Acquiring computer literacyBMJ 1998; 317 doi: http://dx.doi.org/10.1136/bmj.317.7157.2 (Published 22 August 1998) Cite this as: BMJ 1998;317:S2-7157
The full benefits of information technology will be harnessed only when doctors use them in the consultation. Paperless general practitioner David Morris writes for those who want to get by
When the editor asked me to write this piece I responded that I was no expert on computers. That, he replied, was exactly what made me so suitable. So, how computer literate do you have to be to get by? Doctors, much like the rest of the population, straddle a whole range of positions from Luddite to nerd.
I have watched developments in computing since the 1970s with interest but without getting personally involved. By the mid-1990s the world had changed. The activity of general practice now needed so much counting that number crunchers were essential, the Family Health Services people were keen to get electronic links instead of paper, and commercial general practice systems were now impressive. We took the plunge, and in late 1995 we changed overnight from paper only to a paperless computerised practice.
Overnight? Well, yes and no. Yes, because from the day we went live with the computers we made no more paper notes or prescriptions. No, because going live wasn't overnight. We spent an entire year making the practice staff computer literate before our “Go live day,” and we continued up the learning curve for many months thereafter.
Computer literacy: three basic stages
Acquire keyboard skills
Get to grips with the basic operating system
Learn the software packages used
Defining basic competence
You have achieved basic competence when you can use your computer during a consultation as skilfully, and as unobtrusively to the patient, as you would use Lloyd George envelopes or A4 paper notes - both to record appropriate new history and findings and to refer back to older parts of the record as the consultation proceeds. If you don't have this level of competence with your computer, then both you and your patient will feel uneasy and distracted if you try to use it during a consultation.
There are three components to basic clinical competence. Each needs learning thoroughly, and each is necessary before progressing to the next. None of them just happens; each takes time and effort to acquire, and this time and effort has to be found from somewhere. Commercial organisations know this and invest heavily in training their staff in information technology. The dear old NHS sometimes seems to have the fantasy that clinicians - and, for that matter, receptionists - will acquire the skills by osmosis on top of a 60 hour clinical week. This delusion is not useful.
The first component of computer literacy is keyboard skills. This means typing, and it really means touch typing. If you are going to take a sensitive and detailed history fast from troubled patients, neither you nor they want half your attention to be on your fingers as you peck and fumble, so the sooner you master this basic skill the better. “Teach yourself” software packages for personal computers, such as Mavis Beacon Teaches Typing, have all the advantages and disadvantages of any distance learning - you can do it when it suits you, but it can feel lonely and it needs discipline and freedom from distraction. I went on an excellent two day course at a local college, with several hours' homework each night between them. This left me mentally exhausted but grateful not to have to look down at my fingers any more. Incidentally, I was also very grateful to the Welsh Office, which not only financed the course but also paid for a locum to release me from clinical duties. The challenge for the future will be to repeat this for all clinicians.
Will voice recognition make typing obsolete? Although it is becoming increasingly affordable - you can now buy a basic system for under £50 in a high street store - anyone hoping that this could be a salvation from typing will, I think, be disappointed. There will always be some applications for which the keyboard is more convenient than voice recognition, just as pen and paper still beat the keyboard for certain tasks.
The second basic skill is using the rest of the computer. For learning, a small old personal computer may be ideal; you can buy one cheaply or get one on loan, and it will be clear even to the faint hearted that they can play on an old, stand alone machine without risking damage to either machinery or patients' data. When we prepared to go live, we had somebody's old PC sitting in a room for several months of simple practice. The skills here can be as simple as how to switch on and off all the bits - not just at the mains but loading and booting (and the screen and printer if the last user has switched them off). This is when you learn to use a mouse and to get around the screen, Windows, DOS prompts, icons, and personal passwords and security.
There are various simple software games that help greatly with this. My personal favourite, because it is both excellent training and addictive fun, is solitaire - Microsoft's version of the card game patience. For at least one member of our staff, a receptionist of senior years and some apprehension, mouse training playing solitaire was the one thing that helped her relax and enjoy the technology.
Specialist clinical software
It is only when you have mastered these first two components of basic computer skills that you can start on the third level, which is getting to know your own clinical software package. We signed up with one of the market leaders for general practice computing, whose software can be run as either a “live” or “training” system.
When training, you can spend as much time as you like practising on imaginary patients in an imaginary practice. As a new user of clinical software, you should have a mental checklist of the component parts of a consultation. These are second nature to you for manually recorded consultations; the challenge is to make them just as effortless with the computer. You start, of course, by getting out the record of the particular patient you wish to see. How are you sure that you have got the right patient, not one with a similar name? Do you call up the record in the same way if the patient has come in unannounced or from an appointment list? Can you glance at past consultations or other structured parts of the record as the consultation proceeds to prompt you to new directions - for example, to take an overdue blood pressure or repeat a borderline blood test? Can you enter the information that the patient gives you quickly, quietly, and appropriately, including using structured data areas? These are special places to record data such as results of cervical smears, peak expiratory flow rates, height and weight, and smoking, and they correspond almost exactly with the specialised cards in a Lloyd George envelope or A4 file.
Learning to code
A computerised clinical record is not just a manual one that has been expensively typed up. The great difference is that at least some part of the clinical entry is coded or searchable, though with supporting free text. Fitting the universe of patients' experiences into the pigeonholes of a coding system - Read, Oxmis, or whatever other mantra your supplier's trainers use in hallowed tones - can be a considerable hurdle for a newcomer. I would recommend that a clinician new to this exercise, or even new to a particular system, should spend several hours training on this aspect before going live with real patients. If this sounds daunting just think back to your early days as a clinical student and how difficult it first seemed to chop and squeeze patients' histories into a form your first consultant was happy with; this is now second nature to you. Computer systems are no different.
Need for full training
That is the basic computer literacy you need, so how do you acquire it? The same as other skills: with help and determination. Even when you have mastered the first two levels of skill I outlined above you will need human support and guidance as you get to know your clinical software. Our practice was fortunate to get government help with this - the Welsh Office ran a general practice computer demonstration project and provided us with the services of an experienced computer trainer for free. She came to us for a half day every two weeks for nearly two years. She encouraged and taught us and solved problems, and we don't think we could have gone paperless without her. At the end of the project's funding we were very conscious of how much we missed her. Our software suppliers do have a telephone helpline, but it has the usual problems - often engaged and run by a large bank of anonymous staff under pressure of time and with variable experience of any given part of the software.
So, find someone who already knows your software and is local and friendly. If you are already in practice there may well be others at work with you. Another useful source is a local user group: we found it so necessary that we set one up. Health authorities' information technology and training departments are also beginning to realise the need for supplying training locally, and our authority has set up a permanent computer classroom at its headquarters.
I wrote this article from the position of someone already in post in a practice with a particular computer system in place. Plainly, the investment of time and effort has been considerable. What about someone new to such a practice? If you haven't already used that system then you and the practice management need to arrange a formal induction, with protected time and performance review. This is worth while for permanent staff - the old joke is that training people is expensive but that not training them is ruinous.
Where, though, does this leave locums? Out in the cold, it seems. I spluttered when the author of a previous article wrote glibly of “half an hour's training on the computer” to ease a locum into practice.(1)
A few mega-literate locums may exist, and if they do, I'd love to hear from them. For our practice, the need to use the computer well inhibits us from using locum staff if we can possibly avoid it. Our recently retired colleagues are happy to work at local paper based practices, but they and we find things awkward at our practice. We would hope that recently vocationally trained doctors were more familiar with computer systems, but this hasn't always been our experience, excellent though these colleagues have been clinically.