I’ve been working as a junior doctor for almost 2 months now. One aspect I clearly enjoy is running after lost drug charts, trying to decipher bad handwriting and dealing with slow buggy systems. Best part of the job.
It’s almost 2020 and we still have an archaic record keeping system, in an age where you have digital banks, uber, the social media titans, one day prime delivery, facial recognition software, cryptocurrency, google. All of this at your finger tips. And here I am sitting here writing a TTO when ’Notis’ crashes for the umpteenth time.

So far the push for a digital NHS has largely been a false promise. Just words rather than action. Instead of developing a real architecture, what we’ve done so far amounts to just scanning in notes. How can we have such talented engineers at Facebook, Google, Twitter, and then deal with this.

I want to think about what it will take to develop a robust system, what the goals should be and how we might achieve this.


What would a real digital system look like.

1. It would be nation wide:

Currently, there is no monopoly. Each trust uses their own system, contracted by small software companies. There is no hegemony. No ‘winner take all’. There is no ‘Amazon’, no ‘Google’, no ‘Facebook’ of the medical record keeping world. We are living in the 1990’s-2000’s where you had a long tail of small technology companies which of course were eaten up by the tech giants.

The problem with lots of small companies is that you end up with lots of half-decent systems with no compatibility between them, rather than one efficient system that all hospitals and GP’s can use.

We need a system that : hospitals can access. GP’s can access. We need a tech titan to take over medical record keeping.

2. It would be incorporate all uses

Currently at Nottingham, we have three systems. Yes 3 systems.Notis, Nervecentre, and then Medway. All of them do different things. For example, you can only book certain scans/procedures on Notis vs Medway. You can only see observations of Nervecentre. You can only write TTO’s on Notis.

A ‘real’ digital NHS system should incorporate all uses. You should be able to book all scans, see all the results, see all the notes, prescribe, contact doctors, see observations, record observations, Do discharge summaries. An all in one integrated system.

3. It would not scan in old notes

I’m sorry. I know we need to look at old notes, but the problem is you have to kill an old system to bring in a new one. Scanning in all old notes first of all is a gargantuan task. We should instead focus efforts on creating a way to digitally type notes. This would solve so many problems:
Automatic date and time. No loss of data/notes. Easily viewable, accessible, readable. Often faster to type than to write.
Of course it would then mean, we would be starting from zero. But you could still archive old notes and access them that way.
The reality is we need to completely adopt digital note taking. Abandon paper notes.

4. Digital Prescribing

I’m an advocate for digital prescribing. I think it would avoid a lot of errors. With digital prescribing you can put in measures to spot obvious errors in prescribing. You aren’t dealing with bad handwriting. The pharmacists can check the drug charts remotely. You can clearly see what meds are stopped and started. You can ensure that a clinical reason is given for starting or stopping a medication. You can easily trace back. You could generate automatic TTO’s. Overall its a better system.

5. It would be built by the best engineers

We have so much talent in this world. The smartest people in the world currently however are working at the big tech giants : working to manipulate human attention. If only we could grab a handful of talented engineers, lock them in a room, give them money, give them time – and develop a system. We would all be better off. The problem is there is no financial incentive. The NHS doesn’t have the money. So where do we look?

Possible Avenues to Make this a reality

The only avenue I can see is startup culture. The NHS is too big, too bureaucratic , too ancient, slow. Dominated by politics. Limited by a set budget.

A solution has to come from the startup ‘Silicon Valley’ culture, where you have money, talent and determination. Action over words. You have so many examples of disruption in all sorts of fields, even heavily regulated ones. Take the fintech bank ‘Monzo’ which has leapt through the regulation and red-tape surrounding banking. We need a Monzo of digital record keeping.

For example : imagine crowdfunding this.If the wealthy 1% of the UK invest money into this, we could transform healthcare in an unprecedented way. It would be historical.
The problem again, is there is no market force. No financial incentive. It’s hard to make money in medical record keeping, when the NHS is the one buying it. Therefore it doesn’t happen. Innovation is driven by market forces.

One part of the problem is we accept the current system. As I said, we have to tear down the old, to bring in the new. I sound like a revolutionary. But that’s the only radical solution I can see. We need to create financial incentives for engineers and leaders to work on this problem. The only place I can see this problem being solved is in the startup space.

Conclusion

In the end, it all comes down to incentives. The talent is there. However the incentives for the talent to work on this problem is not there.
It can be done. It should be done. It’s a hard problem, but one that can revolutionise medicine. It’s like we are in the preantibiotic or ‘pre-germ theory of disease’ history of medicine.
Hopefully the future generations will look at at how inefficient and slow the current digital system of the NHS is.
I think that this conversation should be brought into the public discourse. The junior doctors of today, future leaders of tomorrow should be thinking about this problem. Not accepting the current system. It’s a problem that the doctors of my generation need to seriously tackle.

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