From the Heart and Chest: on names and roses

 In case you didn't have the happy fortune to study Romeo and Juliet for 'O' level as I did, the quote at the head of this column comes soon after the play's most famous line: "O Romeo, Romeo, wherefore art thou Romeo?”

Juliet, who is despairing that her new-found love is a member of the family that is the bitter enemy of her own, goes on to muse: “What's in a name? That which we call a rose; By any other name would smell as sweet.”

For those of you who don't know what an 'O' level is, the ‘O’ levels were the exams we sat in fifth year before we had GCSEs. For those of you who don't know what fifth year is, that is what year 11 used to be called before the before school years were numbered from school entry. I could go on showing my age for ever…

But back to our dear, sweet, star-crossed Juliet. She is addressing herself to the issue of naming, and specifically to the fact that she and Romeo have a difficult time ahead. Whatever she might have said, try telling her that names don't matter.

e-prefix or suffix-gate?

In e-health, we love bandying names around. Our favourite habit is to put "e-" in front of other, perfectly good words to give us e-forms, e-documents and e-health itself.

It is like our political contemporaries putting "-gate" after every scandal they uncover. On reflection, however, I think we have done the right thing by using a prefix rather than a suffix – and I am confident my haematology colleagues would blood-e agree.

Still, adding an “e-“ to words is not the only way we conjure up new names for what we do. We also have terms such as paper-lite, paper-free, digital, electronic, and information technology. There are nuances of different messages that we convey by using our different or preferred terms. 

International comparisons

As always, there are interesting perspectives to be gained from looking at the international perspective. We have a very active campaign to create a network of chief clinical information officers or CCIOs.

However, in the US, they have CMIOs, with the M standing for "medical". The obvious difference is that "medical" explicitly implies that your CMIO is a medic.

In the UK, while most CCIOs come from a medical background, there is a very healthy cohort that doesn’t. As it happens, I have just been listening to a conference presentation from a CCIO who is a nurse by professional background; and what I heard was a CCIO and not a nurse.

A CCIO needs to support all clinical engagement, not just medical. When we were designing our electronic patient record, we engaged medics, nurses and allied health professionals equally.

I, a medic, chaired the EPR Design Authority during our project, but my deputy chair was the deputy director of nursing.

Indeed, on the Design Authority, only three of the nine members were non-clinical in background and they were the director of service development, the head of information, and our supplier project manager. No members of IT were involved.

EPR vs EMR vs EHR

How about EPR vs EMR vs EHR? In the UK, we have ended up largely settling on electronic patient records as our standard term for the hospital digital version of care records. In the US, it’s more common for “medical” to turn up as the middle initial. Sometimes “health” is used.

I am not sure how that happened and would be delighted if someone could enlighten me. It is firmly engrained in our psyche that our goal is health maintenance rather than sickness management, and has been for some time.

When I last checked, the NHS, or National "Health" Service is well over 50 years’ old. While we have never stopped talking about "patient notes", the person who is accountable for managing them has for some time typically been the health records manager.

At Liverpool Heart and Chest Hospital, we did actively consider having an EHR project rather than an EPR project. However, we decided that we were swimming too much against the tide, and decided to go with the flow – even if this did mean mixing our metaphors.

Barber surgeons

The US preference for EMR, or electronic medical records, is in keeping with the widespread use of the term medical for the medical profession.

In the UK, we tend to use it less and I think that may relate to the stronger division between medicine and surgery that we seem to have.

The most extreme example of this is that surgeons revert to being a Mr, Mrs or Miss once they pass their FRCS exam. This causes intense confusion with patients, who quite reasonably can't understand why their consultant physician is a Dr, while their consultant surgeon is a Mr.

For those who don't know the history, it harks back to the days when surgeons weren't qualified doctors but were instead "barber surgeons".

In the days before the importance of asepsis was known, any patient that was operated on typically got an infection and died. Physicians, being a canny lot, realised that this was bad for business.

If you stuck to wise pontification and herbal potions, then most people got better (even if the major healer was actually rest, nursing care, and the passage of time rather than something the physician had done).

Anyway, the fact that my esteemed surgical colleagues insist on harking back to a time when their forebears weren't proper doctors has always struck me as a perverse form of inverse snobbery. I wouldn't be surprised if stating that openly will get me struck off a few Christmas card lists; but so be it.

Dangers of being limited by name choices

My issue with EPR isn't actually with the second letter, but the third. Talking about a "record" limits our aspiration to positively intervene in the care process through the use of technology.

A major part of the whole benefit of switching to paperless technology is that it isn't just an alternative to paper, but a powerful technology that actively intervenes to support the highest standard of patient care, for example via things like clinical decision support.

I tend to use the term IT-enabled healthcare, but pick your own as long as it sets the right agenda. As Juliet will attest, names are important.

In order to move forward at Liverpool Heart and Chest, we are pursuing a move away from talking about our EPR to talking about an integrated suite of clinical systems.

In our governance structures, these are overseen by the clinical systems authority, or CSA. I get a wry smile when the penny drops that approximately a third of the CSA members have actually had dealings with a different CSA in their personal life.

CSA is yet another example of a TLA, and we do seem to like abbreviating our names to TLAs. For those of you who haven't come across them, TLAs are three letter acronyms and are highly prevalent in medicine and wider life. Obviously TLA is itself a TLA.

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.