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The quality of data - not the quantity
- Graham W Ewing (3 November 2008)
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Delivering e- communication securely between clinicans and patients
- Gillian A Braunold (4 November 2008)
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Graham W Ewing, Director, Montague Healthcare Mulberry House, 6 Vine Farm Close, Cotgrave, Notts NG12 3TU
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The term Information Technology may lead to a false sense of security and consequently a number of erroneous conclusions. It implies that the data which is currently available from medical testing can be used in a better way and that the ability of computers to process the data can lead to improved understanding. It does not consider that there could be fundamental problems associated with the quality and significance of the currently available data. There are fundamental limitations associated with the simplest of medical procedures e.g. the process of taking a blood sample: (1) the mere act of inserting the needle creates an immune system response at the site of the needle, (2) the act of putting pressure on the arm when taking a blood sample alters the potassium levels (and perhaps also levels of other components). There is a need for techniques which avoid such inherent errors. The measurement of blood components e.g. of proteins, is compared with an experientially established range of levels (in the diabetic blood glucose levels should be typically 3-7mmol per mitre) however there are often cases where the healthy patient gives abnormal readings or where the unhealthy patient gives normal readings i.e. false positives and false negatives. Ideally we should be measuring the rate at which proteins and their reactive substrates react together rather than the individual levels of components. Many medical conditions have complex origins. The idea that a symptom or medical condition is the consequence of one failing single biochemical reaction in the body, for whatever reason, is absurd. The body's function is far more complex than the simplistic reductionist model and is regulated by complex structures including neural networks. These 'executive functions', the autonomic nervous system (the body's physiological systems) regulate organ networks and hence cell and molecular biology e.g. the beat of the heart does not function autonomously. It is influenced by the adrenal gland and the influence of other organs and their biochemical secretions. Accordingly, much greater knowledge is required of the role of the autonomic nervous system, how this is influenced by sensory input and how this naturally regulates or deregulates the body's stability. Blood pressure measurements are of course an essential part of medical diagnosis however they are only a crude measure of the degree of progression of disease. The readings differ when taken by the GP, nurse or whether a manual or automatic system is used. It rises and fall during the day and according to external stress influences, when on holiday and many other factors. Ideally the medic should be measuring the varying biochemical or other influences which affect blood pressure. A medical condition does not arise out of thin air typical of some sort of Milligan-esque or Monty Python-esque sketch. Medical conditions develop initially at the presymptomatic stage. The body attempts to mitigate for disease however over time the condition develops at the presymptomatic stage and finally at the symptomatic stage where the persons health worsens and symptoms develop. In time this becomes acute or chronic. In most cases the medical condition will regress as the homeostatic mechanism re-establishes the body's stability. The medical profession requires new tools which are able to track the development of disease. The existing plethora of diagnostic systems are unwieldy, expensive and often quite limited in their capability. Articles published in peer-reviewed journals cite the limitations of the medical practitioner and of diagnostic procedures to diagnose disease at between 20-80% (1) dependent upon the nature of the condition, state of knowledge of the condition, time of consultation and other contributory factors (2-4). IT systems are intended to lead to better means of using existing data. Perhaps the medical profession should demand better means of diagnosing disease and hence the quality of diagnostic test methods and of the existing data before looking at how IT can be of value. Until it does so it is just tinkering at the edge of what cost-savings and/or radical innovations to healthcare management which are possible. G.W.Ewing References 1. British Medical Journal 18th March, 2000 (full edition devoted to misdiagnosis) 2. National Patient Safety Foundation, phone survey 1997 (www.wrongdiagnosis.com/intro/common.htm) 3. National Patient Safety Foundation at the AMA: Public Opinion of Patient Safety Issues, Louis Harris & Associates, September 1997 4. J. Forensic Sci 1999. 44(4)810-3. Minimising mistakes in clinical diagnosis. Ermenc B. Competing interests: co-author 'Virtual Scanning - the next generation of healthcare - beyond biomedicine?' ISBN 978-0-9556213-0-7 |
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Gillian A Braunold, Clinical Director Summary Care Record & HealthSpace Programme NHS Connecting for Health Vantage House 40 Aire Street Leeds ls1 4ht
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HealthSpace www.healthspace.nhs.uk is one of the key programmes being delivered by NHS Connecting for Health. It is being developed to address the patient centred requirements that are identified in the Kings Fund report and elsewhere. Citizens now expect an online environment for their transactions with the health service. HealthSpace offers this via a secure transactional environment. Current advanced HealthSpace users have access to their Summary Care Record and also, in Salford, to their local electronic diabetes record. Web mail communication between clinicians and patients who wish to exploit this secure on line environment will be piloted in 2009. HealthSpace will support the international standards being developed by Continua http://www.continuaalliance.org so that devices can be used by patients to transmit physiological monitoring into their own digital records. The Kings Fund report as well as other reports ( ref American Journal Managed Care 2007;13:418-424) demonstrate the appetite for email consultations as well as exploiting an on line environment for service delivery. HealthSpace will enable this extra dimension to be developed as a tool that will be delivered to the NHS in England. The potential is there for huge patient centred benefit in primary community and secondary care. Competing interests: Clinical Director for HealthSpace |
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