293LEADING ARTICLES

David and Goliath

THE LANCET

LONDON 5 AUGUST 1967

IN the medical uses of electronic digital computersBritain is certainly behind the United States, wherenearly all medical schools have at least one computer;and the longer the school has been engaged in medicalcomputing, the larger is the installation. Computersare also widely used in many American non-teachinghospitals. One reason for this rapid development inthe United States is the country’s system of medicalcare, under which it is necessary to send a bill to most

patients and to prepare careful accounting of X-rays,pathological investigations, drugs, and so on. Whenin 1964 the Medical Research Council and Ministry ofHealth held a conference 1 in Oxford on the medicaland biological uses of computers, many hoped thatthis would inaugurate a wider use of these machinesin medicine in Britain. Since then work has progressed,but only slowly; and the increasing use of computersby medical workers has nothing like matched the

possible applications of these tools. Though a computerin a hospital is uneconomic in the early stages, theultimate benefits can be great. Before computers areinstalled, feasibility studies are usually undertaken,and the areas offering most promise for computeroperation often turn out to be administrative proceduressuch as admission and discharge, ward orders of stock,and pay-rolls. Other subjects on which work has beendone are biochemistry, dietary requirements, radio-

therapy, and electrocardiography. But the byproductsof having a computer in a medical institution are rarelyevaluated.

As demands for computers in medicine increase,how can limited resources be best organised to meetthis need? There are two schools of thought aboutthe provision of computers. The first states that it isbetter to have several very large machines to which anumber of small machines are linked and which can

process all possible applications from many institutionssimultaneously. The second view is that each individuallaboratory or user should have his own small computer- which may eventually be linked to a large computer.The " small computers now and large computers later "school has much reason on its side. The immediateneed for a small computer is relatively easy to demon-strate-for example, to handle the records of electro-encephalograms in one department, or to deal with thefinance and stock-keeping procedures for one group of1. Mathematics and Computer Science in Biology and Medicine. H.M.

Stationery Office, 1965. See Lancet, 1964, ii, 140.

hospitals. Programs for such computers and these

procedures can be written, but they usually apply onlyto the local problem. When, if ever, a large computerarrives, the programs must be rewritten, since the" machine language " suited only the small machine.Admittedly, large computers are not without problems,but their programming languages are relatively simpleand easily learnt.Then there is the little matter of cost: a small com-

puter comes at around E20,000; a large computer maybe anything from E500.000 to E2 million, on top of whichthe necessary terminals will also be required. So it is

easy to see that fifty small E20.000 computers are muchcheaper than one big one. Since relatively few peopleare, at the moment, interested in using computers inthe Health Service, a vicious circle is being established.The man who now requires a computer will usually behappy to have a small machine which he can controland on which all his problems can be solved. And hecan usually get such a machine, because administrativelyit is easier to provide money for a number of smallprojects. The more distant prospect, however, maythereby suffer, since present preoccupation among bothusers and Government with small machines mayseriously impede the development of medical computing.One reason why few people in the National Health

Service are interested in computing is that it requiresa new skill-programming. Although some doctorshave now acquired it, they can usually deal only withthe simpler programs. With increasing shortage ofdoctors (and programmers), tasks must be simplifiedrather than augmented; and the great advantage oflarge machines is their ability to comprehend simplelanguages. The only hope of

" en clair " communica-

tions with a computer lies in the use of large machines.Another problem in the medical services is one of

linkage. Although automation of procedures in chemicalpathology is feasible with a small machine, there islittle hope that the machine will then be able to performthe necessary manoeuvres to link these results with, forexample, details of the clinical record, or to link hospitalrecords with those of the general practitioner and localhealth authority. Though, with a small computer, theneeds of one or two users may be satisfied, no more canbe added. With a large computer and time-sharing,many users can have direct access from a distant console,which is quite cheap (E500-1000). Thus, large machinesmay well turn out to be more economical-and certainlymore satisfying, in that each worker can have his own" private " console.

This dilemma is with us at the moment. Manydoctors want to improve their work and their ability todo research. They can see immediate help comingonly from a demand for small machines-a demandwhich the Government can satisfy fairly easily and thustake off the pressure. Ultimate success, however, maythus be jeopardised by satisfying a few individuals

immediately. The situation can be properly tackledonly by adopting a definite policy at this stage ratherthan living from hand to mouth.