Shared Care Records Flawed. Wasted my time too

Shared Clinical Records Fallacies and its waste of time

 

Some of the work being binned and shredded

I am clearing out paperwork at our old office.  This pile is some of the work I did for NPIT and then CfH, Connecting for Health, the UK health service plan for a single NHS record.  It cost billions. It failed.

Although I got reimbursed for some of my time on committees this was such a waste of time and I knew it.  I was not popular as never liked the concept of a single health records anyway, and detested the idea that Government should write software.  The Government’s agenda and civil service procurement contracts were so precise that it was as if they were writing code.

The main effect, indeed aim at the time, was to kill off multiple medical UK IT businesses.   Only four primary care system survived. NHS bureaucracy believed that it would be so much better if there was only one system, one supplier in the NHS.  The next best option, as far as they were concerned, was that systems should all look and behave in the same way.  The result is that the fast and innovative clinical systems we had have become stuck in aspic.  The drive to innovate, to compete was killed off by the pressure and time needed for government conformance.  Little attention paid to what doctors, nurses or for that matter what a patient might need.  The systems in use now are slower and much less ergonomic than the medical system in place in the late 1990s.  Most UK GPs had systems on their desks by then because they saved time and created legible scripts and records.   Now systems slow down consultations and act as a barrier between doctor and patient. The doctor has to glare at the screen point a mouse at a tiny icon.

Fallacies of a single record

1 “It saves so much money and time, and improves patient safety if there was a single system and NHS record”    Not true.   A single record lead to sloppy thinking and lazy doctors.  The patient is a day older.  The past record is just as likely to bias you in the wrong direction by what was written the past.   There is likely to be something new.  Take a history and examine the patient. It works every time!  This is especially true in an emergency situation.  Junior doctors should be forbidden to look at old records for 48 hours.

In the UK GPs can have access to records (paper for the most part) going back to 1927 as the records follow you around.  When working in Australia there is no such thing, and lo! to my surprise I did not miss the records clinically.  As a matter of prurience I might have.  When I told and Australian patient of GP UK record access she said that would a be gross invasion of her privacy.  She had a point.

2 “But we must know if a patient is allergic” .    If only recording allergy was that simple.  Most people who report that they are penicillin allergic are not.  A patient may report that she felt upset on that green pill, so not unreasonably the GP puts on his record allergy to green pill, so now the system will almost block the GP annoying the patient when attempting to prescribe green and related hues in the future.  Alas a hospital will interpret that to mean the patient will collapse with anaphalaxis to green pills.  To avoid this the GP now needs to record green pill allergy in greater detail, more than the patient nor he needs in his practice.  Detailing what was reaction, what type, intolerance of allergy, rash, urticaria, wheezing and so on and on.  It may need a tree of many codes to describe the reaction and how serious. It is so tedious that it is left.  But this coding dilemma occurs with recording of almost any disease. Heath Data has fractual properties, like the length of the coast of Britain, seemingly approaching infinity once you draw round each pebble or then grain of sand.   The level of detail you need to record depends on your need in front of the patient, its use to you, the patient and locality.

3  That leads onto the provenance of data.  Where is comes from has a huge effect on its meaning.  A nurse may find a patient confused, so she might record dementia on her system (it might even be recorded as Alzheimer’s).  For her work that all she needs to do to remind her.  However this could be any different type or dementia, or even psychological, dementia-precox (psychosis). Who and when was the data entered changes its meaning, and then who can correct it should it turned out to be a toxic confusional state.  Correcting data entered by others is a minefield in shared records.   A GP may record heart failure, but a Cardiologist may need to know what type, or worse it has since resolved and is still there on the record.

4  “Clinical systems can improve safety by warning doctors of interactions of patients other disease and between drugs”.   Unfortunately the fear of being sued by suppliers for failure to provide warnings, means that the most idiotic warnings pop up.  Such as in treating blood pressure: “Adding X with Y will cause BP to fall”…. YES that is what I want!  No intelligence in offering up these warnings which are so frequent, so minor, or that the risks are already fully understood beforehand, that doctors simply flash past all warnings as they are wasting time, in doing so increasing the risk a genuine high risk warning will be missed.  This is true for current systems and would be worse if there was a central record as that has to be designed for the most junior nurse doctor or admin clerk.

 

Solution.  Competing Systems: Healthcare Secure Search Engine.

Keep encouraging different systems.  The can use common coding systems as they do now. They can work differently, have different interfaces functions and innovate.

When a patient is seen at a different place, such as at hospital, an authorised doctor should be able to do a search of all NHS records within date ranges or selected places, to create a new record.  Preferably a day later.  This NHS search engine would be secured with two factor authentication or more, with swipe card; the patient notified that such a search was made and by whom and when.

That way provenance of each item is clear.  There would be no need to create a single record.  There is the NHS spine record, but it is only a summary with few details, and keeping it in sync with GP records is not easy.

Connecting for Heath was doomed.  Its premise was wrong, but those concepts and wish for a single patient record still come up. It still a dream of civil servants everywhere.  It is not needed and it kills innovation in healthcare computing.   Without NHS meddling we would now have slicker, faster, even tablet based clinical systems by now. More patients could be seen in less time.

Gerard Bulger

PS if you invent such a search engine I will need 5% stake in it.

 

https://bulger.co.uk/message.htm

 

 

 

 

 

Using Satellite Slow Connections, Reducing cost.

EXPENSIVE CONNECTIONS

I have just revised my blogs on keeping internet costs down with narrow expensive connections. Its still rather longwinded, so here is a summary!

All  gadget providers now believe that every one has unfettered access to broadband.  Alas there was still part of the world where that is expensive or does not exist, and those of us forced to use Satellite communications from the field have big problems.  The costs are so high an update would break the bank. We cannot control what out phones and PCs do in the background.

My solution was to make sure that anything I plugged into the satellite device/route never knows the route to the internet.  I set them so that there was only one route in the IP tables, the route via the satellite to a proxy server.  Then I used another browsers such as Opera or Sea Monkey as they have email clients.  These browsers can set their own connections via a proxy server independent of the operating system, so nothing else can connect to the internet.

This is detailed on https://bulger.co.uk/satellitecost.htm

other ideas to reduce costs on satellite are here https://bulger.co.uk/satellitecost2.htm

 

 

Relish Broadband. A 4G Alternative to wired connections in London

Relish Broadband

https://www1.relish.net

While everyone goes on about the countryside having poor broadband, it is here in central London, EC1, that terrible domestic broadband connections.   Here with BT or Sky the download speeds are never greater than 7mbs down and 700kbs up. There is no fibre here,no Virgin cable.

So when Relish Broadband came along offering high speed, up to 50mbs using  a dedicated 4G network at only £20 a month unlimited use, I jumped at it.

Alas there is no free lunch.  Here is my list of Relish issues Relish broadband does not tell you, or is so hidden in small print that you will miss it.

  1.  You cannot put the Relsih 4G SIM in any other device than their hub/router (This is in their T&Cs). You cannot for example put in in a 4G dongle.
  2.  The router/hub is locked down. You cannot change much at all.
  3.  The Relish router/hub does offer dynamic IP name assignment with DYNDNS and others, but it will not work unless you buy a fixed IP address!
  4. As above you cannot reach your hub network from the internet because Relish uses CGNAT thus hiding you within their private network. To have normal home broadband you have buy an IP address; that is get the business package.
  5. The router/hub uses Network Translation (NAT) ONLY. The other options are greyed out, so you cannot set it to route the one IP address, and use the router as a modem, which I would much prefer to connect it on to a proper router.
  6. There can be sudden drop outs in connection causing pauses. This problem persists but is now much less often after a firmware upgrade.

At first the service was terrible and hardly worked at all, but I stuck with them. To be fair you can send the hub back and cancel the contract at no charge within a month, so you can test it out for free.  The help line advice was just to give up and send it back!  I wanted it to work.  After six weeks the poor signal strength shot up and I was getting speeds of up to 60mbs down and 10mbs up. Almost Korean speeds.  During busy times, which here in is during the day, it can fall to as low as 8mbs down and 4mbs up for short periods. Still, these speeds much better than Sky. And it is unlimited.

Relish marketing have designed the package to be plug and play. That is all very well, but what REALLY annoys me it that there is no technical information page. It’s take it or leave it attitude.

They describe it as home broadband without wires, but the basic package is not. Their advertising is naughty, especially as there do not give any of the details on their web page of what the service actually is. There is no reason to hide the truth as it is still good value.

You have to go offsite such http://www.london-se1.co.uk/forum/read/1/182386/page=8 to get the flavour of the problems.

The base package is not home broadband as you cannot reach your home from the internet unlike all wired services. This could lead to other problems with games and any home cloud you have. Relish uses Carrier Grade Network Address Translation (CGNAT). In effect you are on their private internal network. You do not have a reachable IP address, so dyndns and similar services will not work. This is in effect double NAT. This does not seem to be necessary is IPV6 is coming along allowing everything and everybody to have an IP address. But is does act as a nasty block from the internet to your home device. Some might like this double firewall.

I fought with their terrible help lines, and to their credit they offered me a business IP address, so I can reach my router here.

I have two connections here. Slow Sky Broadband and Relish.   For me Sky Broadband is now the spare connection (failover) should Relish fail. This is switch is automatic; The Draytek Vigor 2860 router I have does load balancing and failover so I do not really notice how often Relish drops out.   I did have had odd snags with this arrangement. One was that Google Play store would not work on Wifi connected phones. I eventually fixed this my making sure the default preferred route as always Relish, so the router is not really load balancing. Google Play fell over, timed out with this double NAT arrangement of Relish Router/hub connected to Vigor router.  it works when the vigor router was fixed as to the preferred route (Relish) when both lines are up.

It’s getting there Relish, and I so hope they can have the courage to be more honest on their web pages about the product and give much more technical info. It’s still good value.  Its working pretty well, usually very fast but with the occasional drop-out.

Of course I worry that if too many people buy Relish the speeds will slow down again if they are too slow increasing the capacity.

Today, 9th June the service is faster than advertised download.   Upload is still good, but I would prefer nearer 10mbs.

http://www.speedtest.net/my-result/4420599390

http://www.pingtest.net/result/124745357.png

Update December 2015.    An update this month to the hub seems have to resolved the remaining drop outs and its rather a strange latency on firing up web pages.  Previously a web page might take a moment to load, while speed testing showed the link was in good form.  This lag/latency now seems much less, and the connections much smoother.  It is now a viable alternative to a fibre line, with good speeds even in busy times, and would be ideal for those moving house in London.  Currently there is no fast fibre service in much of central London, but when there is I would still prefer a hard wired connection to the internet.

 

 

Revising the Web pages

Once we had various businesses such as the doctor’s surgery in Bovingdon, the Fundholders’ Support Agency and Archway Development and Consulting. In those days then having a web space made sense.

But a personal space,  which is what this has since become, is much less necessary now that Facebook and the rest has taken over any need for a vanity sites.

I think I will keep the website going and add my thoughts, partly because old URLs should never die!   Also I feel slightly more in control.  I am not alone with that thought. If I hit delete.  It’s gone.