An Initial Assessment of the Cost and Utilization of the Integrated Academic Information System (IAIMS) at Columbia Presbyterian Medical Center Paul D. Clayton, Rachael K Anderson*, Claire Hill, Megan McCormack
Columbia Presbyterian Medical Center NY, NY 10032 *University Of Arizona Health Science Library, Tucson AZ internet address "[email protected]" The concept of "one stop information shopping" is becoming a reality at Columbia Presbyterian Medical Center (CPMC). The goal of our effort is to provide access to university and hospital administrative systems as well as clinical and library applications from a single workstation, which also provides utility functions such as word processing and mail. Since June 1987, CPMC has invested the equivalent of $23 million dollars to install a digital communications network that encompasses 18 buildings at seven geographically separate sites and to develop clinical and library applications that are integrated with the existing hospital and university administrative and research computing facilities. During June 1991, 2425 different individuals used the clinical information system, 425 different individuals used the library applications, and 900 different individuals used the hospital administrative applications via network access. If we were to freeze the system in its current state, amortize the development and network installation costs, and add projected maintenance costs for the clinical and library applications, our integrated information system would cost $2.8 million on an annual basis. This cost is 0.3% of the medical center's annual budget. These expenditures could be justified by very small improvements in time savings for personnel andlor decreased length of hospital stay andlor more efficient use of resources. In addition to the direct benefits which we detail, a major benefit is the ease with which additional computer-based applications can be added incrementally at an extremely modest cost. Introduction When the National Library of Medicine announced the IAIMS[l] program in 1983, Columbia University and Presbyterian Hospital, two organizationally separate, but mission and location unified, institutions began to plan for a resource that would allow a user with appropriate credentials to access administrative, research, clinical,
This work was supported in part by the International Business Machines Corporation and by a grant from the National Library of Medicine LM04419 (IAIMS) and the Sherman Fairchild Foundation. 0195-4210/91/$5.00 ©D 1992 AMIA,
Inc.
109
and scholarly information applications from a single "workstation". In addition, the user should be able to use core utility applications such as electronic mail, spread sheets and word processing from the same workstation[2]. In a separate paper, Hendrickson et al.[3] describe the organizational and logistical approaches which we have used to construct this environment. The purpose of this paper is to give some feel for the financial costs associated with such an approach, to assess the utilization of the emerging system, and to compare the information expenditures with possible benefits and overall budgets. In the sections that follow, we will describe the information environment by first describing the network and listing the applications which are currently available on the network. We then detail costs and current levels of utilization. Finally we discuss the magnitude of specific benefits and impact the IAIMS integration effort would need to achieve in order to be economically justified. Network On the CPMC campus there are redundant network backbones connecting 13 buildings; one of fiber optic cable running a 16mb token ring and the other of copper running a 4mb token ring. The fiber is currently activated in seven buildings. In addition, coaxial based ethernet goes into nine of the buildings. There are 39 additional token rings connected to the backbones via bridges, and three Appletalk local area networks connected to the backbones via gateways. Network components (gateways, routers, LANACS) permit connectivity between different networks and devices. The network is extended via Ti phone lines (1.54mb/sec) to Allen Pavilion (a 300 bed community hospital three miles north of the CPMC campus) and the off-site data center located 37 miles north of the CPMC campus. We used split bridges and leased telephone lines (9600 baud) to extend the network to a physicians' office building at East 61st street and two outpatient clinics, and we used an existing microwave link to connect to the Columbia University Morningside Campus at 116th street and to external internet access pathways. (Note: costs of communication links to the hospital and university data centers are not included as part of the IAIMS expenditures.)
In two new hospital buildings (Allen Pavilion and the Milstein Hospital building, 750 beds) a star wired, redundant pathway topology suitable for token ring or ethernet was installed in every patient room and office. A total of 2968 outlet jacks are available in those buildings (2062 in Milstein and 906 in Allen) of which we are currently using 290. The total cost for completely wiring the two hospital buildings was $1,079,000 or $364 per node. We have not totally completed the network in remaining hospital and university buildings; many offices and clinics do not yet have access to the network or IAIMS functions. We have connected three mainframe hosts, 32 minicomputers, 24 servers (Novell, Unix and OS/2) and 797 PC based workstations to the network. Each workstation on the network can access any of the hosts or servers. The net cost of $3300 for a typical personal computer attached to a network consists of $1900 for the computer, $600 for software (word processing, scriptwriter, communication, and terminal emulation), and $700 for a token ring connector card. The total institutional cost for personal computers was approximately $2.1 million. In addition, there are an unknown number of dumb terminals hardwired to one of 26 DEC VAX computers. These terminals communicate to mainframe applications via a DEC/SNA gateway. A new user pays a one time installation cost of $200, and an annual maintenance and support charge of $360, in addition to providing a personal computer and network access card. The typical cost of installing horizontal wiring from a central wiring closet to an office is approximately $600.
Applications Applications now available from the IAIMS network workstations include: Results Reporting: laboratory radiology pathology discharge summaries operative reports neurophysiology obstetrics labor and delivery admit-discharge history cardiology head and neck demographic profile GI endoscopy clinical profile (physician data entry and review) Clinical decision making Surgery Scheduling Medical Records DRG Coding Medical Records Chart Tracking/Chart Deficiencies Scholarly Information Systems Textbook of Medicine Medline Columbia Library Information On-Line
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Mail Phone Directory Word Processing/Spread sheets Hospital administrative systems: Patient management Patient accounting Materials Management Finance Purchasing Transport Payroll Accounts payable General ledger Costs CPMC has established administrative computing systems which have only recently been augmented by clinical and library applications. Costs for providing connectivity to the underlying IAIMS backbone network have been included regardless of whether the workstation was primarily for clinical, administrative, research or library function. The costs which are listed in this article are the incremental costs above and beyond the ongoing expenditures for central university and hospital administrative computing activities and all grant funded research activities outside of the IAIMS initiative. Conclusions in this paper may be regarded as ballpark estimates that might be useful to other institutions as general guidelines, if their environment is similar. We have taken the following approach to calculating IAIMS related costs. We have calculated total expenditures to date (personnel, hardware, software) and allocated these to one of three categories (network, workstations, applications). We then estimated a useful lifetime for each of these categories (network 20 years, workstations 6 years, applications 10 years). We then assumed that the system would stay frozen at its current level of functionality, i.e. no new applications or network expansion. We calculated the cost (people, licenses, hardware maintenance etc.) of maintaining the current system capability for the duration of its useful lifetime using today's dollars. We then calculated the annual cost of each component and summed them to give an amortized, non-discounted annual cost of the system in today's dollars. We have spent the equivalent (some of the external support comes in the form of products) of $23 million in the past four years ($9.8 million, personnel includes salaries, fringe, overhead and indirect costs; $3.9 million, network; $7.4 million, applications; $2.1 million, workstations). We have allocated 20% of the personnel expenses to the cost of the network, and 80% to development, installation, and management of applications. Forty percent of this total came from Presbyterian Hospital operating and construction funds, 10% from Columbia University, and the remainder from
network software), and 24% all other (Chart Tracking, and Medical Records Coding, mail, OS/2 LAN servers, PC LAN servers, LANACS's). Utilization of the largest applications is summarized below: The clinical results review system began operation in July of 1989. There are currently over 2500 active users of the system. Utilization of the system has more than doubled over the past 12 months. On an average weekday, there are over 2500 logins and over 5500 data inquiries, and these numbers are increasing each month. Although requests for laboratory data are by far the most frequent, there is strong and growing demand for radiology, pathology, cardiology and other text reports as well. Approximately 80% of all House Officers use the system regularly, as well as 70% of attending physicians with currently hospitalized patients. Nurses account for 20% of system utilization, and medical students account for 5%. The system is also used regularly by staff in 56 different hospital departments. Five years of Medline abstracts are available for review by clinicians and researchers. The MEDLINE system, implemented last year, is used by approximately 600 individuals each month, primarily house officers, medical students, and attending physicians. There are 135 logins each day, each lasting an average of 15 minutes and containing an average of 10 individual searches. The surgery scheduling system, implemented in 1989, is used by the Admitting department to schedule 30,000 procedures each year, and is used by numerous other clinical departments, clinics, and doctor's private offices to review O.R. schedules. The patient abstracting and DRG coding system, installed three years ago, is utilized heavily by Medical Records and Utilization Review staff, and less frequently by Quality Assurance and Patient Accounts. The system is used 16 hours daily, with an average of 25 continuously active users each weekday. Over 850 patient abstracts are created or updated each week. The chart tracking system was only recently implemented, and is being phased in gradually during 1991. Of the one million plus CPMC charts, over 200,000 have been loaded into the new tracking system, and new charts are being added continually. During the daytime shift several hundred Medical Records and ancillary staff use the system, with another 40-50 using the system during the evening and night hours. Currently the system supports approximately 5700 transactions per weekday.
external sources. This level of expenditures is in line with our initial planning estimate [2] of $34 million for implementation of the IAIMS concept at CPMC. To support the currently operational systems, we would need network and workstation support people, help desk coverage, applications support, technical support, and an operator to operate the host machines (approximately 8 FTE's). Our total costs can be broken down as follows: Network $ 3.9 million for wires, bridges, gateways, fiber $ 2.0 million for personnel to design and implement (7/87 - 6/91) $ 5.1 million for maintenance personnel (5 people, 16 years) $11.0 million total, to be amortized over a 20-year period. ($550,000 annually) Workstations $1.9 million (564 at $3300 includes adapter cards, software, etc.) $0.2 million (231 pre-existing PCs at $850 for adapter cards and software $0.5 million (797 * $150 annual hardware maintenance for 4 years) $2.6 million to purchase, upgrade, and maintain workstations over a six-year period ($430,000 annually). Applications $ 7.4 million for hardware, software packages $ 7.8 million for personnel (7/87-6/91) $ 3.0 million for maintenance (fees + 3 people, 6 years) $18.2 million to purchase, develop, maintain applications over a ten-year period ($1.8 million annually). Thus, our amortized annual IAIMS related costs are $2.8 million. This annual cost is 0.3% of the total annual medical center budget of $950 million dollars. Integration costs (networks and workstations) by themselves amount to 0.1% of the total medical center expenditures or 5% of the total annual expenditures for administrative, clinical and scholarly computing at the medical center. Dividing the annual cost by 365 gives a daily cost of $8000, which we use below to look at cost per unit of access. Utilization The traffic across the 4mb token ring backbone has been analyzed during the peak period of usage. Maximum load was 38%, and average load during the peak period was 16%. The percentage of traffic is as follows: 40% SNA (mainframe applications including results review and MEDLINE), 36% Netware (surgery scheduling, other
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Cost per unit of access is difficult to measure, since the defrmition of access varies greatly across so many heterogeneous systems. There are approximately 2650 total logins per day for the major applications which we monitor. Given a daily cost of $8000, this results in an average cost per login of $3. The "logon" is not a uniform unit of measure, since in some systems a logon-logoff session lasts one minute, while in others it can last all day. Logon figures also may be underestimated because users sometimes fail to logoff before the next user begins to use the system, etc. There are about 13,000 total inquiries per day for the major applications, giving an average cost per inquiry of $0.60. Again, the definition of "inquiry" varies depending on the system - for results review, it means review of one type of result (e.g. all lab data); for MEDLINE, it means one search; for chart tracking, it means one chart inquiry. On an average day, there are 1045 individuals that use one or more of these IAIMS systems, giving an average cost per user of $7.70 per day.
Discussion Analyzing and justifying IAIMS costs is not straightforward [4,5,6]. While our cost figures are comprehensive, our utilization figures are probably under-estimates. We have comprehensive utilization statistics for the clinical results review and on-site MEDLINE systems, and fairly reliable estimates of utilization of the other larger systems, but no data on utilization of many of the smaller or newer systems, such as mail, university administrative computing or fetal monitoring, which are accessible through the network. It is expected that increased access to all types of information will improve the efficiency and quality of our activities in patient care, research and education. We compare the IAIMS costs to the magnitude of some of the specific benefits which we expect the system to provide: time savings for personnel and improved efficiency and quality of care as might be reflected in decreased length of hospital stay. We do not address such issues as improved research productivity, reduced malpractice claims, improved student learning, etc. Our comparisons are not substantiated claims of achievement, but standards for measurement. In our comparisons, we assume that the full costs of the IAIMS activities must be justified by just a single specific effect. If it can be determined that real benefits occur in all or most of the expected areas, then the "break even" threshold for cost justification would be accordingly reduced. The actual time saved by having access to facts about the patient, using Email to communicate, or accessing the literature via Medline, is difficult to assess. The IAIMS
initiative would be cost justified if it saves each of the 1045 daily individual users approximately 20 minutes per day (assuming average salary plus fringe of $50,000). The cost of result inquiry ranges from 1-5% of the cost of performing a laboratory test. Because the paper-based patient chart can only be in one place at a time, it is often impossible to obtain information in the Emergency Room or clinic except by using the computer-based patient record. The $3 per login charge appears well justified in these instances. Recent studies [7] at CPMC have indicated that improved access to information improves efficiency, and reduces time wasted due to lost results, duplicate test orders misplaced patient charts, etc. At CPMC, occupancy rates are high and elective admission waiting lists are long, so a shorter average length of stay would translate directly into increased admissions. Information systems can impact the quality and efficiency of care in four different ways: 1. Improved access to accurate facts about the patient or institution (laboratory results, surgery schedule, etc), 2. immediate, focused access to the literature, 3. critiquing of provider actions or lack thereof, and 4. post hoc analysis of the way medical care is provided. If improved access to information can reduce the hospital's average length of stay by even one percent, that could translate into an additional 450 admissions per year, or an increase in annual net revenue of $3,150,000. This revenue alone would more than compensate for the annual expense of the entire IAIMS initiative. Erica Drazen [8] has estimated that there is a six percent premium added to the cost of health care because of information deficiencies (duplicate test orders, inefficient scheduling, etc.). Given our IAIMS costs of 0.3% of the total medical center budget, we would only have to reduce the chaos factor from 6% to 5.7% or a five percent reduction to hit the break even point. Also, Tierney[9] has shown that displaying the cost of tests, which we also do, has reduced test utilization by 14% in an outpatient setting. Although the need for access to the literature is documented[10], no one has yet measured the value of access to the system. We assume that since extremely busy and intelligent attending physicians, students, nurses and residents use the MEDLINE capability, that it is a useful function. Demonstrating that a Medline search session is worth the $3.00 login cost is best accomplished by comparing this cost to that which members of the community are willing to pay for private dial up access. Leape et al.[l 1] have shown that there is substantial negligence in such information intensive activities as prescribing drugs. Gardner[12], McDonald[13], Evans
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[14] and others have shown substantial cost benefits of critiquing systems. A significant fraction of our application development cost has been directed toward achieving the on-line decision-making capability. We now have such a system operational in a rudimentary way[15]. As we begin to approach the breadth of performance of the HELP and Care systems, the realized benefits would certainly be expected to increase. The costs of integration are small compared to the costs of applications which users desire with or without an integrated information architecture. Two thirds of our costs are attributable to the applications themselves. As we expand our selection of applications, this ratio will increase. Since there are wiring and terminal costs associated with point to point wiring, the incremental costs for network connectivity and integration appear to be well justified. A direct benefit which is very evident to us is the ease and rapidity with which new applications can become available. No longer must every desirable application be written or purchased to run on one mainframe host to which terminals are hardwired. By focussing on relatively inexpensive microprocessor based servers, we are able to purchase or develop many applications, which would be unavailable or prohibitively expensive in the main frame environment, . We feel strongly, but cannot document, that this ability to address the "applications backlog" by allowing parallel development more than cost justifies the system by reducing application development and maintenance costs and improving speed of implementation. In summary, the costs of integration are small compared to the costs of application implementation and maintenance. In the absence of definitive data on actual time saved and/or improvements in the quality and efficiency of care provided, the only standard for which we have quantitative data is utilization. We hypothesize that bright, extremely busy individuals who are vitally interested in providing efficient, quality health care and in pursuing research and educational activities choose to use the system because it helps them to access useful information in ways that are more convenient and effective than traditional alternatives.
References 1. Matheson NW, Cooper JAD. Academic Information in the Academic Health Sciences Center: Roles for the Library in Information Management. J Med Education Oct 1982:57(10):part 2. 2. Anderson RK, Clayton PD, et al. Integrated academic information system (IAIMS)
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implementation at Columbia-Presbyterian Medical Center. New York: Columbia-Presbyterian Medical Center, 1988. Hendrickson G, Anderson RK, Clayton PD. Building the Integrated Academic Information Management System at the Columbia-Presbyterian Medical Center. Accepted for publication MD Computing. Drummond MF, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes. New York: Oxford University Press, 1987. Bakker AR, van der Zanden HGN. Five years of total HIS cost accounting analysis and prognosis. In: Proc. Medical Informatics Europe 85. Roger FH, Gronroos P, Tervo-Pellikka R, O'Moore R, eds. 1985;59-64. Gardner RM, Evans RS, Andrews BS. Impact of a Clinical Information System on Hospital Costs. Chapter 7: Frontiers of Medical Information Science, Edited by Robert Lawrence Kuhn, pp81-89. Praeger, New York, 1986. Summers L, Colombotos J. Using qualitative field methods to evaluate an IAIMS project. Manuscript in preparation. Drazen E Talk given at the IBM Executive Health Conference, Orlando Fla, March 4 1991. Tierney WM, Miller ME, McDonald CJ. The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests. New England Journal of Medicine. 1990 322: 1499-504. Covell DG, Uman GC, Manning PR. Academia and clinic: Information needs in office practice: are they being met?. Annals of Internal Medicine 1985; 103:596-9. Leape LL eL al., The nature of adverse events in hospitalized patients. New England Journal of Medicine 1991 324: 377-384. Gardner RM, Hulse RK, Larsen KG. Assessing the effectiveness of a computerized pharmacy system. Proc 14th Ann Symp Comput Applic Med Care 1990; 668-672. McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability of man. New England Journal of Medicine 1976; 296:1351-5. Evans RS et. al. Prediction of hospital infections and selection of antibiotics using an automated hospital database. Proc 14th Ann Symp Comput Applic Med Care 1990; 663-7. Hripcsak G. The Columbia-Presbyterian Medical Center decision support system as a model for implementing the Arden Syntax. 15th Ann Symp Comput Applic Med Care 1991.
Columbia Presbyterian Medical Center NY, NY 10032 *University Of Arizona Health Science Library, Tucson AZ internet address "[email protected]" The concept of "one stop information shopping" is becoming a reality at Columbia Presbyterian Medical Center (CPMC). The goal of our effort is to provide access to university and hospital administrative systems as well as clinical and library applications from a single workstation, which also provides utility functions such as word processing and mail. Since June 1987, CPMC has invested the equivalent of $23 million dollars to install a digital communications network that encompasses 18 buildings at seven geographically separate sites and to develop clinical and library applications that are integrated with the existing hospital and university administrative and research computing facilities. During June 1991, 2425 different individuals used the clinical information system, 425 different individuals used the library applications, and 900 different individuals used the hospital administrative applications via network access. If we were to freeze the system in its current state, amortize the development and network installation costs, and add projected maintenance costs for the clinical and library applications, our integrated information system would cost $2.8 million on an annual basis. This cost is 0.3% of the medical center's annual budget. These expenditures could be justified by very small improvements in time savings for personnel andlor decreased length of hospital stay andlor more efficient use of resources. In addition to the direct benefits which we detail, a major benefit is the ease with which additional computer-based applications can be added incrementally at an extremely modest cost. Introduction When the National Library of Medicine announced the IAIMS[l] program in 1983, Columbia University and Presbyterian Hospital, two organizationally separate, but mission and location unified, institutions began to plan for a resource that would allow a user with appropriate credentials to access administrative, research, clinical,
This work was supported in part by the International Business Machines Corporation and by a grant from the National Library of Medicine LM04419 (IAIMS) and the Sherman Fairchild Foundation. 0195-4210/91/$5.00 ©D 1992 AMIA,
Inc.
109
and scholarly information applications from a single "workstation". In addition, the user should be able to use core utility applications such as electronic mail, spread sheets and word processing from the same workstation[2]. In a separate paper, Hendrickson et al.[3] describe the organizational and logistical approaches which we have used to construct this environment. The purpose of this paper is to give some feel for the financial costs associated with such an approach, to assess the utilization of the emerging system, and to compare the information expenditures with possible benefits and overall budgets. In the sections that follow, we will describe the information environment by first describing the network and listing the applications which are currently available on the network. We then detail costs and current levels of utilization. Finally we discuss the magnitude of specific benefits and impact the IAIMS integration effort would need to achieve in order to be economically justified. Network On the CPMC campus there are redundant network backbones connecting 13 buildings; one of fiber optic cable running a 16mb token ring and the other of copper running a 4mb token ring. The fiber is currently activated in seven buildings. In addition, coaxial based ethernet goes into nine of the buildings. There are 39 additional token rings connected to the backbones via bridges, and three Appletalk local area networks connected to the backbones via gateways. Network components (gateways, routers, LANACS) permit connectivity between different networks and devices. The network is extended via Ti phone lines (1.54mb/sec) to Allen Pavilion (a 300 bed community hospital three miles north of the CPMC campus) and the off-site data center located 37 miles north of the CPMC campus. We used split bridges and leased telephone lines (9600 baud) to extend the network to a physicians' office building at East 61st street and two outpatient clinics, and we used an existing microwave link to connect to the Columbia University Morningside Campus at 116th street and to external internet access pathways. (Note: costs of communication links to the hospital and university data centers are not included as part of the IAIMS expenditures.)
In two new hospital buildings (Allen Pavilion and the Milstein Hospital building, 750 beds) a star wired, redundant pathway topology suitable for token ring or ethernet was installed in every patient room and office. A total of 2968 outlet jacks are available in those buildings (2062 in Milstein and 906 in Allen) of which we are currently using 290. The total cost for completely wiring the two hospital buildings was $1,079,000 or $364 per node. We have not totally completed the network in remaining hospital and university buildings; many offices and clinics do not yet have access to the network or IAIMS functions. We have connected three mainframe hosts, 32 minicomputers, 24 servers (Novell, Unix and OS/2) and 797 PC based workstations to the network. Each workstation on the network can access any of the hosts or servers. The net cost of $3300 for a typical personal computer attached to a network consists of $1900 for the computer, $600 for software (word processing, scriptwriter, communication, and terminal emulation), and $700 for a token ring connector card. The total institutional cost for personal computers was approximately $2.1 million. In addition, there are an unknown number of dumb terminals hardwired to one of 26 DEC VAX computers. These terminals communicate to mainframe applications via a DEC/SNA gateway. A new user pays a one time installation cost of $200, and an annual maintenance and support charge of $360, in addition to providing a personal computer and network access card. The typical cost of installing horizontal wiring from a central wiring closet to an office is approximately $600.
Applications Applications now available from the IAIMS network workstations include: Results Reporting: laboratory radiology pathology discharge summaries operative reports neurophysiology obstetrics labor and delivery admit-discharge history cardiology head and neck demographic profile GI endoscopy clinical profile (physician data entry and review) Clinical decision making Surgery Scheduling Medical Records DRG Coding Medical Records Chart Tracking/Chart Deficiencies Scholarly Information Systems Textbook of Medicine Medline Columbia Library Information On-Line
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Mail Phone Directory Word Processing/Spread sheets Hospital administrative systems: Patient management Patient accounting Materials Management Finance Purchasing Transport Payroll Accounts payable General ledger Costs CPMC has established administrative computing systems which have only recently been augmented by clinical and library applications. Costs for providing connectivity to the underlying IAIMS backbone network have been included regardless of whether the workstation was primarily for clinical, administrative, research or library function. The costs which are listed in this article are the incremental costs above and beyond the ongoing expenditures for central university and hospital administrative computing activities and all grant funded research activities outside of the IAIMS initiative. Conclusions in this paper may be regarded as ballpark estimates that might be useful to other institutions as general guidelines, if their environment is similar. We have taken the following approach to calculating IAIMS related costs. We have calculated total expenditures to date (personnel, hardware, software) and allocated these to one of three categories (network, workstations, applications). We then estimated a useful lifetime for each of these categories (network 20 years, workstations 6 years, applications 10 years). We then assumed that the system would stay frozen at its current level of functionality, i.e. no new applications or network expansion. We calculated the cost (people, licenses, hardware maintenance etc.) of maintaining the current system capability for the duration of its useful lifetime using today's dollars. We then calculated the annual cost of each component and summed them to give an amortized, non-discounted annual cost of the system in today's dollars. We have spent the equivalent (some of the external support comes in the form of products) of $23 million in the past four years ($9.8 million, personnel includes salaries, fringe, overhead and indirect costs; $3.9 million, network; $7.4 million, applications; $2.1 million, workstations). We have allocated 20% of the personnel expenses to the cost of the network, and 80% to development, installation, and management of applications. Forty percent of this total came from Presbyterian Hospital operating and construction funds, 10% from Columbia University, and the remainder from
network software), and 24% all other (Chart Tracking, and Medical Records Coding, mail, OS/2 LAN servers, PC LAN servers, LANACS's). Utilization of the largest applications is summarized below: The clinical results review system began operation in July of 1989. There are currently over 2500 active users of the system. Utilization of the system has more than doubled over the past 12 months. On an average weekday, there are over 2500 logins and over 5500 data inquiries, and these numbers are increasing each month. Although requests for laboratory data are by far the most frequent, there is strong and growing demand for radiology, pathology, cardiology and other text reports as well. Approximately 80% of all House Officers use the system regularly, as well as 70% of attending physicians with currently hospitalized patients. Nurses account for 20% of system utilization, and medical students account for 5%. The system is also used regularly by staff in 56 different hospital departments. Five years of Medline abstracts are available for review by clinicians and researchers. The MEDLINE system, implemented last year, is used by approximately 600 individuals each month, primarily house officers, medical students, and attending physicians. There are 135 logins each day, each lasting an average of 15 minutes and containing an average of 10 individual searches. The surgery scheduling system, implemented in 1989, is used by the Admitting department to schedule 30,000 procedures each year, and is used by numerous other clinical departments, clinics, and doctor's private offices to review O.R. schedules. The patient abstracting and DRG coding system, installed three years ago, is utilized heavily by Medical Records and Utilization Review staff, and less frequently by Quality Assurance and Patient Accounts. The system is used 16 hours daily, with an average of 25 continuously active users each weekday. Over 850 patient abstracts are created or updated each week. The chart tracking system was only recently implemented, and is being phased in gradually during 1991. Of the one million plus CPMC charts, over 200,000 have been loaded into the new tracking system, and new charts are being added continually. During the daytime shift several hundred Medical Records and ancillary staff use the system, with another 40-50 using the system during the evening and night hours. Currently the system supports approximately 5700 transactions per weekday.
external sources. This level of expenditures is in line with our initial planning estimate [2] of $34 million for implementation of the IAIMS concept at CPMC. To support the currently operational systems, we would need network and workstation support people, help desk coverage, applications support, technical support, and an operator to operate the host machines (approximately 8 FTE's). Our total costs can be broken down as follows: Network $ 3.9 million for wires, bridges, gateways, fiber $ 2.0 million for personnel to design and implement (7/87 - 6/91) $ 5.1 million for maintenance personnel (5 people, 16 years) $11.0 million total, to be amortized over a 20-year period. ($550,000 annually) Workstations $1.9 million (564 at $3300 includes adapter cards, software, etc.) $0.2 million (231 pre-existing PCs at $850 for adapter cards and software $0.5 million (797 * $150 annual hardware maintenance for 4 years) $2.6 million to purchase, upgrade, and maintain workstations over a six-year period ($430,000 annually). Applications $ 7.4 million for hardware, software packages $ 7.8 million for personnel (7/87-6/91) $ 3.0 million for maintenance (fees + 3 people, 6 years) $18.2 million to purchase, develop, maintain applications over a ten-year period ($1.8 million annually). Thus, our amortized annual IAIMS related costs are $2.8 million. This annual cost is 0.3% of the total annual medical center budget of $950 million dollars. Integration costs (networks and workstations) by themselves amount to 0.1% of the total medical center expenditures or 5% of the total annual expenditures for administrative, clinical and scholarly computing at the medical center. Dividing the annual cost by 365 gives a daily cost of $8000, which we use below to look at cost per unit of access. Utilization The traffic across the 4mb token ring backbone has been analyzed during the peak period of usage. Maximum load was 38%, and average load during the peak period was 16%. The percentage of traffic is as follows: 40% SNA (mainframe applications including results review and MEDLINE), 36% Netware (surgery scheduling, other
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Cost per unit of access is difficult to measure, since the defrmition of access varies greatly across so many heterogeneous systems. There are approximately 2650 total logins per day for the major applications which we monitor. Given a daily cost of $8000, this results in an average cost per login of $3. The "logon" is not a uniform unit of measure, since in some systems a logon-logoff session lasts one minute, while in others it can last all day. Logon figures also may be underestimated because users sometimes fail to logoff before the next user begins to use the system, etc. There are about 13,000 total inquiries per day for the major applications, giving an average cost per inquiry of $0.60. Again, the definition of "inquiry" varies depending on the system - for results review, it means review of one type of result (e.g. all lab data); for MEDLINE, it means one search; for chart tracking, it means one chart inquiry. On an average day, there are 1045 individuals that use one or more of these IAIMS systems, giving an average cost per user of $7.70 per day.
Discussion Analyzing and justifying IAIMS costs is not straightforward [4,5,6]. While our cost figures are comprehensive, our utilization figures are probably under-estimates. We have comprehensive utilization statistics for the clinical results review and on-site MEDLINE systems, and fairly reliable estimates of utilization of the other larger systems, but no data on utilization of many of the smaller or newer systems, such as mail, university administrative computing or fetal monitoring, which are accessible through the network. It is expected that increased access to all types of information will improve the efficiency and quality of our activities in patient care, research and education. We compare the IAIMS costs to the magnitude of some of the specific benefits which we expect the system to provide: time savings for personnel and improved efficiency and quality of care as might be reflected in decreased length of hospital stay. We do not address such issues as improved research productivity, reduced malpractice claims, improved student learning, etc. Our comparisons are not substantiated claims of achievement, but standards for measurement. In our comparisons, we assume that the full costs of the IAIMS activities must be justified by just a single specific effect. If it can be determined that real benefits occur in all or most of the expected areas, then the "break even" threshold for cost justification would be accordingly reduced. The actual time saved by having access to facts about the patient, using Email to communicate, or accessing the literature via Medline, is difficult to assess. The IAIMS
initiative would be cost justified if it saves each of the 1045 daily individual users approximately 20 minutes per day (assuming average salary plus fringe of $50,000). The cost of result inquiry ranges from 1-5% of the cost of performing a laboratory test. Because the paper-based patient chart can only be in one place at a time, it is often impossible to obtain information in the Emergency Room or clinic except by using the computer-based patient record. The $3 per login charge appears well justified in these instances. Recent studies [7] at CPMC have indicated that improved access to information improves efficiency, and reduces time wasted due to lost results, duplicate test orders misplaced patient charts, etc. At CPMC, occupancy rates are high and elective admission waiting lists are long, so a shorter average length of stay would translate directly into increased admissions. Information systems can impact the quality and efficiency of care in four different ways: 1. Improved access to accurate facts about the patient or institution (laboratory results, surgery schedule, etc), 2. immediate, focused access to the literature, 3. critiquing of provider actions or lack thereof, and 4. post hoc analysis of the way medical care is provided. If improved access to information can reduce the hospital's average length of stay by even one percent, that could translate into an additional 450 admissions per year, or an increase in annual net revenue of $3,150,000. This revenue alone would more than compensate for the annual expense of the entire IAIMS initiative. Erica Drazen [8] has estimated that there is a six percent premium added to the cost of health care because of information deficiencies (duplicate test orders, inefficient scheduling, etc.). Given our IAIMS costs of 0.3% of the total medical center budget, we would only have to reduce the chaos factor from 6% to 5.7% or a five percent reduction to hit the break even point. Also, Tierney[9] has shown that displaying the cost of tests, which we also do, has reduced test utilization by 14% in an outpatient setting. Although the need for access to the literature is documented[10], no one has yet measured the value of access to the system. We assume that since extremely busy and intelligent attending physicians, students, nurses and residents use the MEDLINE capability, that it is a useful function. Demonstrating that a Medline search session is worth the $3.00 login cost is best accomplished by comparing this cost to that which members of the community are willing to pay for private dial up access. Leape et al.[l 1] have shown that there is substantial negligence in such information intensive activities as prescribing drugs. Gardner[12], McDonald[13], Evans
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[14] and others have shown substantial cost benefits of critiquing systems. A significant fraction of our application development cost has been directed toward achieving the on-line decision-making capability. We now have such a system operational in a rudimentary way[15]. As we begin to approach the breadth of performance of the HELP and Care systems, the realized benefits would certainly be expected to increase. The costs of integration are small compared to the costs of applications which users desire with or without an integrated information architecture. Two thirds of our costs are attributable to the applications themselves. As we expand our selection of applications, this ratio will increase. Since there are wiring and terminal costs associated with point to point wiring, the incremental costs for network connectivity and integration appear to be well justified. A direct benefit which is very evident to us is the ease and rapidity with which new applications can become available. No longer must every desirable application be written or purchased to run on one mainframe host to which terminals are hardwired. By focussing on relatively inexpensive microprocessor based servers, we are able to purchase or develop many applications, which would be unavailable or prohibitively expensive in the main frame environment, . We feel strongly, but cannot document, that this ability to address the "applications backlog" by allowing parallel development more than cost justifies the system by reducing application development and maintenance costs and improving speed of implementation. In summary, the costs of integration are small compared to the costs of application implementation and maintenance. In the absence of definitive data on actual time saved and/or improvements in the quality and efficiency of care provided, the only standard for which we have quantitative data is utilization. We hypothesize that bright, extremely busy individuals who are vitally interested in providing efficient, quality health care and in pursuing research and educational activities choose to use the system because it helps them to access useful information in ways that are more convenient and effective than traditional alternatives.
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