Future Health IT

Medicine as an Information Science

2012-01-07T10:53:29Z

I remember vividly reading about DNA and its mechanisms in James Watson's Double Helix. The unzipping of the two reversed strands interlocked by the strict pairing of nucleotides--adenine to thymine and guanine to cytosine. The complex and choreographed interactions with other molecules leading to the construction of proteins. The systematic beauty at the nucleus of life. It was all engaging enough for me to decide to study Biochemistry at university.

When I finished my degree I worked in international marketing and travelled the world. I was always proud (and grateful!) that English is the most widely spoken language with about 80 percent of the world being able to speak it. But it is not the real lingua franca any more. The most popular language comprises 0s and 1s--the binary language of computers. GB Shaw said America and England were 'separated by the same language,' but the binary language unites the world.

What's more, the two binary languages of DNA nucleotide pairing and computer coding are set dominate the coming decades in a combination of genomics and computer science. David Baltimore said that Biology is today an information science. Indeed, Bioinformatics combines life and computer science so that they are as interlocked as the strands of DNA.

We will see if genomics lives up to its promise, of course. As another scientist, Neils Bohr, said: 'Prediction is difficult, especially about the future.' Even the exquisite DNA translation process sometimes gets it wrong and proteins end up with the wrong amino acids, impairing their function. Indeed the majority of DNA itself is regarded as 'junk', because it seems to have no function. All of this all sounds a bit like computer code and its creation, another systematic human process.

I have been fascinated by interface between man and machine for more than 30 years. Now it seems more alluring than ever.

Sign of the Times

2011-12-28T16:21:45Z

Last week BBC's Click programme showed (6m 38s) a one year old iPad user confused by a print magazine where she couldn't 'flick' the pages: a sign of the times.

]]> Print media have been in decline for some time, long enough to worry the staff at my local Waterstones bookshop who don't know what to make of it all. They are physical book devotees. Even when I tell them how easily it is to annotate and manage the annotations on the Kindle application and how I can even do that on my iPhone, they are unimpressed.

Looking around the carriage on the London Underground as I type this, people are prodding and flicking at their mobile phones. A couple of middle aged travellers flick copies of the Times or Guardian on their tablet PCs. Others stare bored at the reflections in the windows. A sign of the times.

About two thirds of all mobile phones now purchased in the UK are smartphones. And I guess, like me, people rapidly become addicted to them and they become a vade mecum--an essential companion.

We are all riding the wireless wave that is transforming the way we live our lives and making the online world as real and immediate as the real world. Judging by my travelling companions, the online world is sometimes to be preferred: a sign of the times.

Drug Administration and IT Reconciled

2011-11-02T07:19:08Z

A 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.

]]> The findings fly in the face of common sense, of course. Thankfully, a recent study at University Hospitals Birmingham showed that the implementation of a similar system reduced mortality rates among emergency patients by 17 percent, suggesting 16 000 deaths a year could be prevented if a similar system was implemented across England.

The Birmingham study has a crucial difference, because it concentrates on the whole system. Before implementation 1 in 5 drug administrations were missed. Simple functionality addressed this systemic problem in a potent combination of IT and human process change. An important lesson for us all.

Some clinicians disparage such approaches and complain about 'tick box medicine'. But I find tick boxes rather useful for automating routine tasks--which I am not very good at. This frees my mind to address less routine matters and to be more creative. I am not the only one to think so: read Atul Gawande's Checklist Manifesto. However, I am not suggesting they make human intervention redundant.

Changed practice with the support of IT is the way of 21C healthcare, and if that means clinicians ticking boxes to relieve them of routine, free their creativity and reduce errors, so be it.

What's After the NHS IT Programme?

2011-10-16T16:39:14Z

Colin Jervis, Kinetic Consulting http://www.kineticconsulting.co.uk

]]> My second patient record procurement gained the attention of those setting up what would become the NHS National Programme for IT. I remember suggesting there were essentially three options for a national health IT system: replace everything with one system, seek to integrate exisiting or disparate systems, or something in between. I said the integration option was the one most likely to be successful.

Of course, I speak with the advantage of 20:20 hindsight, but maybe we are about to find out if I was right. In a recent interview Katie Davis, managing director of NHS informatics, says the new watchword will be connect all rather than replace all.

The NHS IT Programme squeezed out many of the smaller, and more innovative, suppliers from the health IT market, something Katie Davis accepts. Thankfully, some determined suppliers have managed to hold on and are now ready to re-enter the market applying their long experience of the NHS. Also, though my cartoon pokes fun at them, IT departments have been itching to deliver local solutions that add real value for 9 long years.

The energy of NHS IT staff and suppliers and the need for more efficient services may be enough to carry us through this very difficult phase in the evolution of healthcare IT. Let's hope so.

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Do Doctors Dream of Electronic Records?

2011-10-11T08:55:52Z

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

]]> When I first came to healthcare fresh from completing my MBA, my head was full of ideas of quality management. In leading my first electronic patient record programme in a London teaching hospital, I found doctors warmish at the prospect of having transactional information, like diagnostic test results and visit information, but distinctly cool at the prospect of recording outcome information.

Evidence-based healthcare should encourage the analysis of the relationship between process and outcome, but much clinical practice still seems to have no evidence base. Could this be the reason for slow uptake of electronic records?

In an insightful article in Information Week one chief medical officer supports this view, pointing out that most doctors still prefer medicine as an art rather than a science. That being the case, electronic records would represent a cultural mismatch.

In the UK all GPs now use computers to automate their practice and information from them them is used to manage the Quality and Outcomes Framework (QoF). For me QoF has some way to go before it manages quality rather than process. Nonetheless, GPs regard themselves as being at the forefront of medical computing.

GP systems have automated GP practice and eliminated some routine tasks, but this is hardly a revolution in care delivery. My former GP was one of the last to computerise his practice and the main benefit for me was that I was handed a typewritten prescription--though I did have to go back among the sick in the waiting room to an erratic printer to collect it. It is difficult to identify the direct patient benefits of GP automation. Given it began in the 1990s, this is very disappointing.

It is unfair for doctors to shoulder all of the blame for the slow uptake of IT, but they must shoulder some of it.

Robots in Healthcare

2011-09-29T18:49:00Z

'Bots are back. It's a while since I wrote about them--for example, see here for a collection of musings--and in the interim they seem to be moving into the mainstream.

]]> BBC Radio 4 has a series: Robots that Care. The first episode poses an interesting question: if robots are to live with us, are they pets, slaves or companions? It includes interviews with Rodney Brookes a robot luminary.

With aging populations in many countries, particularly in Japan, robots are seen as a means of filling the care gap. Panasonic is set to introduce three new robots at the 38th Home Care and Rehabilitation Exhibition: a communication robot, a hair washing robot and a robotic bed.

Gamers Solve Medical Problem

2011-09-28T09:00:08Z

Never say your kids are wasting their time with online gaming again. On the Foldit site gamers resolved the structure of a protein that had foxed scientists for 15 years in only three weeks.

]]> M-PMV retroviral protease causes AIDS in rhesus monkeys. After the failure of attempts to find the crystal structure of it by other techniques, Foldit challenged players to produce accurate models of the protein. They did, and the structure was confirmed by x-ray crystallography. A paper has been published in Nature Structural and Molecular Biology with the gamers as co-authors.

These types of enzyme help the AIDS virus to develop and proliferate and intensive research is seeking to find a way of blocking them. But this was hampered by ignorance of the molecule's structure.

Foldit encourages gamers to collaborate and compete in suggesting the structure of protein molecules. Tools, and some assistance from a computer program called Rosetta, encourage participants to shufffle graphics into protein models.

Who said online games are all fun and no work?

Online Antics

2011-09-22T14:17:59Z

Clinicians are still struggling with relating information technology to their jobs. No, I am not referring to the dilatory uptake of electronic patient records, but to social media.

The Daily Telegraph reported the social networking antics of doctors who made references to 'birthing sheds' (maternity units) and "cabbage patches" (intensive care, from CABG). The former was regarded as worse by a consultant because it entailed having to work with 'madwives'. On being questioned online about their opinions, the doctors resorted to some unconvincing post hoc rationalisation.

]]> Now doctors are not the first to have posted unwisely on social networks. Politicians and policemen have also been caught out. Still, you wonder how many employees of other organisations could get away with being so disparaging of their customers and colleagues.

This coincides with the removal of the combinations to locks posted on patient records on the national Patient Demographic System (PDS).

Do we see the mistakes of an industry taking its first awkward steps into the information age?

Punk Rock People Management

2011-09-20T17:25:48Z

I have just received an advance copy of an unusual book on managing people by the business author and speaker called Peter Cook. He is the author of ‘Best Practice Creativity’ and ‘Sex, Leadership and Rock’n’Roll’, acclaimed by Professor Charles Handy and Tom Peters. Peter mixes up business academia with music in a heady cocktail that reaches the parts that other business gurus do not dare to touch.

]]> Peter has just released his latest 'album'. The curiously titled Punk Rock People Management takes a critical look at Human Relations and offers some short and straightforward advice on hiring, inspiring and firing staff.

In the spirit of punk, Peter has made each chapter just two pages long – ideal for busy people and those who now browse books online. On hearing of the idea that you could read a chapter in less time than it would take to pogo to a Ramones or Linkin Park song – international author and speaker Tom Peters tweeted just four characters to Peter – “DO IT”. That’s economy!

Peter offers keynote seminars and more traditional business consultancy without guitars, based on his ideas – you can find out more at The Academy of Rock. He also invites you to connect with him on LinkedIn.

A full colour printed book and a Kindle version are available.

Informed Patient: how do you know?

2011-09-20T16:37:17Z

A couple of years ago I suffered many sleepless nights owing to some excruciating pain in my stomach area. After about three months of misdiagnosis, I was referred for an ultrasound scan that showed damage to my gall bladder. The consultant packed me off with some OTC remdies and told me that the offending organ would have to be removed if the symptoms persisted. Another sleepless night gave me time do some Internet research and as a consequence I asked my GP for some antibiotics as a last resort. Within a week of taking them the pain was gone.

]]> Nowadays, people have a marvellous knowledge base of information on the Web and they should use to it to challenge experts, including medical practitioners. The Sense About Science organisation seems to agree and has launched an ask for evidence campaign.

I strongly believe that the best person to look after your health is you. Moreover, by being an informed customer you will also play a part in changing healthcare delivery to meet the needs of the 21st Century. So, as Sense About Science recommends, always be ready to ask the experts: 'How do you know?'

EPR Models: checklists or constraints?

2011-09-13T11:56:00Z

I was reminded of the good old six level Electronic Patient Record (EPR) model that originally appeared in Information for Health back in 1999 through a posting on the E-Health Insider group on LinkedIn. For those of you who haven't seen it or have maybe forgotten it, here it is...

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Level 6 Advanced multi-media and telematics Level 5 plus: telemedicine, other multi-media applications (e.g. picture archiving and communications systems)

Level 5 Speciality specific support Level 4 plus: special clinical modules, document imaging

Level 4 Clinical knowledge and decision support Level 3 plus: interactive care pathway support, electronic access to knowledge bases, embedded guidelines, rules, electronic alerts, expert system support

Level 3 Clinical activity support Level 2 plus: electronic clinical ordering, results reporting, prescribing, passive multi professional care pathways

Level 2 Integrated clinical diagnosis and treatment support Level 1 plus: integrated master patient index, departmental systems

Level 1 Clinical administrative data Patient administration and independent departmental systems

Unfortunately, it never really influenced NHS thinking outside of the IT department. Most Chief Executives hadn't heard of it and---dare I say--neither had some IT directors. To some extent this ignorance paved the way for the NHS National Programme for IT. Now the HIMMS EMR adoption model gains in popularity.

But I am not sure that these models are any good at all, other than as a communication tool. At a time when healthcare should be looking sideways to its partners and forwards to its customers, these models encourage introspection. Good IT Directors will implement a strategic plan appropriate to their organisation's starting point and to look outwards. At best these models are useful ticklists, at worst misleading anachronisms.

Is That it Then?

2011-09-05T11:51:30Z

The NHS National Programme for IT (NPfIT) seems to have come to an anomalous end. No-one seems to be clear about what is happening to it. The most likely scenario is that the contracts for the local service providers will be allowed to run their term, because it will be too costly for the NHS to exit. This will leave large sums of money tied up--money that could be invested by NHS organisations to procure information systems to help them to realise the £20bn of economies expected of them. But that isn't the worst outcome.

Worse is that a new generation of ICT manager and Directors have spent the last 9 years in meetings watching Gantt charts slide to the right as NPfIT deliverables were continually rescheduled. Existing ICT systems became obsolete; strategic and procurement skills grew weaker, because the world's biggest IT programme would take care of everything.

The NHS will now have to learn all of the old skills again from those left who still remember.

HC2010 Conference: sitting uneasily?

2010-05-01T12:22:07Z

Doubling the quality of thinking on the podium of the opening plenary session of HC 2010, veteran Professor Heinz Wolff arrived late and stole the show.

After listening to the platitudes and threadbare academic definitions of the three previous speakers, octagenarian Professor Wolff hobbled across the stage on crutches, followed at a respectful distance by a cushion for his rear carried by the session chair, and applied his razor sharp mind.

The UK's aging population would ensure healthcare became unaffordable, so it would be split into acute and community care, he suggested. Acute care, treating and operating on disease, would be the job of the NHS. Community care, watching out for your neighbours and helping to care for them, the job of the local community. To fund your own community care, you would acquire credits throughout your life by good deeds and community service. Agree or not, at least it was insightful and stimulating.

Which is more than can be said of Dr. Ben Goldacre's after dinner speech that evening. Delivered at the rate of the 36 barrel Metal Storm gun, his speech was too clever, too factual and too long. After 15 minutes I watched Blackberry ® smartphones (yes, I did look up the plural) being unsheathed and eyelids drooping.

But any who did drop off were galvanised to wakefulness by the first chord of Helter Skelter's set, so potent it immediately drove guests at the tables nearest the stage to the exit with the rest of us soon following. 'Was the enterainment no good?' asked one of the cloakroom staff as I left for my hotel 40 minutes later. 'About 200 people left all at once.' The band was very tight, I assured him, but their music inappropriate and too loud.

Though it has been relocated, recovered with go faster stripes and refitted with stereo headphones, the comfortable old chair that was the HC conference stands unsteadily.

iPad: genius?

2010-01-28T18:00:00Z

BBC Breakfast hosted by Sian and Bill (my favourites) showed us the scruffily dressed but extremely rich and successful Steve Jobs launching Apple's iPad apparently the next monster to follow in the slipstream of iPod and iPhone.

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

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

iPhone not the One

2010-01-17T07:58:52Z

Use IT now to help the people of Haiti.

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

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

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

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

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

JRR Tolkien, Lord of the Rings.