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REVIEWS: Engaging clinicians in IT—one step forward, two back BMJ 2006; 332: 127 [Full text]

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One step forward

Mark E Lloyd, Paul A Reilly   (20 January 2006)

Have you consider a FLOSS alterative?

David P Mitchell   (29 January 2006)

One step forward 20 January 2006
Mark E Lloyd, Consultant Rheumatologist Frimley Park Hospital, Frimley, Surrey, GU16 7UJ, Paul A Reilly Send response to journal: Re: One step forward	We read with sympathy the experience of setting up and maintaining a database. As two rheumatologists (MEL,PAR) in a DGH we went through a similar process, though with more positive outcome. We initially explored stand alone databases, which were costly, not guaranteed to link with our hospital systems and required annual back up expense. One of us (MEL) offered to sit on the hospital IT committee (on which, unsurprisingly, there were plenty of vacancies for clinicians). We were able to work with our hospital IT department to set up a system based on the hospital PAS, a surprisingly powerful data storage tool. It took several months to complete but resulted in a robust and well supported system which has survived to the dawn of NpfIT (1). Like the author, we have been lucky to have adaptable and dedicated secretaries. Although the system is more cumbersome to type in, time is saved by pulling all demographic data automatically via hospital number. It worked well enough that the diabetic clinic also adapted it. We learnt some lessons: 1. You can't underestimate the lack of knowledge IT departments have about clinical practice and process. 2. IT departments can't underestimate the lack of knowledge consultant rheumatologists have about computing. 3. If your hospital IT department didn't install your system don't expect them to be able to back it up when it goes wrong (and it will go wrong). 4. If there’s a hospital committee that has a major impact on your work try to get a seat on it. The electronic patient record will make our database, and others like it, obsolete. However the effort was worth it. Our department and IT understand each other a bit better and we have a more realistic view of what can and can’t be achieved. We’re still talking to each other, and to the IT department. 1. Lloyd ME, Burkitt D, Gilliland S, Linge L, Reilly P. Creation of a robust rheumatology database in a district general hospital. Rheumatology 2002;41;supp 1:39 Competing interests: None declared
Have you consider a FLOSS alterative? 29 January 2006
David P Mitchell, medical microbiologist Trinity Collge, Dublin Send response to journal: Re: Have you consider a FLOSS alterative?	I read this letter with some interest. There have been an entire series of problems with "upgrades" with MS products for a number of years. For many years - possibly up 1997/8 Microsoft maintained a huge database of 'legacy' software to tried very hard to ensure that all or almost all the programmes in widespread use would continue to run after an 'upgrade'. They made exception for programmes that directly competed with their interests - notably Word Perfect (currently subject to an ongoing federal law suit) and others. After this date it was decided in Redmond (where Microsoft's headquaters is based) that this effort was no longer worthwhile. Since then it is only Microsoft products that will be certain to work after an upgrade. The vendors of the software running on Windows may be able to fix the problem but not in all cases. It is standard practice in most sensible IT depts to do an entire back up of the hard disc before messing with the operating system - especially Windows as Windows upgrades not uncommonly expect an entirely empty disc to work with. Portable hard discs are cheap, resuable and have considerable storage capacity (~100 gigabytes). If I might suggest an alterative here, I would suggest going for a FLOSS alternative. FLOSS is an acronym for 'Free, Libre and Open Source Software.' This is a generic term for software where you get to see and to modify the software yourself. There are some philosophical differences between the Open Source and Free/Libre Software organisations which I wont bother anyone with here. Linux is an operating system. GNU is an organistion that produces software that will run on Linux and other operating systems with Linux being the most widely known user. There are several database systems that will run on Linux with the list including IBM's DB2 and Oracle's Oracle. These I think might be overkill for the needs expressed here. There are many other alteratives including MySQL and Postgress (PG). PG is a database administrators database: essentially bombproof. While still not quite in the league of DB2 and Oracle the gap is closing. MySQL on the other hand is a LOT easier to set up and use. Most of the Web runs on MySQL simply because of its speed and ease of use. PG or some other system may be a better choice - it depends on your needs. There are no licence fees to pay. You may work with and modify the code as you see fit. If you want some one to fix problems for you or help you set it up there is a maintance charge attached. MySQL is a company that does this. For Linux maintance there is a multiplicity of companies with Red Hat, IBM, Novell and Mandriva probbaly being the best known. For such an important system maintaince would seem a sensible option. Since most people need some sort of word processor there is a multiplicty that come with most Linux distributions. Probably the most powerful of these is Emacs which includes a module to run your coffee maker - Im being serious. The coffe maker Im told is not standard issue with the software however. Emacs runs email, an internet browser, several programming languages and other. This may be an overkill situation. Its interface is quite different to other word processors and takes some getting used to. A more practical alternative would be Star Office from Sun or Open Office. Open Office is FLOSS and ships with virtualy all Linux distributions. Compatable with Word documents, Excel spreedsheets and Powerpoint presentations. Not so good on the database front but improving. Open Office looks very like Microsoft office. Star Office on the other hand is an entire office suite with a fully functional database. It is available as a 'free' (= no cost) download from Sun. A boxed set with support for bug fixing can be purchased from Sun at ~10% of the cost of Microsoft Office. Star is compatable with just about everything in the Microsoft office suite. Star looks a bit different to Microsoft Office but normally takes only an hour or so to get used to. If these office suite are not suficient then MySQL or PG which comes with all Linux distributions can be configured to work with any of these. This might take a bit of work to customise but should run problem free ever after. Where do I get this software? Mandriva, Red Hat, Novell and others all have web sites from which you can order it. If money is a problem then Mark Shuttleworth in South Africa will send you any reasonable mumber of CDs with the Ubuntu version of Linux with all the goodies listed above and more beside for free. This includes shipping. The only charge that they wont pay is customs duty as this varies dramatially. Once you have a Linux disc you may make as many copies as you like and give them away. This is completely legal and this is what FLOSS is about. Printing will work out of the box for almost any known printing system and is managed by a suite known as CUPS. Installation to the hard drive is not even necessary: there are a number of distributions that will work off a CD or memory stick. Knoppix is probably the best known here. Storage of the files that are changed eg letters written will need to be stored to some form of medium. This can be the hard drive with Windows on it. Linux can read Windows files and indeed run most Windows programmes. It is probably worth repeating at this point that there are no licence fees. There are no fees for bug fixes. There is no limit to the number of copies you can make or to whom you can give them. Interoperation with a Windows network is managed via a programme known as Samba. The documention with Samba is so good that the Microsoft programmers use it themselves rather that their own. This too will normally work straight out of the box. There are no known viruses for Linux. There is a free antivirus software suite - ClamAV - for the truely paranoid. A firewall comes with any standard distribution. Security should not an issue: the US military have certified Linux as being acceptable for 'senstive but not classified' documents. There are several encryption systems that come with the distribution. One of these proved uncrackable by the US military even after 3 months of trying which should be sufficient for most hospital letters. All files on the disc are encrypted with 64 bit encryption - hopelessly inadequate for security but enough to discourage casual snoopers. For those that need more the National Security Agency in the US provide a 'hardened' version for free - SELinux. The NHS are investigating the use of Linux at the present time having been a Windows only shop. The French government has moved much of its tax system over to Linux. Several local governments in the UK, Germany, France are using it. Much of South America, China and South Korea are already using Linux at governmental level. The 'only' problem many hopsitals will have with this is that most do not have people trained to use Linux. Microsoft have had a monopoly in the NHS for a number of years and consequently most NHS IT depts do not know anything but MS products. One of the upsides of using Linux is that you can fix the problem yourself instead of waiting for the IT dept to do for you. This takes a bit of work but at least you might get the problem solved. If you are having problems similar to those outlined this might solve a few of your problems Competing interests: I have used GNU/Linux, Open Office, MySQL, PHP and related materials in the past and intend to continue to do so. I have also used many Microsoft, Apple and Unix software.