Adapting EMR Processors to the PCG
Genericising Knowledge Service API

In the near future clinicians will use systems already on the market to read and write medical records.
The idea of the PCG implies a need to provide identical material to every clinician, and for this to work it must be presentable at the time it is relevant.[1]

For instance feedback relating to the number of lumbar spine X rays ordered by a particular Practice or GP, with the implicit aim of influencing this[2], would best be presented as a selection bar hovers over the symptom code for back pain, the node for investigation in the script for handling back pain as this is reached should it be in use, the Xray ordering menu choice for spinal Xrays and so on.

The method of choice for constructing such advice documents is to write them as either plain text, or lightly marked up HTML, the latter has an advantage in that graphs and diagrams may be of some value[3] and deliver them through a generic web browser window alongside the EMR.

The advantage of genericising it thus is that a PCG or indeed a national health service in which exist several different clinical systems could nevertheless produce consensus documents in a single format, moreover one which is internationally standard. Disadvantages appear to be confined to the commercial interests of suppliers[5], and the need for sufficiently sophisticated displays[6] on clinicians' desks.

The API Required

Hardly so complicated as an API, in fact what is needed is the capacity for a clinician, a practice, or a PCG to place a URL in a table with a hook into the EMR, so that for instance when the EMR processor is about to display an investigation dialog for back pain, if a URL is entered opposite that, up comes the relevant page. From there the HTML can include links to anywhere appropriate, remaining in the Knowledge Service browser.

The size of screen is significant at this point, as the screen area used by a dumb terminal or a 14" VGA display is reckoned to be the minimum acceptable for displaying the EMR, and many users still panic if one full screen application supplants another. On a 17" CRT there is plenty of room for overlapped windows.

Moving on to a display of the EMR in one browser window, from an interface to the existing EMR engine and database seems an uncontroversial development but not one for which there is a great rush.

Cascade

Using HTML it is quite straightforward[7], to supply sets of pages from one or more central location, which can be supplantd by a locally edited version which either augments them or indeed contradicts them. Attempting to remove the possibility of such contradiction is unwise as the central guidance would instantly lose any respect, but it would be prudent of each practice and PCG to apply editorial rules that include a linkage to the centrally held version by which a user can drill down to get at the first opinion.

It would also be prudent of a central body, the NHSIA or the national electronic health library, to seek out variant documents and appraise them, leading in some cases to an editing of their own version and a convergence toward a wider consensus. Modemocracy crossfertilising with a universal data corpus.

[1] One cannot oblige people to read anything, but it would be foolish not to provide it in an easily readable form at the time when it is most likely to be useful if read. Paper guidelines are of little value or effect.

[2] In theory toward the correct number, in practice toward fewer.

[3] For instance a frequency histogram of the number of lumbar spine xrays ordered in a given quarter per principal - the information fed back to N&E Devon GPs, with a pointer to show where in this the particular practice or GP falls.

[4] This has been applied in the Wirral hospitals, but so far only to clinicians in the hospital.

[5] And in fact several of the suppliers are content to work at perfecting their EMRs, and collaborate with suppliers of Knowledge Services, and this is probably in their interests as well as their customers' and the State's.

[6] Although a WinTerminal or other new device could be used, effectively this means a 15"-17" CRT screen or equivalent, with a PC running on a LAN. This is basically the standard device nowadays in most professions.

[7] Admittedly the magnitude of the task could become a problem to manage, but the management of it can also be done in a distributed fashion, if the managers can open their minds to the possibilities of the technology.