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.

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 practice[4] - the information fed back to N&E
Devon GPs, with a pointer to show where in this the particular practice or
GP falls.
[4]  Oddly enough without any indication of the number of partners in the
practice, in order to preserve a confidentiality some GPs still feel to be
proper and necessary.
[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.

--
Adrian Midgley  GP, Exeter



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