What medical journals do and do not tell us

Tony Delamothe

Editor, bmj.com

What medical journals do and do not tell us…

…about how those whose task is to deliver innovative health technologies

cope with the demands and opportunities

BMJ theme issue

http://bmj.com/collections/specials.shtml

Questions posed in initial editorial

• What is the impact of eHealth innovations on the health system?

• Are we healthier because of them?

Whose presidential slogan?

• A chicken in every pot and a car in every garage

Herbert Hoover (1928)

• Stockmarket crash

• Great depression

• Hoover Dam

A computer on every desk, with access to the internet.

Eurobarometer survey

found that 97% of UK

GPs were online

(2002)

Impact of computers

• Medical records

• Prescriptions

• Databases

• Integrated decision support

Impact of internet

• Email

• Web access

Put them together:

NHS National Programme for Information Technology (NPfIT)

• NHS care record (EHR)• Outpatient booking• Electronic prescriptions• Network

£100/head

NPfIT

• Does seem the right thing, doesn’t it?

• After all, most of us have got a computer at work, a computer at home, web access in both places, and access to a portable PC when we’re not in either place

• Compared with 10 years ago?

Defects of many submitted articles

• Process measures far removed from health outcomes

• New electronic tools to perform old tricks

• Little evaluation other than “acceptability” to patients and doctors

Message: maybe conventional methods of evaluation aren’t adequate

What did get published

• “Nuts and bolts”– Advertising on Yahoo– Critical Care mailing list– Learning from e-patients at Mass General– HINARI– Two articles about the transmission of tacit

knowledge

• Lots on “the human dimension”

Advertising campaign on Yahoo to promote colorectal cancer screening

Critical care medicine mailing list

• Begun 1994• Aim: “to provide an internet forum for healthcare

professsionals”• Dedicated to the discussion of holistic care of

patients in intensive care units• Membership: >1000 physicians, nurses,

pharmacists, researchers, and allied healthcare professionals across 6 continents

• List members broke the emerging story of SARS from Hong Kong in real time

Learning from e-patients at Mass General

• In 1994, dept of neurology “began to study how patients with neurological concerns were using online health resources”

• Found “thousands of patients and their care givers had already created an impressive variety of online health resources”

• Bowled over

Learning from e-patients at Mass General

ButGroups were scattered and uncoordinatedUncommon conditions not catered for

So “Instead of traditional ‘provider as authority

role’ we decided that we would think of ourselves as architects and building contractors, creating an online system in response to our end users’ requests”

HINARI

• WHO initiative• “Providing access to reliable health information

for health workers in developing countries is potentially the single most cost effective and achievable strategy for sustainable improvement in health care”

• 2000, six or world’s largest STM publishers agreed to provide free or greatly discounted material

HINARI

• Now enlarged to 50 publishers

• >2400 journals

• 1100 institutions in 102 (of 113 eligible countries)

• New initiatives– AGORA– INFORM (publishers reaching out to patients)

Search engines

• PubMed

• Google

300,000

200,000

100,000

Total Users per Weekday - NCBI WebsiteJune 1997 - May 2003

Jan. 1998 Jan. 1999 Jan. 2000 Jan. 2001 Jan. 2002 Jan. 2003

IHTs and tacit knowledge

• Flooded with information (920 instances of innovative health technologies)

• Medical educators 100 years ago were the first physicians in history to feel the real shock of the information explosion.

• Exacerbates the problem of information overload

• Missing component: judgment, or “knowing in action”

Daniel Klass on e-learning (editorial)

• The information revolution is just another, albeit amazingly effective, way to deliver information

• We confuse information with knowledge and knowledge with judgment

• So the real challenge is to find ways that “expert judgment” gets transferred to doctors in the field

• Few examples exist of this…

Move away from the gizmos, and gadgets, and toys for the boys to the people who use them or don’t use them

• Terrible attrition rate

• 50% of information systems either fail or people fail to use them to their full capacity

• Why?

• When things fail, people tend to blame “the technology,” whereas social, behavioural, psychological and cultural factors are to blame.

You cannot introduce new technology into a system without changing behaviour

Four rules for the reinvention of health care (Enrico Coiera)

• Technical systems have social consequences

• Social systems have technical consequences

• We don’t design technology, we design sociotechnical systems

• To design sociotechnical systems, we must understand how people and technologies interact.

Doctors’ experience with handheld computers in clinical practice: a

qualitative study

Non users (17%)

(Had never used or who had abandoned)

• Sceptical, uninterested in change

• “Paper references and nurses are quicker”

Handhelds 2

Niche users (20%)

(Regular use limited to single application)

• Busy, but list oriented, curious but hesitant

• “I don’t have a lot of extra time”

Handhelds 3

Routine users (50%)

(Regular use integrated into clinical workflow)

• Willing to experiment gradually

• “I know it can do more; “I think this is great”

Handhelds 4

Power users (13%)

Constant use characterised by desire to push device to its functional limits

• Technophiles, peer champions, active promoters (show offs)

• “It’s my life;” “I’ve always loved technology and gadgets”

10 years later..

Delbanco T, Sands DZ. Electrons in flight –email between doctors and patients.

New Engl J Med 2004; 350:1705-7.

• A quarter had communicated by email with patients, but few encourage it as routine practice

• Two-thirds would use email only if they were paid for the time involved

However, skills will not be enough, particularly in the clinical setting. Even if doctors become proficient in using new communication technology, their fears about the internet's impact on their workload, income, personal liability, and quality of life need addressing urgently.

What work patterns, services, roles, legislation, and reward mechanisms will be required to help more doctors use the internet to communicate with their patients over issues that do not require a clinic visit?

A sort of summary

• Waves of technological innovations are crashing over us, which get implemented, or semi-implemented, or not implemented

• We have no idea whether health is better as a result, although it probably is

• The technology-human interaction is an uncharted country - not least because the country is changing all the time

What medical journals tell us is…. …that they don’t tell us about lots of things that really matter because not a lot of people are looking at them

http://bmj.com/talks/