As my working week is evenly divided between General Practice and Health
Informatics, this discussion is right up my street. I could go on for ages,
but for the time being can I point to a report, from an RCGP standing group,
that covers some of these issues and make a couple (!) of brief points?

The first URL is for the whole report, the second to a section that I think
is pertinent.


http://www.schin.ncl.ac.uk/rcgp/scopeEPR/report/i-a-22.htm

http://www.schin.ncl.ac.uk/rcgp/scopeEPR/report/i-a322.htm#3.2%20Structure%2
0and%20representation%20of%20the%20EPR


General points:
1. One of the things with electronic records is that they have been
presented as being able to perform lots of different functions, such as the
narrative record as well as the reductionist coding that Bruce H is
referring to.
2. I think that some care is required when we use 'linear thinking' as a
pejorative. There are some situations in medicine where cause and effect are
directly linked (e.g. E coli: UTI: antibiotic).
3. There is also the issue of medium and message. Most computer programming
is linear, but then so are screenplays, scripts, novels (in the sense that
the text has a start and finish and it is important that all the symbols
that make up the text are in the right order).
4. I've been working on a project looking at computer use during the
consultation. I'm sure that the presence, and use of, an electronic
information source in the consulting room will alter clinicians' behaviour
and will alter the way we work: but not in the way that Bruce H thinks.
5. Many of the issues of health records (whatever the medium) come down to
the problem of trying to capture a complex interaction and represent the
essence of that in a way that can easily be communicated. Read codes (or
Snomed terms) are one way of approaching this, Trish Greenhaulgh's narrative
based medicine is another, significant moment audit (used by teachers of
consultation skills to undergraduates in Leeds and Leicester for instance)
is a third. What interests me is that they are all so different, but all
share the limitation of being incomplete.

Happy to continue this ;-)

Paul


Paul Robinson
General Practitioner, Scarborough
GP Consultant Sowerby Centre, Newcastle
Hon. Senior Clinical Lecturer, Leeds

-----Original Message-----
From: Complexity and chaos theories applied to primary medical and social
care [mailto:[log in to unmask]]On Behalf Of Iona Heath
Sent: 02 June 2002 18:11
To: [log in to unmask]
Subject: Re: NHS Information Agency

Dear William

I thought your letter was quite superb and the obtuseness of Bruce
Hutchcroft's response a demonstration of the extent of the challenge that we
face.

With very best wishes
Iona

-----Original Message-----
From: William House <[log in to unmask]>
To: [log in to unmask]
<[log in to unmask]>
Date: 30 May 2002 19:27
Subject: NHS Information Agency


>There is an opportunity to spread the complexity message to the NHS
>Information Agency - which seems to me to be a bastion of linear
>thinking. The Agency publishes Inform (a 'corporate' newspaper) every 2
>months. The March 02 issue contained an article from a consultant
>physician in Sheffield, Dr Bruce Hutchcroft, entitled 'Why effective
>clinical recording requires major change in clinical practice' in which
>he claims that clinicians need to change the way we work in order to
>support the electronic patient record. I was sufficiently incensed by
>this bizarre conclusion that I wrote a letter to the editor along with a
>plea for a correspondence section - so that the profession might feel
>some sense of ownership. To her credit she published the letter in the
>May 02 issue in a new 'Letter to the Editor'  section, incorporating a
>response from Bruce Hutchcroft - the relevance of which you can judge
>for yourselves! If you don't have paper editions, you can read the
>original article (quite short) and my letter etc (shorter) on line on
>the NHS IA web site - from outside NHS net: www.nhsia.nhs.uk or within
>the NHS net: nww.nhsia.nhs.uk: From the Home Page click on 'Inform' on
>top menu bar - you can then access the March and May issues. If you feel
>moved to write something for the next issue - get typing! My letter is
>mainly about holism but I have put in a plug for complexity to give you
>an opening. Send your letters to: [log in to unmask]  Good luck
>and enjoy the Jubilee weekend! William House
>
>Dr W.House
>St Augustines Practice
>4 Station Rd
>Keynsham
>Bristol BS31 2BN
>Tel 0117 9862343