Tuesday, February 13, 2007
All at Sea
Not much changes in 10 years! Here is an updated and shortened version of a paper, which was first published in the Health Service Journal on 30 Jan 1997.
Until the 18th century, everyone agreed that going to sea was dangerous and navigation was a major problem. The loss of a ship at sea was a human and economic disaster. Most people considered the failing to be one of culture, organisation and education. If only sailors drank less, were more vigilant and better trained, fewer ships would sink. Others claimed that astronomers would produce a solution by tracking the movements of the stars and planets. Indeed, astronomers had already solved the problem of finding a ship’s latitude, by measuring the angle of the sun. Few believed that the problem of navigation would be solved by combining astronomy with a new technology – clock-making. Yet this is what happened when the development of accurate chronometers allowed sailors to calculate their longitudes.
Today, we have more fear about going into a hospital than going to sea or flying. Experienced observers claim that the problems are more of organisation, culture and education than of technology. Others suggest that current technology can deliver what is required, provided implementation is done carefully and with greater commitment to data quality. Such arguments can be supported by evidence, but they do not provide the breakthrough that is so badly needed. Indeed, in the 18th century, experienced, vigilant seamen with some astronomical knowledge were less likely to be shipwrecked than those that were not.
Clinical decisions determine more than 80 per cent of the variance in the cost of non-acute hospital care for patients with similar conditions. All decisions, clinical or otherwise, are based on the information available at the time. It is the therefore remarkable that only about 5 per cent of hospital doctors use computers in their clinics. Compare this with the number of clinic clerks (95 per cent) who use computers. This phenomenon is not confined to the UK. In all countries, hospital doctors have resisted using computers.
Let’s go back to basics. Computers serve two main functions: communication and counting. Communication is a core healthcare activity. Billions of documents are produced every year in the NHS. The main reason why hospitals exist is to facilitate the exchange of communication (verbal and written) between the staff. It is useful to distinguish four levels of communication:
1 within the work-group responsible for the care of individual patients;
2 between specialised diagnostic and treatment departments to request services and to report on procedures;
3 between hospital clinicians, GPs and community staff;
4 from the care provider to purchasers and other agencies.
There are listed in decreasing order of volume of information, but paradoxically, in increasing order of investment in technology. One important reason is that computers are paid for by managers. Managers need information that can be counted – the second basic function of computers. Counting is the basis of all management, accountancy and research.
We need a system that enables both communication (messaging) and counting, but the requirements of messaging and counting cannot easily be reconciled in a single structure. You cannot use e-mail for counting, and you not use a spreadsheet for messaging. They perform different jobs.
One way to resolve the issue is to combine the approaches. In the mid 1990s, the NHS electronic patient record programme defined the electronic patient record as “a dynamic collection of messages, held electronically, created by healthcare professionals principally to inform themselves and others about the provision of health to an individual patient”. This mirrors the paper record, which consists of referral letters, assessments, test reports, nursing notes, clinic letters, discharge summaries and a wide range of other notes.
Well-formed messages (electronic or paper) have a clearly identified originator, a list of recipients and a clear context. The content is determined by the author. If there is any doubt about how to interpret a message, the receiver can contact the author requesting elaboration.
Database structures are designed by a computer professionals, who neither originate nor use the records they contain. The creator of each database record usually has little if any control over who if anyone will ever see the data, or for what purpose. The user seldom knows who entered the data. Lack of context information makes it difficult for the reader to evaluate the trustworthiness of what it contains.
Today, databases provide information for healthcare management, but databases need to be used together with communications and messaging tools, to help clinicians help patients and enable improvements in productivity, for example by performing simple safety checks automatically.
The solution to the maritime navigation problem lay in combining different tools. It took both good technology (clocks) and good science (astronomy) to solve the problem of finding longitude. Similarly we need to focus on communications as well as data base tools to help solve our healthcare problems.
Until the 18th century, everyone agreed that going to sea was dangerous and navigation was a major problem. The loss of a ship at sea was a human and economic disaster. Most people considered the failing to be one of culture, organisation and education. If only sailors drank less, were more vigilant and better trained, fewer ships would sink. Others claimed that astronomers would produce a solution by tracking the movements of the stars and planets. Indeed, astronomers had already solved the problem of finding a ship’s latitude, by measuring the angle of the sun. Few believed that the problem of navigation would be solved by combining astronomy with a new technology – clock-making. Yet this is what happened when the development of accurate chronometers allowed sailors to calculate their longitudes.
Today, we have more fear about going into a hospital than going to sea or flying. Experienced observers claim that the problems are more of organisation, culture and education than of technology. Others suggest that current technology can deliver what is required, provided implementation is done carefully and with greater commitment to data quality. Such arguments can be supported by evidence, but they do not provide the breakthrough that is so badly needed. Indeed, in the 18th century, experienced, vigilant seamen with some astronomical knowledge were less likely to be shipwrecked than those that were not.
Clinical decisions determine more than 80 per cent of the variance in the cost of non-acute hospital care for patients with similar conditions. All decisions, clinical or otherwise, are based on the information available at the time. It is the therefore remarkable that only about 5 per cent of hospital doctors use computers in their clinics. Compare this with the number of clinic clerks (95 per cent) who use computers. This phenomenon is not confined to the UK. In all countries, hospital doctors have resisted using computers.
Let’s go back to basics. Computers serve two main functions: communication and counting. Communication is a core healthcare activity. Billions of documents are produced every year in the NHS. The main reason why hospitals exist is to facilitate the exchange of communication (verbal and written) between the staff. It is useful to distinguish four levels of communication:
1 within the work-group responsible for the care of individual patients;
2 between specialised diagnostic and treatment departments to request services and to report on procedures;
3 between hospital clinicians, GPs and community staff;
4 from the care provider to purchasers and other agencies.
There are listed in decreasing order of volume of information, but paradoxically, in increasing order of investment in technology. One important reason is that computers are paid for by managers. Managers need information that can be counted – the second basic function of computers. Counting is the basis of all management, accountancy and research.
We need a system that enables both communication (messaging) and counting, but the requirements of messaging and counting cannot easily be reconciled in a single structure. You cannot use e-mail for counting, and you not use a spreadsheet for messaging. They perform different jobs.
One way to resolve the issue is to combine the approaches. In the mid 1990s, the NHS electronic patient record programme defined the electronic patient record as “a dynamic collection of messages, held electronically, created by healthcare professionals principally to inform themselves and others about the provision of health to an individual patient”. This mirrors the paper record, which consists of referral letters, assessments, test reports, nursing notes, clinic letters, discharge summaries and a wide range of other notes.
Well-formed messages (electronic or paper) have a clearly identified originator, a list of recipients and a clear context. The content is determined by the author. If there is any doubt about how to interpret a message, the receiver can contact the author requesting elaboration.
Database structures are designed by a computer professionals, who neither originate nor use the records they contain. The creator of each database record usually has little if any control over who if anyone will ever see the data, or for what purpose. The user seldom knows who entered the data. Lack of context information makes it difficult for the reader to evaluate the trustworthiness of what it contains.
Today, databases provide information for healthcare management, but databases need to be used together with communications and messaging tools, to help clinicians help patients and enable improvements in productivity, for example by performing simple safety checks automatically.
The solution to the maritime navigation problem lay in combining different tools. It took both good technology (clocks) and good science (astronomy) to solve the problem of finding longitude. Similarly we need to focus on communications as well as data base tools to help solve our healthcare problems.
Labels: Computer Projects, e-Health, Healthcare IT
