In a book chapter I wrote on the subject of information management in critical care, I concluded that one of the most important challenges for this generation of doctors is the transfer of clinical information management from paper to electronic systems. So far we have failed that challenge, the vast majority of clinical information is still being recorded and managed (rather poorly) on paper. Those parts that are managed electronically are, in general, still cumbersome, bespoke systems that serve functions other than the delivery of clinical care far better than the needs of doctors, nurses or even patients. As a result a lot of these systems are at best grudgingly tolerated, often despised and sometimes even avoided altogether. The majority of doctors, with the exception of the minority enthusiasts, have withdrawn from the conversation on development of information management systems (or even been left out altogether) because it has been seen as a technological challenge rather than a clinical one. This is wrong and has to change because the way we manage clinical information is a crucial enabler for radical change in health care delivery. If doctors fail in this challenge we will find ourselves marginalised and obsolete in an ‘innovatively disrupted’ health economy.

Early Adopters

There is, of course, some history here which partly explains our current situation. Electronic clinical information systems have been in existence for over twenty years. The early years of the development of these systems was dominated by the technological challenges. The sheer volume and complexity of information that is collected in the course of delivering clinical care was a challenge when the cost of electronic storage was high and networking infrastructure not well developed. Taming the complexity of the information – codifying it and structuring it so that it could ‘fit’ in a conventional database – was not only difficult but also met with resistance of professionals as it constrained practice and the PC / workstation became a barrier between doctor and patient. Despite these challenges there are examples of hospitals and hospital systems that showed the world how it could be done (Burton Hospital being a notable example in the NHS) and also how it could go wrong.

The Lost Decade

If the nineties was the pioneering decade for clinical information systems then the first decade of this century can only be characterised as the ‘lost decade’ – whilst the Internet flourished and the age of distributed, personalised, world-in-your-pocket computing dawned – hospital IT systems remained desk-bound, cumbersome, inflexible, centralised systems. The need for information sharing was misinterpreted as a need to provide a single solution for all. A strategy that has cost billions, failed to deliver and diverted funding and more importantly the engagement of the medical profession (it was often doctors with IT skills that where the pioneers of the early adoption period) away from user and patient centred solutions.

A Tablet Ushers in a New Era of Medicine

Technology is no longer the problem – storage is cheap and abundant, networks are reliable and fast and devices are powerful, intuitive and mobile. Data management has transformed as well. XML allied to sophisticated search algorithms means less taming of information is required, the structure of the ‘database’ need not trouble the user any longer. Cloud technology means that information can be kept absolutely secure whilst not compromising the freedom of permitted users. The technology really has come of age and has surpassed the specification required to deliver clinical information management that truly serves the needs of patients, doctors and managers. Mobile devices like the iPad can give doctors both tools for information gathering and the tools to access it when it is needed without the technology getting in the way of the transaction with the patient.

Paper, Paper Everywhere!

But we are still using paper – tons of it. Medical records are stuffed with cardboard folders bursting with, mostly useless, pieces of paper. The information is locked away, unstructured and inaccessible – every request for information (and there are lots) is a mountainous struggle, consuming hundreds of man hours to extract it. The functions of the paper medical record as care coordinator, communicator, clinical process manager, monitor and legal witness are all conflated and result in an extreme precautionary approach to the retention of information which completely subsumes the probably more important function as informant almost as important (and often more informative) as the patient themselves.

It’s the Information Stupid

It’s time for the conversation to move from the technology to the information. We must focus on the type of information we gather, how we gather it, what we need and when we need it in order to deliver safe effective care. So much duplication and iteration and re-iteration of clinical information has evolved as a defence against the in-accessibility to information. Most patients I have met are astonished at the number of times they are asked the same questions over and over again even within the same clinical episode – they see the duplication and fragmentation that we as professionals miss.

The care we give our patients is complicated and messy – partly because our patients are complicated and inflict on us huge variance in presentation, severity, comorbidity and response to treatment. That is the nature of medicine and what makes it so all consumingly interesting. But we make life exponentially more difficult for ourselves by imposing our own variance in practice and reliability on this already unpredictable background. Doing it differently every time, sometimes even changing our mind half way through results in variance on variance which is the definition of chaos. Chaotic medicine results in unpredictable, usually poor, outcome and huge waste – and is bad medicine.

There is an answer to the information problem which also solves the chaos problem and results in not just better care but dramatically better care. Healthcare organisations that adopt this solution are not only better than their peers they are exponentially better. The solution is the key to delivering reliable care and it is the Clinical Process Model. This will be the subject of my next blog.

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