Appeared in Rethinking IT and Health, J. Lenaghan (ed), Institute of Public Policy Research, London, 1998, pp16-29

Even if we steer clear of the media hyperbole, it is apparent that we are entering a period of accelerated social and technological change, in part driven by advances in information and communication technologies. At the same time, forces of a very different kind are refashioning our healthcare system. Working with ever restricted resources, and unable to keep abreast of the knowledge of best practice hidden in the ever-growing literature, the basis of clinical practice now trails far behind that of clinical research. Driven by these changes, both internal and external to the healthcare system, information technology has a large and growing role in the delivery of healthcare.

Amongst the many possible relationships between healthcare and information technology, there are two extreme points of view. On the one hand there is the sceptic who sees nothing special in these technologies for healthcare, and votes to do nothing. At the other extreme, there is the technophile who demands that we rapidly embrace new technology, and paints vivid pictures of a world populated with virtual doctors and cyber-consultations. While both are extreme views, they help mark out the space for discussion. In all likelihood, the truth will lie somewhere in between. However, attempting to predict how new communication and information technologies will interact with the delivery of healthcare is well nigh impossible. Yet we must try if we are to proactively shape the outcome.

Marshall McLuhan was faced with a similarly daunting sea of circumstances in the early '60s when he coined the phrase "the medium is the message" (McLuhan, 1964). In trying to bring order to the emergence of new mass media such as television, and the widespread social unrest of that time, McLuhan made a pivotal link between technology and society. He saw that we cannot separate what we say from the way in which we say it.

It is now time to refashion McLuhan’s analysis to gain insights into our own decade. The Internet is the newly emerged technological substrate that we must now integrate into our society, alongside television and the telephone. No matter what its ultimate form, the Internet will change the way we see and react to the world. So, if the Internet is the medium of the coming millennium, what messages does its advent carry?

As we try and answer these questions, we should in particular look at the changes occurring in healthcare. It is perhaps no accident that a major new movement like evidence-based medicine should emerge now (EBMWG, 1992). The problems of poor evidence-based practice have been with us for decades, but it is probably only in the socio-technical context of the last five years that they could begin to be addressed in any profound way. The lack of uniformity in the quality of clinical practice only becomes apparent when we have the information tools to step back and examine healthcare from a broader system viewpoint. The globalisation of information publication and exchange we now see has thus been a necessary condition for the widespread focus on clinical evidence and practice.

In the remainder of this paper, we shall examine these broad issues by examining four 'myths' about the role of technology in healthcare. Using the Internet as our touchstone, we shall see that the messages it brings invert many of our preconceptions about the role of information technology in healthcare (Kelly, 1997). For each myth, I will also propose a challenge to policy makers, healthcare workers, and technologists.

If broadcast television is the classic information 'push' technology, pumping information into people's homes, then the Internet is the canonical example of an information 'pull' technology. The Internet’s most immediate effect is to create a huge, publicly accessible information space, in which we can publish or access information on most things. We are already familiar with the lack of controls this implies, and that patients now have access to ‘evidence’ and ‘guidelines’ that are as likely to have come from world experts as they are to have been fabricated by self-styled health gurus. We now need to think about the consequences of this new information resource.

What message about the state of medical knowledge do patients get when they can call up a dozen conflicting treatments for their symptoms from the Internet? What message about competence do they receive when they see their doctor hasn't read the latest paper on their disease, but they looked it up themselves before coming into the clinic? What message about their relationship to the healthcare professions is delivered when they see that their doctor is uncomfortable with new technology, or alternatively spends half the consultation starring at a computer screen rather than the patient?

Alternatively, what message is sent when a patient sees that their doctor has just accessed the latest Cochrane recommendations for their treatment during the consultation, and makes that information available to them? Or how do they feel when, unbidden, their doctor’s clinic sends them an e-mail to check up on their progress? Perhaps the e-mail advises them of a new research that suggests a change in treatment that might be beneficial, or simply passes on some new dietary information to help in their self-management. What message does a patient receive about their relationship to their disease if they exchange experiences with others around the globe through a self-help group on the Internet?

There are also interesting consequences of the free market in health information on the Internet, and the way in which that clashes with controlled resource healthcare systems (Coiera, 1996). We must assume that patients will soon have access to information on best practice from a variety of sources on the Internet and will demand it when it is known. However the health service is resource bound, and must attempt to ration treatment (Klein, 1995). Treatments that are the most cost-effective over a population may be favoured over treatments that are best in class. This will lead to a conflict between the informed desire of patients to obtain the best treatment for themselves as individuals, and the system’s ability to deliver. Will individuals who have an almost limited access to information, but limited access to healthcare resource, tolerate sub-optimal care? Patients are as likely to find geographic inequities in access to treatment exist within their own country as well as between their country and others. The recent Child B case in the UK (Ham, 1995) is a prime example of the type of conflicts that will arise between a free market in information and a controlled market in healthcare. Will information rich patients feel less satisfied if they discover evidence supporting new and expensive therapy, but find that their resource-limited healthcare system is unable to provide it? This brings us to the first challenge.

Technology changes the opportunities for human relationships and perceptions, but that change has everything to do with the way technology is used. Thus the Internet increases patient access to data and to other people enormously, and it changes the way in which they can interact with workers in the healthcare system. It clearly has the power to make patients more informed, self-reliant and empowered but the challenges posed above carry the seeds of alienation and confusion.

The sceptic's viewpoint would have us do nothing, but it is clear from this analysis that the relationship of the healthcare system to its patients is being changed on a daily basis by the transformational effect of the Internet, and information technology in general. So, inaction is not an option. However, rather than reacting to these changes, there is plenty of opportunity to proactively use this new medium to shape healthcare services. So, how will the health service provide networked information to the public, both in support of preventative healthcare, as well as for personalised ongoing management of illness?

The immediate response to the first challenge is to demand that we rapidly embrace these new technologies for healthcare. Yet, while there is always some value in speculative technological experimentation, it is not a good foundation for public policy. In the mouths of unapologetic technophiles this approach becomes our second myth:

What we do need to do, irrespective of the pressures of time or resources, is to be clear about what we are trying to achieve, and how, if at all, technology can help us in attaining these goals.

The Internet has been in existence for 30 years now, but it has only had widespread impact in the last few. When it did suddenly transform from an academic backwater into a major public communications system, it took nearly all the major computer and telecommunications companies by surprise. While they were all working on ever more complex technologies, developments at CERN (the European Particle Physics Centre) produced the very simple software which created the World Wide Web (Bereners-Lee et al., 1994). Arguably containing no substantive technical innovations, this work single-handedly transformed the computer and communications industries.

At the heart of the Web’s success is a profound demonstration that people will only use technologies en masse when they actually solve their problems. The Web clearly has filled some deep information and communication need for a wide sector of the public. Consider in contrast the fate of video telephones, which have been technically possible for several decades, but add so little of value over voice telephony that telecommunication companies have been unable to sell them.

There are important messages within these events and they can be summarised in the following way. There are essentially two ways in which a technology can be applied to solve a problem. The first approach is technology driven. Here one asks ‘What problems will best be solved by using this new technology?’ Inevitably, whatever the problem, the answer will always be that the technology is the solution. This approach is often useful when trying to demonstrate the potential of a particular technological innovation.

The second approach to the application of technological is problem driven, and asks the question ‘What is the best way to solve this particular problem?' In this approach, all kinds of solutions are explored, from changes in clinical process to the introduction of a new technology. Consequently, sometimes the answer to the problem may be that new technology is not the best solution.

This distinction between problem and technology-driven innovation helps us understand why so much information technology fits so poorly into the healthcare environment. For example, the modern personal computer (PC) evolved from the typewriter and was at least initially a good example of problem-driven technology. When it was created, it was designed to solve the problems of office workers. It is no accident that the basic metaphors of documents and files run so deeply through today’s computers. These were the 'natural' tools that office workers were observed to use when Xerox did the initial studies that created the mouse pointing device and windows interfaces.

Yet if we look at the natural information tools of healthcare workers, we don’t find them preferentially using typewriters or computers, but the telephone, the note pad, and the Dictaphone. They work in a very different environment to the office worker and do very different things.

The challenge is to try and solve the information and communications needs of this very different group. So, if we were to have started the evolution of the modern PC from healthcare, rather than the office, where would we be now? Perhaps healthcare workers would all be using something like a smart mobile phone, which took and transmitted dictation, allowed us to query laboratory databases using simple voice commands, and so forth.

To create such new tools, we need to recognise that the key to applying technology is as much about understanding our environment and its problems as it is about technology. And, there is no reason why the next generation of innovations for the computing industry shouldn’t start from the heart of medical practice.

At present the press is flooded with articles describing unending tele-variations of existing medical services from teleradiology and telepathology, through to remote cybersurgery. These innovations are championed by telecommunication companies because they have the potential to become highly profitable businesses for them (Bowles and Teale, 1994). Healthcare researcher often complicity collaborate in the technology drive, because it is easier to test a new technology and produce 'hard' scientific results than it is to formulate problem assessments which require qualitative research methodologies and seems to many to be 'soft' science. Perhaps influenced by these forces, much of today's telemedicine is a classic example of technology driven innovation, rather than being based upon the needs of clinicians and patients (Coiera, 1996; Wyatt, 1996). This brings us to our next myth:

There is indeed evidence that remote consultation using facilities like video-conferencing is of value (e.g. Wooton, 1996) What remains unclear is whether there is any substantial cost-benefit from this approach. For example, comparing the costs of providing a rural population with radiology services from a small community-based unit, against a teleradiology system, the communication option fared poorly in one study (Halvorsen and Kristiansen, 1996).

Almost invariably, when cost-benefit assessments are made of telemedical systems, the comparison is made against the existing situation. Studies rarely look at the actual communication problem and test alternative solutions. For example, sometimes changing practice to rely more heavily on the telephone can substantially improve effectiveness (Rao, 1994).

We need studies that examine communication needs independent of any technological solution. We should not prejudge whether the answer to the problems found is a change in public policy, a rearrangement of organisational structures, changes in work practice, or occasionally, the introduction of new technological systems. I believe that the current technology-driven momentum is preventing us from focussing on the real clinical communication problems because our view is clouded by 'telemedical' technologies like real-time videoconferencing.

What can we learn about communication problems from the experience of other groups? The World Wide Web was purpose built for one reason – to allow geographically separated physicists to share data and documents, and to permit rich collaboration with these resources over communications links. It allowed them to collaborate on activities that would otherwise have been difficult or impossible (Bereners-Lee et al., 1994).

This approach to solving their problem is supported by advanced research in the computer industry which is generating what is now known as the 'video-as-data' hypothesis (Whittaker, 1995). Allowing people to use communication channels to share data and discuss it using conventional channels like the telephone seems to work well. In contrast, using the channel to provide video to look at each other's face seems to deliver very little benefit (Williams, 1977).

The implication here is that since much of what healthcare workers need to 'see' to collaborate is document or still-image based, we will not require heavy investment in real-time video technology. Most of this clinical data can be transmitted on normal computer networks using so-called 'store-and-forward' mechanisms like the Web, e-mail and file transfer protocols.

So, if we are to take a problem- rather than technology-driven approach, what are the critical communication problems now facing our healthcare system? Unfortunately, there is almost no literature in this area to help us make any rational assessment at all. Some preliminary information exists on communication practices within hospitals (e.g. Coiera and Tombs, 1998), but there is little if any information about communication practices or needs between the different sectors within the healthcare system. What we do have are hundreds of papers and books on telemedicine, focussing solely on the application of communication technology. We do not know what communication problems exist within the healthcare system at all. For such profound ignorance to exist whilst we are in the midst of a 'communications revolution' is a potent reminder of the power that technology has over us.

In such an information vacuum, we therefore need to start by developing some informed hypotheses about what a real communication problem might look like. Perhaps the biggest obstacle to delivering effective healthcare is our inability to use our knowledge of best practice captured within research to drive routine clinical practice. In response to these healthcare problems, we have seen that the evidence-based movement has risen up within medicine to try and bring research and practice closer together (EBMWG, 1992). In its complete expression, evidence-based medicine would have us create a knowledge base of expert consensus on best-practice for most treatable conditions, and disseminate this knowledge so that it is actually used. This leads me to propose a new challenge:

One of the major physical barriers to delivering such an evidence-based medicine (EBM) is the problem of arriving at expert consensus on best practice from the literature. When experts are geographically separated, how do you permit them to interact, share current evidence, discuss their concerns and questions, and arrive at consensus? Face to face meetings are probably the ideal, but the cost in time and resource is prohibitive.

Further, given the frequent need to re-examine evidence, and the huge number of guidelines that may eventually constitute the "best-practice knowledge base", it is clear that the process of consensus formation is one of the major bottlenecks to guideline creation. It is probably unthinkable that in the future such a consensus process would not occur over the Internet. The Web seems custom made for evidence-based medicine. Indeed, it is probably inconceivable in its complete expression without it. How this is to be set up and managed as the evidence-based enterprise grows is a problem that needs urgent attention.

Unfortunately, those working in telemedicine have focused largely on technology-driven applications, and as a result found a very different set of problems. While they are concerned with delivering video-based medical consultations, remote surgery or tele-radiology, there is little evidence that these are critical problems for healthcare. The problems of evidence-based medicine are more pressing and may present the real telecommunication challenge. In the end, the healthcare system needs to take the responsibility for defining and owning it's communication needs, whatever they may ultimately be. Without such an ownership, healthcare workers will be unable to set their own agenda and explore it in partnership with technology companies, but will inevitably be driven by those who have a ready made technological agenda.

Everyone now takes for granted the sudden and dramatic growth in the Internet that was fuelled by the introduction of the World Wide Web. However, it is worth asking what was the essential change provided by the Web that transformed the Internet? The deep answer has probably a lot to do with understanding the human process of communication.

At its simplest, people need two things to communicate – a common channel over which to speak, and a common view of the world with which to make each other understood. Communications falters when we have little formal world view in common, starting with language and culture. It also falters if there are so many rules and regulations about what should be said and how it should be said that creating a message is hard.

The Web is not without its critics, and it is certainly not a panacea to all of society's information and communication needs. Nevertheless, it seems to have found a middle ground that makes it relatively easy for people to use it as a communication channel. It has simple models of what a document looks like so that it is easy to create and share them. In contrast, earlier document standards permitted great complexity of content but in formats that users were unable to easily share.

From an information science viewpoint, this is profound, since it suggests that we need to find relatively simple levels of formalisation if we are to allow our systems of medical knowledge to be easily used and shared. This brings us to another pernicious information myth:

In healthcare, as in many highly bureacreatised enterprises, there is a strong belief that the introduction of formal processes is invariably beneficial in bringing structure and efficiency. Amongst information technologists this view reaches its extreme when they formalise processes within software, defining each name and element in an organisational system, ultimately fixing the way things 'should be done'.

The reality however is that formalisation costs. The process of creating organisational models is expensive, both in terms of staff time, and in their implementation. Worse, once a model is canonised in a traditional computer system, the organisation loses flexibility to adapt as requirements change. Invariably, by the time a computer system is introduced into a healthcare organisation, it is out of date either in its model of user needs, organisational structure, or technology (Coiera, 1997). Yet, unlike the software or hardware components of information systems, the process of formal definition of process and organisational models is rarely bounded by cost or rational assessments of need and benefit.

The experience with the Web points out a different approach. It states that there is a spectrum of formality that one can adopt in defining a system, from the relatively unstructured and informal to the highly detailed. Choosing the appropriate level of formalisation in a system is highly dependent upon how much people can afford to spend in the definition process, and the role the system will ultimately fulfil. There is no purpose served in over-specifying an information system.

The same holds true for clinical guidelines developed by evidence-based groups. For guidelines to be easily understood, shared, edited and modified, they need to be created at a level of detail that makes it easy for people to understand and discuss them. So, while it may be enticing to the formalists amongst us to come up with rich and precise definitions of medical languages and clinical practice guidelines, the evidence of the Web suggests that this is misguided. We need to be reminded that the simple delivery of guidelines on computers is not of its own intrinsically valuable. The guidelines need to be in a form that allows it to be of value. A guideline used in an emergency situation cannot be overly complex and detailed - indeed in such situations there may not be time to even look at a guideline. Equally, guidelines used by patients and by trained professionals will need to be very different for identical situations, acknowledging the difference in understanding and language of these groups.

Since the primary goal of evidence-based medicine is not the creation of a library of near-perfect guidelines but the improvement of clinical practice, we need to step back from the false goal of beautifully codified medical knowledge, and its computer-based distribution. Instead we should ask "what is the level of formalisation and presentation that will make it likely that we influence clinical practice?". In many respects, this is simply a recapitulation of the historical debate over whether medicine is an art or a science, and the introduction of the computer simply recasts this age-old discussion.

I have tried, through the eyes of the Internet, to explore what I believe are four central myths at the intersection of healthcare and technology. It is clear that we still have much to learn about the way that new technologies like the Internet will affect the healthcare system and clinical practice. It is also obvious that their effects will be substantial. More critically, we still are embarrassingly ignorant of the true information and communication needs of the healthcare system, and have left it to the technologies themselves to define our problems.

The study of medical informatics should help us arrive at such an understanding. If physiology literally means ‘the logic of life’, and pathology is ‘the logic of disease’, then medical informatics is the logic of healthcare. Thus, first and foremost informatics is not about computer technology, but is the study of how information and communication structures support the practice of healthcare. It is the rational study of the way we think about patients, and the way that treatments are defined, selected and evolved. It is the study of how medical knowledge is created, shaped, shared and applied. Ultimately, it is the study of how we organise ourselves to create and run healthcare organisations. With such a pivotal role, it is likely that in the next century, the study of informatics will become as fundamental to the practice of medicine as anatomy has been to the last.

We need to educate healthcare professionals about the importance of informatics. It will soon be an essential component in the training of all doctors since it is as much about how we think of and use technologies as it is about the technologies themselves. It is also critical that we do not forget those already in active clinical practice. They are busy people, with little formal training in these issues. Yet many face decades of clinical practice in which ignorance of informatics will become increasingly burdensome.

In the four myths discussed in this paper, we have seen a very different picture of informatics emerge from that articulated in the past. Technology is de-emphasised, and an understanding of human communication and information needs comes to the fore. Things like the telemedicine, the electronic medical record and clinical coding and classification systems may not be the things we would now chose to work on first.

To understand which problems really are important, we need to set up high quality and multidisciplinary research groups. Medical practitioners need to work along side computer scientists, cognitive psychologists, and experts in telecommunications and artificial intelligence. No one group has all the answers in this complex field. In its absence well-meaning engineers or technologically uneducated clinicians have little option but to focus on technology-driven research since they have no strong grasp of the key problems.

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