John:

> X400 is an international standard which has an existence totally
> independent from NHSnet.

Of course,  and I don't have any probs with that at all.

> The reason why this is of interest is that in the short term we need
> a reliable way to exchange structured clinical messages.  As you
> know, the NHS standard is EDIFACT.

(Snipped the rest of this paragraph as I am aware)...

I will try to argue below the case for 'not' using edifact and x.400.
In the meantime,  I will also offer a vision and a strategy that
are credible and feasible. Many people now subscribe to that
strategy.

I believe my argument is reasonable and thoughtful.  It is also
inclusive of NHSnet.  I will keep on repeating the points until
someone sees the light :-)

1. The choice of EDIFACT as NHS standard has dictated a whole string of
complex and expensive solutions.

2. I am aware that if you want to send 'structured messages'  you
need 'edifact'.

3. My question is:  *why* do you need to send structured messages in
the first place?  To date,  no one has come up with a convincing
answer.

4.  Now turn that on its head and ask:  what do I want to achieve by
exchanging messages of any kind?  Answer:

5.  Exchange information between,  say,  a Trust and a GP,  for
example,  pathology requests and results.

6. If we switch off the 'edifact/X.400' mind set for a moment we can
begin to think how we might achieve no.5 above simply,  effectively,
cheaply and securely.

7. Imagine the following case:

Trust A has connection to NHSnet
GP B has PC and modem
What is missing?

Trust A needs:

- keep their existing information systems
- a web server
- a protocol that acts as gateway between existing system and
  HTML/SGML (this already exists).
- a bank of modems

So far,  all of the above is either in place or cheap to acquire.

What does GP B need?

- a dial up connection to Trust A's Intranet (TCP/IP)
- an HTML browser

Both are also very cheap and available now.

The exchange of information:

a) Trust A 'publishes' the path results as they are onto the intranet,
ie,  in which ever format the existing system produces them,  only in
HTML format (no need here for edifact at all) :-)

b) GP B dials up (securely and all that) and logs on to his 'authorised'
area of access and views or downloads his results.

What we have here is an Extranet between Trust and GP with NHSnet
providing a very useful infra structure.

Please note:

1. I have not mentioned anything about 'down with NHSnet',  on the
    contrary,  I see NHSnet as an integral part of that scenario.

2. Neither have I mentioned anything about SMTP (useful as it is for
   async. email) or any fancy futuristic technology that is not here
   already.

3. The information remains (underlined) within its applications and
    with the owner who has responsibility for its security.  In other
    words,  the Web becomes the agent between servers and applications.

4. The key word here is 'applications'.  Keep thinking applications
    and you will see it.

We shall work on a proper business case with costing etc. and present
it to anyone who is interested.

I know that I may be shot down by the edifact/X.400 lobby.  My only
hope is that the mind may be set free to consider the alternatives.

I also know that you might say " ah,  but we need to integrate those
results with our medical systems databases".  The problem here is
the GP computer systems and the strategy not the solution offered.
I do not see that as justification for the current strategy.  Maybe
we ought to think about that but this is another story ;-)

> Yes, yes - I know we can argue till the cows come home whether all
> of this will / should be possible with SMTP.  Or we can reject the
> lot and wait for cable technology / WWW etc to sweep everything
> aside.  But I am trying to find a pragmatic 'reasonable value for
> money' solution that works NOW, and which will allow us to insert
> the necessary safety and privacy features..

I hope that I was able to demonstrate above the fulfilment of that
pragmatic reasonable value for money solution that we are all after
without any reference to technology that is awaiting the cows
homecoming :-)

> So for SHORT TO MEDIUM TERM to get GP - hospital clinical EDIFACT
> links running reliably I suspect we do need to use X400.

The above case can be implemented TODAY!

> I think we need to clarify the debate by considering EDI and
> 'Internet services' (eg WWW and email) as two quite separate issues.

Of course they are.  The point is:  one of them is available now,
the other is riddled with problems and complexity.  Otherwise,  IMG
and Syntegra wouldn't be desperately trying to find out,  through
research,  why the uptake has been so poor (allegedly) and,  as a
result,  try to fudge the issues yet again with more complex
technology and cost (ROME) just to keep on justifying a strategy
that ain't gonna work ;-)

I do hope that I made my position clear.  I am not in fantasy land.
My case above is here and now.  What is needed is to stop 'talking'
and get on with the job of making a business case and go ahead with a
showcase implementation as soon as possible.  But that requires
courage,  conviction and a vision for a credible strategy.

All I am asking for is that people begin to say we have made a
mistake.  It is good to say that.  When the strategy was conceived,
it was the right one. Three years later,  it is not.  Those who are
able to say that are brave and credible people and no one can ever
say they are bad at their job.  On the contrary,  I,  for one will
give them my wholehearted support and admiration.

Ahmad
_______________________________________

Ahmad Risk MB BCh
Gestation:  Medical NetNoire


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