Engaging clinicians in IT—one step forward, two backBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7533.127 (Published 12 January 2006) Cite this as: BMJ 2006;332:127
All rapid responses
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
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
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 -
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
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.
Competing interests: No competing interests
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
Competing interests: No competing interests