What can you say about a man who had two lives?

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

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

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

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

Sri Chinmoy

Ben Goldacre’s Bad Science has had excellent reviews. Read some of them on Amazon. I also enjoyed it, but I found myself more interested by what it doesn’t say.

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

Dr. Goldacre is also big supporter of evidence-based medicine, which he says has saved millions of lives. He doesn’t give any evidence for that, but we can believe it to be true. In the chapter entitled Is Mainstream Medicine Evil? we find this: Doctors can be awful, and mistakes can be murderous, but the philosophy driving evidence-based medicine is not. Let’s not worry about the odd cast of this sentence and assume he means: medicine is sometimes bad, EBM philosophy isn't.

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

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

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

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

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

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

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.

From 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."

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.

Imagine 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.

George’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.

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.

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.