Digital age distraction or radiology revolution?
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November 2007
JAMES FAIRLEY, a consultant ENT surgeon, responds to an article on Picture Archiving Communication Systems (PACS) which featured in The Clinical Services Journal (“A Revolution in radiology: diagnosis at a distance”, September 2007) with an alternative viewpoint. He gives a personal account of his experience of IT implementation and outlines his concerns.
IT support systems that cause the doctor to disengage from the patient for more than a second or two are inherently counter-productive. In aviation, it has been recognised for decades – anything that distracts the pilot’s attention from the main task of flying the plane is dangerous. GPs are well ahead of hospital specialists in using computers in clinical practice. Is this why so many of my patients tell me that their GP doesn’t listen to them any more? They feel marginalised and ignored as the GP is absorbed by the computer screen and keyboard.
Therefore any information support provided to working clinics must be done in ways that minimise input from the doctor. No system that diverts the doctor’s attention from the patient for more than a second or two should be tolerated. Unfortunately, virtually all current clinical IT support systems fail this test.
PACS
My local NHS hospital Trust changed from hard copy films, viewed on traditional wall-mounted light boxes, to digital images called up on a computer screen (PACS) last year. Paradoxically, this has had a detrimental effect on the quality of some of my clinic consultations.
Before PACS, clerical staff were employed by the radiology department to provide the films of all patients attending a given clinic. The pile of X-ray films would be sorted and, while I talked to and examined the patient, my clinic nurse would quietly put the films up on the X-ray viewer, ready for me to look at when the appropriate time came. There was no need to search online for the films, no need to input patient demographic data in order to pull up the correct film and the distraction time for the doctor was minimal. I could simply look up from what I was doing and see the films ready and laid out on the light box viewer.
Typically twice or four times the size of the computer screens that replaced them, they made it much easier to get a quick overview. These working practices evolved for good reason. They maximise efficient use of the clinic’s most scarce and expensive resource, skilled consultant medical time.
The staff who pulled the films from store and made sure they were taken up to the clinics have either been redeployed or made redundant. When the time comes during the consultation to look at the X-rays, I am forced to stop mid-flow.
PACS is only one among several mutually incompatible and “clunky” IT systems we have had foisted upon us – all of which have different usernames and password update schedules. I have to remember that this time I want to look at an X-ray – if I want to order an Xray it is a completely different programme, username and password.
I spend time typing, turned away from the patient, ignoring potentially important non-verbal cues, and then spend further time typing in demographic data in order to bring up the relevant films. I do not find the system intuitive or user friendly. Of course there were flaws with the old way of doing things. The films could only be in one place at a time and weren’t always available. But, by and large, they were there when needed, and it was much easier to view them.
Can the software be improved to make things more like they were before? Could the system not be programmed to know that a particular patient has an appointment and, by default, schedule the right data to appear? Surely it should not be necessary for the doctor to have to type in demographic data to search for the appropriate patient? In addition, there should be a common login for a clinic that will enable the doctor to access, without further input, all relevant information for that session.
All our clinical software seems to have been designed the wrong way round, from the top down, instead of from the bottom up. Several mutually incompatible systems each demand that we alter our way of doing things to suit them.
The doctor-computer interface should be largely in the background, requiring minimal active input. It must be lightning quick. Seamless integration with best clinical practice should be designed in to all clinical IT support systems. Badly thought out and implemented IT forces changes in clinical practice which makes the patient experience worse.
Any new information support system must be designed to help the end user in an unobtrusive, background way, that does not distract him/her from their main task. Vast amounts of money have been spent perfecting the seamless provision of information at the point of use for the military aviator, why not for the medical professional? We are constantly being told to fit in with the machine, instead of having the machine designed around the way we work. With the billions being spent by the NHS on new IT solutions, it would be a great shame if the so-called solutions became just another set of problems for the clinicians on the front line.
James Fairley
Mr Fairley is in private and NHS practice as a consultant ENT surgeon in Kent, UK. With a special interest in the application of computers in medicine for over 25 years, he was a founder member of the Royal Society of Medicine’s Forum on Computers in Medicine in the early 1980’s.
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