F.Healthcare's standards

A focus on healthcare — the knot of healthcare standards is partially unravelled — medical education standards and standards concerning specialties — the role of scientific authority in standards — scientific accounting — computers in medicine — clinical decision systems — technical standards and nomenclatures — the knot of healthcare standards is severed, leaving radiology standards — radiology workflow — diagnostic standards — DICOM takes up space — and time — informants are called upon to distinguish standards — Sean talks of DICOM and HTTP — Tim talks of IP and OSI — stupidity beckons.

1. The number and kinds of standards in healthcare is overwhelming. The word itself is a disseminated and weak word that is used just as often to refer to a moral imperative as it is to a specific, institutional standard. The present inchoate demand for standards in the hospitals I observed is not wholly new, and the word 'standard' itself has a notorious and important history in 20th century healthcare.

2. To begin with, there is a semantic confusion that cannot always be relabeled: standard as a minimum level of quality, beneath which doctors and hospitals should not slip; and standard as a measure for comparison and control. The confusion is complex, quality fades to quantity and back again in each empirical example, as each problem of improvement demands its own measure. Measures might tend towards the objective in Porter's sense, or toward the ideological, as a cover for power. Convention, guideline, protocol, rule all have a similar vagueness, but they all signal a similar desire to figure out a way to progress. A call for standards most often hides a call for some kind of measurment of quality, often elided in call itself, since it is precisely that slide between medicine as a science and medicine as an art that is at issue in such discussions [1]

3. The Flexner report, for example, is a commonly cited example of the beginning of the standardization of medical schools. The measurement of such standards however, was by no means itself 'standard' but represented a long-standing elite consensus on reform . However, its effects were extremely significant, despite their justification now or at the time, and the report has become, in a strange roundabout way, the "standard" reference for doctors of the improvement of medical practice [2]. As such it served as a kind of legitimation for other attempts over the course of the Progressive era to institute standards. Flexner had collaborated with the American Medical Association's Council on Medical Education, which controlled the rating of colleges [3], as well as writing the report for the Carnegie foundation. The combination gave the new "medical standards" legitimacy in the double form of the AMA's stamp of approval and the virtual guarantee of foundation grant money as well. It was not an accident that Flexner stressed the role of the university as medical educators, over the proprietary medical school [4]. During this time, the professional organizations also developed or expanded institutions to monitor, certify, and licence doctors, nurses, hospitals, and schools. The structure of rhetoric was the same, a "standard" identified always as something everyone would agree should be improved, used as a political tool. The growth of specialties in the same period is yet another example as orgainzations like the American college of Clinical Pathologists and the American College of Surgeons formed and gained power over their members, licencing boards were used to prevent the growth of other specialties, like osteopathy and chiropractic medicine, as well as to increase the power of state licencing boards in the face of potential government control [5].

4. Rosemary Stevens makes a strong case for viewing these transformations in healthcare as a kind of national medical enterprise [6]. The intense desire for scientificity that historians have located in so many areas of early twentieth century life (from taylorism and scientific accounting, to sociology and economics) was certainly no less present in medicine, and formed some of the basis for "standardization" such as the strengthening of hospital administrative staff and the implementation of "scientific accounting"[7]. Science bred authority, authority allowed benevolent control, and everything from recalcitrant cancers in the mouths of presidents to the sewers beneath (or inside) Tamany hall were fair game for the simultaneous improvement of health, medical authority and national pride. These national infrastructural standards bear comparison, or geneology, because they occasioned similar debates about the nature of legitimate authority, the role of government in delegating the authority to standardize and oversee to administrative bodies, professional societies, and corporate interests. The quantification of quality is necessitated as soon as the rule of law meets the demand for expertise. The standards are not "information technologies" as Alder might call them, but closer to Porter's trust in numbers— the beginings of an age of accountability unto accounting.

5. Scientific Accounting is usually represented as the beginning of "information technologies" in healthcare, by virtue of the growth of the standardized medical record it produced, and the subsequent possibility of comparison it created. Interestingly, there has been little historical work on previous schemes for measuring the efficiency of hospitals, especially in terms of the "outcomes" (a fraught word that, like "information technology" would be anachronistic here) of patients. However, a certain story circulates in the trade and business press of hospital administration in my fieldsites, about Ernst A. Codman. Codman is identified as the origin point of "outcomes measurement" [8]. His standardization reforms, more familiar to a history of taylorism than of medicine, have become a kind of historical object lesson for contemporary efforts to measure patient outcomes. His desire to record data, and to make it available to hospitals and doctors rings common sensical to ears adjusted to the sound of mortality and morbidity rates. But as Millenson notes, his reforms had little financial impact at a time when the Flexner Report's blessing combined with the AMA's rating of med schools, usually meant massive endowments from Carnegies and Rockefellers, for which it was more lucrative to compete. Codman's failed attempts at reforms left him looking a little inhumane (which seems to have been exacerbated by his tendency to make bets with his fellow doctors on who could achieve the best numbers).

6. Over the twentieth century, both the medical enterprise and the methods of measuring and standardizing information have grown significantly. Bonnie Kaplan's study of the computerization of medicine cites a persistent sense of "lag" in the perceptions of medical doctors of the pace of this change, and the result that computerization is often used to justify certain policy changes in the name of improving quality and efficiency [9]. The education of doctors, and the specific languages of medical diagnosis and treatment have met the demand for standardization as a result. One of the most common calls for research in the early literature on computerization was for the creation of databases of medical knowledge and "clinical decision systems" [10].

7. Clinical Decision systems are already a kind of classic problem for the ethnomethodologist and the sociologist of work. Marc Berg's Rationalizing Medical Practice is an instructive introduction to the localization of theories as tools and the difficulties of medical action that result. Information cleaves to the theoretical in these cases, as a kind of distilled scientific theory that doctors are trained to occasion. Of course, action in the medical domain has never been so simple, and it is only in cognitivist and behaviorist accounts that it is represented as such, much less experienced as such. And yet, the scientificity of medicine, especially its use of statistics and probability, is its highest virtue, and the doctor that rejects it is rare. So the problem of standardization and classification becomes less a problem of showing that medical reality is messier than medical science, and more a pragmatist problem of adjusting available scientific measures and information to a constrained series of situations. [11]

8. Today, the number and kind of standards is huge. Any given professional medical organization will offer a variety of practice guidelines, ethical guidelines, medical statements, care protocals, ethical positions, scientific statements, prevention guidelines— the list is nearly infinite [12]. Some are legally binding and intersect with administrative and legal concerns for both patients and doctors, some are purely political (statements on assisted suicide for instance), and most are very specific protocols for doctors that represent a professional organization's customs, scientific opinions, in codified form. Then there is a range of technical standards and standard nomenclatures that exist to help standardize things, machines, procedures, and language,

9. The standards that govern the machines, or the components that make up the machines (for instance, those published by the National Electronic Machinery Association {NEMA}, the American National Standards Institute {ANSI} or the Institute of Electrical and Electronics Engineers {IEEE}) intersect uneasily with the proliferation of standards, codes and nomenclatures of the medical field (The international classification of Diseases {ICD9, ICD10}, the Logical Observation Identifiers, Names and Codes {LOINC™}, or Systematized Nomenclature of Human and Veterinary Medicine {SNOMED}) which are only partially integrated in the various attempts at systematic standards for storage, transformation and communication of medical information (The Digital Imaging and COMmunication standard {DICOM} and the Health Level Seven {HL7}). To complicate matters, most nomenclatures and codes, as well as several of the communication protocols are developed by specialty: ambulatory, acute care, pathology, radiology, nursing, pharmacy, dentistry, public health all have systems specific to them that are not designed to communicate with the others. And of course, when a standard involves a specific piece of technology, such as a CT scanner, there are various corporate-owned formats and standards that must be included. The list is complicated enough to merit research groups devoted to standards, such as the one at Duke University Medical School, which appears to be at the center of the healthcare standards universe [13].

10. The original calls for standards have generally been made in the name of reducing the existing complexity of the healthcare industry. Ironically the field is so dense with standards that even the DUMC standards research group uses the Tower of Babel as its emblem. However, the metaphor of the Tower of Babel slowly loses its force as a warning, and becomes a myth of failure, in particular, of an aging system of organization in healthcare. The fact that standards have become important to all participants in healthcare not only as a technical sine qua non, but as a kind of disciplinary demand, a commercial imperative, or now, especially, a moral one (q.v. "quality of care" debates, accredidation agencies, the media life of the HMO-as-villain, stories of stupid mistakes and denials of care), signals that some other kind of convention has lost its power. Whatever it has been over the course of the twentieth century that has allowed the particular organization of healthcare in America to resist being dismantled (whether inertia, the prestige of the Hospital as an emblem of America, or the power of professional groups' interests), the demands for standardization today, always call for the "integration" of healthcare [14].

11. Formal nomenclatures, bodies of rules, and software and communication standards are the quotidian appeal of editorialists, journalists and doctor-engineers everywhere. These demands often take the place of an appeal to the medical authority of the doctor, or to the embodiment of standards of excellence in his person [15]. Certainly these calls often supplement the calls for the improvement of medical education with the improvement of existing doctors retraining in computer skills. If this distinction between the hierarchical, paternalistic authority of the doctors' standards (bearing a burden of history that must be reproduced through the customs and rituals of training and eductaion, themselves subject to standardization, which do not disappear, only fade in terms of power) [16], and the objectified rules for the standardization of medical concepts, terms and procedures is allowed, then we can temporally site the relations of scale and convention in healthcare.

12. Organizations (and specifically the Hospital) that once served as boundaries for this culture fall away and the primitive operators of healthcare become information and communication. The changes that Amicas identifies in rediology and radiology's confrontation with the internet are an example of this relationship between culture and standards, between scalability and location. The re-integration of healthcare's infrastructure as the internet (q.v. Chapter Q) is a response to a fragmenting national medical enterprise, and the examples of radiology, teleradiology and telemedicine are particularly important to understanding this transformation. The asynchrony of healthcare, its willful contradictions of traditionalism and progress, militate against a simple break from the era of the cultural authority of physicians to the technical authority of standards. Yet the transition that occurs at the level of representation (the information and communication of images for the purpose of diagnoses) has a tangible effect on the configuration of before and after. It not only creates a new organization, it builds subjectivities that can negotiate that structure [17].

13. In the radiology context, the standards are equally complex, but at least enumerable [18]. The standards that govern the image, the diagnosis of the image, any manipulation of the image, and any kind of radiological treatment are governed primarily by the American College of Radiologists, first through an array of diagnostic standards (availble at the ACR website) and second through the creation of the Digital Imaging and Communications Standard (DICOM, in collaboration with the National Electronic Manufacturers Association (see more, below). It would be false, however to suggest that they are in control of all the standards. Especially in the case of digital modalities introduced by commercial companies into hospitals, the technical formats for images were initially (and remain) proprietary. Steven Barley's dissertation [19] on the entrance of digital imaging technologies in radiology describes how the change from film to digital imaging affected the practice of producing reading and diagnosing from such scans and it is useful as a comparitive historical point. Barley describes what the introduction of new "modalities" did to radiology, at the time, he claimed "it is in the creation of new modalities that computers have played their greatest role in radiology." Each modality— CAT, Ultrasound, PET, DSR— initially produced data in its own format. This make sense, if we consider that until the mid eighties (and in all of Barley's examples) the end point of imaging study was a film printed out for a radiologist to use in diagnosis [20], the digital data doesn't need to leave the machine, and if it does (on a magnetic tape, for instance) it is under the assumption that viewing it means putting it back into the same scanner. Of course it is also Barley's point that the standards of diagnosis published by the ACR also changed as a result of the introduction of new technologies.

14. However, the standards relevant to the question at hand are those that conquer distance. Short and Long. For the "modalities" of Barley's thesis the transmission of images is an afterthought. In digital terms, such modalities are imagined as self-contained, even if that self-containment includes a local network of workstations and devices. Imaging in healthcare, conceived as broadly as possible, has been primarily a film medium, born of photography and intimately connected to that world through corporations like Agfa, Kodak, 3M, Polaroid. X-rays set the standard early on. The work flow of examination, x-ray, and diagnosis was built up and sedimented around the film. Consider then, the transmission of images in the case of film. The "communication" of film images means simply moving them around by hand, or by taxi or by an individual hired specifically to run films back and forth from a library or archive to a reading room or to doctors offices. Even when the CT Scanner and Magnetic Resonance Imaging came onto the scene during the 70's and 80's, the practice was to print the digital images onto film, as is evident from Barely's dissertation. This allowed them to be viewed in the same rooms, with the same technologies that had grown up around X-rays (viewing boxes, and the big mechanical drums, cylinders and boards that allowed radiologists to view several images next to each other and in rapid succession)[21].

15. Even today, when many hospitals are installing computed radiography (CR) stations for taking X-rays, such fully digital X-rays are still printed to film (as are the digital CT and MR scans), as a result of an institutional and organizational workflow that knows little of the digital communication of image and text. Massachusetts General Hospital, for instance, was still at full film production until April of 1997. The transition to viewing digital images on digital screens is still not complete [22]. In this site the entrenched conventions emplotted by one technology (x-rays, and their kin) serve as model and metaphor for subsequent innovations. The organzational theorist, or the sociologist would be at home here following workflows and watching the negotiations wrought by uneven technical constraints, professional identities, moral authorities. At the limit, however, moving digital images chip at the very boundaries of the organization that would contain these intellectual interlopers— challenge the very possibility of identifying a hospital as the locus of practice— as it does in my case.

16. Enter telemedicine. Telemedicine has never been the sole province of any specific discipline or professional society. It's history seems to be one of isolated research projects of a variety of medical specialties. Over the thirty years that it has existed in various forms, and in various places it has remained relatively obscure. One reason that "telemedicine" has remained so unknown and so powerless has been its singular focus on the arbitrariness of the very powerful boundaries of the hospital. The boundaries of hospitals and specialties sedimented over a century are not so obviously removed even when efficiency, patient care, and access claim self-evidence. This is the persistent frustration of telemedicine researchers [23].

17. The irony of telemedicine should not be lost here. Those individuals who saw the potential of telemedicine in the 70's and 80's saw it as the possibility of transmitting images over long distances— between two organizations whose institutional connection (or lack of) was nothing more than a bureaucratic roadblock to the innovative researcher. The mundane problem of transmitting images from a CT scanner to a physician's computer in an adjacent office was ignored, in part because the problem was already practically solved (by physically moving film around, or by running a wire from the CT scanner to the radiologists' workstation) and in part because it never would have had the sexiness necessary to generate research money. When interest in solving this problem met the internet something like telemedicine finally begain to appear at the back door, though without that name and at the expense of existing projects that called themselves telemedicine. This is precisely the fate of Partners Telemedicine at the MGH, where tele-radiology is conducted without their help, or oversight, because of the development of technologies like Amicas and its predecessors in R*Star and the company that became WorldCare. It is in this context that Adrian Gropper turns out to be a far better organizational theorist than any in the university, having identified precisely these constraints of the film workflow and precisely the capacity of the internet to supercede them [24].

18. Since the standards (or proprietary formats) that existed for the image capturing devices of the 70's and 80's treated them largely as stand-alone devices that would be installed one at a time in hospitals or clinics, even when images were moved around, they were moved from, for example, a GE CT Scanner to a GE CT Technician workstation, to a GE archive, to a GE film printer. The fact that GE didn't make all of these devices rarely posed a problem for the customer: GE sold the whole workflow to a hospital, along with software, training, service, repair and little lables that said 'GE'. In many ways, this strategy reflects the era of vertical corporate integration that went largely unchallenged until the 70's, and for a relatively protected realm like healthcare, well into the 80's. Standardization in this context is therefore was not an issue of compatibility at the level of image capture devices, and certainly not at the level of the image.

19. In early 1983, the DICOM committee was formed by the ACR and NEMA. The original impetus, according to an article by Bidgood [25], was to create a standard that would allow an "interface between imaging equipment and whatever the user wanted to connect," and "a dictionary of the data elements needed for the proper image display and interpretation. The ACR's role, presumably was to specify those data elements. First published in 1985, it was designed primarily to standardize point-to-point transmission of images. We might assume thatsome version of telemedicine played a part in justifying the development of the standard. According to Sean Doyle, it was largely a quasi-academic effort to produce an extremely rigorous and complete standard concerning the presentation, storage, and transmission of images— too rigorous for his tastes. Quasi-academic, Sean suggests, because it was clear to everyone involved that GE played an enormous role in getting the standard written. The original DICOM standard (Version 1.0 1985-88), because it began as an attempt to provide only point to point transfer, had no rules for using an existing network. In some ways this is telling: it signals the strength of the boundaries that existed around radiology, and around hospitals, that the designers started with the assumption that users would be in control of all of the layers, from application to the wires it ran over.

20. Soon enough, however, the demands from users to connect to independent networks led the DICOM committee to begin work on defining the transmission of images using two protocols in addition to the point to point protocol of the first version: TCP/IP and ISO-OSI. That the standard is defined for both protocols reflects both its deliberate complexity, and the nature of the competition between these two standards (discussed in more detail below). According to Sean (perhaps with a dash of conspiracy theory, or perhaps just because he is an internet proselyte), the DICOM standard has resisted the inclusion of such "open" standards as TCP/IP because for large companies like GE, such openess was viewed with suspicion. Sean offers a brief description of how GE and its model of vertically integrated control affected hospitals:

It was made really clear to me by this one engineer slash sales guy that it really wasn't in their interest to let other people connect to GE stuff. You know, if they could sell, like a tape drive that they got from HP and put a private label that said GE on it and then charge a lot more money for it, that was a lot more lucrative for them. And he also said it was better for the customer, because the components on the market weren't really components, they really required a prime vendor like GE to pull them all together and when things failed in a hospital they wanted a single point of contact in the hospital, they wanted to call GE. ANd if GE's gonna take that call, they need to get the reimbursement, so I thought what they did was rather extreme, but there is some truth to their argument.

21. The truth to this argument is that hierarchically organized firms supposedly manage failure better, where a system of non-integrated firms each focussing on separate parts would lead to chaos, or worse a total lack of liability leading to moral collapse (and, of course, all of these implications depend on the status of the standards that would allow such an organization). Adrian Gropper and Sean Doyle would both disagree strenuously (with the benefit if hindsight from atop the internet). The success of large organizations in getting technology to work and keeping it working has nothing to do with their hierarchical structure. Large vendors promising total solutions are Adrian's bugbear, especially in an era when the process of technology innovation has become increasingly cyclical, as parts of the network and computing infrastructure become "componentized" or "commoditized." To him, this is every reason for to users take control of their own tools. Sean continues this thought:

But now it's what seven years later? Components are much more real. You know different SCSI devices from different manufacturers really do work together. Ethernet cards from different manufacturers, even at MGH in 1990 or so, just putting different PC's on the local net was problematic because different vendors equipment worked very differently. So its not that they're, that it's all nefarious motives, it's that the world has become a much more open place, where different devices and protocols are commodities.

22. Sean realizes that there is a kind of temporal displacement that has driven corporations to try and resist the "componentization" of technologies. Speaking in 1998, however, Sean has little respect for corporations that simply resist the possibility of really improving healthcare by taking advantage of the openness and interoperability he sees everywhere. Though he maintains some cynicism about the hype of openness (from open standards to open source, he sees the protocols of the internet, like HTTP and HTML, as the very model of openness (and I would agree with him). His story emphasizes the university as the origin of the standard in order to suggest (and I disagree with him) that standards are more likely to be open if corporate interests are not involved [26]:

The closest [to an open standard] was probably HTTP and HTML and that's because it started getting defined outside of the commercial realm, you know it was like a commercially trivial thing, there were like these researchers trying to set up this global mind, you know, to communicate around the world, and some of them were really clever and they did a good job and they were focussed on what they did and so you ended up with something that actually worked...

23. The objectives of the internet are obscured here, partially because Sean is arguing for its difference from the world of proprietary systems and industry standards, but also because, for many participants in the growth of the internet, its motives must remain pure (ARPA, for instance, is almost never mentioned, and disavowed when it is). Sean's division of the world into industry and academia is not firm, he constantly recognizes that the boundaries are thin and that hypocracy seeps in both directions, but it does serve to make a provisional distinction in order to understand how different organizations can use standards to different ends:

But with standards like DICOM, it's much harder, because those really are owned by industry groups, they didn't spring out of academia in the same way. Um, lots of people that pushed them were very academic folks and wanted to interconnect different things and get images for research purposes, but there's been so many games played with the committee, that it's hard to really know. For years GE— and GE is in some way the hero of DICOM, they're the ones who really pulled it together, made our company possible, and a bunch of other companies because it finally reached a certain level of standardization— for years they played with the standard too, they had a, you know with ACR/NEMA 2, they had a special card, everything was like Ethernet, same as ethernet, same resistance characteristics for the cable, lot of the same signaling stuff, but the plug was a different shape. And they did this, as far as I can tell, well the stated reason was that they didn't really trust ethernet and they wanted to have a medical protocol. But rather than adopt something off the shelf that worked really well, they said "In order to be ACR/NEMA compliant you need to have this card (which only GE makes)," I think it was a few years before anyone made it commercially, so all that it really did was it served to push things out to the future.

24. The interplay of commercial and academic interests is visible in the relationshp that the DICOM standard has to networking capabilities. According to Sean, HTTP, TCP/IP and HTML were "commercially trivial" because they defined networking as something that provided unlimited interconnection, whereas the stake of a large organizations is hierarchical top-down control, and therefore, deeper and more control over the movement of data. To return to the fact that the DICOM 2.0 standard defined protocols for both TCP/IP and ISO, it is conceivable that such a choice was facilitated by industry concerns over which standard would dominate, but also because the standards represent two very different modes of standardization, and hence, two different forms of political orgainzation.

25. TCP/IP and OSI represent two worlds, or perhaps, two ways of making the world one. These two standards represent the political heart of the difference between the 'open' chaotic, quasi-libertarian ethic of the internet and the 'closed' hierarchical, authoritarian world of healthcare-hospital organization and legitimate government rule. Though, make no mistake, the U.S. and other governments were involved in both of these realms, neither was strictly commercial or strictly unregulated. While the debate has crucial technical components that serve to convince advocates of one or the other (which hopefully, are somewhat clear from chapter E, above), when the technical details do not decide, the political and theological debates peeek through. These debates are not only rhetoric based on a dogmatic position, but signal a much deeper conflict over the constitution of the state and the market.

26. By 1999, the OSI seven layer model remains little more than a model. In the section on international standardization organizations (q.v. section H) the relationship between modes of national and international governance and particular types of standardization— such as the OSI stack— are explained briefly. If there is a connection between ISO-OSI and a model of overly bureaucratic, centralized, international state based control, then the internet's standards and its standardizing body, the IETF opposes that directly. The internet and its TCP/IP stack appear to all onlookers as The Way of The Future because it represents a different mode of governance, not because it represents a different technical configuration (except to the extent that "it works" can be invoked more readily in the case of the TCP/IP protocol). But OSI as a model and protocol for networking will not totally disappear. There will always be "legacy" systems, and complex networks that use the standard just for the sake of using it; but then it will no longer be a standard, but an anomaly.

27. Only in the last five years has this fact emerged. As an example, I take the activities of the Partners Telemedicine Center, where it became clear that there was a certain conflict between the desire and the promise to use the internet, generated out of an incessant and unavoidable hype all around, and the training and explicit knowledge embodied in the employees.

28. At Partners Telemedicine, there was only one engineer— Tim O'Neil. Tim was in the peculiar position, though probably typical of healthcare, of having to know intimately both the technical and economic details of the techology. In particular, Partners' most successful endeavor--technically and economically— during my tenure, was the videoconfernecing network. Success in the form of revenue, because much of the service provided was the televising, to each other and to associated clinics, of MGH and BWH grand rounds— for which they could charge the individual physicicians organizations for the service (nursing, pediatrics, neurology, etc.). Tim's familiarity with teleconferencing systems had brought him to Partners in the first place. Tim trained in the Navy as an electrical engineer, "electricity, electronics, power plants, dish frequency regulators, complicated high technology electronics." He realized, along with a generation of people trained in electrical engineering, that what used to be "straight-up electronic systems work" was going to digital networks: "I kept bumping into a technology barrier in the systems I was using, no industry systems, everything was going to the LAN [Local Area Network], and nobody could do it right." By 'nobody' Tim means primarily telecommunications companies. Tim's training in EE is circuit and signal based, not software-control based, yet Tim recognized that the systems were not so theoretically different:

So I kept seeing what I was doing and I saw the correlation to information systems. And about three years ago I jumped ship to the information systems department of the government, federal [at] the VA. And at first, one of the first projects I got to work on was pretty neat, I saw a videoconferencing unit, and I said: I understand how all this works.

29. Tim's introduction to the videoconferncing unit at the VA was not via a demonstration, however, because the whole system was still in the box. Tim explains the reason for this:

They spent a quarter of a mllion dollars and everything was in boxes. Because the telecommunications industry was having so much trouble at the time trying to supply fractional T-1 and the bandwidth so they were wallowing for a year and a half.

30. Of course, this was Tim's lucky break, since he both understood the basics of how it worked and thought it was cool. Within six weeks, he had the first one up and running. The system he installed was made by Vtel, a company that builds a variety of desktop and free-standing videoconferencing units. Vtel systems are not internet-based (packet-switched network, running TCP/IP), they are glorified video-telephones (circuit-switched network, using a proprietary data format and the H.320 compression standard for the signal). Both networks run over the same physical layer, using many of the same low-level protocols (such as ATM and ethernet), and it is this layer that Tim is most familiar with. However, the systems do not dial and connect as simply as a telephone, but require software that runs on Windows/NT to control the connection. So Tim went back to school:

So that's how I got my start running the video portion, I mean I'd run cable TV networks before, same kind of technology, no compression, broadband network. And I moved my way over to the bits and the bytes and the digital compression, went to school at night for about 7 months two hours a night two nights a week, eight hours every other week to get Windows NT administrator certified. So that's the Industry standard right now within Wide Area Networks enterprise, "Are ya an MCSE, or have you at least been trainied as a Microsoft Certified Systems Engineer? Do you have a Microsoft certified professional number?" And I do [laughter].

31. This portrait of an engineer between the worlds of "bits and bytes" and "straight up electronic[s]" is interesting in itself, all the more so because it takes place in the context of healthcare. Tim's experience in getting this system to work was valuable, for him and for Partners, but eventually led him out of healthcare and into the heart of videoconfernecing work with one of the firms that he dealt with on a daily basis. Instruction consists in the path that leads out of the application and into the details, the passion of engineering lies in getting things to work, not in working for things, and this passion was as familiar and obvious in Tim as it is in Sean (q.v. Section J below) The difference between Sean and Tim lies less in the zeal with which both of them pursued their work, as the particular kinds of technologies, and specifically, the standards they relied on. These differences were both technical and "cultural" at the same time (though it is less and less meaningful to consider this difference as a "cultural" one, since our "culture" in this investigation is tied to standards and programming through its relation to law, regulation and custom— convention— and to the constitutive effect standards have on locale— scale. Ho Hum.).

32. Tim explains at length the technology that he understands in the transcript here. It is an expansive and detailed understanding of the physical layer of the technology involved in networks and the cost per megabit per second of various configurations. Because videoconferencing is a synchronous two-way signal, a great deal of bandwidth is required in order to transmit and receive synchronized audio and video. Most of the systems for video conferencing use a hardware codec and rely on the ITU-T standards suite H.320 for designing and connecting systems (Available online for 49 Swiss Francs at the ITU store). There is a standard in this suite for video conferencing over packet-switched networks (H.323), but most videoconferencing systems are built to use the H.320 standard over ISDN, because the cost/quality ratio is best for that combination (ISDN was the next big thing in the early nineties in telecommunications, and as a result many large institutions have ISDN phone systems installed (this is the case at MIT, MGH and BWH), but more importantly because circuit-switching is the only way to guarantee "Quality of Service."

33. "Quality of Service" is a term of art in telecommunications engineering that refers to the reliability of an open circuit. Tim used it relentlessly to reference the problem of putting medical data on the internet. No quality of service is a failing of a packet switched network. The issue only concerns transmissions that require synchronous two way connections, like a telephone call, or in the extreme case, a real-time two way echosonography session, which Tim was trying to plan. In these cases, packet-switched networks are liable to drop out some data or to have data arrive in less than a continuous stream, which accounts for jitter and jump. For internet promoters like Adrian, QoS is a red herring, because, he says, 99% of healthcare happens asynchronously anyway, so why not design systems that replicate that.

34. Tim, howver, would not choose to use IP precisely because it is packet switched, thus necessitating either a very high bandwidth internet for synchronous transmissions (which just wasn't available during this time, and still isn't in 1999) or more control. From Tim's perspective The Way of the Future was not necessarily the internet, and in the particular case of medical data, especially synchronous image traffic, where interaction and relatively lossless transmission is necessary, the only guarantee was to have more control over the network itself, sacrificing its extensibility or the flexibility of the ends.

35. From Tim's perspective, TCP/IP could be made to work on high bandwidth physical layer protocols such as ATM, but it was not in the interest of the applications that were being developed for videoconfernecing [27]. Internet ideologues seized on this fact, which is where stupidity enters.

Last Modified 11-Sep-99 9:01 PM ckelty@mit.edu

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