What medical journals do and do not tell us

1
What medical journals do and do not tell us

• Tony Delamothe
• Editor, bmj.com

2
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

3
BMJ theme issue
http//bmj.com/collections/specials.shtml
4
(No Transcript)
5
Questions posed in initial editorial

• What is the impact of eHealth innovations on the
  health system?
• Are we healthier because of them?

6
Whose presidential slogan?

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

7
Herbert Hoover (1928)

• Stockmarket crash
• Great depression
• Hoover Dam

8
A computer on every desk, with access to the
internet.

• Eurobarometer survey
• found that 97 of UK
• GPs were online
• (2002)

9
Impact of computers

• Medical records
• Prescriptions
• Databases
• Integrated decision support

10
Impact of internet

• Email
• Web access

11
Put them together

• NHS National Programme for Information
  Technology (NPfIT)
• NHS care record (EHR)
• Outpatient booking
• Electronic prescriptions
• Network
• 
  100/head

12
NPfIT

• Does seem the right thing, doesnt 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 were
  not in either place
• Compared with 10 years ago?

13
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 arent adequate

14
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

15
Advertising campaign on Yahoo to promote
colorectal cancer screening
16
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 gt1000 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

17
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

18
Learning from e-patients at Mass General

• But
• Groups were scattered and uncoordinated
• Uncommon 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

19
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 worlds largest STM publishers
  agreed to provide free or greatly discounted
  material

20
HINARI

• Now enlarged to 50 publishers
• gt2400 journals
• 1100 institutions in 102 (of 113 eligible
  countries)
• New initiatives
• AGORA
• INFORM (publishers reaching out to patients)

21
Search engines

• PubMed
• Google

22
(No Transcript)
23
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

24
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

25

• Move away from the gizmos, and gadgets, and toys
  for the boys to the people who use them or dont
  use them

26

• 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.

27

• You cannot introduce new technology into a
  system without changing behaviour

28
Four rules for the reinvention of health care
(Enrico Coiera)

• Technical systems have social consequences
• Social systems have technical consequences
• We dont design technology, we design
  sociotechnical systems
• To design sociotechnical systems, we must
  understand how people and technologies interact.

29
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

30
Handhelds 2

• Niche users (20)
• (Regular use limited to single application)
• Busy, but list oriented, curious but hesitant
• I dont have a lot of extra time

31
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

32
Handhelds 4

• Power users (13)
• Constant use characterised by desire to push
  device to its functional limits
• Technophiles, peer champions, active promoters
  (show offs)
• Its my life Ive always loved technology and
  gadgets

33
(No Transcript)
34
(No Transcript)
35
10 years later..

• Delbanco T, Sands DZ. Electrons in flight email
  between doctors and patients.
• New Engl J Med 2004 3501705-7.
• 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

36

• 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?

37
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

38
What medical journals tell us is. that
they dont tell us about lots of things that
really matter because not a lot of people are
looking at them
http//bmj.com/talks/