Three parables of IT and CRS (16 Oct 2006)

From Nhs It Info

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Clinical Records System (CRS), Some Allegorical Stories

By Dr Gordon Caldwell FRCP, a senior Consultant in the NHS with considerable clinical and IT experience

Doctors and nurses can find it hard to make other people understand what they want and need from IT systems to help them in their work. This results in confusion, and delivery of unsuitable or unusable software. I believe this has happened with the National Programme for Information Technology (NPfIT) Clinical Records System (CRS) in the programme “Connecting for Health”. I think our basic needs are simple: who are our patients, where are our patients, what problems and diagnoses do they have, what are we treating them with, some space for free text, and an ability to print the information. Anything else is a major luxury once these requirements are met. I have written three stories as allegories or parables to help to shed some light on the problems.

I like stories, so here are some brief ones to have in mind as everyone tries to address these issues.

The Armed Forces and IT

The Minister of Defence decided to computerise all the armed forces, to make them more effective in their vital roles of defending the country and maintaining democratic processes. The process started by installing new software for Human Resources, Payroll and Logistics for the forces supermarket chain, the NAAFI. This generally went well, with the usual small number of objections and hiccups. Then the Minister decided to computerise the SAS, because it was recognised to be a key force. The SAS already had an amazing record of confidentiality and secrecy, even after a member left the forces. This was based on an ethical tradition and also backed up with a very specific contract of employment. The SAS were introduced to the new computer system 6 weeks before go live. They had been too busy in Afghanistan and Iraq to attend training earlier. After 5 minutes the commanding officer said “This will not work, it does not fit with our modus operandi!” and the developers said “We go live in 6 weeks, it has cost a fortune, it has to work, you will have to find workarounds, or new ways of working.”. The officer pointed out that his team often worked in the rain, ice, and the dark. The new laptop computers were not even waterproof and he had found this out after he spilled his coffee on the keyboard. A major concern was that at night the screen would light up their position to the enemy. He said his men could not even enter a password, whilst wearing gloves and climbing a slippery hill in the dark and rain. The project went ahead, and the SAS team were sent out on a reconnaissance mission in enemy territory at night in the wet and cold. Dutifully they raised the “workaround” blackout umbrella over the laptop and opened communications. Unfortunately it was also a windy night, so the umbrella blew away. The enemy immediately fired a mortar, taking out half the team, including the soldier logged on at that moment. One of the survivors knew it was vital to get the mission data back to HQ, and without logging off the dead soldier, hit return and sent the data back. Miraculously the well trained squad completed the mission and returned to HQ. Of course the soldier who used the dead soldier’s logon was called to court martial and convicted of this disciplinary offence, and dismissed from the army. The HQ staff were proved right – front line staff always resist new ways of working, and cannot be trusted to follow even the most simple of commands. The moral of this story is that the computer system must match the working environment and practices of the skilled expert for whom it is intended.

The House of Commons and IT

The Speaker of the House decided that too much valuable time in the Commons was taken up after the division bell, in the lobbies and counting the votes. He asked for a top notch IT company to come in to computerise the voting. He worked out that on average there were 150 members in the chamber at any one time, so that 200 laptops would suffice. The IT Company suggested that speeches and question time were unruly and devised a system in which anyone who wanted to interrupt a speech to raise a point or ask a question had to logon to his laptop and join a queue visible on the Speaker’s laptop. The Speaker could then logon, ask the Member who held the floor to logoff, the Speaker then had to logoff and allow the next Member to logon, using his ID and eight character password (so many forgot this, it was embarrassing) and ask his question. That Member then had to logoff, to allow the Speaker to logon to ask the first Member to logon to answer the question and so forth. The system was a limited success. Uninteresting debates lasted only a few minutes, because no one could be bothered to interrupt, and there was no problem with access to the laptops for voting. In major debates the MPs became increasingly frustrated and wrote letters to the papers on their laptops, rather than the usual animated and amusing repartee of the House of Commons. Sadly the improvement in voting time was not realised in popular debates because of the shortage of PCs in relation to Members and the logon and logoff process was too slow. Some saw this as an advantage that the House of Commons could no longer carry on its business, whereas others worried where the Members might now wreak havoc. The moral of this story is that computer systems must make processes more efficient and not interrupt the business of an organisation.

The Prime Minister and His Resignation

This is a more fanciful story. At the Party Conference the Prime Minister decided that he would announce his resignation to the country the next morning at 08:10 on “Today” on Radio 4. He felt it a duty of honour to inform his party faithful in person by letter that night before the announcement. He had absolute faith in those at the conference that they would not leak the story to the press. He wanted to write to each attendee personally, so he quickly drafted a letter, which his secretary printed using a mailmerge. He signed every letter personally and went peacefully to bed at 10 p.m., asking finally that each letter be put under the door of each delegate by midnight. His secretary then realised that she did not have a list of the delegates by hotel and contacted the accommodation officer. Fortunately he had a list of hotels and delegates by room number. The mailmerge had been printed off alphabetically. It took hours to match the letters to the correct hotel, and then the letters were organised by hotel and alphabetically. Sadly the assisting team had not put the room numbers onto each letter as they sorted them into hotels. They set about reordering the letters by room number. Finally they were bundled up and sent out for delivery just as the Prime Minister’s words could be heard on Radio 4. The whole party was caught unawares and embarrassed in front of the nation. The party lost the next election. The moral of this story is that vital data must be available to be ordered and used to the user’s requirements.

Problems not at all dissimilar to these riddle the CRS system that I have seen for our Cluster.

Useful IT systems can only be developed by systems analysts who are interested in people and the work that they do, are curious about current processes and can develop solutions that make the user say “Wow, that is good, when can I have it!”. The PACS for X ray viewing is a winner like that, the CRS is a disaster like the three scenarios above – but worse!

A really useful really simple IT system to improve patient care

What would be really good and useful and simple? One NHS Intranet page for every NHS number holder containing each person’s demographic data (name, address, GP, next of kin), his diagnoses and health related problems, his medications ordered alphabetically and some free text, in an open architecture system, i.e. the data could be merged into clinic letters, discharge summaries, referral letters, letters to take on overseas travel. A clever IT programmer could devise this within a week, and could transform patient care and safety, because medical language is one of the most economical and effective languages in the world – huge meaning can be transmitted in a very few well chosen words. Computers can deal with tiny amounts of data very effectively. These tiny amounts of data about each person are of major meaning to a doctor or nurse, and can support clinical judgement and decision making.

[Name and address supplied]

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