Connecting Primary Care

Adrian Midgley April 1998 (further details Adrian Midgley)

The purpose of this exercise is to save money, lives, and time.

Let us define at least part of the task as providing each clinician or manager in primary care with access to a knowledge server - a knowledge service.
Given the large number of different sources of information we would reasonably hope to integrate them into a single interface - by all means with some variation according to taste and need, but basically a single set of rules to learn to operate it.
This should eventually apply to patient records as well as other information.

Initial steps

What we discussed was setting up an educational what's on register, on a system with the capacity to handle sharing a lot more information and providing guided access to the general resources of the internet.

The same system should either initially or in due course carry audit information and form a part, perhaps the major part, of the communication layer of the PCG organisations.

The administrative aspects of it are not to be minimised, and likely to need more effort than the technical ones.

The requirement is for a web site, hosted on a computer which need not but could be in the University, or at SWIS.

The site should be backed by a database set up for the purpose.

The database is intended to return web pages giving all events known, or a subset by location, date range, content or intended audience at least. (The example template provided has 19 fields).

It was regarded as desirable that some form of feedback could be mediated through the database.

Organisers of courses or meetings are intended to first access the database to find a blank time, and then claim this time for themselves by making an entry on an onscreen form. The University must have the ability to remove entries, and entries which have not been validated or approved by the university should indicate this, for instance by being displayed in a less emphatic colour. It would be welcomed if the application for PGEA (or its successor) recognition for the course could be generated on-line, on a web form, and submitted electronically for validation. This could be in the form of an e-mail, or in a more organised database which could then maintain part or all of the records required to determine the status of Principals with regard to the PGEA. This in principle could relieve us of the problem of issuing PGEA certificates, distributing them and then counting them in various places, in favour of telling practices they need to check on the web page. Access should not be too large a problem but practices which do not have web access should have some fall-back means of knowing their status.

Sharing

The site should function as a server for any other organisations wishing to include information on forthcoming educational events in their information system - by providing a page in response to a search string presented as a URL, or by offering pages which can be framed or whatever.

Likewise the site should be able to incorporate a reference to a static or dynamic page which another organisation may maintain.

Maintenance

All those with a need should be able to add material from a variety of locations. One member of the PGMS would be tasked to maintain the material, and this would arrive by web forms, by e- mails and by paper forms and telephone calls. It must be possible to add items simply and easily and ideally the system would become the reference database for this information used within the PGMS and PGMC as well as outside. (Indeed if it did ot, it might be thought to have failed) The addition of material must happen essentially in real time - a 10 minute delay is quite acceptable.

The assumption was that a Weblike approach over the internet would be appropriate. At least a few minutes thought should be devoted to Web compatible groupware solutions such as Lotus Notes, and to dialup synchronised database systems such as Healix, but I think we can assume that internet access rather than dial- up access is appropriate, and that the timescale required means that NHS Net is not presently the ISP of choice.

Some elements of security must therefore be considered.

The essential nature of the Web is that not all resources need be on a single computer, but that it is easy for people to become lost. An idea I had a while ago was to maintain a hub or central register of pages making up a Devon Health Constellation, with people managing particular resources registering their sites and pages with a central database which would then generate pages linking to them, on demand. It may be that this can be included.

A model of the world

The administration of medicine, of the NHS and of the local area are successively more complex. It is unlikely that any one person in fact has a complete or correct list of all those committees, their members, and the officers and offices of the organisations concerned. Added to this the difficulty of finding out where somebody is and getting a message to them occupies a huge amount of time. Holding a list of people and organisations on a database which is used by all these organisations as their means of publishing their members and functions is an ideal which may be too hard to achieve, but even within the health service it is likely to be useful.

This could replace many of the expensive directories which are slightly out of date when published, and then lost in practices, and the tatty notebooks which practices actually keep details in.

FAQ

How can you make sure that when somebody switches on their machine they see this page?

First answer is they need to want to, therefore it must do something for them, and what we propose to do for them is save them money.

Technical

Windows 3.1, 95 and NT as well as OS/2 allow a startup group to be set, so that all the programs or documents in that group open automatically on starting the machine.
Browsers allow home pages to be set, IE the browser shows that page when it starts.
Netscape and Internet Explorer only allow a single homepage to be set, by default initially this is the homepage of whoever set up the installation eg Eclipse; Compuserve CIX and the like. Altering the homepage is a simple task beyond 90% or so of users, so we need to set it up from the start for users. Opera allows several documents to open simultaneously, and each of these windows to have a separate homepage. I use Opera.

Connection - permanent?

Providing a permanent connection, either by cable or by using a proxy server or practice intranet will cause people to run the browser all the time, whereas using dial-up connections causes people to tend not to run the browser unless they decide to look something up.
An Australian GP recently posted on GP-UK an account of routinely using the Web for reference during consultations - partly because the cable network cost was purely subscription. We should explore this with Eurobell.

Choice of Clincal Software

Running greedy software such as Vamp ViSion causes problems when greedy software such as Internet Explorer is also running. Using a clinical record system which delivers patient information through the same interface as the knowledge service will reduce this, as will running software which works through a terminal emulation with a server doing much of the work. Examples are EMIS, the Exeter GP System, Microtest, Vamp Medical. DOS programs also tend to co-exist well. Surgery Manager is an example. The client server programs are well adapted to conversion to a Web like interface.

Content, Reliability and Acquisition

The most potent factors are content and reliability. If the content of the information system is good, and particularly if it is there before it is circulated as paper, and preferably much is never circulated as paper, then people will use and rely upon the service. Therefore, provided they are enabled to produce relies and request action or further information while accessing it, it will grow in usefulness. A particular advantage is if it requests and accepts information from users.

Example

Wax - a project mixing hypertext and synchronisation of databases which was tried out in the Wirral while Frank Burns was Chief Executive there, before moving to secondment as head of NHSE IMG - did this. Simon Rains, IT man on the Exeter Commissioning Group executive has tried out a later version of Wax than I did, both were impressed. Alan Hyslop has also evaluated Wax in the Scottish NHS IT establishment.

Generally the move is toward a generic format and implementation of hypertext and the Web does really seem to have made this sensible.

Speed of Information

The cascade system used by the DoH is slow and unsatisfactory, running by fax. Passing the information by a combination of e-mail to a listserver, and backup and detail material placed on web pages or transmitted as attachments or archive files intended only to be accessed at a time of need would increase the effectiveness of distributing the information, and reduce the cost of doing so and handling it once distributed.

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