Contemporary Issues in Medical Informatics: Good Health IT, Bad Health IT, and Common Examples of Healthcare IT Difficulties
From: "Geoff Carlin" < geoffcarlin@blueyonder

Ignoring HIT anecdotal evidence:  done at your peril

This unsolicited email was received from a retired Scottish GP.  While it is anecdotal, sometimes anecdotal stories are important, for one form of thought dysfunction (unfortunately too prevalent for comfort in the Medical Informatics Ivory Tower) is “ignoring all anecdotal evidence,” even when that evidence is abundant.


Example: I always get hives immediately after eating strawberries. But without a scientifically controlled experiment, it's not reliable data. So I continue to eat strawberries every day, since I can't tell if they cause hives.

The email thread follows:

From: "Geoff Carlin" < >
To: < >
Date: Tuesday, March 04, 2008 07:41AM
Subject: Your website - Healthcare IT difficulties

Hi, let me introduce myself, my name is Geoff Carlin, I was a Scottish GP with responsibility for 2000 patients in my practice, I retired on health grounds in April 2007 aged 52 after a year on sick leave. [List of medical conditions redacted – ed.]


I congratulate you on your site and think it should be widely read by health professionals.


I endured years of enforced computerisation at the hands of Lanarkshire Health Board and my main concern was that the way I worked was completely changed. I found that consultations became formulaic in a rigid time frame with over half of the available time spent looking at a screen and filling in data. The time spent directly observing the patient was reduced and the potential observation of subtle clues and body language thus reduced. Computerisation spread to the new out of hours service and the situation described on your web site in the ITU scenario with PC's as a source of infection and contamination was replicated (small overcrowded rooms jammed with clinical and IT equipment) - I suspect it remains the same today. I felt I was more a keyboard monkey than a doctor.


I have grave concerns about confidentiality and feel that once data is in the system it can be accessed easily by managers and administrators to pursue whatever agendas their political masters have ordered them to follow. The introduction of IT technology coincided with the imposition of direct line control by managers in the UK health system with overt political interference down to surgery level at times.


Your contributors comments about Board level inefficiecies, bungs and corruption struck many chords with me, but proving these things from ground level is almost impossible, especially as any complaint to National level is immediately referred back to the Board concerned for "local resolution". So in a fight with the Health Board you are effectively bringing a catapult to a gunfight.


Overall I feel the technology has become the master and the health professional the slave, I'm no Luddite by the way. I feel the approach to setting up IT systems in health care should be led by clinicians but achieving this, while meeting the needs of clinicians and patients, through the imposition of National systems is probably impossible. Let the medical practices who become completely paperless beware when they receive s serious malpractice suit! 


Good luck in your work, Geoff Carlin.



From: Scot Silverstein

To: Geoff Carlin

Sent: Wednesday, March 05, 2008 2:00 PM

Subject: Re: Your website - Healthcare IT difficulties



Thanks for the email.  Sorry to hear about your retirement.

Fighting the Health IT irrational exuberance is similarly tiring.  It's a runaway train.  Have you seen my webcast on this at the Government Health IT web site?  link

May I share your email with my students and others in the healthcare informatics community, either with name or in anonymized form as in my web site?

Best regards,





From: "Geoff Carlin" < >
To: "Scot Silverstein" < >
Date: Wednesday, March 05, 2008 01:13PM
Subject: Re: Your website - Healthcare IT difficulties




      Thanks for the quick reply, feel free to quote me or share the e-mail (I have nothing to hide) if you think it will help matters. The last part of the mail was rushed as my wife requested I drive her over to visit our infant grandson who was ill with croup. She wanted me to reassess him again, so I had to go.


I was going to add at the end of the mail that becoming paperless was legally hazardous, as there have been instances of data being lost or corrupted in the health services I worked for, and that lack of a written or electronic record leads to grave difficulties in mounting a defence, as well as being professionally slack. This was a particular problem in the out of hours service IT system in Lanarkshire when complaints were received. Luckily I had kept independent written records of my work that vindicated me in the face of complaint and indeed allowed me to address a complainant's concerns or fears. 


The NHS out of hours has gone from the patient or their family being able to talk directly to a doctor (our old system, run by the local GP's in a cooperative) with all calls being dealt within two hours (visit, consultation at centre, advice, prescription or referral to other service) to contacting a centralised answering service (NHS 24) where calls are processed by a nurse referring to algorithms.


This, as you can imagine has led to various problems and some notable disasters (mainly with meningococcal infection) or inappropriate advice or referral. I worked extensively in the various out of hours services that existed over the years in Scotland and developed an expertise in detecting the sometimes very subtle signs of meningococcal or other life threatening conditions at an early stage. Indeed I developed an instinct and a feel for these potential problems being present when taking the initial telephone call. With the system that now prevails delay in arranging the face to face consultation with the doctor is sometimes delayed for six hours or more or, worse still, innapropriate advice is given with instructions to call back if there is a problem (this from a centre that is being overwhelmed with calls and which is experiencing difficulties in dealing with patient demand).


 I remember on several occasions encountering distressed mothers, bearing seriously ill children at the door of the out of hours service, who had rejected the algorithm generated advice they had been given and simply rushed to where they knew they could get help. Following the advice given in some cases would have led to a tragedy.


My point is simple, the cumbersome IT systems and procedures that have been adopted nationally in the UK act as a barrier between the patient and the physician both in speed of access to care (out of hours situation) and to effective person to person communication (surgery consultations), and therein lies hazard. Everybody seems to look at the screen instead of each other! It would appear that the computer now has a usurped dominant role in the theoretical 'doctor led' or 'patient led' balance in consultation as it takes information input, or slowly and reluctantly provides output of necessary information. Goodness, now I'm personifying a machine!


Scot, I listened to your interview and appreciated what you said and I wish you every success; you would seem to be a voice crying out in a glittering, attractive, expensive technological wilderness that needs to be listened to by our political masters. Enormous amounts of money have been spent in introducing systems that, in my view, have led to greater clinical inefficiency in terms of delay for patients accessing care and which have impaired how a doctor-patient consultation runs and develops.


Best regards, Geoff Carlin.