I use handheld computers extensively and posted the following reply last
year regarding a discussion on paperless EDs:
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I don't think the principal of a computerised clerk-in is a problem, but the
fact that they force the user to follow a prescribed route and style is.
Current medical software is not "intuitive" enough for medical staff. Too
often it is designed around the software's needs or the number crunchers'
wants (ie event codes) and not the users needs. Lateral thinking on the
part of the software designer may help here and the interface is the key.
For instance allowing mouse-selected free text entry in multiple fields at
once which the user can freely move around - looking much like a paper
record on a large screen. HTML-style interface records may be another idea,
as they are quite intuitive. Being able to draw diagrams on a touch screen
and place text or parts of an ECG trace etc. anywhere on the "page" is also
important.
There is a lot of work going on at the moment to find better ways for
professional to interface with computers. Think back to the punched card
interface before VDUs or the DOS interface before Apple OS / Windows. Then
the computer interface was thought of as being like a typewriter. Now we
use an interface that resembles our office desk. The future interfaces are
hopefully going to provide a similar paradigm shift in the way we interact
with computers. Hopefully we will interface with the computer as though it
were a secretary or assistant.
In GP the requirements for an effective system are less. The Torex Premier
GP system is pretty impressive - a desktop based consulting and prescribing
system it can synchronize all the patient data with a Windows CE palmtop via
a cradle. This means you can take all you patient info with you on visits
and update it in the patients house (see my website
http://www.coull.net/computers.html to see other ways in which palmtops can
help in GP out of hours cover). Still, even this is too cumbersome for a
more chaotic clinical environment such as A+E. I've based my entire GP
approach around a palmtop and am very happy with the results, but all my
attempts to use one in A+E or BASICS-type calls have not worked well. The
interface is just too fiddly for effective use in those environments and
because they are clumsy to synchronize, they don't lend themselves well to
team information sharing.
Up and coming Bluetooth technology may solve this. Bluetooth
(http://www.bluetooth.com/) is a wireless protocol that allows multiple
computers to network automatically in the background with each other when
they come in range of another device. The idea is that you tell your
palmtop that you have, say, an appointment at a set address at a set time
and you also select a recipe for your evening meal. The palmtop tells your
alarm clock the time to get you up and tells the water heater when to switch
on in anticipation of this. When you go to your car it then tells your car
GPS where you are going. When you come home the oven is pre-heating because
it told the oven when to switch on, and there is a delivery waiting for you
because the bar-code-reading fridge realized you needed more ingredients
based on the recipe the palmtop had told it you chose.
Applied to healthcare this may make EHRs much more practical with each
member of staff using palmtop devices for all patient events AT THE POINT OF
CONTACT. These devices all communicate silently and automatically with
central hub computers in the department and/or with the devices of other
members of staff and/or other department's computers. I suspect this may be
the key breakthrough technology for hospital EHRs. This may make your A+E
staff look a bit like the cast of Space 1999 (lets hope they don't make us
wear the flares).
However, all this is in the future and this brings us to one of the major
problems with IT implementation. IT software developers are dreamers
pushing out a new frontier. So they get very excited and tell you what tbey
can achieve for your department, and you then spend millions to find out
that they were basing their promises on technology still being or to be
developed and none of it actually works. (I remember being told by the IT
specialist when I was on the IT liason group in Tameside in 1993 that we
could have palmtops with pen based bedside medical software. Complete
fantasy at that point, but presented as fact.)
So, you should be sensible about what parts of your process you can improve
by using current computer technology and what can be done better with paper
and pen. For example, do you really need an ISDN link to order the staff
Chinese take away over the internet or would a paper/pen/telephone approach
be better? A more difficult question is would a palmtop internet link to
the eBNF site http://www.bnf.org/ be better than having to distribute paper
BNFs? With current technology probably not, but in the near future that
will change.
> Computer systems also need to have reliability records approaching that of
> aircraft.
This is another critical point. Almost all GP practices use Windows based
systems that are hopelessly unreliable. Web servers almost all use Linux
based systems because it is a much more stable system.
So basically, the problem with a paperless system in A+E is...
1. the hardware development is not advanced enough yet to cope with near
patient use by teams working in a chaotic environment.
2. the software interface is inadequate
3. the server systems are not reliable enough to be depended on.
Static business offices are much simpler and the technology to make them
paperless has been around for a while. GP surgeries - which are less
chaotic in their patient contacts - are just about there, but the paperless
clinical department will probably take a little longer.
-------------------------
Robbie Coull
email: [log in to unmask] website: http://www.coull.net
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