Delivering Medical Care over the 'Net?

The network is about to become pervasive. Over half of General Motors' cars next year will have their own IP address. Meanwhile, the NHS struggles to connect itself to exchange emails. Nevertheless, the tide of history and technology is sweeping us all along, and medical care will involve the internetworks that connect clinicians to their patients, as well as the putative intranets that will allow the business to keep the secrets an administration of the old economy assumes work cannot be done without.

How can network access contribute to medical care? A ridiculous idea to many of my colleagues. Medicine or nursing can only proceed in direct physical contact or at least sitting next to the patient.

Yes. And someday every town in America will have a telephone [1] , but it will never have a place in medicine [1a] , there is a world market for as many as 5 of these devices [2] .

Eliza and her friends

People are more honest with computers than with people. If this is not one of the key reasons for introducing computerisation into the administration of the NHS in preference to the plethora of meetings-in-person held around its running then it is at least a reminder of the usefulness, not to mention the placebo power, of interactive programs in mental health. Beyond such programs http://www.ex.ac.uk/cimh/ offers some useful examples of the interaction of therapist and patient mediated by the common technology of the 'Net.

Gadgets and Counters

Much of chronic disease management is thoroughness, detail, information handling. In all these the naked physician can be and is being augmented by devices, leaving more time for the exercise of human virtues.

Diabetics can have their blood glucose monitoring uploaded to GP or hospital computer - although locally the two will not talk to each other yet, and the only monitor in the hospital is several minutes walk away from the working space of the nurse whose time with the patient is so precious and in such short supply.

Blood pressure measurements, ECG monitoring and even pill and puffer-taking can be handled in similar fashion, and as always, the involvement of technology improves the regularity of activity.

The New Economy

While much of the stock market's interest in dot.coms threatens to bubble, there is no doubt that we will have the capacity to deliver whatever information-based services exist to anyone in the developed world, wherever and whenever and by whichever of a variety of means they choose. The convergence of companies such as Linus Torvald's Transmeta, of brain drain from the old media, and the expansion of the mobile phone industry means that whether it is squeezed through WAP or the rather larger screen of a PDA with added voice networking, the service will be possible. I can already give my bank instructions at a time of my choice, not when their branch is open, what excuse could I offer to a patient who asks why this is not true of the NHS for administrative purposes. I can answer them if they ask why they cannot see me at all hours, because the continuity of care I offer is a value added service worth more than the convenience of any particular opening hours. The time available to add value by personal contact is too precious for it to be wasted on routine administratrivia so an expansion of asynchronous work between practices and patients is to the benefit of both.
repeats@homefieldsurgery.nhs.uk is a start.

Alligators and Turkeys

Whether we see the NHS as being too busy to change to working more efficiently, or having lost sight of its mission of draining the swamp due to being waist high in alligators, or more cynically look to a horde of apparatchicks shuffling paper toward meetings and as unlikely to choose a new way of working as turkeys are to vote for Christmas, it is clear that it is time to change. The realisation that the NHS compares poorly in many areas to countries we expect to be ahead of is creeping in, the largest difference between the first world and the third world is now in knowledge work, and our citizens deserve better than they are getting in the implementation of what is known to work.

The Dread word - Wessex

The management culture of the NHS has set itself up to be almost unable to make IT work. From senior administrators with the twin worries that if they display competence or interest in IT they will be sidelined by those of their peers who can discuss Mozart and Brahms, but do not know a mouse from a rodent, and that if they are made responsible for an IT project that it may turn out like Wessex did, to juniors who can expect to spend half their term in a particular job before the office is equipped, there is little chance of a manager innovating.

General Practice is hamstrung by defficiencies of funding and over-regulation, innovations there are painfully hard to make.
The private sector then will seize the baton.

Performance

Imagine a world where a patient need only lift their hand to see what the ideal management of their condition is, and need merely click to go from that page to a solicitor or other advocate, for a small fee appearing later on their network bill.

I think it would be better if the clinicians concerned already knew what the ideal management was, and could pass the responsibility for any divergence from it to those responsible - the administration, the political leadership, and the citizens themselves.

But to do so demands a reversal of the IT fortune of the NHS, and not soon, but now.

Footnotes

[1] Attributed to Alexander Graham Bell. Back

[1a] can't you just hear the AMA of the time saying it? Back

[2] Attributed to Thomas Watson of IBM - just before they sold a lot more than 5 on a basis of making their costs back on sales of 5. May have been an underestimate but IBM did OK on it. Back

Published on paper in 1999-2000 in the PCG magazine edited by Eva Dyer

In the real thing at www.homefieldsurgery.nhs.uk that produces an email to the prescription clerk.

Back
Version date ..... 2003 top of page | Tested in Opera and Netscape