MFD. INFORM.

(1979), V O L . 4,

NO.

2, 79--88

Characteristics of the software for computer applications in medicine

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F E M I AGBALAJOBI Department of Computer Sciences, University of Lagos, Lagos, Nigeria (Rpreived 15 October 1978) T h e requirements of clinical medicine which have tended to make the design and implementation of software for hospital computer systems more difficult than that elsewhere, are discussed in this paper. Specific constraints on the software for selected computer-assisted activities in a hospital environment are examined in considerable depth. It is s h o w n that since sonic. of tliesc actt\-itic.s h a v e co~interlxii-tselsclvherc, Iiospital computing can benefit Irum the accumulated c.xpcricncc i n dealing with similar pi-ohlcrns In business and scientific environments. T h e argument is put forward that developing countries, with their characteristic problem of acute shortage of skilled manpower in both medicine and computing, should initially concentrate on applying computers to these activities alone. Furthermore, medical education in such countries should incorporate programmes relating to computer technology in general and the softlvare aspects in particular. I x s exigriices de la Mkdecinc, q u i contribucnt i rcridre la conceptioii c t I’implkmenration des systemes inforniatiques hospitaliers plus difficiles que dans d’autres domaines, sont discutees dans cet article. Les contraintes sptcifiques, liees au logiciel repondant aux activitCs assistees par ordinateurs dans le cadre d’un hbpital, sont ktudites en detail. I1 apparait que certaines de ces activites se retrouvent dans des domaines autres que la Medecine et que I’Informatique Hospitalihre pourrait beneficier d e l’exptrience acquise dans les milieux scientifiqucs ou d’affaires. Ides nutcurs sugg6rcnt quc lcs pays cn voie d e diwoloppcmcnt, handicapcs par Ic nianqiic i i i f i u d e c n m p h n c r s ;iussi bien niidicalcs qu’informatiques, devraient concentrer avant tout leurs efforts sur les applications communes au milieu hospitalier et aux milieux scientifique et de gestion. D e plus, dans ces pays, l’enseignement medical devrait inclure des cours d’informatique genkrale et des cours portant sur certains aspects systemes.

1. Introduction Of the many factors which have hitherto been identified as affecting the successful implementations of various projects on the application of computers to medicine, three are more discussed than the rest. T w o of these factors, namely the suboptimal mix of the medical and computer specialists, and the inadequate commitment of capital for long-term investment, have long been emphasized by Collen[l]. T h e third factor is concerned with either the complexity of the userinterfaces to such computer systems or their obtrusion on the normal modes of working of the user. Opit and Woodroffe [2] and Gledhill and Mathews [3] have pointed out that,if the operation of the computer system ‘is foreign to the medical practitioners and also imposes additional burdens on their time’, then such a system is likely to be unacceptable to them. Seaton [4] later identified simplicity of a system as a factor of immense importance where many of the intended users have n o computing experience, since there may be barriers of prejudice and inertia to be overcome before the system is accepted. This factor is particularly relevant to most developing countries where these situations exist in practice. 03iii.:h40 7~ o 4 i n (1079 so? no [ TWIW& Francis L i d

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T h e first nvo factors have farmed the subject of several other papers for quite some time. However, it is only quite recently that attention has been drawn to the problems posed by the third factor. Although the solution to these problems can benetit from technological advances such as large-scale integrated circuits, the littlementioned enhancement to the practice and techniques of software design is more crucial towards meeting the users’ needs effectively. Well-designed software, which takes into consideration all the sociological implications of computing in medicine, will remove some of the prejudices formed by the users of medical computer systems. This paper is addressed to specific constraints on the design and implementation of non-trivial software for carrying out the various health-carc delivery activities.

1 . l . Computing processes for health-care activities It will be recalled that the rapid pace of development in the design of sophisticated computer components and the extent to which computing was making in-roads into the various areas of human activity in the late 1960s encouraged broad prophecies on the potential of computing in medicine. I t was predicted that successive generations of computers would render substantial assistance to doctors in the direct delivery of care in the 1970s [j].Today, this prediction has not been fulfilled in spite of the efforts which have since been put into the application of computers to health-care delivery activities. This suggests that there could be more to this particular area of application than it appeared to the early prophets. One of these, it seems, is the fundamental difference between computing and medicine as distinct areas of activity. T h e premise held here is that patient-care-related activities have not so far been regarded as ‘natural candidates’ for the application of computing technology. The practice and procedures of the delivery of care, though traditionally conseraative, are fiiridamentallj~pexihlc and infinitely adaptable while computing processes are not. On the assumption that these processes are carried out by software when the computer hardware installed is a general-purpose system, any fundamental differences there are between computing and medicine should be related to the current state of the practice and techniques of software. A non-trivial piece of software makes use of formalized procedures and algorithms. I Iowevei-, the medical procedures, which are mirrored by the software, are based on a different concept. T h e hospital environment, being a sociological one, is very flexible. It is acknowledged that the principles and practice of medicine, like those of other sociological activities which involve human beings and human procedures, do not respond to formalized procedures and logical algorithms alone[6]. In contrast to computing, medical activities belong to a world where provision is, ips0 facto, made for meeting the requirement for action under all circumstances. Such an action does not have to be predetermined as it does in computing. For example, a doctor does not have to prescribe a standard therapeutic procedure for his patient unless he believes its contribution to the total well-being of the patient is the best possible. It is in the context of this difference that the requirements of medicine for software are considered in this paper.

2. General requirements Hospital procedures are traditionally people-oriented. A consequence of the human element of hospital computing is that more efforts have to be made to ensure

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that the computer system involved is reliable, that it possesses integrity and that it is secure. It is important that the entire system, the hardware and the software, is reliable. A protracted hardware failure, unless there are adequate back-up and restart facilities to aid recovery, can cause a complete stoppage of the hospital activities. T h e software, in particular, must be reliable; programs must not develop bugs which, for example, might stop the system during critical stages of its operation. I t is an implicit requirement of computer programming that a program shall be correct. This means that it shall behave correctly in all circumstances. However, this objective is very rarely known to bemet by any non-trivial program. And when it is not, the behaviour of programs can be quite unpredictable. It is well-appreciated that data stored in a failed computer gives non-computer staff a strong feeling of impotence [7]. Beyond reliability, the software must also have integrity which is concerned with how robust to accidental interferences the system is. Because of the sensitive nature of much of the data which the system will be handling-particularly when it is system must have the identifiable as belonging to a particular individual-the capability of ensuring the security of the data and in the case of psychiatric data the integrity of the entire system is very important [S]. These constraints on software are not necessarily peculiar to the medical environment. Computers used in industry and research have similar constraints imposed on their respective software components. However, because computers in the direct delivery of patient care have to cater for a variety of users who enjoy a fair amount of freedom in their traditional mode of working, they possess special characteristics which distinguish them from those in these other environments. It is important that the programs, as well as the devices for carrying out activities related to health care, are flexible. This is so because computer systems in the direct delivery of care will be used by administrators, doctors, nurses, technical and clerical staff who are used to a high degree of independence and have well-established responsibilities. There are very few areas of human activity in which such a high degree of independence exists among the staff of the same organization. Three consequences of this variety of users are: the variety of tasks performed, the different requirements of users in the different categories, and the flexibility demanded of devices with which such users interact. If there are devices with which the variety of users interact, such devices must have the capability to accommodate differences. First, the devices must appear to be useful. Secondly, however useful these devices may be, the different categories of the hospital staff, who are conservative by nature, are not going to be interested in the computer if it conflicts with their traditional mode of working. If the devices do not have the capability to accommodate these differences then they are likely to be rejected. An important element in this regard is the software for controlling the devices. Thus, it should be expected that additional constraints would be imposed on the software for the hospital computers beyond those on the programs for business o r scientific computers. T h e extent to which the above requirements have been met is henceforth discussed in respect of each of the four main areas into which hospital activities in most countries can be categorized. T h e areas are: ( a ) Hospital administration. ( b ) Clinical research. ( c ) Clinical laboratories and specialized service units. (d) Direct management of patient care.

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T h i s classification has been adopted in this paper for convenience and does not preclude applications in one category from being part of another.

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3. Hospital administrative systems T h e basic requirements of computer systems to support administrative activities in the hospital are not very different from those performing similar activities outside the hospital environment. These activities readily come under the existing administrative headings, such as: ( a ) Finance and accounting: dealing with payroll, ledger account, budgetary control and other accounting activities. ( b ) Establishment: involving manpower and personnel control and planning. (c) Stock control: planning and maintenance of the hospital resources. ( d ) Transport management and control: involving the use of the hospital vehicle fleet for scheduled and unscheduled (for example, emergency) services. In the application of computers to these activities, most attention is usually paid to the mode and the format of the input data into the systems and of the results and to file organization in general. A yardstick normally employed for measuring the efficiency of programs or packages in these areas is the ease with which the data file can be accessed. It is, however, recognized that any method of file organization and of file processing, which completely simplifies the use of a non-trivial file, is relatively difficult to design and takes a long time to implement. For these administrative activities, the mode of processing the files is usually non-interactive and the language of implementation is often business- and report-oriented. One advantage of the latter is that most packages which exist are transferable with little or no modification. I n theory, the application of computers to administrative activities in the hospital can draw on the experience of business computing. Like the business world, the medical environment requires timely production of results in the relevant field of activity, for example, staff pay. Unlike the former, the hospital environment is not primarily concerned with these activities alone. In practice, the application to transport management and control, for example, may require meeting the transport needs of the hospital patients at times dictated by the exigencies of patient admission and discharge. T h e need to reorder the priorities in vehicle allocation to meet the urgency demanded by the two latter activities, imposes further constraint on the software for transport management. Thus, it must not be expected that a piece of software developed for an administrative activity elsewhere can be easily transferred, without modification, to become part of a hospital-wide information system.

4. Clinical research Clinical research makes extensive use of computers in ways similar to those employed in research projects in the pure, applied and social sciences. Clinical research as discussed in this paper, includes the fundamental research projects carried out in teaching hospitals and in specialized research units and institutes and funded by the appropriate national councils for medical research and similar organizations. It has long been pointed out that the ease with which computers can perform complex calculations using standard statistical techniques has firmly established their role in the routine handling of data, for epidemiological studies, in a wide range of research contexts [9]. Special software, the so-called packages, have been designed for use in medical and in social science research. T h e well-known

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BMD package [lo], the IBM SSP 3 package and the Statistical Package for Social Sciences (SPSS) are examples of efforts made at providing the researcher with a ‘unified system of programs’ [l 11 for the manipulation and statistical analysis of data, with a particular emphasis on the needs of the social sciences. T h e B M D package includes programs for many of the standard forms of statistical calculations, for example analysis of variance, covariance, discriminant analysis and principal component analysis. In reviewing the first edition of the SPSS package, Wilson and Barrett identified two important features of the package [12]. T h e first is the ease with which the data can be organized and the calculations controlled by means of control cards. T h e second is the ability of the package to direct calculations to compensate for data which has been missed during the experiment or survey. Attractive as these features are, it is noteworthy that many medical researchers, particularly those in environments where computing techniques have not been widely accepted, have not found the package easy to use and indispensable to clinical research. It should also be pointed out that in designing those packages and others [13, 141, decisions about the appropriate calculations which the computer has to perform, had to be made by someone knowledgeable about statistics. T h e decisions are neither those which can be made by the computer program at run time nor those made by the medical researcher.

5. Laboratory and specialized service systems Clinical laboratories and other specialized areas involved in chemical and biochemical analysis, signal analysis and process control, have functional characteristics that distinguish them from hospital administration or clinical research. First, because of the increasing demand for pathological investigations and the shorter turnaround expected between making the requests and getting the results, it is no longer feasible to employ manual techniques for some of the activities associated with laboratories and specialized service units. T h e processing of test results and work schedules, the calculations of results and the provision of management and epidemiological information are some of the current and potential activities in this category to which computers are applied. Computing in clinical chemistry, haematology and histopathology, for example, enable the analysis of anatomical, blood and body fluid specimens to be carried out promptly and accurately. Secondly, there are those activities which appear to make a wider demand on the calculating capability of computers because the activities relate to complex and laborious tasks which otherwise could not be effectively performed manually within a relatively short period. For example, in their current use in radiotherapy, the computers are not only employed for radiation treatment monitoring but also for the calculation of radiation dose in order to improve patient treatment plans. T h e process of radiotherapy treatment planning involves a complex mathematical calculation of the arrangement of beams such that the resultant radiation, to which the patient is exposed, is maximized in the area where the tumour exists and minimized in the surrounding healthy tissue. Thirdly, there are other activities which appear suitable for dedicated computers because they have high cli&cal content. An example is a patient-monitoring system which is concerned with the production and use of data, for example, on body functions of patients in intensive therapy units.

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Common to the three classes of activities outlined above is their long association with process control and some degree of automation. It is noteworthy that some of the medical activities with which computing was involved in the early 1960s, were those associated with the functions performed in specialized service departments, where some degree of automation was already taking place o r where the demand for process control was fundamental to their activities. Although these departments and units performed distinct functions, some of them have always shared the problems relating to the process control of analogue devices and the need to produce reports generated from iterative calculations. Quite early in the history of computers, process control was identified in principle as a natural application for computers and this led to the development of highly sophisticated hardware for such and related functions. Nowadays, the state of the technology enables versatile general-purpose computers running the appropriate software to functionally replace, as processcontrol devices, the earlier special-purpose computers in several areas other than in the ultra-specialized ones such as air-borne systems. Software for computer systems in this category of medicine has learnt successfully from the accumulated experience of scientific computing to which the medical laboratory technologists and pathologists have been exposed. I t also benefits from the fact that the work performed in these various units represents, as a group, some of the most readily quantifiable aspects of medicine. Some of the individual programs developed for work in clinical laboratories have been mentioned in Whitby [9] and it suffices here to consider the constraints imposed on the software associated with the use of computers, for example, for continuous capture and on-line monitoring of analogue data. Although this class of computers used in the control of processes is similar to that in business and scientific environments in that they both benefit from technological advances such as large-scale integrated (LSI) circuits, they differ from their siblings in at least two ways. First, they have to accept input directly from the processes and secondly, they have to operate continuously in most adverse conditions. These two constraints make the software more difficult to implement. Further, the thought and planning preceeding its design are usually longer than in the case of business and scientific software. This is essential because once implemented, the application must operate in an error-free manner since re-run time does not exist in a medical activity which runs on-line either for a whole day or at specific periods during the day. In general, the software is relatively smaller and the language of implementation is more machine-oriented, than elsewhere.

6. Direct management of patient care T h e day-to-day activities which contribute towards the direct management of patient care in a hospital are concerned with, for example: ( a ) Meeting the administrative and medical needs of the in-patients. ( b ) Organizing the out-patient population. (c) Providing the appropriate nursing and ancilliary services. ( d ) Retrieving or creating, updating and storing the personal medical records for the patients. ( e ) Administering drugs and other forms of therapy. (f) Clinical decision-making.

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Although these activities are more fundamental to the principles and practice of health-care delivery than those in other areas of hospital medicine, they constitute, in theory, the least quantifiable aspects of the medical care. In practice, however, programming the computer to carry out these activities demands, not only a quantitative specification of the required steps, but also a formalization of both the input data and the expected output. These become particularly difficult to meet in viexv o f the acknowledgement by the medical staff that these activities do not respond to logical algorithms alone. Hence, some of the drawbacks which have impeded the progress of computers in medicine are more remarkable in the application of computers to direct delivery of patient care than in their application to hospital administration, clinical research and clinical laboratories and specialized service units. Specific examples are given below to illustrate the types of problems encountered in each application.

6.1. In-patient and out-patient systems There are no special problems encountered in writing programs to carry out activities related to, for example, waiting list and admission of in-patients, indexing and tracing of patient records, appointments and work-lists in the in-patient departments, as well as those related to pre-registration and registration of hospital out-patients. These ‘clerical chores’ involve access to, and retrieval from, files of data on the patient population of the hospital. Computing here can easily learn from the experience in business environment where file handling is a major computing activity. However, judging from the way patient-scheduling systems have been relatively neglected, software design for this activity is not so easy. In patient-scheduling applications, the computer offers the capability for providing information on scheduling the movement of patients (both in-patients and out-patients) sometimes to several points in the hospital in turn. To be able to carry this out effectively, the software may need to take into account the human element involved in such movements. T h e required scheduling algorithms become complex as they attempt to marry the sociological demands of the environment to the inflexibility of the techniques of computer programming. 6.2. Nursing and pharmaceutical systems A computer system which is implemented to process requests from nursing stations must take into consideration the traditional commitment of nurses to the physical and emotional care of the patients. If a nurse has to perform functions related to health care about the same time that she has to operate a computer terminal, the latter activity should be able to wait when the nurse has an urgent situation to attend to. It is inconceivable to expect a nurse to sit at a terminal in a ward to complete data-entry when a patient requires immediate attention. Real-time processing of data, in the case of nursing systems, demands a software which can adapt to the changing situations characteristic of patient-care. Moreover, since various grades of nurses would be required t o operate the devices for processing any requests through the computer, the software must enable such devices to cope with any resultant differences. In addition to the above constraints, there is a greater demand on the software for controlling, monitoring and prescribing drugs to patients in hospital than on that for similar activities in business and scientific environments. A computer-based drug prescribing system, for example, is not only meant to retrieve drug information in \I.[.

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real-time, it has to make use of statistical techniques to determine the appropriateness of the drug to the current use. This is because in helping the doctor to prescribe efficiently and accurately, the system has to provide him with information about the qualities, including incompatibilities and contra-indications, of different drugs.

6 . 3 . Patient-record systems Quite early in the application of computers to health-care delivery, it was identified that computers could render substantial assistance to doctors in the storage, update and retrieval of medical data. Subsequent attempts made at achieving this realization have, in turn, led to the emergence of a variety of computer-based patient-record systems. Some of these have been labelled ( a ) abbreviated patient-record systems, (6) extended clinical-record systems, (c) integrated patient-record systems, (d) direct medical history-taking systems, and ( e ) problem-orien ted medical-record systems. These systems currently make use of techniques previously applied to the organization of data files in non-medical environment. However, the software designer has two problems to solve. First, he has to make the operation of the devices for recording the data less obtrusive on the other activities related to health care. Secondly, he has to choose one method of implementation which makes the computer-based patient-record system readily acceptable to the various departments whose activities involve the recording o r retrieval of patient data. Inability to give adequate attention to the first problem has led to the failure of some computerbased patient-record systems. T h e second problem is even more difficult to solve since it may cause a new technique to be imposed on different departments in the hospital who normally enjoy a fair amount of autonomy in carrying out their tasks.

6.4. Clinical derision-making By far the most difficult application of computers to health care is in the area of clinical diagnosis. Two factors can be identified as being responsible for the slow progress of computer-based or computer-aided clinical decision-making systems. First, it is widely claimed by many medical practitioners that the process of diagnosis is, to some extent, a form of art which may be difficult to formalize or to express in the form of algorithms alone. Secondly, current computing techniques rely on explicit definition of the steps required to attain a desired result. However, one way of viewing the process of diagnosis is expressed by Card: we may think of the strategy of the doctor as a function whose argument is his present state of knowledge and the current probability vector and whose value is the choice of the next facet. Provided we know the likelihoods of all the indicants in our system and the probability disease vector, we can calculate which facet is likely to be the most informative in the sense of altering maximally the probability vector [15]. T h e techniques at the disposal of the software designer are still far from adequate for dealing with such a subjective approach to an extent which makes the medical practitioners accept computers as indispensable tools in the processes associated with clinical decision-making.

7. Concluding remarks ‘The general requirements of medicine for computing have been discussed. Specific constraints on the software for carrying out selected activities have also been

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highlighted. I t is apparent that not all the activities present non-trivial problems to software designers. Hospital administration, clinical research and laboratories (including specialized service units) can benefit from the accumulated experience in similar areas outside the medical environment. However, there is still more work to be done before computing can render the expected support to doctors in the direct delivery of care. On the one hand, the computer system should be flexible to accommodate the different requirements of the various users. T h e language of communication with the system should be less formalized. On the other hand, the users must learn to adjust the existing traditional modes of carrying out those activities for which the implementation of computers can be of immense benefit. T h e existing barriers of prejudice and inertia should be removed. Nigeria, as well as most developing countries, can learn from the experiences of developed nations. T h e acute shortage of skilled manpower in both medicine and computing imposes the need for caution in the unrestrained implementation of computers to various health-care activities in Nigeria. With a ratio of four clinicians to about 75 000 of the population, the Nigerian medical staff are already deeply engrossed in the basic health-care delivery activities to the extent that they have no time left to get properly acquainted with any new demanding devices introduced by computing. Furthermore, with the low level of computing experience in that country, it is more difficult to expect that they can effectively contribute towards the development of computer-based systems for use in their own environments. Efforts must therefore be directed towards introducing computers into those activities which either have counterparts outside medicine or can be carried out by specialized equipment under skilled supervision. Beyond this, it is very important that the training of the medical and paramedical staff be restructured to reflect the changes which computing is currently bringing to medicine. More than a decade later, developing countries can still benefit from the conclusion of the Pierce Report that: ‘most people educated beyond the high school level will have occasion to make use of computers and computing as essential tools and all will need sufficient understanding of their possibilities and limitations realistically to appraise the new opportunities now available for information processing’ [ 161. Medical education in developing countries must incorporate programmes relating to computer technology. I t is not presently important to stress the hardware aspects of computing; but the wider ramifications of software dictate that the computer programming aspects are essential. For a start, awareness of the capabilities and limitations of computing in medicine must be awakened. Awareness may generate interest; and interest may lead on to a desire to learn about the practical details of applying computers to medical problems. An important objective of an educational programme relating to computer technology should, therefore, be to ensure awareness of the broad principles, to back this u p with opportunities to learn more about computer programming and to use the computing equipment under supervision. Medical education in developing countries must seek, and co-operate with, this type of programme.

Acknowledgements Some of the ideas contained in this paper arose out of the author’s experience in developing an appropriate software for a psychological testing system in a London c2

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hospital. T h e author is grateful to both Professor Keith Wolfenden of University College, London, and D r Alick Elithorn of the Royal Free Hospital, London, for their immense contributions towards the development of those ideas. Special thanks to Professor M. Healy of the School of Hygiene and Tropical Medicine, University of London, for enlightenment and to both Messrs Richard Cooper and Alex Telford for their technical advice and support d.uring the design and implementation of the software.

References 1. COLLEN, M. F., 1974, General requirements.In M . F. Collen (Ed.) HospitalComputer Systems (John Wiley & Sons) 3-23. 2. OPIT,I . J . and WOODROFFE, F. J., 1970, Computer-held clinical record system-11: assessment. The British Medicul Journal, 4. 3. GLEDHILI., V. X. and MxrHEws, J. D., 1972, An operational medical records system: Acquisition, storage and retrieval of formalised medical data. International Journal of Biomedical Computing, 3 , 59-70. 4. SEATON,B., 1974, Data processing by computer: on-line or off-line? Computers and Biomedical Research ( C B R ) , 7, 2, 142-156. 5. ASHFORD, J. R., 1970, The patient record in acommunity-based medical information system. In M. E. Abrams (Ed.) Medical Computing: Progress and Problems (Chatto and Windus) 85-93. 6. REICHERT, P. L., 1975, Hospital and health care system. Proceedings I F A C , the 6th Triennal World Congress held in Boston, Mass. 7. VICKERS, M . D. and WOLFENDEN, K., 1974, Time-sharing as a method of providing computingpower to the smaller hospitals. In J . Anderson and J . M. Forsythe (Eds) Medinfo (74), (North-Holland) 59-62. 8. BAI.DWIN, J . A,, I,EFF,J. and WING,J . K., May 1976, Confidentiality of Psychiatric data in Medical Information Systems. The British Journal of Psychiatry, 28, 41 7-427. L. G., 1971, A general review of computer application in medicine. In L. G. Whitby and 9. WHITBY, W. 1,utz (Eds) Principles and Practice of Medical Computing (E. & S. Livingstone) 58-73. 10. DIXON,W. J. (Ed.), 1968, B M D : Biomedical Computer Programs (University of California Press). J. G . , STEINBRENNER, K. and BENT,D. H., 1975, SPSS11. NIE, N . H., HULL,C. H., JENKINS, Statistical Package for the Sorial Sciences (McGraw-Hill). 12. WILSON,J. A , , and BARRUT,G., 1973, An introduction to programming. I n M. J. Apter and G . Westby (Eds) The Computer in Psychologji (John Wiley) 27-56. 13. HORST,P., 1967, Factor Analysis of Data Matrices (Holt, Rinehard and Winston). 14. SING, G., 1968, Multiple Vaviate Counter (University of Imndon, Atlas Computing Service). 15. CARD, W. I . , 1969, T h e diagnostic process. In M. E. Abrams (Ed.) Medical Computing: I’rogress and Problems (Chatto and Windus) 29-34. 16. Report of the US President’s Science Advisory Committee, 1967, Computers in Higher Education (Government Printing Oftice, Washington, D.C.).

Characteristics of the software for computer applications in medicine.

MFD. INFORM. (1979), V O L . 4, NO. 2, 79--88 Characteristics of the software for computer applications in medicine Inform Health Soc Care Downlo...
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