Bookmarkers beware: Bookmarks to pages other than the home page may not work after we change servers in April Editor's Choice | This Week in BMJ | Press releases BMJ No 7125 Volume 316 Medicine and multimedia Saturday 10 January 1998 Guide to Medical Informatics, the Internet and Telemedicine Enrico Coiera Chapman and Hall Medical, £29.99, pp 376 ISBN 0 412 75710 9 Cybermedicine Warner Slack Jossey-Bass Publishers, £15.95, pp 214 ISBN 0 7879 0343 4 In his Guide to Medical Informatics, the Internet and Telemedicine Enrico Coiera defines medical informatics as "the rational study of the way we think about patients, and the way that treatments are defined, selected and evolved. It is the study of how medical knowledge is created, shaped, shared and applied." This definition is a great deal broader than just "computers in medicine," and the vision implicit in Coiera's book is not merely of medical practice improved and assisted by computerised systems but of health care thoroughly transformed through the adoption of rational procedures. Importantly, these procedures are not necessarily the consequences of new technology but of thinking stimulated by the need to consider its potential. A good example of this comes in Coiera's consideration of telemedicine. The term telemedicine exists because computer derived images transmitted over digital networks allow medicine to be practised at a distance. In dealing with telemedicine, Coiera considers the more general communication needs of the different players in health care. He argues, for example, that the stress associated with highly "interrupt-driven" environments (such as hospitals) can be reduced if they take advantage of asynchronous systems such as voicemail and email, which guarantee the sender a rapid response without interrupting the recipient. Coiera provides, more successfully than his predecessors did, a textbook that identifies and explains the basic concepts that give substance to his definition of medical informatics. The clarity of his opening section gives the reader a firm understanding of abstractions such as models, information, and systems. This helps enormously in explaining issues such as the classification of clinical data and the representation of medical knowledge. It is because the book deals successfully with these issues that it can give a fair account of the potential and limitations of electronic patient records, telemedicine, and clinical decision systems. In Cybermedicine Warner Slack also writes about the impact computers are having on health care, but in a dramatically different style from that of Coiera's elegant and lucid textbook. Slack draws almost exclusively on his experience in projects as diverse as hospital-wide clinical computing systems and "computer-assisted soliloquy." The latter is an intriguing idea: encourage patients to talk about their problems while alone with a computer which, although unable to decipher speech, detects pauses and uses knowledge of the patient to provide cues according to the strategies of different schools of psychotherapy. The idea, and the book, is imbued with a sense of fun combined with a strong and appealing commitment to the principle that medical computing is about improved patient care. Slack's stance is that of a liberal minded individualist - the "authorities" are potential enemies, and the great thing about computers is they can put power back in the hands of patients and clinicians. What is missing from Slack's book, and what is perhaps the most important contribution of Coiera's, is an explanation of why the computers Slack describes cannot understand language or respond intelligently. Coiera draws on ideas in psychology and philosophy to show that medical terminology, or rather terminologies, exist within a social context, and their meanings depend on the purposes for which they were devised. Coiera argues that there are definite limits to what can be achieved in the coding and classification of medical terms. It is the inextricably human nature of the language we use to represent and communicate medical information that limits the extent to which computers can "understand" or "practise" medicine. The question doesn't arise for Slack, for whom the barriers to clinical computing lie with hospital administrators and bureaucrats who wish to use computers as agents of control. Paul Taylor, lecturer in telemedicine and clinical decision systems, Centre for Healthcare Informatics and Multiprofessional Education, University College London Medical School Rating: ****, ** Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline