HIStory 10

IBM’s “SHAS”
Why would IBM ever write a system that might end their near-monopoly of mainframes? Two answers: greed & Medicare. Let’s look at each :
Greed - By the mid-60s, most of the ≈1,000 large hospitals over ≈300+ beds who alone could afford the mega-bucks for a System 360 mainframe had already done so, so sales were slacking off a bit…
IBM’s “Shared Hospital Accounting System” (SHAS) probably automated more hospitals than any other system in HIS-tory. Ironically, it marked the end of IBM’s 1960’s mainframe dominance, and the beginning of shared systems in the ‘70s.
What better way to sell 360s to the ≈6,000 smaller hospitals (there were about 7,000 total US hospitals back then) than have 2 or 3 small ones share a 360!
So SHAS was launched as a joint project between with 5 Michigan BC/BS hospitals, to enable member hospitals to share the cost of a pricey 360,
Plus the dozens of programmers and operators required to feed the beast!
Of course, no one in Armonk ever dreamed companies like SMS would end up sharing a few 360s among hundreds of hospitals - but that’s a later story...

2 nd Reason for SHAS: Medicare
Medicare raised the bar in patient billing significantly
No longer could hospitals submit bills from simple ledger cards, but suddenly had to submit complex new billing forms, each filled out with different fees:
Green 1453 bills for Inpatient charges
Yellow 1483 bill for outpatient charges
White 1554 bills for professional fees
In 1965, Medicare or “Title XVIII of the Social Security Amendment” was signed into law by LBJ as part of his “Great Society” program.
Title XIX created Medi caid , funded 50%/50% by states & the feds…
Sound simple, right? However, Medicare was administered by “intermediaries” in every state who each had their own ideas on how to fill out the boxes on each bill.
No HIPAA or EDI standards back in the 60s – intermediaries ruled!
Besides billing complexities, Medicare introduced cost reports, which required elaborate “2552” step-downs forms for allocating costs between Medicare and other insurances, making general accounting much trickier too!
(ironically, Medicare also inspired Walt Huff to build HFC at OSF in Peoria, which gave birth to another shared system giant – more on that story later…)

SHAS’ Applications
So based on those Medicare-inspired beginnings, you can deduce what applications IBM’s SHAS offered:
Census – to capture the patient demographics required at the top of Medicare bill forms, plus room & board fees.
Billing – both inpatient and outpatients, to crank out the 1453s , 1554s and 1483s correctly , especially that darned “Item T” for miscellaneous charges like Blood Bank.
AR – with pro-rated balances to track what $s third parties should pay, versus deductibles & co-pays the patient owed.
GL – to keep track of Medicare revenue by department.
CAP – a “Cost Allocation Program” to allocate the costs from non-revenue to revenue producing departments, to determine Medicare’s fair share on 2552 cost reports.
Quite an attractive menu back then, when CFOs ruled DP!

SHAS’ High Tech I/O
So how did those 5 hospitals spread out all over Michigan communicate with the central 360?
Input :
The same ancient 5081 keypunch cards from the “pre-cursor” era were holed on 029 keypunch machines like that pictured on the right:
“ Drum cards” automated mundane tasks like Mod 10 self-check-digits, duplicate date fields, etc.
Cards were batched and read into 1056 card readers, one agonizingly slow click at a time…
Output :
1052 terminals communicated over 1200 baud (that’s bits per second, not MB! ) leased phone lines
Green-bar paper printed daily census reports, while weekly ATBs were shipped via Fed-Ex or snail mail!
On-line AR & BL inquiries were hot stuff – though only updated as of last midnight’s batch processing…

SHAS Flexibility
Hospital Profiles :
Records for each user hospitals to define their own parameters for Billing (Record 6), AR (7), hospital services (OJ) nurse stations (OK), etc.
When SHAS programmers hit key decision points, they reached out to a profile record on disk to see how each hospital wanted things done...
Report Selection Parameters :
JCL cards that allowed each user hospitals to define their own parameters for reports like ATBs
(sick to still remember all this detailed crap 40 years later…)
Some of the many innovations IBM built to make the fixed COBOL code of SHAS flexible for custom use among many users were :

SHAS Remnants in 2011!
So who cares about this ancient stuff? Well, amazingly, some of it is still used today , 40 years later!
TCEs - Transmission Control and Error reports were created by the Balance and Edit program (BLE) to report errors in keypunch cards back to hospitals.
A paragraph printed for each batch of cards submitted, with errors identified by the card code (11 = Admit, 42 = charge, etc.) and card number (eg: 3 rd card in batch #145).
Sound familiar to you 600+ hospitals still running on Siemens’ Invision today? Now you know why there’s a “re-circulating error file:” there are no keypunch cards to resubmit!

How did SHAS sell?
Fantastic! After all , it was being pedaled by IBM reps! SHAS was sold (along with pricey 360s) to scores of organizations, each processing dozens of hospitals, eg:
Hospital Associations and Blue Crosses in many states:
Michigan, Vermont/New Hampshire, New Jersey… to name a few
Who followed in Michigan BC/BS’s footsteps running it for members
Large mainframe hospitals
SHAS financial apps were very functional compared to oldies like IBM’s “PAL,” so many large 360 users installed it just for their internal use.
And a growing number of commercial firms:
Eg: GAMUT in NYC, founded by John Depierro, a true HIS pioneer who sold SHAS to many New York hospitals in 1968 & 1969, before he went on to found MDT (Medical Data Technology) in NJ, sharing TDS!
And the biggest SAHS success story: SMS, our next HIS-tory subject, which alone installed SHAS in over 1,000 hospitals over 30 years...

SHAS’ weaknesses
So if SHAS was so great, why didn’t every US hospital install it? Well, it did have a few flaws:
Complex Job Control Language (JCL) cards for operators were easily botched up by these low-paid, mere mortals, eg:
Don’t forget, next Tuesday , Memorial closes its month-end…
What , I said Tuesday , not Wednesday ! Now we have to re-run both days…
Make sure to run this hospital profile maintenance for record 06, field 004
What , you didn’t ? Now there will be tons of late charges to re-bill!
- And, as with any new system, there were a few “oversights” and outright bugs:
No way to add an insurance to an account in AR after bills were rejected by third parties.
Maximum amounts in key fields too small: $999 limit on charges, $99,999 max in AR.
And god forbid you did profile mtn to records OJ or OK in the middle of a census run!

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HIStory 10

by histalk on May 28, 2011

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HIStory 10 — Presentation Transcript