From the Heart and Chest

I like David Bowie, and I like electronic patient records. Coincidence? Probably.

As our project to implement a comprehensive EPR at Liverpool Heart and Chest Hospital nears go-live, the greatest living innovator in popular music releases his first new album for ten years. Coincidence? Definitely!

Why do we struggle so?

I was depressed, but not surprised, to read the feature EHI’s recent special report on desktops, "XPediting change".

It chronicled the widespread, on-going use of the Windows XP Operating System in UK healthcare, even though there have been three subsequent generations of Windows and support for XP will cease in less than a year.

We have just about completed a trust-wide update to Windows 7, and it has been a struggle. The two main blockers have been engagement and suppliers.

Before embarking on this particular programme, we undertook an extensive exercise to understand our existing estate, to make sure it was Windows 7 compatible. Surveys were sent out, line managers contacted, and our ‘Information Asset Register’ consulted.

Even so, when our erstwhile desktop engineers visited individual locations to do the upgrade, they were not infrequently met with: "Oh, and of course can you make sure that we re-load program X" (where program X is a random but entirely indispensable work-flow enabler that they haven’t told us about that won’t run on Windows 7).

At this point, the process stalls (incidentally we do remotely deliver the Windows 7 install over the network, but bitter experience has taught to visit first – because of program X, and program Y and program Z).

Our other struggle has been our suppliers. It took some time to achieve a version of the PACS web-based viewer that we use that would work on a version of Internet Explorer that Windows 7 could run.

This sounds terrible, but it was noticeable that when we were working as part of a consortium on a tender document for a PACS replacement, there were differing requirements from neighbouring trusts.

We wanted support for new versions of all three major browsers within six months of launch; while colleagues were asking for guaranteed, on-going support for IE 6 for the entire five year contract.

Our last hurdle to upgrading to Windows 7 has been Medcon (a cardiac PACS system). This isn’t even our system but, as a tertiary cardiac centre, we need to be able to remotely view angiograms performed at surrounding trusts.

Unfortunately, the viewer isn’t Windows 7 compliant (there may be compatible software available but, as the host trusts aren’t on Windows 7, it’s a moot point).

Anyway, necessity is the mother of invention. We have chosen to go live with Version 6.0 of the Allscripts EPR, which only runs on Windows 7 – so we are running Medcon via a terminal server and all systems are go.

Linux and text consoles

I’d hate to imply that I’m an unabashed fan of either Microsoft Windows or of constantly updating software for the sake of it.

I have run Linux on my home PC for 15 years, and believe the most efficient interface possible is a well designed text console. Nothing can beat the speed of keyboard short-cuts and tabbing between fields.

The issue is that text consoles have a long and steep learning curve. Healthcare enabled IT needs to be used by doctors and nurses. My general experience is that these individuals are good at making people better, but pretty useless at typing.

Anyway, I would rather they filled their heads with medical knowledge and the latest developments in their field than with keyboard shortcuts. So their software needs to be user friendly and have the supportive interface that they use at home.

So, what we need to do is retain the best of the past, but to deliver it in a user-friendly and intuitive interface. To a degree this is what the US Veterans Administration has achieved, and we are advised to learn from them.

The underlying architecture for the Vet’s Vista software is built using an old (some might say arcane) console-based language called Mumps. That solid base has then been layered upon with a Windows front-end and the adoption of new ways of working, such as videoconference consultations and web-based patient access to records.

We need to demand better and aspire to better

We are looking to replace some medical grade PCs for our Drager monitoring system, and guess what? The supplier is only supporting Windows XP. As outlined above, I can’t exactly blame them as, collectively, we in the NHS aren’t exactly creating a driver.

However, progress is exactly that – progress. The era of dedicated workstations has gone (or at least massively contracted). We have created a standard build of our Windows 7 install that means that any clinician can log-in to any workstation and have an excellent chance of being able to do whatever clinical IT task they want to do.

When every PC in our organisation so powerful that it could easily have run an entire university department 25 years ago, is that an unreasonable baseline?

So back to David Bowie – what can he teach us? I like to feel he provides a nice allegory for what I have been saying.

He has never disavowed himself from his previous career (apart obviously for that horrible venture into commercial pop in the mid 80’s); yet he continues to innovate.

His latest album is creative and new; yet it is unashamed to hark back to the best of his past and, in particular, to his Berlin-era classic, ‘Heroes’.

Actually, Bowie had three classics – many argued that ‘Low’ is his best ever album, and yet my favourite of the trio is ‘Lodger’. David Bowie – you rock!

Dr Johan Waktare

Dr Johan Waktare is a consultant cardiac electrophysiologist at Liverpool Heart and Chest Hospital, specialising in interventional procedures for heart rhythm disorders. He is the clinical lead on the trust’s electronic patient record project, as well as being a clinical lead for IT and the trust’s Caldicott Guardian.

A self-confessed IT geek, Dr Waktare has always been interested in computer hardware and software. His status was cemented when, several years ago, the IT helpdesk agreed to replace a user’s PC rather than look at it – after hearing that he had failed to repair it.