June 02, 2013

Process and Outcome

It's years ago, but I still remember the reception I received when during my first large-scale NHS IT implementation I suggested that doctors might like to record outcome information. I can still recall the smell of my singed fingertips. Until recently, the NHS has been obsessed with recording process data fitting an organization with its roots still in the mid-twentieth century.

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May 10, 2013

Stop Saving the NHS: new book

Stop Saving the NHS cover (small).jpgWell I have done it. My book Stop Saving the NHS and Start Reinventing it has been published in Kindle and paperback. It's aimed at NHS leaders and managers, but will probably interest anyone who is interested in the shape of 21st century healthcare.

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June 10, 2012

Twenty First Century Healthcare with IT

There was a good turnout of clinicians at the planning session with an NHS client the other evening. Main strategic work streams were quickly agreed, and we got onto enablers. I expected the usual suspects: more consultants, more nurses and more money. I was wrong. Almost all of the groups chose IT as a major enabler of change for the better.

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November 02, 2011

Drug Administration and IT Reconciled

Picture of pillsA few years ago there was a kerfuffle in healthcare IT. A study at the Childrens Hospital of Pittsburgh concluded that mortality rates had increased with the implementation of Computerised Physician Order Entry System (CPOE). Despite being rebutted almost immediately after publication, the study gained wide credibility. It was still being quoted without qualification by a prominent academic at a UK healthcare IT conference a couple of years ago.

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October 16, 2011

What's After the NHS IT Programme?


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October 11, 2011

Do Doctors Dream of Electronic Records?

A former Apple CEO says healthcare missed the PC and Internet revolutions. He loads the blame squarely on the shoulders of reluctant doctors.

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December 06, 2009

Healthcare IT does not Reduce Costs

If you have researched academic papers you will have read much that is derivative and little that demonstrates new insight. This state of affairs is exacerbated by a general academic tendency to prolixity and bad grammar that rivals a breakfast news TV programme.

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?

November 15, 2009

Learn from the Past

It's been a while since I last posted. Personal matters, my workload and the departure of the muse are among my excuses.

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.

October 01, 2008

Future Imperfect

Is a man in fluorescent gear riding a mountain bike a suitable metaphor for innovation, information and technology? The Health Service Journal Intelligence supplement* seems to think so.

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

September 30, 2008

Defining the Electronic Health Record

Is it an EMR, an EPR, an EHR or a CRS and who cares anyway?

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.

Recycling for Health

Picture of dawnFrom my office window I usually see the dawn. Sometimes the sun burns through the mist as a silver flash; sometimes as a red orb. Other days it’s a nondescript glow behind clouds. Part of a continual recycling that brings a new day.

The BBC’s Click reports how recycled computers are being used by the blind in Africa. Loice does not need to see the screen because she can touch type quickly and hear what she is writing thanks to a USB dongle running software from a company called Dolphin. She can carry the dongle with her and use it on almost any Windows PC. With such software and training, people like Loice can compete in the jobs market.

Computer Aid that leads this scheme is looking for a way to reduce the costs of this software. Computers can be refurbished for $60, but the software costs 40 times that amount.

For Bil: "Do not go gentle into that good night. Rage, rage against the dying of the light."

September 17, 2008

Random Thoughts

I like to find a unifying theme to my posts, but this one seems like a loose collection of thoughts.

The UK’s Times published a "Body and Soul" special issue on 6 September 2008 containing a few short articles which caught my eye.

First was a report on viral voltage. MIT says that viruses could reverse some of their poor reputation by powering tiny batteries in medical implants. At the US National Academy of Sciences Professor Angela Belcher reports her team has harnessed genetically engineered M13 viruses to produce a battery the size of a human cell. The battery could power tiny monitors in the body that might spot proteins given off by cancerous cells.

Yesterday I attended a meeting on the integration of health and social care. This is badly needed to address the likely increased prevalence of long-term conditions, such as COPD, epilepsy, asthma and diabetes, in the UK predicted to grow 23 percent in the next 25 years. One speaker argued passionately that lack of shared information was holding back progress. Staff were ready to work more closely but without shared information standards and governance this was being hindered. A multi-disciplinary care record was essential.

But writing in the same Times supplement health columnist "Dr Copperfield" (apparently a GP) tells us Electronic Care Records have “little to do with the health needs of patients and everything to do with politically driven focus groups”. Oh dear! I don’t know about you, but I prefer ex cathedra utterances to be backed by argument. Let’s give Dr. C. the benefit of the doubt, because the article is short. Nonetheless, so-called experts have a duty to give reasoning with their opinions or risk misinforming their readers.

August 24, 2008

Surgery Past and Future

da-vinci-healthcare.jpgImagine how a single operation with a 300 percent mortality rate would appear on NHS Choices. In the 19th Century John Liston—proud of his ability to amputate the limb of an unanaesthetised patient in less than 30 seconds—accidently amputated an assistant's fingers along with the patient’s limb. Patient and assistant died of infection and an observer of shock.

Blood and Guts by Richard Hollingham is a pithy and readable history of surgery that does not hold back on the successes and the botches. One of the most amusing anecdotes became known as the “night of the pigs” and takes place in the National Heart Hospital in London in 1969.

Surgeon Donald Longmore waits for a delivery of pigs. He plans to graft a pig’s heart and lungs into a patient to keep him alive. One pig has other plans and makes its escape onto Wimpole Street, pursued by gowned, capped, masked and booted theatre staff.

The pig, now secured, is taken to the mortuary to be put to sleep, but the anaesthetist assigned to the task is Jewish. Another anaesthetist is found, but there is another problem: the patient is also Jewish and now unconscious so unable to take any decisions for himself. Mr. Longmore calls a rabbi who in fits of laughter gives the go ahead for a genuine attempt to save the patient’s life. Unfortunately, the operation fails in its final stages owing to an unforeseen reaction of pig heart to an injection of calcium.

Also described is the sad life of Ignaz Semmelweis who drastically reduces cases of puerperal fever among postnatal women in Vienna General Hospital by insisting doctors wash their hands in a chlorinated lime solution before entering the ward and with soap and water in between patients. Ironically, an embittered Semmelweis, whose findings were rejected by many experts, himself dies as a consequence of an infected wound two weeks after he is committed to a mental institution. A doctor’s touch could mean death.

In an interview on BBC Radio 4 Lord Winston debates the future use of robots in healthcare with Professor Noel Sharkey. One of Winston's main arguments is that patients need human contact and the healing touch. I wouldn’t disagree, but I do not think that precludes an increased use of medical robotics. The two go together. Certainly, as discussed before research in Cognitive Based Therapy indicates computer software is at least as effective as human practitioners.

For me one of the most noticeable aspects of the Radio 4 debate is the mismatch of the views of doctor and roboticist. In the history of surgery, robotics will not be the first innovation to have been resisted by established experts, though, as Hollingham reminds us at the end of Blood and Guts, modern surgery is based on brilliant, courageous and misguided individuals who were prepared to have a go. Sometimes they succeeded; sometimes they failed, but their efforts have helped future patients to live.

August 11, 2008

Healthcare IT: no evidence

cane.jpgGeorge’s nightmare began with a succession of illnesses. At the beginning of the year he endured agonising head pain for a week after he was discharged from hospital. He was eventually readmitted, and medical staff discovered he had a bleeding capillary in his head. After some persuasion from my Mother--they are of a generation that prefers not to disturb doctors “unnecessarily”--he had called the out-of-hours GP service, but the doctor attending said he could do little because he did not have George’s medical record, thus lengthening the agony. But they say there is little evidence to support the use of ICT in healthcare.

Last week my Mother tried unsuccessfully to call George for several days. After calling his family and even sending an acquaintance round to his house she thought she had done all she could. After all, he was the customer of a care service that checked his well being with telephone calls and that would send someone around if there was no reply—except it didn’t.

He was found on Thursday lying paralysed and unable to speak on his bathroom floor having suffered a stroke on the previous Sunday evening. Of course, the technology to monitor remotely is available, but they say there is little evidence to support the use of ICT in healthcare.

I have been reading Max Pemberton’s Trust Me I’m a Junior Doctor in which he relates his experiences of the UK’s National Health Service. I worked in the NHS for 10 years and many of his anecdotes brought on a wry smile of recognition.

When I was studying for an MBA I remember learning about corporate culture (now an overused and devalued term) and how it might be described using myths, heroes, legends, stories, jargon, rites and ritual. An NHS manager on my course suggested the consultant’s ward round as an example of a ritual. In it the medical consultant and a retinue of junior doctors progress through a ward reviewing and discussing patients. An extreme example can be seen in the film Doctor in the House (1954) when the formidable Sir Lancelot Spratt humiliates his underlings.

Max Pemberton was also at the bottom of the pecking order, because he’s packed off to get the coffee and croissants for the round. That seems poor reward for the time he spent excavating X-ray films from behind radiators and tracking down missing pathology samples and results in preparation for the ritual. He even has to transpose manually drugs charts by interpreting the glyphs of senior medical staff. But they say there is little evidence to support the use of IT in healthcare.

A rigorous scientific approach to medicine is to be applauded; but using demands for “evidence” as a way to slow down IT adoption in the face of common sense is not.

July 23, 2008

Medical Teleconferencing: easy to adopt

Picture of a procedure in an operating theatre.A subset of applications seem to slip smoothly into healthcare causing minimum disruption and delivering maximum benefit. Examples are PACS, Electronic Document Management, the Vocera Communications System and Teleconferencing.

On 4 July 2008 Mr Prakash Punjabi, a leading NHS cardothoracic surgeon working at Imperial College Healthcare, performed a heart valve repair in West London while in conference with more than 40 other surgeons throughout the world using high definition equipment provided by Multisense Communications.

Mr Punjabi says: "This is an excellent illlustration of the use of modern technology to provide advanced surgical training and techniques, which is enabling us to provide best treatments to patients across the NHS."

Perhaps we should base our efforts to increase the adoption and integration of ICT into healthcare on such technologies and build on them.

July 16, 2008

RFID and the Future of Healthcare

Much has been heard and said about the use of Radio Frequency Identification (RFID) technology in the healthcare setting; the issue has been discussed and debated since the science found its way into hospitals to be used to track patients, medicines and equipments. In spite of all the negative publicity that’s been accorded to RFID, the technology has done more than its share in augmenting the care that’s offered to patients, especially those hampered by other disabilities and chronic conditions. Here are some issues in the medical field RFID can address:

  • The horror stories we hear about the wrong drugs being administered or incorrect treatment being provided to patients is enough to make us wary of hospitals, no matter how ill we are. But thanks to RFID, error-free patient, treatment and drug identification and verification is now a reality. RFID tags on patients allow electronic storage of information that allows healthcare practitioners to provide the right treatment and administer the right dose of medicine at the right times. Tags also carry the patient’s medical history which can give doctors information on the allergies that the patient has and the previous treatments that the patient has received.

  • Hospitals are now reducing their inventory and logistics expenses and also avoiding losses due to lost and misplaced shipments by using RFID to track their medicine and equipment supplies. Supply chains are also being equipped with the technology to prevent the counterfeiting of drugs.

  • RFID tags are being used to set off alarms and issue warning signals when something untoward happens – like when Alzheimer’s patients wander outside the limits of their home or when wrong dosages of medicines are administered. RFID tags can also act as reminders of important medical procedures or even dosage timings.

  • Some RFID tags are being used as sensors to warn clinicians of changes in temperature and humidity that control the storage of sensitive drugs.

  • Talking RFID tags are now being used to help visually-impaired patients with their medicine dosages – the tag reads out the name, dosage and time the medicine should be taken.

While the proponents of RFID cite these and other advantages as reason enough for a more widespread adoption of the technology in hospitals and other healthcare settings around the world, there are dissidents who raise concerns about the radio frequency waves interfering with other vital and life-saving equipment that are regularly in use in all medical settings.

A new study by RFID consulting and systems integration company BlueBean in conjunction with the Indiana University Purdue University Indianapolis has found that passive RFID can be safely used in a hospital environment. Hopefully this piece of news will herald a wider use of RFID in all aspects of healthcare, across the world.

This post was contributed by Heather Johnson, who writes on the subject of Cruise Nursing. She invites your feedback at heatherjohnson2323 at gmail dot com.

July 03, 2008

In Fine Voice: Vocera improves patient care

vocera.jpg"The patient I was accompanying for a CT scan suddenly became very ill. I was immediately able to call the emergency department for backup from my Badge.”

No, not Bones speaking to Kirk in an episode of Star Trek but a quote from a staff nurse at Belfast Health and Social Care Trust (BHSCT). The Trust employs 22,000 staff members and serves 500,000 people a year. Its Emergency Department treats more than 50,000 patients a year and obviously enjoys a challenge, because in December 2007 it deployed the Vocera Communications System at the same time as relocating to an interim facility.

Kinetic Consulting Ltd. was chosen to carry out a benefits study of the implementation before and after deployment the findings of which are summarised here.

Data were collected before and after implementation using a combination of questionnaires, observational research, activity data analysis, interviews with staff and the collection of anecdotal evidence. Kinetic Consulting found Vocera System benefits included: savings in clinical time; more efficient processes; reduction in delays; increased clinician satisfaction; and improvements in patient care and safety. Ninety-eight percent of staff interviewed said internal communications had improved.

The Vocera Communications System consists of two main components: the Vocera System Software and the Vocera Communications Badge. The System Software runs on a standard Windows server and houses the centralised system intelligence: the call manager, user manager, and connection manager programs, as well as the Nuance speech recognition software and various databases.

The Vocera Communications Badge B2000 is a wearable device weighing less than two ounces. It enables instant two-way voice conversation. Features of the badge include:

  • Voice controls, enabling users to answer incoming calls hands-free

  • Intelligent system software allowing staff to call associates by name, function or group with no need to remember numbers

  • Supporting group communications with conference calling, broadcast messaging and voice mail

  • PBX integration enabling users to make and receive internal calls from their Badges.

Given the usual difficulties of implementing ICT in healthcare to everyone’s satisfaction, it’s a great pleasure to find a system that is unobtrusive, improves patient care and gives such immediate benefit.

June 20, 2008

Mancunian Ways

Mountain ViewIf you think Windows Vista is slow you should have tried using Fortran IV. I studied at Manchester University where we were able to take advantage of the computing facilities—quite novel in those days. This entailed creating a stack of punched cards which I dutifully placed in a tray in the morning.

After lunch I returned keen to see if my program for calculating square roots had worked only to find the dreaded words “run time error” on the print out, usually after the first milliseconds of the programme’s run. I found my mistake, corrected it and put the cards back in the tray and thus it continued until I got my brainchild to work.

It’s the birthday of Baby the world’s first electronic computer created by Manchester University in 1948, the BBC reports today. Baby could complete calculations in hours that would have taken days by hand.

The UK NHS, also born in 1948, celebrates its 60th anniversary. Health Secretary Nye Bevan was ceremoniously handed the keys to the Park Hospital (now Trafford General ) in Manchester to mark the foundation of the Service.

As if that wasn’t enough coincidence, this year’s NHS Confederation Conference took place in Manchester this week. I was surprised to see how many NHS agencies had individual stands: NHS Improvement, NHS Pathways, NHS Connecting for Health, NHS Institute for Innovation and Improvement, NHS National Technology Adoption Centre.

They all do worthy work, I'm sure. But I was heavily influenced by the work of Enid Mumford who was a professor at Manchester Business School and her promotion of socio-technical systems, so I find it odd the NHS should have so many trays in which to stack what should be a unified blend of people, processes and technology. One day we will produce that blend, but only after this tendency to reductionism is addressed.

Listening to Joe Simpson (Touching the Void) tell the story at the Conference of his ascent and unconventional and agonising decent of the Siula Grande in the Peruvian Andes puts life into perspective. If we only have a fraction of his courage and dogged determination the NHS will become the socio-technical system it must and gain again the envy of the world.

June 11, 2008

NPfIT: full circle?

The departure of Fujitsu from the NHS National Programme for IT (NPfIT) dealt the Programme another body blow. Where does NPfIT go from here, if anywhere?

Perhaps the Southern Programme for IT should be handed to one of the remaining huskies . But this summary from the UK's Guardian newspaper leads to the conclusion that would not be easy because of the alleged poor reception of the Cerner Millennium system.

Yesterday I attended a talk at the Smart Healthcare 2008 conference in London. Last year a similar talk was packed to capacity. This year the same venue was barely half full.

Although the speakers were meant to address healthcare transformation, I heard little evidence of it. The speaker from NHS Choices came closest showing the NHS Choices website had the potential to increase the power of patients by providing them with real performance data on healthcare providers. But the CIO of the London Programme for IT gave a history lesson on NPfIT and implied that NHS organisations would play an even greater role in the choice and implementation of IT.

Now I have tried a few times to read James Joyce's Finnegans Wake. I have never succeeded fully, but I know, set in world between dream and reality, it begins and ends with the word "riverrun" having come full circle: "riverrun, past Eve and Adam's, from swerve of shore to bend of bay, brings us by a commodius vicus of recirculation back to Howth Castle and Environs". So it seems with healthcare IT.

For decades NHS organisations implemented their own choice of IT systems before the intervention of NPfIT. Is the dream ending and flowing back to a parallel reality having run full circle?

June 01, 2008

IBM Helps to Share Health Care Information

Artefact Informatique, a Canadian division of IBM, will be part of a new initiative to share health information with patients and doctors around the globe. This has begun with the creation of the Centre of Excellence in Quebec City, which acts as a repository and registry for healthcare information. It is through the Centre that authorized personnel can search and retrieve important documents, thus improving the efficiency of many patients' medical care.

The Centre of Excellence contains lab reports, digital images, drug profiles and other critical medical documents. This repository was created with IBM WebSphere and DB2 software and was designed to be easily compatible with commonly used Electronic Health Record (EHR) systems. Health facilities that are now using EHR technology should be able to communicate with IBM's new software.

IBM has instituted this new technology as a part of the Integrating the Healthcare Enterprise (IHE) initiative, which aims to improve the way information technology is used within the health community. Primarily, it is making the world safer for patients by keeping better medical records for easier transfer.

Says Jose Mussi, the executive director of IHE Canada:

It has been shown many times that systems using IHE communicate with one another better, are easier to implement, and enable care providers to use information more effectively. Physicians, medical specialists, nurses, and other care providers have been waiting for the day when vital information can be shared seamlessly regardless of where they are or which system they are using. That day is now.

The new software took three years to develop and was created by researchers and software engineers from Haifa, Israel; Rochester, Minnesota; and San Jose, California. IBM is now promoting the system for more widespread use.

Heather Johnson is a regular commentator on the subject of CNA Certification. She welcomes your feedback and potential job inquiries at heatherjohnson2323 at gmail dot com.

May 16, 2008

Future Health

Man using PCA few weeks ago the BBC's Click programme showed us the possibilities of technology in health. PACS and voice recognition at the Countess of Chester Hospital; Radio Tagging of equipment at Bristol Royal Hospital for Children, in fact examples of what you read about on this site, and that made me sad.

No, not because the examples broadcast were poor. Not at all. But because it reminded me (yet again) of the difference ICT can make to healthcare but the slowness of its adoption. The Royal Berkshire Hospital in Reading, where I once worked, implemented PACS and voice recognition 6 years ago. Nor was it the first hospital to do so, with others like the Hammersmith near London already having led the way.

Seen all at once the examples in the Click broadcast give the impression of a high tech NHS; in truth, it is far from it. However, to challenge the funereal pace at which healthcare exploits ICT, perhaps we need some pilot sites where all of these technologies are embedded into business as usual that would serve as an example to the rest of the NHS.

Those hoping for the National Programme for IT (NPfIT) to help quicken ICT adoption would have been further disappointed by the UK National Audit Office's report this week. The report suggests that the NPfIT is running 4 years behind schedule and will not be implemented (whatever that means) until 2015 (if then). Many will once again be asking whether systems specified 3-4 years ago and targeted for implementation in 6 years may be obsolescent, not to say obsolete.

February 07, 2008

Health Informatics and Science

I've been reading Garrick Alder's Mind Bombs which is a collection of short articles designed to galvanise your thinking.

He reports Professor Richard Smith, editor of the British Medical Journal until 2004, said only about 5 percent of the entire planet's scientific papers came up to scratch. In most journals, Professor Smith said, it was less than 1 percent.

I have a comparable view of most of the Health Informatics publications I have read. They fall into two categories: the bean counting variety best kept by the bedside as a soporific and the other weak and subjective.

Health Informatics faces the same challenges as fields like sociology and psychology which also depend highly on the interpretation of human behaviour. At this stage in its evolution, the success or failure of healthcare IT is largely determined by how well users apply it. Therefore, IT must become fully integrated into healthcare, not seen as something separate. This goal is not best served by the creation of another specialty, Health Informatics, in a field already overflowing with them. That just gives practitioners an excuse to continue to pass the buck: "It's not my specialty, mate".

December 31, 2007

Bolton Care Records Pilot

Picture of laptop, chain and lock.This morning the BBC followed up previous reports on the summary care record pilot in Bolton. The piece was generally supportive, but the customary GP expressed concerns about the security of information on a national system compared to that held locally.

Such concerns are not fully addressed by technical security, as I have previously argued, secure human systems are also essential. When I was young the escapologist Harry Houdini was a hero of mine. When asked why he found it so easy to escape from the most secure of safes, he answered it was because they were designed to prevent people from getting in not getting out. Recent events show even though getting in to secure IT systems may be difficult, taking large amounts of data out is not.

People need to decide if the benefits of an online record outweigh the risks and in the Bolton pilot they can opt out if they think they do not. But eventually we should all be given sufficient information to make that decision ourselves.

Some may want their GP to be their advocate in such matters, and some may not. When I registered with my GP I was not given an option to opt out of having my information stored locally on his IT system, which at least 7 other people in the practice can access.

Also read this article in the Manchester Evening News about the theft from the Royal Bolton Hospital of patient-based information on a local computer.

I wish you a happy and successful New Year.

December 24, 2007

More Losses of Confidential Data

files.jpgThe BBC reports this morning that a number of NHS trusts have admitted losing patient-based information that seems to have been carried on CDs and memory sticks.

It's a sad indicator of the sophistication of UK healthcare IT that it still needs to transfer confidential data by what the US calls "sneaker net" and has only recently been able to transfer computer records electronically between GP practices.

Higher levels of technical security on the planned National Care Records Service should make NHS data more secure, but, as I have said before, technical security takes us only so far and must be underpinned by secure human processes. Recent events suggest we have some way to go.

Not a long way to go to Christmas day, though, so I wish you a joyful and peaceful time.

December 23, 2007

It's in the Cantenna

I have asserted the rapid adoption of wireless technologies will be a potent force for change in healthcare. In South Africa only 1 in 100 have broadband and remote areas may not even have telecommunications.

An episode of the BBC's ClickOnline this morning described how an AIDS clinic in the rural community of Peebles Valley is exploiting wireless to improve care. Clinic and a hospice are several kilometres apart and find it hard to communicate because of the hilly terrain. They have solved this problem by using a network of antennae inserted into tin cans, which focus the full power of the wireless transmissions giving the WiFi network added range.

Nurses and doctors now access the patient database and communicate using Voice over IP (VOIP).

Read the full article on the BBC site.

December 12, 2007

Sign Health

Picture of Sign.SignHealth helps GPs to communicate with deaf patients who use British Sign Language (BSL). Also a team of interpreters work at partner company SignVideo and can be booked by a GP's receptionist. The basic SignHealth programme gives immediate access to BSL translations using short video clips.

Here is a guide to BSL. No doubt someone will tell me the picture is American Sign Language :(

December 08, 2007

Healthcare IT is Not an Intervention

Picture of an abacus.In a previous entry I drew an analogy between developments in weaving and the introduction of IT into healthcare. In Jacquard's Web I read:

“The real problem was that the drawloom was not a machine at all. Instead, it was only a device for facilitating the manual weaving of patterns or images in the fabric...”

Facilitating the manual weaving... The status of Healthcare IT is somewhere between an abacus and a calculator. This is why I find it interesting when academics and others claim there is little evidence of its value.

Some of you may remember a controversial study on the introduction of a CPOE system that suggested it had led to a sharp increase in mortality. You can follow the resulting exchange by following the links here. When the dust settled the most satisfactory explanation for the study's results was the system had been used and implemented poorly.

John Glaser's article IT is Not an Intervention summarises the situation nicely. At this stage in its evolution, healthcare IT does not carry out direct, independent patient care. Its success depends on a complex of factors, not least of which is the competence of the people implementing it.

November 28, 2007

Self Knowledge

Though γνωθι σεαυτόν (Know Thyself) was written on the gates of the Delphic Oracle, I don't think using Phillips Brilliance CT machine was what the ancient priests had in mind.

I spotted some of the machine's images on Monday in an article in the London's Metro. The Brilliance machine produces 3D images, yet reduces a patient's exposure to radiation.

Phillips Medical Systems predicts the machine will change the way Radiologists work—it can even see into your heart and capture an image of it in two beats.

November 27, 2007

Two CDs and a Storm

Picture of CDs"Please check the coffee cup coasters on your desk just to make sure," quipped a colleague today. But it's no laughing matter. Who would have thought two mislaid CDs could brew such a storm?

And it's just beginning. In future, cyber criminals will target high-value information. Personal emails, grocery purchases and—dare I say—patient record information such as the results of genetic and HIV tests, will have value on the black market and could lead to anything from spam mail to blackmail.

Technical steps such as encryption and identity management take us only so far. I remember hearing an anonymous cyber thief on the radio saying he wouldn’t bother trying to hack computer security. It was easier to simply bribe unscrupulous employees to get information.

But most people working with sensitive data take their responsibilities very seriously, though, as HM Revenue and Custom's loss of CDs packed with confidential information shows, it only takes one mistake (and we are human) to rattle plans for large databases of shared records to the roots.

October 11, 2007

A Question of Identity

fingerprint.jpgI have been working on identity management recently. It’s a Tír na nÓg for techies: tokens, certificates, assertions, authentication. But the real challenges may have more to do with human processes than technical ones.
Recent workshops suggest the biggest problems may be in user management and the granting and revocation of access rights.

The NHS has implemented high levels of security with its use of smartcards based on chips with high levels of PKI encryption and sound processes for user registration and authorisation. But this article shows how users can still thwart security, in this case by remaining logged in and allowing colleagues to use their access rights.

Gerald M. Weinberg says (I probably misquote): all problems are people problems. Perhaps one day someone will come up with an incompleteness theorem like Kurt Gödel’s: that confirms no matter how sophisticated IT becomes users will always break the system.

July 03, 2007

Growing Patient Power

Picture of a mother and babyGoogle has set up a panel of experts to enhance its ability to respond to those of us seeking health information: Google Establishes Panel Of Health Care Experts . The ready availability of healthcare information has shifted the clinician patient relationship irrevocably. Now some doctors even encourage patients to become better informed and to challenge diagnoses.

One such is Jerome Groopman who in How Doctors Think tells of Rachel who adopted baby Shira in Vietnam. US doctors held Shira was suffering from SCID, an acronym for severe combined immonodefficiency disorder. Rachel researched SCID and was unconvinced. She thought Shira had a nutritional deficiency and insisted tests were redone. Rachel was shown to be right.

July 01, 2007


Old bicycle.Though I had Salvador Dalí posters plastered to my bedroom walls at University, my passion for his work cooled. However a visit to the Dalí & Film exhibition at London's Tate Modern has warmed it again.

I was particularly engaged by Destino a short film sketched out by Dalí and Disney in 1946 and only completed in 2003 after both of them had died. It's a blend of Dalí and Disney clichés: ants that morph into Sisyphean cyclists carrying rocks on their heads and two chiseled lovers separated by walls are reconnected by flocks of birds.

With his friend Luis Buñuel, Dalí also created the visceral and influential surrealist film Un Chien Andalou. The film's weird(est) actor resembles Buster Keaton, perhaps not surprisingly because Dalí and Buñuel loved the silent comedies.

Keaton also made Electric House about the havoc wreaked when modern technology is installed in an old house...(!)

June 03, 2007

Electronic Empathy: computers can care

Man using a computer.TV psychiatrist Professor Raj Persaud reports* the National Institute for Health and Clinical Excellence (NICE) has recommended making computer-based treatments for anxiety and depression more widely available. He argues this may be seen as another effort to reduce cost rather than meet patient needs. After all, patients want to be seen as individuals and prefer a person to a chip.

I’m not so sure.

In 1995 while researching for a MBA I came across some relevant research into the use of expert systems (considered part of artificial intelligence). Many patients who had consulted an expert system called ELIZA that did little more than ask reflective questions—for example: “Tell me more about…” or “What do you mean by..?”—responded positively. One woman left in tears saying she had never before met someone who understood her so well. Try some therapy from ELIZA.

In 2004 Whitfield and Williams asked: If the Evidence is so Good, Why Doesn’t Anyone Use Them? Surprisingly only about 5 percent of cognitive-based therapists were using computer-based self help as an alternative to face-to-face contact.

Today, if it comes to a choice between a highly personalised computer program, available day and night with no waiting list or 40 minutes with a busy human practitioner, I know which I prefer, Professor Persaud.

*Health Service Journal, 24 May 2007

May 13, 2007

Surgical Robots on the Surface and in the Deep

Surgical robots are putting themselves about.

A fantastic experimental robot is reviewed in 24 April 2007 New Scientist. The Heartlander is inserted using a minimally invasive technique. It then attaches itself by evacuated suckers to the heart and inches its way across it concertina like injecting medication and attaching devices. You can read the article and see the device in action here.

Meanwhile, aquanauts on the NASA NEEMO mission are experimenting with telesurgery using robotic arms.

May 12, 2007

IT from Outside to In

Picture of surgeons at work.New Scientist (5 May 2007) describes transgastric surgery—a technique pioneered in India that passes surgical tools and a camera through the patient’s mouth to operate on their abdomen. The article ends with:

“Historically surgery is notorious for following fashions and ignoring evidence--to the detriment of patients....”

In an article on the 21 May 2007 A Helping Hand for Keyhole Surgery New Scientist describes a three-fingered hand researchers at Tokyo Institute of Technology have developed that is assembled inside the patient. Professor Sir Ara Darzi (that man again) endorses the novelty of the idea, because until now surgical toolmakers have concentrated on making keyhole surgery instruments smarter and more articulated.

Regular readers will know of my passion for the full integration of IT with patient care. At the moment IT comes later or is considered nice to have. We should build our care processes with IT on the inside rather than making it smarter on the outside. Then maybe we will have the evidence to underpin improvements to surgery and care.

Negative to Positive

I have been reading FierceHealth IT's website that has been making awards to hospitals for innovation. I was taken by Licking Memorial Hospital that since 1999 has been publishing quality information—good and bad—for 12 clinical specialties, including cardiology, chronic heart failure, maternity care, respiratory care and diabetes care. By addressing its failures openly it has turned this process into competitive advantage.

April 29, 2007

To Go and To Come?

In its editorial the Health Service Journal of the 19 April 2007 says Mr. Richard Granger, the Director General of NHS IT is "expected to leave soon". Now how many times have I heard that in the last 2-3 years? Nonetheless, the recent mostly critical report on NHS National Programme for IT by the House of Commons Public Accounts Committee (PDF 4.5Mb) cannot have strengthened his position.

The HSJ also refers to a report by Professor Sir Ara Darzi, the national advisor on surgery and one of the medical profession's rare technological innovators. In Saws and Scalpels to Lasers and Robots Professor Darzi suggests 80 percent of local surgery could be carried out in health centres and large GP practices.

It seems if anything is going to drive NHS modernisation it will be public expectation combined with the march of technology--with or without a centrally led IT programme.

April 07, 2007

Who is Sick?

Given healthcare's dilatory acceptance of IT it may be customers who force the pace. I received an email about a newly launched website: It uses Web 2.0 technology to generate user content displayed through a simple Google Maps interface.

The website started in 2006 after the founders' poor experience with health services in the US with a mission to "provide current and local sickness information to the public - without the hassle of dealing with hospitals or doctors". The founders believe in the power of user generated content about local sickness.

Note: FHIT is not accountable for the content of other websites.

March 25, 2007

Then We Will Fight in the Shade

Ancient Greek ruins touched by the rising sun.The Healthcare IT conferences in Harrogate may be an ember of their glory days, but one determined to continue glowing. Maybe in sensing that, I enjoyed HC 2007 more than its recent predecessors.

Given the UK release of the movie 300 about the battle of Thermopylae, it is topical for me to refer to a tale of ancient Greece.

The crowd jeers an old man looking for a seat at the Olympic Games until he reaches the Spartan section, when every Spartan younger than him, and some older, stand and offer him their seat. The crowd applauds and the old man turns to it and says: "Ah, all Greeks know what is right, but only the Spartans do it."

I attended a couple of notable presentations and I’ll write something about them next. After 20 years in healthcare IT maybe I have become jaded, but many of the presentations reminded me of that tale: many know what to do, few do it.

March 17, 2007

Forward, Back or Blight?

Picture representing decision making.I have been occupied with work outside healthcare and it may be true what they say: distance enhances review. What I notice is how quiet the sector seems. Even the ever-alert E-Health-Insider is reduced to writing about the lifting of bans on mobile phone use. Nor am I the only one to comment on this. I have also come across a number of healthcare consultants taking similar time out. All mention frustration and lack of progress in the sector.

Has the leviathan that is NPfIT cast a giant restraining shadow over healthcare IT? A colleague recently described the situation as 'planning blight'. But it reminds me of a passage from Lord Macaulay's poem "Horatius at the Bridge" that my class read with Mr. Walker when I was about 11: "But those behind cried ‘Forward!’, and those before cried ‘Back!’".

I am preparing to go forward back to Harrogate for the HC 2007 Conference where I am chairing a debate. Last year in the plenary sessions speakers from NHS Connecting for Health hinted at reorganisations. This year speakers from NHS CFH's top team have withdrawn from the conference, generating considerable speculation. Nonetheless, Lord Hunt the minister in charge of NHS CFH's NPfIT will be speaking. Many will listen carefully to what he says.

January 27, 2007

What is the Sound of One Wing Flapping?

butterfly.jpgListen, do you hear it? Has a balloon been pierced by a pin? Or is NHS Connecting for Health deflating? If so, how quickly and by how much?

Government agencies aren't the only ones to have felt a jab. The Guardian's Polly Toynbee in a jerkily argued article says underperforming GPs should be brought into the fold of the NHS (more interesting are the emotional arguments in the comments section that follows it). Also, in a recent TV program management trouble shooter Gerry Robinson turned his attention to Rotheram General Hospital where consultant medical staff apparently arrived late, left early and were never in theatres on Friday. Undoubtedly tensions between managers and clinicians are still with us.

Let's hope it's the sound of metamorphosis then. For with or without a national IT programme it is beyond debate that a 21st Century NHS must emerge as a system where humans and technology seamlessly interact. The real question is how that is to be created. Many of us who have worked in the NHS could have saved Gerry Robinson the walkabout by pointing out the problems. Maybe he could then have turned his talent to addressing them. That would have been interesting.

December 29, 2006

Melting the Darkness

Picture of dawn with a lighthouse.“Dark days before Christmas,” my Mother says. It may be those short days just after the winter solstice that are dulling my mood while I look back on my time in healthcare IT. How much has changed and how much have we learned? Not nearly enough.

Darkness hangs over the NHS National Programme for IT (NPfIT) as we end the year. Accenture has left and the future of software supplier Isoft is unclear. Progress on the core cross-organisational National Care Records Service—for me the Programme’s essence—is also well behind schedule.

But shafts of light pierce the dark. NPfIT’s PACS deployments have progressed well. Though an easy win, they are nonetheless an important one because they highlight the benefits of sharing electronic patient-based information. Also, Cinderella sections of the NHS like Community and Mental Health are benefiting from the deployment of new systems.

My mood has also been lightened by the number of young clinicians, especially doctors, excited by the possibilities of information technology. I have recently met several—some working with Professor Sir Ara Darzi’s unit in London, which looks at the integration of technology into medicine.

At this time of year the days lengthen slowly with the darkest hours just before dawn.

December 15, 2006

Admiring the Heights, Gazing into the Chasm?

Mountain ViewIn the last month or so I have attended a couple of conferences as a speaker and a chair. What caught my attention were the number of opportunities for using technology in healthcare--particularly in remote monitoring and diagnosis--and how this contrasts with the situation of UK healthcare ICT.

At the BCS eBrochan conference in Glasgow (brochan means porridge, apparently) Prof. Frances Mair, Professor of Primary Care Research, at the University of Glasgow, talked about the real application of telecare and telemedicine, stressing the importance of having clear aims and of adequate preparation and reorganisation. Too often such projects are tacked on to existing practice, which often means staff have to do their day job and manage the pilots.

I chaired the recent Mobilising the Clinician conference where talks ranged from making better use of the PDA to remote monitoring and diagnosis using wireless and GPRS. On the second day, Professor Istepanian of the Mobile Information and Network Technologies Research Centre (MINT) described an array of applications some using GSM or the faster GPRS for monitoring vital signs; for example, transmitting ECGs, blood oxygen saturation and blood sugar levels. Ultasound scans have even been taken remotely in Cyprus.

Dr Omar Aziz works in Professor Sir Ara Darzi's unit at Imperial College in London. He described the possible use of body sensor networks (BSN) in mobile health (m-Health). BSN could be applied widely in healthcare; for example, in monitoring vulnerable patients and post-operative recovery.

Lest we lost touch with reality at these rarified heights, Jon Holmes, Informing Healthcare Project Manager at Gwent Healthcare Trust in Wales, told us about the challenges of implementing wireless computing on wards, which allowed nurses to record Admissions, Discharges and Transfers in real time.

In the UK, 21st Century ICT must be implemented in a 20th Century healthcare system. Benedict Stanberry of Avienda suggested healthcare IT is on the brink of the chasm referred to in Geoffrey Moore's book Crossing the Chasm. The chasm is a void on a notional curve that spans the phases of technology adoption. Moore's chasm opens up between the phases of early adoption (comprising the enthusiasts) and early majority (the pragmatists), because expectations are distinctly different.

The illustrious Royal Society also suggests UK healthcare's adoption of ICT is dilatory. Its report Digital Healthcare covers familar ground for readers of FHIT. As well as looking at the view from the top, it suggests more can be made of existing systems and that even applications like mobile phone SMS messaging still offer unexploited footholds.

Hmmm. When it comes to integrating ICT into healthcare, scaling the peak will be an achievement and the views will be fantastic--but there's a lot of abseiling and climbing still to do.

November 26, 2006

All Change

doctor-film.jpgTechnology, shifting demographics and better informed customers will bring about the biggest changes in the NHS's history. But the reorganisation needed to meet the changes may not please everyone.

For example, the UK's Daily Mail described the tension between Nurse Practitioners and GPs at a walk-in centre in Canary Wharf, London.

To take part in Whole System Long-term Care Demonstrators, the UK's Department of Health is asking the NHS and Local Authorities to work together, supported by technology. But how will they do that?

Many of the pilot studies of long-term care have been telecare, or assisting people to remain remain independent at home. Very worthy. But telecare will not benefit the majority of people with long-term conditions who care for themselves. To support them and reduce demand for expensive hospital admissions we need real time monitoring on an unprecedented scale. New organisations and jobs are inevitable.

Technology is also making medical knowledge a commodity and medical pracitioners must adapt. A study published by the British Medical Journal suggests GPs unsure of a diagnosis search the internet with Google. That study used a general search engine: what levels of diagnostic accuracy will be achieved by specialist neural nets and the application of Bayesian learning?

November 13, 2006

Long Term Care Demonstrators

Hand holding a walking cane.That will teach me to ask rhetorical questions at the end of posts.

In a previous post on management of chronic conditions I asked where remote monitoring appeared in the vision for the NHS and in its NPfIT. The DoH has announced its intention to fund up to three Whole System Long Term Care Demonstrators covering a population of one million. The pilots will run for up to two years.

It will be interesting to see how the pilots are organised and their technical solutions. The DoH wants the NHS and Local Authorities to partner. The workings of such partnerships--which could include contributions from the primary and acute care in the NHS as well as the private, voluntary, charitable and private sectors--will be key to their succeess. And where will organisations like NHS Direct fit in, I wonder? All in all, we should gain insight into the structure of future healthcare and the technical, human and organisational dynamics needed to support it.

Partnerships will be able to draw upon offerings from 15 suppliers from a pre-competed Telecare National Framework Agreement.

November 03, 2006

Chronic Disease Management (More)

Continuing the theme of chronic disease management, I notice Dale Hunscher on the US cousin of this site has posted on the use of the Internet in managing chronic disease. The post also refers to Cognitive Based Therapy websites that allow supported self-management of some psychiatric disorders. Take a look.

November 01, 2006

Healthcare on Wireless Waves

Toumaz device being used.My previous post discussed the reality of remote health monitoring. I noted the high compliance of study participants monitored using large arrays of stick-on sensors. Such discomfort may now be unnecessary.

Toumaz Technologies has developed new, small, low power, wireless sensors that can be attached to the body with sticking plasters. These devices enable non-intrusive, continuous monitoring and analysis of ECG, temperature and at least one other vital sign, such as respiration or activity level. Vital signs are transmitted to a PDA or mobile phone and monitored with software that includes an arrhythmia detection algorithm for real-time monitoring of ECG.

You may also be interested in an article I wrote for an IT innovation magazine about real-time remote health monitoring (well, everyone likes to back a winner sometime) though I was thinking of a wristband.

Visit the Toumaz site for more on their device.

October 29, 2006

Telemedicine and Self Care

Worker with a PC.jpgPhysician, heal thyself with the support of remote monitoring, suggested Dr. Paul Johnson, Director of the telemonitoring service Xenetec last week at the International Healthcare Innovation Congress in London.

He pointed to a pandemic in lifestyle-related diseases exacerbated by growing levels of obesity in Western countries (in the UK 23 percent of us are now classed as obese—the highest level in Europe). As a consequence, incidence of chronic diseases—like asthma, coronary heart disease and chronic obstructive pulmonary disease—is increasing. In the UK, chronic disease apparently accounts for 65 percent of the visits to Accident and Emergency departments.

With such a pandemic, it's fortunate advances in IT and communications make 24-hour health monitoring a reality. Vital signs like respiration and heart rate are useful indicators. A healthy heart rate has a high degree of variance, showing as a spikier trace than an unhealthy one. In addition, nocturnal breathing disorder is often a co-morbidity in asthma, COPD, hypertension and heart disease. Close monitoring of such signs could assist sufferers to manage their conditions and carers to pre-empt crises.

Dr. Johnson said that multi-centre trials in Europe show such monitoring is practicable. Patients in the trials had worn a cluster of electrodes on their chests stuck on with adhesive tape that reminded me of the spaghetti at the back of my aging HiFi system—yet compliance was high. This is a good sign. If patients can tolerate being wired up like that then compliance with newer, wearable equipment should be at least as high (see future posts).

Supported by monitoring centres, self-management of chronic illness is real option. As an example of its possibilities, Dr. Johnston referred to work by Dr Dean Ornish et al on the effect of diet, exercise and stress management on heart disease. Dr. Ornish's work assessed the power of a rigourous risk management regime to arrest—or reverse—the progression of atherosclerosis.

If it's practicable (inevitable maybe), where does remote monitoring figure in NHS plans, or indeed in the NHS National Programme for IT (NPfIT)? Do the operational vision for the NHS and the technology planned to support it need revision?

October 22, 2006

Electronic Health Record: different nations, different approaches

view.jpgIn a panel session at last week's International Healthcare Innovation Congress in London speakers from Denmark and Canada spoke about how their nations are tackling the Electronic Health Record (EHR).

Continue reading "Electronic Health Record: different nations, different approaches" »

Healthcare Must Ride the Wireless Wave

Picture of surfer.I used this soapbox piece as a the basis for a short introduction to the session I chaired at last week's International Healthcare Innovation Congress in London. I will also be posting on a couple of talks that caught my interest--though all of the speakers were good.

Though information is its basic currency, healthcare has been remarkably slow to embrace Information and Communications Technology (ICT). It has mostly been applied piecemeal to automate existing practice rather than transform it. As a consequence, ICT implementation has rarely dramatically improved care or the patient's experience of it.

Continue reading "Healthcare Must Ride the Wireless Wave" »

October 04, 2006

Closing on Remote Care

The US Defense Advanced Research Projects Agency (DARPA) seeks to investigate and exploit promising technologies for use in the defence industry. Its Trauma Pod program (see article and animation at bottom of the page)--an outgrowth of earlier telepresence surgery R&D--seeks to meet the military’s need for trauma care and autonomous surgery by 2025. It is part of the Army’s goal to remove medical personnel and all hospitals from battlefields.

This program supports immediate diagnosis, therapy and evacuation of casualties. Deliverables include advances in teleoperation and surgical procedures, mechanical movements, directed energy, software development, miniaturization and the automatic management of medical supplies in theatre.

Since 2004, DARPA principal investigators have designed and prototyped novel systems. Commercial use of Trauma Pod technologies could lead to greater medical efficiency and the better use of specialist staff.

DARPA Advanced Biomedical Technology Program.

Thanks to Lance Manning for this entry. Lance is a business consultant providing client support in research, development and implementation of emerging health care technologies.

August 06, 2006

Acute to Primary Care at Tipping Point?

Is it me or is UK healthcare changing faster than we expected?

I mean, we thought a switch from acute and late-stage to primary and prophylactic care was inevitable. But have we reached a tipping point?

Continue reading "Acute to Primary Care at Tipping Point?" »

July 27, 2006

Heathcare IT: helping to collect the evidence

Picture of a judge with scales.I have mentioned my wife often spends evenings scouring medical publication databases for evidence to support her practice as a physiotherapist. This approach has been hammered into her by her tutors. But I have recently read two articles about medical practice that suggest there is further to go.

The first was picked up by the vigilant eHealth blog. An article on BusinessWeek online suggests that only 20-25 percent of medical practice is supported by evidence.

I am told the UK is a leader in implementing evidence-based healthcare. The National Institute for Clinical Excellence (NICE) provides "national guidance on promoting good health and preventing and treating ill health" that can be used by patient and practitioner. Also, the National Electronic Library for Health offers a range of resources, including a link to the Cochrane Library that offers "high quality evidence to inform people providing and receiving care".

However, a second article in New Scientist sees the challenge from another angle. In The Illness Industry Jorg Blech (the science correspondent for Der Spiegel) claims that "cures" for illnesses we did not know we had are converting society into a big hospital.

For instance, Herr Blech highlights the Western tendency to consider menopausal women as ill and to treat them with oestrogen and progesterone based on little clear-cut evidence. The "male menopause" shows a similar pattern, he says, with men now encouraged to use medications like testosterone gel.

In his book Inventing Disease and Pushing Pills Herr Blech quotes Aldous Huxley:

Medicine is so ahead of its time that nobody is healthy any more.

Both of these articles convince me that an integrated national Electronic Health Record, such as NHS Connecting for Health's NPfIT's Spine, has a crucial part in future healthcare. The analysis of anonymised data on patient care and outcomes could lay an even firmer foundation for medical practice.

July 24, 2006

High Street Healthcare

Picture of a doctor with a stethoscope.Several UK newspapers have reported plans for the UK's high street retailer Boots to house NHS GP surgeries and hospital consultants in its stores. The Government has apparenly been impressed by its management of free testing for Chlamydia, which about 14 000 people have taken advantage of. Boots is discussing its plans--which may entail offering in store podiatry, orthopaedic and physiotherapy treatment, as well as healthy heart checks--with UK Primary Care Trusts (PCT) .

The Boots group has three main businesses: Boots the Chemists, Health and Beauty and Boots Opticians. It operates from about 1 500 branches in the UK and Republic of Ireland and serves 8 million customers a week.

Boots has invested about £120m in one of Europe's largest SAP systems, which encompasses finance, treasury, HR and property and is also used to to plan the optimum layout and stockholding of its retail outlets. It has begun to use radio frequency hand-held terminals to manage stock in real time, and its MyStoreNet intranet site provides store managers with real time information on performance.

Decentralisation of healthcare and a move away from centralised, highly skilled specialists were hinted at in last year's NHS Chief Executive's report (see FHIT posting).

July 13, 2006

Breathe Easy: testing breath for disease

A mobile phone carrying a breathalyser is about to be launched in the UK the Sunday Times on 9 July 2006 reported. The Samsung LP4100 tests drinkers's fitness to drive and may also lock out certain numbers to prevent embarrassing drunken calls to bosses, former partners or the local takeaway. The phone is multifunctional, even offering a remote control for karaoke machines.

I also spotted this article about a breath test for metabolites asssociate with breast cancer.

Lack of testing and diagnostic devices not needing specialist intervention have limited remote monitoring and the development of carebots, but that's changing fast with breath testing a promising area.

July 09, 2006

Consequences of Healthcare Convergence

I love films like Fritz Lang's Metropolis that are centred on the ultimate machine that resembles a bodge of a steam engine, a badly wired fuse box and the contents of a mad scientist's lab. So, it was a treat to visit an exhibition on Modernism in London.

A 1919 quote from Walter Gropius, a member of the era's hugely influential Bauhaus, caught my eye:

The old forms are in ruins. The benumbed world is shaken up, the old human spirit is invalidated and in flux towards a new form.

For a recently-published article on the flux in healthcare to a new form, convergence, I spoke to Microsoft's John Coulthard, Director of Healthcare, UK. He thinks predictive DNA testing, wireless communications and burgeoning diagnostic and monitoring devices herald a decisive shift from the management of late-onset disease to prophylaxis.

The Modernists were also inspired by a form of convergence. They found the separation of Art, Craft and Design artificial and admired the machine as the epitome. Le Corbusier, another of the movement's leaders, even described homes as "machines for living".

Today's acute hospitals may be "machines for health"...but that doesn't seem to follow, because they are centred on the management of illness, which, if Mr. Coulthard is right, makes them obsolescent.

Healthcare in the 21-Century is a new form. Though founded on technology, it will be less like a machine and more dispersed, amorphous and pluralistic. Not focussed on managing illness, but on maintaining health.

Read Come Together the article on healthcare convergence I refer to.

June 18, 2006

Changing the System: NAO’s report on the NHS IT project

For weeks the UK’s media have been cleaning and oiling their guns preparing to lay a broadside on the NHS IT Project.

Last Friday, on the morning of the release of the National Audit Office’s report on the NHS National Programme for IT (NPfIT), even my favourite BBC Breakfast news presented by the elfin Sîan Williams and the grounded Bill Turnbull could not resist a ranging shot: the NAO report would “criticise” the NHS IT project.

Continue reading "Changing the System: NAO’s report on the NHS IT project" »

June 11, 2006

Lean Keenness: transforming healthcare with Lean thinking

The National Motorcycle Museum near Birmingham, UK seemed an apt venue for a conference on a change philosophy pioneered by Toyota. Despite the early start to the Lean Healthcare Forum on the 6th of June, the buzz at coffee was palpable. This excitement continued throughout the event, though at times it verged on overzealousness.

Continue reading "Lean Keenness: transforming healthcare with Lean thinking" »

May 05, 2006

Sounds Healthy: iPOD in healthcare

On the London Underground everyone seems plugged into one. Even above ground in healthcare MP3 players are becoming ubiquitous.

Continue reading "Sounds Healthy: iPOD in healthcare" »

May 01, 2006

SmartPill® Tracks Your Tract

In 1995 I visited the exhibition in London's Tate Gallery of the (infamous) Turner Prize shortlist. Stepping into the darkness of Mona Hatoum's installation Corps Etranger I watched a video journey through her intestine and other bodily passages. Today she could avoid the discomfort of the endoscope in the interests of Art by using the multi-vitamin-pill sized Smartpill®.

When swallowed, SmartPill records its trip through the digestive tract using its battery of on board equipment and sensors, like a thermometer, pressure gauge and acidity meter.

Unlike the miniaturised submarine carrying Raquel Welch et al in the 1966 movie Fantastic Voyage, SmartPill is propelled by peristalsis. When excreted 24-48 hours later, a doctor downloads its data in less than 10 minutes and analyses them, a process which could transform the diagnosis of conditions like dyspepsia, constipation and irritable bowel syndrome.

For more see Roger Dobson's article in the UK's Daily Mail of 25 April 2006 or visit SmartPill Corp's website.

April 24, 2006

Winning Ways: transforming healthcare using IT

I am a big fan of Idries Shah’s tales of the Sufi wisdom of Mulla Nasrudin. Here is one of my favourites:

One night a neighbour found Nasrudin down on his knees looking for something under the street light: "What have you lost, Mulla?"

"My key," said Nasrudin.

After a few minutes of searching, the other man said: "Where did you drop it?"

"By my house."

"Then why, for heaven's sake, are you looking here?"

"There is more light here."

A veteran of a Hospital Process Redesign, I remain an advocate of transforming healthcare with IT. So, I enjoyed consultant vascular surgeon Simon Dodds’ book Three Wins, which recounts his experience at the Good Hope Hospital, Sutton Coldfield, UK of developing the Leg Ulcer Telemedicine (LUTM) Service.

Continue reading "Winning Ways: transforming healthcare using IT" »

April 16, 2006

Commanding Voice: combining telephony and wireless

vocera.jpgNow I am a sucker for a cute gadget, especially one finished in black and silver that combines telephony and wireless. No surprise then that I spotted the Vocera badge on Telindus' stand at HC 2006. Vocera's system combines software with the badge to integrate PBX, pager, cellphone and push to talk.

Continue reading "Commanding Voice: combining telephony and wireless" »

April 09, 2006

Connecting for Health: awaiting the winds of change

Connecting for Health faces the winds of change.Political and technological winds of change whistle through NHS Connecting for Health's National Programme for IT (NPfIT). They may erode the notion of a single, comprehensive, monolithic system serving GPs and acute, community and mental health care settings and deposit the spores of innovation, clinical inspiration and supplier diversification.

Continue reading "Connecting for Health: awaiting the winds of change" »

March 28, 2006

Human Biology and Health

Nice entry here on the Nature Newsblog: 2020 Computing mostly about the integration of IT and human physiology.

Also see this entry on our US cousin with a link to articles on Nature.

March 27, 2006

Views of a Hybrid: clinician and informatician

Picture of surgeonSimon Dodds is a Consultant Vascular Surgeon. He refers to the debate reported in this FHIT entry. I am posting this extract from an email he sent me with his permission.

With my clinical head on I rant about the informaticians that never actually come and see what frontline healthcare delivery entails, never experience for themselves what the problems are, or help tease out the information requirements from the rest of the process (i.e. write the information requirement specification), then offer simple, workable, quick, cheap options based on existing technology, then help choose the most viable options, then quickly design and build prototypes that are usable, then test options and find those that actually work better than what we were doing before, then implement the best seamlessly so we never really even notice it's there (until it goes away and we suddenly realise we can't do without it).

Continue reading "Views of a Hybrid: clinician and informatician" »

March 09, 2006

Full Integration of IT into Healthcare

da-vinci-healthcare.jpgWe need the full integration of healthcare and IT. Today it’s an optional extra for clinicians, perhaps not surprising, because applications are often little more than jumped up number crunchers that are irksome to use.

Continue reading "Full Integration of IT into Healthcare" »

March 07, 2006

Evolving Medical Relationships

In January, delegates at a conference at the the Regenstrief Institute Inc. discussed Relationship Centred care and how important it is to success. The conference considered the interactions of the healthcare team, the patient and the patient’s relatives and friends. But a more virtual relationship is increasing in importance.

Continue reading "Evolving Medical Relationships" »

February 26, 2006

Close Communities or Remote Monitoring?

I have just come back from visiting my Mother, who lives in the north of England. On the outbound train I found myself sitting next to a recently-qualified GP, and we talked about primary care. I explained to Helen (let’s call her that) I thought using IT for remote monitoring would be the key to healthcare in Britain’s aging population. She thought that closer communities and families were needed.

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February 11, 2006

Healthcare IT: past, present and future

rbbh.JPGYesterday evening I went to a leaving do for my friend and former colleague Roger. He leaves the Royal Berkshire Hospital in Reading after 12 years in the IT Department to join NHS Connecting for Health.

Continue reading "Healthcare IT: past, present and future" »

February 08, 2006

Podcare: Care and iPod

Following from FHIT posting on a US doctor using 21st century iPods to improve students skills in the use of 19th century stethoscopes. Please read this article from Wired that shows how podcasting can be used to improve patient care.

February 03, 2006

Forget Clinical Involvement

pacs.jpgAt a conference last week in London, UK “Successful Implementation of NPfIT 2006” engaging clinicians in the National Programme for IT was brought up time and again by speakers: let's engage them, let's involve them, let's get them on board—phrases that to me are meaningless shibboleths. I do not want to involve them at all.

Continue reading "Forget Clinical Involvement" »

January 30, 2006

Reposting for Eyeforhealthcare Delegates

This is a re-post of three entries about the increased mortality reported in “Pediatrics” after the implementation of a Computerised Physician Order Entry System (CPOE) for the convenience of delegates at the “Successful Implementation of NPfIT 2006” in London. These entries relate to discussions during the sessions I chaired on 30 January 2006.

First entry on the Pediatrics article.

Second entry on the article.

Third entry and link to post-publication peer review.

Links to other relevant blogs and websites are in the postings.

January 29, 2006

Sound teaching: updating the stethoscope

The stethoscope was invented by Rene Theophile Hyacinthe Laennec in 1816 and has become the letimotif of the doctor. It still provides the clinician with a concerto of medical information, about heart and lung conditions. To help medical students to tune their ears, Dr. Michael Barrett of Temple University, Philidelphia has used digital sound recordings.

Continue reading "Sound teaching: updating the stethoscope" »

January 26, 2006

Telemedicine: changing the way healthcare meets

telemedicine.jpeg I did not know it was so isolated. The nearest referral centres to the north, south and east are more that 2 hours drive away. To the west the nearest is across the Irish Sea in Dublin. But Bronglais General Hospital in Aberystwyth, Wales overcomes distance with telemedicine.

At a seminar in Slough, UK on Tuesday held by Multisense Communications Ltd. clinicians from Bronglais described (online, of course) how they manage cancer cases at the hospital using multi-disciplinary teams (MDT) and virtual consultation. Telemedicine combines live video with diagnostic data, images and even access to the Web.

Continue reading "Telemedicine: changing the way healthcare meets" »

January 22, 2006

Bridging the Quality Chasm or Falling Into it?

I know I am at a stimulating talk when I feel my passion rising. So it was last Friday when I attended a talk given by Professor Marc Berg from Erasmus University Rotterdam at a NHS Faculty of Health Informatics Masterclass in London.

Professor Berg argues that quality improvement and health informatics must be combined if healthcare it to be improved and healthcare IT projects to succeed. At the core of his proposal is standardisation: of practice using Integrated Care Pathways (ICP), of semantics (using common health languages-like SNOMED CT) and of IT.

Continue reading "Bridging the Quality Chasm or Falling Into it?" »

January 17, 2006

Documents and databases for the NPfIT record

paper-records.jpegWilliam Hooper is Senior Advisor, Healthcare, Xerox Global Services and writes as a guest author.

This blog has frequently looked at humans and computers in healthcare. Let us introduce another factor—types of information.

Historically, pretty much an entire acute note has been un-structured. Some forms have been used for transactions such as ordering tests or receiving results, and nurses, as ever, are organised. I have not yet found a fag-packet in notes, but you get the idea.

The National Programme attempts to take a structured approach. GPs have been working this way for years, and it has many advantages. Computers are good at validating entries, when supplied with sensible rules. The advantages in terms of activities such as prescriptions are obvious. They can also be programmed to make sensible suggestions on care given a set of patient conditions. To say that programming these care paths is complex and time consuming is an under-statement.

Databases (which are what underlie the clinical systems of CRS) are good at holding structured observations and measurements. But, it will be many years before they have comprehensively encoded the bulk of medical practice (if ever).

Meanwhile, clinicians today are still adding both free-text and documentary additions to GP and acute notes, to say nothing of psychiatric observations. Paper is being generated too, and a tiny proportion is now being scanned and added to the database note.

A database stores a blood-pressure reading effectively where the care-plan says one should be taken. Documents can store anything and everything from the patient’s mood this morning to a sketch of a planned intervention.

The technology is now available to integrate documentary with data notes. This is to be supplied in most NPfIT clusters. Rather than talking about heaps of paper as being a problem for records managers to sort out, should we not be concentrating on who needs what information to deliver care, and how best to make best use of this?

January 14, 2006

Healthcare IT will not fix broken health processes

operating.jpgThose of you who have been visiting regularly will know this topic is a hobby horse of mine. Often, healthcare finds an operational problem, and instead of addressing it by changing human activity (which is difficult) it decides to buy a computer (which is easy) hoping that it will sort everything out. Invariably the IT makes matters worse or creates a new set of problems.

For an example of IT in action, please read this account on HHN Most Wired of a man who took his son with meningitis to a US hospital: “A Patient's View of Health IT”.

Now, of course, there is no excuse for poor customer service. Healthcare in UK is different from that in the US, and, in the main, I have had few problems with it. Most of my irritation is caused by long waiting times and administrative processes that often seem to be for the benefit of staff rather than the patient.

However, I guess what I should be concerned about is outcome. After all, poor processes and old-fashioned buildings are much less important than a first-class outcome. The National Patient Safety Agency in the UK in “Right Patient, Right Care” (PDF) identified a 10 percent mismatch between required and delivered treatment for the UK's annual 8m inpatients.

Is that mismatch symptomatic of broken processes? And, if it is, will the deployment of the National Programme for IT's (NPfIT) information systems make them better or worse? I remember reading this on a poster in an office:

“We all make mistakes that's very true indeed,
But to really mess things up a computer's what you need.”

Shouldn't we address the real problem before implementing the IT?

January 07, 2006

Healthcare IT: full integration in care

da-vinci-healthcare.jpgI am reading an excellent book: “Jacquard's Web” by James Essinger.

Joseph-Marie Jacquard was a master silk-weaver in Napoleonic France. Jacquard invented a loom that accelerated the rate at which master weavers could create their exquisite fabric by 25 times. The loom stored patterns and instructions for the beautiful designs on punched cards, which were in turn used by Charles Babbage to programme his Analytical Engine--the world's first computer.

The precursor of Jacquard's loom was the drawloom. Individual threads of the warp were lifted by it to create a path through which the shuttle was passed by a draw boy. The drawloom allowed patterns to be weaved at the unprecedented rate of two rows a minute (!)

This book is an excellent read and this caught my eye:

“The real problem was that the drawloom was not a machine at all. Instead, it was only a device for facilitating the manual weaving of patterns or images in the fabric...”

Facilitating the manual weaving. It seems to me that is what healthcare IT does: it's an aid to care rather than an integral part of care--still somewhere between the condition of an abacus and a calculator.

The picture is of the da Vinci operational robot which is used by surgeons to achieve unprecedented precision in minimally invasive surgery. It eliminates a surgeon's hand tremor, which is magnified by the lever effect of the long keyhole surgery instruments, and further improves visibility by the stereoscopic view of the site that its twin lenses provide.

Sure, it needs a surgeon to operate it remotely but how much longer before IT and tools are further integrated creating the medical equivalent of Jacquard's loom and freeing professionals to weave even better patterns of care?

Picture of the da VInci copyrighted property of Intuitive Surgical.

January 04, 2006

Health IT: making care better or worse? (cont)

The debate about the sharp increase in mortality reported in Pediatrics after the implementation of a computerised physician order entry system (CPOE) at the Children's Hospital in Pittsburgh. (See FHIT entry) rumbles on.

I spotted this reference to a post-publication peer review, which states:

“A more accurate summary of the findings is that there were significant problems with the implementation process for CPOE at this hospital and that the hospital simultaneously instituted other system changes that may have accounted for adverse effects.”

Compounding the criticism of the study by health IT experts and others, the hospital’s medical director and other hospital officials have also disagreed with the study's findings, according to the Wall Street Journal.

In the UK the original study was also picked up by the E-Health-Insider website. Please look at the comments after the article, which are instructive and tell us about the polarisation of opinions on healthcare IT in the UK.

Even after 15 years of implementing health care IT it never ceases to astonish me how quick people are to criticise it and how little healthcare has learned about its implementation.

Implementing information systems without first changing processes and medical practice to accommodate them and carefully monitoring the result is folly, not to say negligence. This applies doubly to processes that may already be poor.

How long will it take us to learn these lessons?

More on the on the eHealth Blog.

January 01, 2006

Health Informatics: a rant to begin the new year

I was woken by the sound of a text message arriving on my mobile phone. Ahh, I thought, a message from my old university chum who lives in Mauritius. Or, maybe my Mother has learned to text and is about to impress me with a New Year's greeting.

No such luck. A message from my accountant telling me that my VAT (UK sales tax) return is due. Brought down to earth with a bleep and a buzz. As Bono sings: "Nothing changes on New Year's day".

Suitably grumpy, I thought I would write about this field of Health Informatics that has been on my mind.

I took a partial sabbatical from health to work in other areas of the UK public sector, thinking to expand my experience and skills. During my time away from full-time engagement in healthcare IT, Health Informatics in the UK seems to have grown from an egg into an assertive fledgling.

I looked up a definition of it on Wikipedia:

“Health Informatics or sometimes Medical Informatics is the intersection of information science, medicine and health care. It deals with the resources, devices and methods required to optimize the acquisition, storage, retrieval and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems.”

Now, having worked for about 15 years in healthcare IT and led three major Electronic Patient Record Implementations I became used to walking the tightrope between the views of clinicians and NHS IT professionals. In general, over the years these two poles have learned to co-exist.

Into that polarization—for me rather uneasily—come the Health Informaticians. Are they clinicians, healthcare IT professionals or a new breed of academic? Why are there no fields called Finance Informatics or Supermarket Informatics..?

Wikipedia's entry did little to help me, giving the following as aspects of the field:

  • Architectures for electronic medical records and other health information systems used for billing, scheduling or research

  • decision support systems in healthcare

  • messaging standards for the exchange of information between health care information systems (e.g., through the use of the HL7 data exchange standard) - these specifically define the means to exchange data, not the content controlled medical vocabularies such as the Standardized Nomenclature of Medicine, Clinical Terms (SNOMED-CT), Logical Observation Identifiers Names and Codes (LOINC) or OpenGALEN Common Reference Model - used to allow a standard, accurate exchange of data content between systems and providers

  • use of hand-held or portable devices to assist providers with data entry/retrieval or medical decision-making

If this is a correct description (and it may not be, given the democratic nature of Wikipedia) it seems to sit firmly on the IT professional end of my conceptual tightrope.

Having read the Wikipedia description and having looked at a HI text book it seems to me that this field misses best half of our affair: the integration of IT into, and the transformation of, medical practice. To succeed it is essential that IT becomes fully integrated into care. Is Health Informatics the best way to bring that about?

Only joking about the grumpiness. In fact, it is a lovely day here in London and I enjoyed my run!

I wish you all a happy and successful 2006.

Health Informatics: a rant to begin the new year

I was woken by the sound of a text message arriving on my mobile phone. Ahh, I thought, a message from my old university chum who lives in Mauritius. Or, maybe my Mother has learned to text and is about to impress me with a New Year's greeting.

No such luck. A message from my accountant telling me that my VAT (UK sales tax) return is due. Brought down to earth with a bleep and a buzz. As Bono sings: “Nothing changes on New Year's day”.

Suitably grumpy, I thought I would write about this field of Health Informatics that has been on my mind.

I took a partial sabbatical from health to work in other areas of the UK public sector, thinking to expand my experience and skills. During my time away from full-time engagement in healthcare IT, Health Informatics in the UK seems to have grown from an egg into an assertive fledgling.

I looked up a definition of it on Wikipedia:

“Health Informatics or sometimes Medical Informatics is the intersection of information science, medicine and health care. It deals with the resources, devices and methods required to optimize the acquisition, storage, retrieval and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems.”

Now, having worked for about 15 years in healthcare IT and led three major Electronic Patient Record Implementations I became used to walking the tightrope between the views of clinicians and NHS IT professionals. In general, over the years these two poles have learned to co-exist.

Into that polarization—for me uneasily—come the Health Informaticians. Are they clinicians, healthcare IT professionals or a new breed of academic? Why are there no fields called Finance Informatics or Supermarket Informatics..?

Wikipedia's entry did little to help me, giving the following as aspects of the field:

  • architectures for electronic medical records and other health information systems used for billing, scheduling or research

  • decision support systems in healthcare

  • messaging standards for the exchange of information between health care information systems (e.g., through the use of the HL7 data exchange standard) - these specifically define the means to exchange data, not the content

  • controlled medical vocabularies such as the Standardized Nomenclature of Medicine, Clinical Terms (SNOMED-CT), Logical Observation Identifiers Names and Codes (LOINC) or OpenGALEN Common Reference Model - used to allow a standard, accurate exchange of data content between systems and providers

  • use of hand-held or portable devices to assist providers with data entry/retrieval or medical decision-making.

If this is a correct description (it is subject to the democratic nature of Wikipedia) it sits firmly on the IT professional stretch of my conceptual tightrope.

Having read the Wikipedia description and having looked at a HI text book it seems to me that this field misses “best half of our affair”: the integration of IT into, and the transformation of, medical practice.

To succeed, it is essential that healthcare IT become fully integrated into care. Is “Health Informatics” the best way to bring that about?

Only joking about the grumpiness. In fact, it is a lovely day here in London and I enjoyed my run!

I wish you all a happy and successful 2006.

December 26, 2005

Healthcare and the Internet: Dr. Google

In November 2005, Google and--within a year of its release--Google Scholar are the top referers to the British Medical Journal (BMJ). If this is a general trend I have an idea why it may be so.

My wife is studying Physiotherapy and attempts to use the user-hostile Athens to find relevant material in databases such as Medline and Cinahl to read and cite.

Her fellow students express disdain when she tells them she prefers Google to find her sources. Enduring the pain of academic search engines is, it seems, essential in the quest for the same knowledge. Or is this learned academic snobbery?

Dean Giustini, the author of the BMJ article, thinks that Google ought to create a medical portal. Fortunately, the National Electronic Library for Health (NeLH) already provides an excellent interface to a number of databases for clinicians and laypersons and my wife and I recommend it, together with Google as a general source.

The power of the internet in the hands of laypersons was amply demonstrated in 2004 when a 15-year old boy used the internet to track down his genetic father using a sample of his own DNA and on-line facilities.

Medical knowledge is no longer the domain of the few.

December 23, 2005

Internet has further to go in healthcare

The NHS Direct website is a popular resource in the UK. While in the US recent research indicates that patients trust their doctors but frequently use the Internet.

As access in the UK increases, more laymen will use the Internet to inform themselves about their condition, drugs, treatments. That shift in knowledge will fundamentally alter the relationship between clinician and patient.

But there is more to come. On-line consultations and routine monitoring will become normal, reducing the need for sick patients to wait and share infections in the GP's waiting room. It will also ease the GP's workload, making home visits less necessary.

Recent research indicates that about half of people in the UK have Internet access. Increased access may have a more profound effect on care than the whole of Connecting for Health's National Programme for IT (NPfIT).

I wish you a peaceful Christmas time and a successful New Year!

December 21, 2005

Health IT: making care better or worse? (cont)

I notice that the E-Health-Insider website also picked up on the increased mortality reported in Pediatrics after the implementation of a drug management system (see FHIT entry). This led to an interesting exchange of views the most important points coming out of it so far are:

  • IT systems do not automatically result in a net benefit. They may make care worse—at least for a while;

  • IT systems can distract carers from patient care; and

  • IT systems can improve patient safety—studies report that e-prescribing reduces errors, for example.

No-one knows how many people die as a result of medical accidents in the UK NHS—estimates vary from a few hundred to 40,000 a year (see "Patient safety: safer on a plane than in hospital").

I believe healthcare IT will improve patient safety, but its paradoxical nature needs careful management.

See "Increased Mortality Rate After Drug Entry System Installed" on the E-Health-Insider site.

December 17, 2005

Healthcare IT: making care better or worse?

Reposted. Original post on 10 December 2005.

Of course, computerised systems, by improving patient safety, improve outcomes. No doubt about that is there? Supporters of the National Programme for IT (NPfIT) assure us that is the case.

So we wouldn’t expect to find a drugs order entry system—one of the mainstays of the Care Records Service (CRS)—associated with increased mortality rates. But a study in the American publication “Pediatrics” found just that.

“Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System” describes a retrospective analysis of mortality in the Children's Hospital of Pittsburg for 13 months before implementation and for 5 months after it. Mortality rates increased significantly after implementation.

The study concludes this is an unexpected finding—it may have been due to delays in treatment. The study recommends that mortality rates are monitored post go-live.

Improvements do not arise by simply switching on IT systems. Inexperienced users and the rigour forced by computerised-systems may slow processes initially. Therefore, it is essential that IT-system benefits are rigourously identified, monitored and realised--many pay lip service to this, few practice it.

More discussion on this topic on the HISTalk Blog here.

December 14, 2005

NHS and Government IT Transformations Compared

I compared the NHS Chief Executive's Report (PDF) with Transformational Government (PDF) released a month earlier in November 2005.

In its vision, Transformational Government states: "Technology alone does not transform government, but government cannot transform to meet modern citizen's expectations without it." Amen to that.

Transformational Government's strategy has three prongs:

  • Services designed around the citizen or business;

  • A move to a shared services culture;
  • and
  • A broadening and deepening of the government's professionalism in planning, delivery, management, skills and governance of IT-enabled change.

Services based on customers or patients is a common theme in both documents.

Transforming government recognises the importance of the Internet and mobile phones in communications. These do not have quite the prominence in the NHS document.

Now, it may be that the NHS already feels it has already achieved a lot with NHS Direct and associated website. That is a good start, I say, but there is much more that can be achieved in transforming care with these two technologies.

Transformational Government specifically addresses the possible creation of shared HR and Finance services. Will NHS overspending lead to similar initiatives in the NHS?

On page 19 the NHS report emphasises the need for innovation and new ideas and services, However, it relies on a description of progress on NPfIT for its IT-enabled change—though, as usual, the question: "Change to what?" remains unanswered.

Nonetheless, there are some interesting snippets in the NHS report. Page 4 refers to a neurology outpatients clinic that is held in a GP’s practice near patients' homes. On page 5 a description of changes to traditional roles: emergency care practitioners and a bigger part in prescribing for pharmacists and nurses. Decentralisation and a move away from highly skilled specialists: a taste of things to come?