developed under a partnership program such as the one described here. Individual hospital systems are being developed on a micro-level, without knowledge of how to make the most out of communications through the NII. Individual institutions are developing specific technologies. For example, Dr. Paul Clayton, Director of Medical Informatics at Columbia Presbyterian Hospital in New York, reports the development of automatic warning labels on packaged products and database linkages. ATP can serve as the catalyst for bringing the various healthcare projects and sectors together. Without the catalyst provided by ATP funding and activity, true collaborative networks will be delayed for a number of years. Additionally, the development of an NHII is a high-risk and long-term venture. ATP can minimize the individual risk so that investments can be made in the long-term issues needed to accelerate a NHII and a NII.
The Computer Systems Policy Project is an affiliation of chief executive officers of American computer companies which develop, build, market, service, and support information processing systems and software. This group "recommends implementing a joint public-private sector effort to significantly increase the information technology investments made by major healthcare stakeholders, to accelerate nationwide deployment of a healthcare information infrastructure."  The cited report from this organization asserts that the Center for Healthcare Information Management has also recommended developing cooperation mechanisms for the government and industry partners to share in the costs of development and implementation of needed technology. To date, though, "questions remain regarding how to fund its widespread implementation and the cost savings that are possible from such implementation."  An ATP program can provide this mechanism.
Similarly, Marilyn Cade, Director of Technology Infrastructure, Computer Products and Services for AT&T, testified on behalf of the National Healthcare Industry Consortium before the Senate Subcommittee on Science, Technology, and Space (August 5, 1993). She stated that development of a healthcare information infrastructure is a task "which requires a partnership between government and industry. No single firm or group of firms have found themselves able to produce [the shift to a new healthcare information system] alone." Relevant issues include not only cost, but market uncertainty and significant technology challenges.
Other government agencies are investing in information technology applications in healthcare. But the money flows almost exclusively to funding either strictly basic research, or to solving low-risk, near-term problems directly related to the mission of the funding organization, or to establishing small, isolated pilot projects using existing technology. The ATP focused program in this area is unique in providing long-term funding for high-risk projects, led by industry with the motive of economic benefit to the United States. To assure synergy and maximize potential success, however, representatives from other Federal agencies are active participants in the ATP review and selection process.
The healthcare industry is at a critical time in development, and today's decisions will set precedents for future generations. New projects funded through this ATP focused program competition will:
The long-term vision and impact of this ATP focused program is clear: despite the significant increase in the number of customers who will need to be served, the healthcare industry will achieve an increase in the quality of results, consistent quality between rural and urban providers, accountability for outcomes, and accurate measures of success. All this may be accomplished with lower costs. The driving force behind these advances is the development of open, interoperable, yet secure systems - systems that will provide the medical community with the capability to integrate diverse information and business systems as well as the data necessary to support continuous quality improvement. Through enhanced user interfaces the real needs of the healthcare providers will be met, improving the information aspects of long-term care, preventative care, inpatient care, elective surgery, and home care for patients ranging from prenatal to geriatric.
1. Technologies included in this list are representative of those suggested by white paper submissions from industry as well as recommendations taken from R&D for the NII: Technical Challenges, edited by Mary Vernon, Edward Lazowska, and Stewart Personick, published by Interuniversity Communications Council, Inc. (EDUCOM), 1994. Many thanks and acknowledgment to the members of the program committee, the track chairs, and the participants who played a role in the workshop and the ensuing writing of this report.
11. Gardner, R.M., et. al. Assessing the Effectiveness of a Computerized Pharmacy System. Proceedings of the Fourteenth Annual Symposium on Computer Applications in Medical Care. Los Alamitos, CA: IEEE Computer Society Press, 1990.
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