Spencer Kelly (presenter of the BBC's gadget gorge Click) told us that the weighty iPad has a stand so you can use it sitting at a desk and comes with a QWERTY keyboard, which he described as "genius". Playing with too many toys has impaired your judgement, Spencer.

See previous discussion on FHIT about data entry and QWERTY keyboards.

I dismissed suggestions that I would become one. One of the spiral-eyed ring wraiths from Morden (and everywhere else) who ride the London Underground white stoppers in their ears and 6 inch square screens before their eyes through which they experience reality while reality passes by.

I was excited. My telecoms provider had called me to tell me that I could renew my contract and become a proud user of iPhone. I called a friend who enthused about its apps and gave me the impression it was the coolest thing since a morning dip in the Ford of Bruinen.

Almost convinced, I was passing a retail outlet and couldn’t resist taking a peek. What a shocker: the touch screen text entry system is one of the worst I have experienced. Even after a bit of practice my typing speed would have fallen by 25 percent at least.

One ring to rule them all? I’ll stick to my Blackberry. When it comes to a method of entering text which is quick, portable and unobtrusive we are still bound in darkness.

"One Ring to rule them all,
One Ring to find them,
One Ring to bring them all and in the darkness bind them."

JRR Tolkien, Lord of the Rings.

Adapted from the book by Susan Hill, it invokes a spooky atmosphere with only two main characters and one other (guess). But you are led to believe the cast is augmented by a small dog, a horse, a cart and supporting cast using acting skill, a good sound system and a minimal but ingenious set. Despite having played for 21 years, the small theatre was full (I spotted Neil Tennant from Pet Shop Boys) adding the force of intimacy to the plot's crescendo.

For a millisecond I glimpsed the small dog out of the corner of my eye: suspension of disbelief or the power of imagination? Amazing what you can conceive when you release your mind from the chains of reality. Einstein said: "Imagination is more important than knowledge. For knowledge is limited to all we now know and understand, while imagination embraces the entire world, and all there ever will be to know and understand."

WH Smith bright and inviting. On the shelf the US edition of Wired. What's inside? Yes: The Body Synthetic. Something to enjoy on the journey.

In 1997 David Eddy applied a model he designed called Archimedes to predict the result of a clinical trial named Collaborative Atorvastatin Diabetes Study or CARDS.

Archimedes is like a Treasury Model of human physiology: knowledge from epidemiology, clinical trials and clinical interviews encoded into differential equations.

Using broad patient data, Eddy and his team constructed a comparable trial to CARDS in 2 months and issued the results. When the 7-year clinical trial reported, it turns out the findings of the model were remarkably close.

It is also remarkable to read the criticisms of the model: a self contained ant farm that has no bearing on reality, a black box. Interesting remarks, because the whole of medical practice is based on abstractions, assumptions about biological reality. Do we fully understand the complexity of human physiology? We do not.

Medicine is often quick to point to the mote in the eyes of others (black box, lack of evidence), while forgetting the beam in its own (black box, lack of evidence).

Nonetheless, it’s refreshing to read about people prepared to face criticism and innovate with IT. To open eyes. Like shutters raising in the morning.

NPfIT has been incessantly critised since its inception, but you cannot run a £100bn healthcare system with little more than quill pens and ledgers, so I wonder if the cuts will arouse as much discontent as planned expendiure did...

I can't comment on the quality of the writing in this case, but E-Health-Insider reports Harvard Medical School et al have concluded that healthcare IT systems do not cut costs. That may be news to the researchers, but it is not to me.

Many authorities have pointed out that the introduction of IT does not cut costs. See Paul Strassman or Leslie P. Willcocks' Beyond the IT Productivity Paradox. But the myth persists.

A few years ago I heard a woman present on the use of Lean in her hospital. Though it's a method specifically designed to remove activities that add no value and speed up those that do, it had not reduced costs, but then, she said, they had not implemented any IT systems, which, she asserted, were good at reducing costs. There is little evidence to support this assertion. Nor is that a surprise.

If we add an IT system to a mix of unchanged processes then we must expect costs to increase, especially if workarounds have to be implemented because the system doesn’t support "the way we do it here".

Peter Drucker said: “Whenever anything is being accomplished, it is being done, I have learned, by a monomaniac with a mission.” Benefits from IT systems do not magically appear as soon as the boxes are switched on. Implementing beneficial processes, and thereby saving money, with the support of IT requires the courage to challenge status quo, the analytical skill to identify shortcomings and the determination to implement real change. Is healthcare ready for such a mission?

Dr. Brooke Magnanti outed herself as the author of the infamous Belle de Jour blog just before the UK's tabloid press did it for her. Despite hyperbolic media speculation about her identity, it turns out she is a previously unremarkable UK healthcare research scientist with a qualification in health informatics.

I have never read the blog (honest!) though I knew about it and had seen the resulting books in Borders. OK, I was a bit envious that someone could make so much money out of blogging, but, I comforted myself, health IT does not have the same mass appeal as sex.

Back to Clive James: though I've read a couple of Martin Amis' novels, I did not enjoy them as much as his other writings and reviews; for example, take a look at War Against Cliche in which his feel for words and general erudition sparkle. No wonder he was named "Smarty Marty". So does Dr. M's writing really compare?

This article describing an autopsy was written under her real name. It describes man after the god has left the machine and even makes a couple of analogies with IT. The image of a cutting scalpel in a curved fist is one that sticks with me. She's good, not as good as Amis, but good.

But the events leading to the denoument form a subplot worthy of John le Carre. A fellow blogger guesses her identity and sets up an early warning Googlewhack on his website. Galumphing newshounds on the cyberscent trigger the alarm. The blogger tracks IP addresses back to Associated Newpapers: the game is up. Before being shoved, Dr. Magnanti steps out of the shadows. You can read all about this from
the blogger himself (under Me and Belle de Jour...).

The veil of Internet anonymity has been sliced open, what now? Well, placing your life (fact or fiction) into the public domain on the Internet can affect your health. No-one will regard you in the same way again.

The latest edition of New Scientist* has a nice article by Gaia Vince titled Rise of the Medibots which suggests surgeons of the future may be too small to see.

The entomological metaphors in the article strike you: many of the devices are like centipedes or small spiders that are guided by humans through the heart, eye and other inaccessible parts of human anatomy. At this, some of you may think of that bug-thing that the Agents insert into Neo's navel in The Matrix, and it may be like that, though the ones described in the article are good guys.

Some of you may also recollect I posted about a discussion on BBC Radio 4 in which Professor Robert Winston took part. Prof. Winston was of the opinion that patients needed the human touch, and suggested robots were good but would never catch on. This is nonesense, of course. Healthcare in the future will apply robot and human touch.

* 21 November 2009 pp50-51

I sat bang in the centre of the front row, so I noted the veteran band members are looking a bit older these days (unlike me who hasn’t aged a day) but their fingers still fly nimbly over those arpeggios and scales. A night to remember!

I have a fascination for robots, probably stemming from trying to make one as a child from a shoebox, flashlight bulbs and odd bits and pieces from my Father’s workshop, So perhaps it’s not surprising I spotted an article in the BBC’s Focus magazine which made me hope when I do age a few days, I may even have one as a carer.

The Japanese are way ahead in the field of robotics, fortunate since they are short of nurses and have the most rapidly aging population in the world. Perhaps supporting a phenomenon named uncanny valley Japanese researchers found people warier of human-like robots. Robo bears are their solution. Cute…or what??

I am back at a time of transition. The NHS waits for the official line of the NHS National Programme for IT (NPFIT). The Department of Health’s November 2009 deadline for Local Service Providers (LSP) to have made significant progress is here.

Perhaps the plans for the NPfIT Southern Cluster are a hint to the future of ICT implementation in NHS. In limbo since the departure of its LSP, Fujitsu, it seems Southern cluster organisations might be allowed to select systems from the pre-competed framework contract, the Additional Supply Capability and Capacity (ASCC).

I have always suggested that allowing organisation to choose their own systems adhering to reasonable standards--whether from NPfIT, the ASCC or by independent procurement-- is where the NHS would end up. Indeed, some foundation trusts have already gone and done it, and the tide of trusts preparing to do the same threatens to end the 7 year interregnum imposed by NPfIT anyway. For many organisations the years of waiting for NPfIT to deliver while their existing systems became obsolete proved too long.

I may have suggested independent choice was the way forward, but I didn't say it would be a panacea. Successfully implementing major health IT is difficult. However, a legion of consultants and assorted contractors wait to help trusts through these challenges, particularly since LSPs have been downsizing.

During a recession, you can hardly blame people and organisations for presenting their experience in the most positive way, but the head of NPfIT's office must have been very crowded if all of the people and organisations who, according to their biographies, played a 'major role' in it were accommodated there.

Aldous Huxley quipped the most important thing we learn from history is that we never learn from history. We risk repeating the mistakes of the past if we simplistically believe that a different approach will be a better one, particularly if we (again) accept the advice of those who have little or no real experience of the challenges of major healthcare IT procurement and implementation.

If you are considering an independent procurement or are simply assessing your options take advice from someone who has at least implemented a major healthcare system and learned from the experience.

After a period in the UK where CDs, zip drives and laptops containing large numbers of confidential data have been mislaid at a mind boggling rate it is hardly surprising that information security is now at the top of the agenda of many health organisations and their suppliers. I have recently been engaged in work for clients on information security particularly related to the ISO/IEC 27001 and 2 standards.

At the word standard eyes glaze because we assume they are as impenetrable as my first year thermo lectures. But if you want impenetrable try reading some of the books that are supposed to make the subject more accessible for your average manager or board member. They make the standards look like models of clarity.

If you are seeking to review your information security using ISO 27000 as the basis take my advice and read the standards, and, if necessary, get the right person who understands how they are applied operationally to help in any risk assessment and implementation. Don’t waste your money on derivative books.

After the D-Day landings in 1944, Bil was on reconnaissance in Normandy prodding the positions of the retreating German army. While on high ground the scout car he was in was struck by a shell from a battery manned by a small group of recalcitrant German officers. That was the end of the line for the rest of the crew, but Bil was blown clear suffering a shrapnel wound to his foot.

In his second life he went on to exploit his love of Nature as a Landscape Architect, becoming a driving force in the restoration of the historic gardens at Hestercombe and at many other sites.

At a celebration of his life in a Sussex country church his friends and family heard about these and other achievements on the golf course and as a talented writer. It says much for someone when the people who knew him will travel hundreds of miles to pay their respects.

Live, love and leave a legacy: I can hope to achieve as much. Make sure you tell your loved ones how much you care and appreciate them before it is too late. It's the best health information technology we have got.

No more my heart shall sob or grieve. My days and nights dissolve in God's own Light. Above the toil of life my soul Is a Bird of Fire winging the Infinite.

Sri Chinmoy

Sure, Dr. Goldacre does a good demolition job on homeopathy, nutritionists and media cover of MRSA by turning the laser of critical thinking and science on their claims. He also gives a good summary of the scientific approach to medicine, asserting the importance of the proper construction of medical trials with randomisation and the maintainenance of proper controls--though to those who, like me, studied science none of that is news.

Dr. Goldacre is also big supporter of evidence-based medicine, which he says has saved millions of lives. He doesn’t give any evidence for that, but we can believe it to be true. In the chapter entitled Is Mainstream Medicine Evil? we find this:

Doctors can be awful, and mistakes can be murderous, but the philosophy driving evidence-based medicine is not.

In the same chapter he tells us about 13 per cent of all treatments have good evidence, and a further 21 percent are likely to be beneficial. A bit low, so he tries again. Ah, but if we look at how much medical activity is evidence-based that rises to 50-80 percent. Depending on how you interpret this and the method by which these figures were derived, that means a large chunk of medical practice has no evidence underpinning it.

In response to Archie Cochrane's call for up-to-date, systematic reviews of all relevant randomized controlled trials of healthcare, the Cochrane Collaboration was founded in 1993--perhaps the real birth date of EBM. But what happened before that?

OK, you say, we are where we are. So let’s not bother with what happened before. We are now flowing into an enlightened era of more scientific medical practice. Or are we?

We really do need to understand why the scientific approach seems to have been marginalised in medicine, because Sue Dopson’s Knowledge to Action? Evidence-Based Healthcare in Context suggests the flow to an enlightened era is turbulent. Interdisciplinary tensions, over assertive practitioners and the subjective conversion of evidence into practice make for erratic progress, it seems.

No matter how strong the philosophy of EBM may be it's in the integration into practice where the real patient benefits of it lie. Rather than trashing questionable reasoning in other practices, maybe Dr. Goldacre should redirect his laser logic onto that challenge. After all, conventional medicine is where most of us seek health care and where a substantial chunk of our taxes is spent.

The HSJ's coverage of such matters is usually low key. This probably reflects the interests of its readers, which is a shame. Mind they did publish one of my articles on healthcare IT which now seems 15 years ahead of its time (!)

The supplement considers Imperial College London's construction of a virtual model of a future NHS in Second Life. I visited the site a couple of years ago to look at a construct of Polyclinics, which was eerily empty at the time. This future world seems locked into current models of care with a general marginalisation of the role of ICT. We need to realise that demographic and epidemiological trends mean that is not sustainable.

The HSJ also considers emergency services, their adequacy and their future--hence the mountain biker. They say they are not as fully integrated into the system as they could be. And this touches a common theme througout the supplement: the benefits of sharing of information and of the integration of ICT into practice--whether by COIN or by joining insular GP systems. That is the future of healthcare.

*18 September 2008

Professors on international trips measure how many hospitals are using order communications (or is it resulting and reporting) or computerised referral against their template of academic definitions, which I can guarantee fit almost no IT system in the real world, let alone (crucially) the manner in which it is used.

For some of us, Software Advice has tried to clear the matter up in EHR vs EMR - What's the Difference?

But do definitions help? I enjoyed reading about Socrates when I was at school. This gadfly of ancient Athens liked to ask questions such as “What is good?” or “What is the pious, and what the impious?” Then, by adroit questioning, he would lead his targets to realise what they thought they “knew” led to a contradiction.

But simply because you cannot define something does not mean you cannot appreciate or understand it—or, in the case of healthcare IT, use it. I worry the upsurge of academic interest in healthcare IT leads to introspection, and, like a hot bath, the more we contemplate it the colder it gets. Definitions have their place, but let’s get on with implementing healthcare IT and also learn from experience.