Table Of ContentCOMPUTERS
AND
THE GENERAL
PRACTITIONER
General Editors
ALASTAIR MALCOLM
and
JOHN POYSER
Published for
THE ROYAL COLLEGE OF GENERAL PRACTITIONERS
by
PERGAMON PRESS
OXFORD · NEW YORK · TORONTO · SYDNEY · PARIS · FRANKFURT
U.K. Pergamon Press Ltd., Headington Hill Hall,
Oxford OX3 OBW, England
U.S.A. Pergamon Press Inc., Maxwell House, Fairview Park,
Elmsford, New York 10523, U.S.A.
CANADA Pergamon Press Canada Ltd., Suite 104,
150 Consumers Road, Willowdale, Ontario M2J 1P9, Canada
AUSTRALIA Pergamon Press (Aust.) Pty. Ltd., P.O. Box 544,
Potts Point, N.S.W. 2011, Australia
FRANCE Pergamon Press SARL, 24 rue des Ecoles,
75240 Paris, Cedex 05, France
FEDERAL REPUBLIC Pergamon Press GmbH, 6242 Kronberg-Taunus,
OF GERMANY Hammerweg 6, Federal Republic of Germany
Copyright © 1982 The Royal College of General Practitioners
All Rights Reserved. No part of this publication may be
reproduced, stored in a retrieval system or transmitted in
any form or by any means: electronic, electrostatic,
magnetic tape, mechanical, photocopying, recording or
otherwise, without permission in writing from the copyright
holders.
First edition 1982
Library of Congress Cataloging in Publication Data
Main entry under title:
Computers and the general practioner.
Edited versions of papers which were read at GP-INFO-80:
1. Medicine—Data processing—Congresses.
2. Family medicine—Data processing—Congresses.
3. Ambulatory medical care—Data processing—Congresses.
I. Malcom, Alastair. II. Poyser, John. III. Royal
College of General Practitioners. IV. GP-INFO (1980:
Royal College of General Practioners) [DNLM:
1. Family practice—Instrumentation—Congresses.
2. Computers—Congresses. W 26.5 C7457 1980]
R858.A2C65 1981 610'.28'54 81-15783
AACR2
British Library Cataloguing in Publication Data
Computers and the general practitioner.
1. Family medicine—Congresses
2. Electronic digital computers—Congresses
I. Malcolm, Alastair II. Poyser, John
362.1Ό425 R858.A2/
ISBN 0-08-026865-X
In order to make this volume available as economically and
as rapidly as possible the authors' typescripts have been
reproduced in their original forms. This method
unfonunately has its typographical limitations but it is hoped
that they in no way distract the reader.
Printed in Great Britain by A. Wheaton & Co. Ltd., Exeter
FOREWORD
In July 1978 a College Working party was charged with the task of reviewing the rapidly
advancing computer technology, and making recommendations for its possible application
in general practice. Before finalising the report (which has now been published*) we felt
the need to canvass a wide range of opinion, and a conference and exhibition seemed an
appropriate way of achieving our aim.
In the event, the success of GP-INFO-80 greatly exceeded our expectations. This publica-
tion records the formal part of the proceedings, but it cannot convey the extraordinary
sense of novelty and excitement experienced by those who were fortunate enough to be
present - fortunate indeed because the conference was three times oversubscribed. Our
handsome headquarters building was packed tight with computers, and festooned with hund-
reds of yards of electric cables specially installed to provide the additional mains
power required.
The College and the Working Party are particularly indebted to Dr Alastair Malcolm, who
took the main responsibility for the organisation. We are also grateful to Joan Mant and
Dick Lloyd-Williams of the headquarters' staff who translated his ambitious plans into
ordered reality.
CLIFFORD R.KAY
Chairman
Royal College of General Practitioners' Computer Working Party.
*Royal College of General Practitioners. Computers in Primary Care. Report of the
Computer Working Party. Journal of the Royal College of General Practitioners, 1980,
Occasional Paper 13, 1-19.
PREFACE
Each decade has a character of its own, the 'eighties being hallmarked by the tremendous
increase in the importance of rapid and easy communication. Our history has been written
by invention and the micro-chip will be the pen of the 'eighties. Already there are millions
of miniature electronic devices employed in performing complex and repetitive tasks busily
at work in all sections of society and the trend towards miniaturisation, further complexity
and increased capability continues apace. Such tools will revolutionise the work of the
world and, indeed, the reversal of the roles of work and leisure has already been foreseen.
The Medical Profession at large cannot afford to ignore the changes which are taking place
and for this reason the Royal College of General Practitioners created the symposium GP-
INFO-80, allowing those pioneers of medical computing to discuss and display their work.
For three days a number of interested doctors inspected the array of systems on display,
they discussed the relative merits of their application and they debated the issues surround-
ing these innovations. The symposium achieved many things, not the least an opportunity
for those dedicated pioneers of medical computing, such as Dr Bob Johnson of Oldham, Dr
Mike Sheldon, late of Banbury, and Dr Bob Bowles of Lyme Regis, to receive such credit
as is theirs for being driving forces in the spirit of medical computing innovation. Future
generations of medical computer users will owe a considerable debt of gratitude to these
men and their colleagues who have invested so much of their time and money, with little
thought of return, to produce the forward momentum of present trends.
The importance of the symposium in our minds was that it brought together for the first
time the dedicated pioneer and the new generation of computer users. It exposed the soft-
ware developers to the ideas and expectations of their prospective customers, showing them
the potential of the use of computers in general practice. The participants themselves
were distinctive, ranging from the experienced academic, well grounded in the medical in-
formation field, to the outright curious, from teachers of computing science in tertiary edu-
cation to the sceptic.
This book comprises edited versions of the papers which were read at the symposium, the
text being derived either from the author's own written submission or from tape recordings
made at the time and later transcribed and approved by the authors. The order in which
these papers appear in the book is not that in which they were presented - we have re-
arranged them to provide a more coherent and readable whole. A glossary has been added
vii
viii Preface
along with a few brief notes of explanation where applicable so that the book should, we
hope, provide both the interested novice and the experienced doyen with easily understand-
able and useful information.
Chapter 1 sets the scene; David Metcalfe opens with some remarks on the needs of general
practice, its current information systems and the trends he foresees for the future. David
Reid of IBM responds with a glossy catalogue of current and future possibilities in the
realm of computing hardware and includes some words of wisdom and caution, culled from
his twenty or so years in the computing world. From the outset it was considered that sy-
stem failure, problems and disappointment were a part of the experience of today's men
and that this must be reflected in the proceedings. Thus Chapter 2 brings together four
voices, sometimes optimistic, sometimes humorous but at all times enthusiastic, portray-
ing the reality of 'grass roots' medical computing.
Security is the foundation stone of the doctor-patient relationship, it could not be otherwise.
The techniques and systems described by David Yates (Chapter 3), backed by the authority
of the National Physical Laboratory, seem to go a long way towards dispelling the fears of
the profession that confidentiality is not possible within the context of the electronic record.
Hugh Fisher, long involved with the Exeter project, uses his vast experience of demonstrat-
ing the system to sceptics to outline to us in Chapter 4 his views on the direction of pre-
sent trends. His paper represents, perhaps, the ear of a man who has listened to many
doctors talking about their dreams and hopes. It does not reflect the work of the Exeter
Project, but rather the wisdom of a man who has heard many voices and encouraged many
dreams.
From this wide programme we move in Chapter 5 more directly into the health centre to
explore the probable structure of a workaday system. Some hints may be gained both on
the design of the general practice computer and on the range of tasks we may expect it to
perform. The aim is to show the present movement in medical computing as a response to
the changing attitudes towards the computer as a new and exciting aid to clinical medicine
rather than a simple tool and an end in itself.
From the very beginning we have had to try to predict what sort of behaviour modifications
the doctor would have to undergo in the surgery if computers ever get that far. In Chapter
6, John Fox and Alastair Malcolm present two different but exciting glimpses into the
possibilities for the future. These must be considered as embryonic but they do enable the
profession to appreciate the prospects of a changing role and a new methodology.
In the early days of computing Southampton numbered among the pioneers, indeed they used
a system characteristic of the late 'sixties and early 'seventies, the batch processing sy-
stem. We are grateful to Ewan Clark and Andrew Basden (Chapter 7) for showing clearly
that the design of a system needs to take into account the patient and the quality of care that
he might expect. The computer will not just modify the work of the office or receptionist,
it will extend care exampled by Patrick Hoy te (Chapter 8) who demonstrates considerable ex-
perience with electrocardiograms and their interpretation using the pattern recognition ca-
pabilities of the computer. Again this highlights the wide potential for application of today's
technology.
As with most meetings the group discussion generated the most diversity of opinion and GP-
INFO-80 was no different. However, the striking feature of this debate was the way in
which the needs of the patient were kept sharply in focus. Chapters 9, 10 and 11 are the
Preface ix
editors' attempt to recapture this scenario. Hugh Dinwoodie spoke on the last day and re-
lated quite forcefully how his pre-conference attitudes had been altered. Howard Rosen-
brock attempted to give the historic social context of the application of computers to medi-
cine.
The failure of the written word to convey the excitement and enthusiasm of small group de-
bate and subsequent plenary sessions is relatively well known, so rather than attempt a re-
port the last word belongs to one of us, a trainee to whom belongs tomorrow.
We would like to take this opportunity to thank the college staff, the exhibitors and partici-
pants who together made GP-INFO-80 possible. We are also indebted to Mr. Geoffrey
Jones who encouraged and supported this publication.
Alastair Malcolm
John Poyser
CHAPTER 1
GENERAL PRACTICE AND
TECHNOLOGICAL PROMISE
What would the doctor be without his books and scientific journals, or a college without its
library ?
'Historians have traditionally credited the printing press as one of the great inventions
of all time. Undoubtedly it is, but both its importance and the speed of its impact on
society will be dwarfed by the electronic information machines which are propelling
us into the Communicative era' (Stonier, 1979) .
The doctor needs to know the potential of the era and the inventor the problems that worry
the profession; the conducting of the dialogue must be public and the setting that of a con-
cern to bring optimum care into the lives of patients.
The two following papers open the dialogue. Professor Metcalfe paints the canvas and
David Reid draws in some of the general flora of the new scene. Neither would dare to pre-
dict the finished work that perhaps is the excitement open to those willing to participate in
tomorrow.
INFORMATION SYSTEMS AND GENERAL PRACTICE
David H.H. Metcalfe
What do we know ?
In England in 1976 the 'average' general practitioner had a list of 2,351 patients, did 8,934
consultations, arranged directly or through 'out-patients' some 365 out-patient referrals
and 256 in-patient episodes, asked for 381 lab tests and 1195 X-ray films, at a total cost to
the NHS of £197,1381 Any business with a turnover of £200, 000 should know a great deal
concerning their customers, their orders, their throughput, their suppliers, and their
finance. Otherwise they would not only go bankrupt, but also be in breach of many articles
of company law.' Yet, the 'average' GP has no information system which will tell him his
consulting rate, home visit to surgery ratio, old to new ratio, case mix, or one which will
identify defaulters, those in need of immunisation or screening procedures, or control his
repeat prescription routines. Even his clinical records are in a format designed in 1911
and, except for the provision of gussetted envelopes, remain unchanged since - a confession
1
2 David H. H. Metcalfe and David A. T. Reid
of failure if ever there was one. Today, no other science-based technology attempts to
work from such an incompetent information system.
(An information system is a collection of components which are interrelated in such
a way that its effectiveness is greater than the sum of its parts. Its objectives are to
facilitate better preventive medicine, better care of patients with chronic disease,
better practice administration and forward planning, quality control, and valid and
relevant continuing education. )
But do GP's want to know these things? Richard Madeley (Madeley and Metcalfe, 1978)
made a study of doctors in Derbyshire. He found that some 40 - 50% of a random sample
of doctors of all ages and both sexes, all sorts of educational backgrounds, in town and
country practice, in single and in group practice, wanted feedback on various aspects of
their practice. Subsequently in Nottingham, we did a large survey of the process of care
given by a random sample of general practices.
Being very much aware that everything had to be kept confidential, and that it is supposedly
unacceptable to let a GP know what another GP is doing, we wondered whether the par-
ticipants would like feedback in terms of how they compared with their colleagues and, if
they would, how that information could be provided without breaching such confidentiality.
We concluded that all the findings should be printed on percentile charts and each partici-
pating doctor given a chart with a personal 'X' to indicate their position relative to their
colleagues. This would enable them to see whether 95% of doctors wrote more prescriptions,
or did more out-patient referrals, or whether only 50% did more certificates than they did.
We assumed the recipients would keep their personal print-outs close to their chests. Not
sol For weeks Nottingham was full of GP's waving print-outs and asking each other 'Where
are you on the graph?'. A further interesting finding was to do with the question of age. It
seemed that the older the doctor, the less interested they were in feedback. There was one
curious exception to this trend, however: those born between 1940 and 1949 (presumably
qualifying between 1965 and 1974) were highly resistant and very negative. This may be a
group of GP's to be watched very carefully having had no undergraduate experience of general
practice and no vocational training, as we understand it today. Apart from this group, dis-
satisfaction with the current records was indicated by the following figures: only 16% thought
current records could provide decent back-up for prevention; only 30% thought they were
satisfactory for follow-up care; and 66% of the respondents thought that they were no good in
the acute situation. This then is some evidence that doctors are ready for information systems.
Why have we had to wait for computers ?
Enthusiastic members of the College (RGCP) pioneered each and all of the components
needed to achieve the objectives of an information system in the late 1950s and early 1960s,
using manual (paper and pencil) methods. These have never found wide acceptance for the
following reasons:
(a) They were seen as research rather than 'management' tools.
(b) They required multiple data entry.
(c) They tended to deteriorate in accuracy as the honeymoon period wore off.
(d) They were difficult to correlate with each other.
In general, while data entry was somewhat laborious, data retrieval and analysis was
horrendously so.
General Practice and Technological Promise 3
The computer system avoids these difficulties. Although data entry into it is just as de-
manding, except that multiple entry is unnecessary, it does not suffer from 'entropy' (in
cybernetic usage - the tendency for systems to lose energy and organisation), and is flex-
ible, so that the system can grow, develop and respond to changes in the needs of the popu-
lation and the technology of medicine. Above all, data retrieval and analysis are quick and
easy. The computer provides the crucial tool for being on top of, rather than underneath
the practice.
It is important to recognise that the coming of small, cheap, and reliable hardware, and the
development of sophisticated flexible systems of software represents a major change, not
only in industry, commerce, and medicine, but in society itself. The microcomputer is
'metatechnology', i.e. a technology which allows of the development of a whole new tech-
nical era. Comparable events are the coming of the steam engine and the invention of the
wheel. The steam engine, the metatechnology of the Industrial Revolution, vastly enhanced
mankind's muscle power. The transistor, the metatechnology of the electronic expansion
of the third quarter of the century, enhanced man's special senses (tele-phony, tele-vision,
tele-communications and a whole range of transducers). The microcomputer is the meta-
technology of the Post Industrial society because it actually enhances mankind's thinking
power.
What is the current state of play?
At the moment there are available to us systems that can be bought off the shelf and on an
'a la carte' basis able to do quite a lot of the jobs required. A practice could run an
appointments system, have a population register, a disease or risk register, a repeat pre-
scription register and various other logs powered by a microcomputer. For a four-man
practice with 10, 000 patients, the microcomputer system, probably using a rigid disk
memory storage unit would provide nurses, administrative staff and the doctor with a lot
of 'clout' along with a lot of understanding of what goes on in their practice which, I have
already demonstrated, they do not have at the moment.
The appointments system, the population register and the repeat prescription register
could be run in real time whereas nearly all the other jobs are of the 'make me a list of
type. For example, 'Make me a list of diabetics over fifty and on insulin', or 'Make me
a list of the over seventies, their diagnoses and whether they live alone', etc. It can be
seen that some of these activities are the direct responsibility of only one cohort of staff
but many of the others are of doctor and nurse or doctor and administrative staff (Fig. 1).
Some will say 'but what about the patients?' Does it not seem, theoretically at least, that
the computer could free the doctor from the weight of administrative thought which weighs
him down, giving him more time to interact with the patient. It is of importance to look
briefly at this because the doctor working in the consulting room, nose to nose with the
patient, somewhere along the line, may or may not make notes in the manual record and
this record is entirely passive.
From our research, following on from the work of Byrne and Long (1976) on verbal be-
haviour in the consultation we know that the moment the doctor turns away from the patient
to the notes, the exchange of information and its quality changes. We also know that
doctors tend to shuffle through the notes (and with a gussetted Lloyd George envelope,
there's a lot of shuffling to be done'. ) when they cannot think what to say next or what next
to ask the patient. The passive manual record is sometimes needed as some form of cover
4 David H. H. Metcalfe and David A. T. Reid
Population Repeat pre-
Appointment (age/sex) Disease/risk scription Other
system register register register logs
Real time Real time Batch Real time Batch
Fig. 1. Computer-supported information system
but basically, in most consultations, the record does not come between the doctor and the
patient. Many of the systems on display in the symposium exhibition deliver many different
functions without impinging on the doctor/patient relationship; however, I have certain
anxieties to express. If it is imagined that as GPs we can go from the underlying practice
registers to an active record that prompts and cues within the consultation, then we must
accept that the dynamics of the consultation are going to be significantly altered. I have
no data to justify this statement; but it seems to be a reasonable supposition. It is im-
possible to pretend that the patient will not notice an active terminal, whether or not he is
in a position to read the screen, so I suspect much more basic research will have to be
done on the mechanics of the consultation, which will become triangular (Fig. 2).
In the meantime there is a more fundamental task. Decision-making is not only dependent
on the information available, but in the order and method of presentation. What is not
fully understood, and will have to be researched, is exactly how doctors make their
decisions. The research that has been done strongly suggests that the process is far more
