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There have been several recent calls for better data on NHS outputs and outcomes in England, which will require new data collection with long lead times. In this, the first of two articles, the authors show what can be done now with existing routine data across many sectors and raise issues about assumptions and technical aspects for discussion.

Lack of infrastructure, including information and communication systems, is considered a barrier to successful HIV treatment programmes in resource poor areas. The authors describe how they set up a web based medical record system linking remote areas in rural Haiti and how it is used to track clinical outcomes, laboratory tests, and drug supplies and to create reports for funding agencies

Electronic communication promises to revolutionise the delivery of health care. In the second of two articles considering the potential for email consultations, Car and Sheikh summarise the evidence about public and professional attitudes to them and discuss how to ensure their safe use

One of the key elements of the NHS information strategy of 1998 was the development of electronic patient records.1 These were expected to be developed within organisations and to be capable of being linked into a patient focused electronic health record, which would form a lifetime record of health and health care for each patient within the NHS.1 This vision has been modified slightly by updates of the strategy, and the electronic health record has been renamed and redefined as the NHS Care Record Service, but in many ways the original concept has remained the same.2 The purpose of the electronic health record—now the NHS Care Record Service—is twofold. Firstly, to provide support for the clinical team to help them recall and communicate health status and treatments for patients in a coordinated way, and, secondly, to act as the source of statistical information on types of patients seen and the process and outcomes of their treatment. Although there was much expectation that these goals could be achieved, there was little evidence to prove that this was the case for the original strategy and its subsequent refreshes.2 For that reason, the NHS Information Authority sponsored 18 pilot projects which ran from April 2000 to March 2003 to test the concepts in several locations. The central Hampshire electronic health record pilot project was supported from September 2000 to March 2003. During that time it evaluated the practicality of linking records from a wide range of organisations to support emergency and out of hours care, as well as providing information that could support data analysis and clinical governance. The project, originally based at North and Mid-Hampshire Health Authority, linked with several key organisations within the area, which included three general practices (one in Eastleigh and Test Valley South primary …

Objectives: To systematically review cost benefit studies of telemedicine. Design: Systematic review of English language, peer reviewed journal articles. Data sources: Searches of Medline, Embase, ISI citation indexes, and database of Telemedicine Information Exchange. Studies selected: 55 of 612 identified articles that presented actual cost benefit data. Main outcome measures: Scientific quality of reports assessed by use of an established instrument for adjudicating on the quality of economic analyses. Results: 557 articles without cost data categorised by topic. 55 articles with data initially categorised by cost variables employed in the study and conclusions. Only 24/55 (44%) studies met quality criteria justifying inclusion in a quality review. 20/24 (83%) restricted to simple cost comparisons. No study used cost utility analysis, the conventional means of establishing the “value for money” that a therapeutic intervention represents. Only 7/24 (29%) studies attempted to explore the level of utilisation that would be needed for telemedicine services to compare favourably with traditionally organised health care. None addressed this question in sufficient detail to adequately answer it. 15/24 (62.5%) of articles reviewed here provided no details of sensitivity analysis, a method all economic analyses should incorporate. Conclusion: There is no good evidence that telemedicine is a cost effective means of delivering health care.

Information and its handling and transmission form an essential part of health care and are reflected in professional standards. Automated information systems in health care—health informatics services—will improve these functions and bring new opportunities through the harnessing of modern information and communications technologies. Thus, computer support is now essential in many parts of medicine, the US Institute of Medicine has long espoused the value of computerised patient records,1 and many countries have developed strategies on this topic, and there are countless health related internet sites. However, as new information and communication technologies in health bring new opportunities, they also bring new risks. Emphasis has rightly been placed on ensuring appropriate levels of confidentiality in electronic information systems—to the point that the highly exacting requirements being demanded by independent commentators and professional bodies2 are difficult to satisfy without jeopardising the functioning of core services 3 4 or the interests of the most vulnerable groups.5 In contrast, much less thought has been given so far to ensuring the appropriateness of the design and integrity of functioning of health informatics services. #### Summary points Like drugs 40 years ago, products in health informatics are unregulated with regard to safety and efficacy A European project has now recommended ways of accrediting healthcare related software, telemedicine, and internet sites A scheme like CE marking of electrical goods is recommended for software, national regulatory bodies should be identified for telemedicine, and a European certification of integrity scheme developed for websites If informatics systems are increasingly essential in the delivery of health care then their integrity and quality must be of equal importance, but this has been scarcely recognised to date. In 1963 the then UK secretary of state for health stated to the House of Commons: “The House and the public suddenly …

Objectives: Use of cumulative mortality adjusted for case mix in patients with acute myocardial infarction for early detection of variation in clinical practice. Design: Observational study. Setting: 20 hospitals across the former Yorkshire region. Participants: All 2153 consecutive patients with confirmed acute myocardial infarction identified during three months. Main outcome measures: Variable life-adjusted displays showing cumulative differences between observed and expected mortality of patients; expected mortality calculated from risk model based on admission characteristics of age, heart rate, and systolic blood pressure. Results: The performance of two individual hospitals over three months was examined as an example. One, the smallest district hospital in the region, had a series of 30 consecutive patients but had five more deaths than predicted. The variable life-adjusted display showed minimal variation from that predicted for the first 15 patients followed by a run of unexpectedly high mortality. The second example was the main tertiary referral centre for the region, which admitted 188 consecutive patients. The display showed a period of apparently poor performance followed by substantial improvement, where the plot rose steadily from a cumulative net lives saved of −4 to 7. These variations in patient outcome are unlikely to have been revealed during conventional audit practice. Conclusions: Variable life-adjusted display has been integrated into surgical care as a graphical display of risk-adjusted survival for individual surgeons or centres. In combination with a simple risk model, it may have a role in monitoring performance and outcome in patients with acute myocardial infarction. What is already known on this topic The national service framework for coronary artery disease requires minimal standards of care and audit of patients with acute myocardial infarction but does not integrate clinical status into the audit tool Predictive models using only a few factors to adjust for case mix are easy to use and may be as accurate as more complicated methods Early identification of variations in patient outcome is not revealed by block audit, and, instead, a continuous monitoring process is required What this study adds Using just patients9 age, blood pressure, and heart rate to adjust for case mix, a continuous plot can be derived to compare observed and expected outcome for patients with acute myocardial infarction This method of monitoring outcome over time can be used as an early warning system to allow more detailed audit to be performed

OBJECTIVES: To compare use, effect, and cost of personalised computer education with community psychiatric nurse education for patients with schizophrenia. DESIGN: Randomised trial of three interventions. Modelling of costs of alternatives. PARTICIPANTS: 112 patients with schizophrenia in contact with community services; 67 completed the intervention. INTERVENTIONS: Three interventions of five educational sessions: (a) computer intervention combining information from patient's medical record with general information about schizophrenia; (b) sessions with a community psychiatric nurse; (c) "combination" (first and last sessions with nurse and remainder with computer). MAIN OUTCOME MEASURES: Patients' attendance, opinions, change in knowledge, and psychological state; costs of interventions and patients' use of NHS community services; modelling of costs for these three, and alternative, interventions. RESULTS: Rates of completion of intervention did not differ significantly (71% for combination intervention, 61% for computer only, 46% for nurse only). Computer sessions were shorter than sessions with nurse (14 minutes v 60 minutes). More patients given nurse based education thought the information relevant. Of 20 patients in combination group, 13 preferred the sessions with the nurse and seven preferred the computer. There were no significant differences between groups in psychological outcomes. Because of the need to transport patients to the computer for their sessions, there was no difference between interventions in costs, but computer sessions combined with other patient contacts would be substantially cheaper. CONCLUSIONS: The computer based patient education offered no advantage over sessions with a community psychiatric nurse. Investigation of computer use combined with other health service contacts would be worth while.

Editorial by Kelly The success of the internet poses two challenges to thinking about electronic networking in health care. One is technological: if you do not want to use the internet you need to show that your chosen alternative is more appropriate and cost effective. The second challenge is more conceptual. The internet embodies a particular way of thinking about communications, emphasising open and sustainable solutions. Are these the key concepts that should drive our thinking in health care, or are others more appropriate? At present the NHS has a dedicated private electronic network service called NHSnet, which has now been operational for four years. Throughout its history it has been dogged by negative publicity, stemming in part from unhappiness with the user charges levelled before 1999, a lack of useful resources to access, and detailed objections to policies for security and access to personal data.1 However, the NHS Executive signalled changes in its policies for NHSnet in late 1999,2 which might make it a more attractive option for clinicians. In addition, the NHSnet commercial contracts are due for renewal from 2002 to 2004, so there is merit in reviewing the current networking strategy to inform future decisions. #### NHSnet contracts through the private finance initiative The central backbone of NHSnet is provided under contracts, through the private finance initiative, with BT, BT Syntegra, and Cable and Wireless. John Denham, minister for health, stated in the House of Commons in April 1999 that NHSnet is: “provided to National Health Service organisations as a service by commercial contractors who funded its development and meet its running costs and are, therefore, confidential to the contractors.”5 The provision of the service is therefore notionally free, and the contractors gain their income from charges for use of the network. Until April 1999 individual NHS organisations and general practices had …

During a visit to India in March President Clinton watched a woman enter a village health centre, call up a web page on the computer, and get information on how to care for her baby.1 It is possible that this baby will have better health because of the availability of information on the internet. However, this possibility is underpinned by several assumptions, and the potential of information and communication technologies still has not been harnessed systematically to bring about important improvements in the health of populations, particularly among those who are poor and isolated in developing countries. This article explores the potential of advances in information and communication technologies to disseminate information and describes the availability of access to technology in developing countries. It also discusses issues of accuracy and the relevance of content. #### Summary points Information and communication technologies have not been harnessed systematically to improve the health of populations in developing countries These technologies empower those who use information by providing them with a choice of information to be accessed in their own time and by allowing them to put their own information on the web The current digital divide is more dramatic than any other inequity in health or income The quality of health information available on the web is inconsistent, and the visibility of research from developing countries is limited The way forward is to exploit the full interactivity of the internet, which allows rapid feedback and change to continuously mould information into useful knowledge Sources for this paper were obtained by searching Medline using the term dissemination and from visits to websites and links to related organisations known to be working in the areas of health research and information and communication technologies in developing countries. Information was also provided by key informants working in international health …

Computers may be used to support information management, general administration, and clinical practice in a health service. I review the last use, drawing on examples in child psychiatry. Advances have been made over the past 30 years in the use of computer aided assessment, diagnosis, and treatment in many clinical specialties. The place of computers in clinical practice depends on whether they confer an overall advantage, im whether they are acceptable to patients and clinicians. Child psychiatry is a clinical specialty: management rests very much on the skills of the clinician, with little use of automated investigation or instrumental intervention.1 Thus, the principles governing the use of computers in this specialty may apply to many other clinical specialties. Coiera forecast the essential role of informatics in medicine in the coming century, describing it as fundamental to medicine as the study of anatomy.2 However, the application of modern technology frequently fails because of inadequate dissemination, which I hope to overcome, at least in part, in this review. #### Summary points This article explores the use of information technology in child psychiatry, a specialty that relies almost entirely on clinical skills, so many of the principles may therefore be applicable to other specialties Use of computers in clinical practice is at present largely limited to computerised versions of written tests or interviews Future developments may use technologies such as voice activated software, graphics, measuring response time, tailored testing, and virtual environments for tests that cannot be transcribed to written tests or performed during standard clinical interviews Outcome studies are needed to assess the impact of such technology Clinicians are best placed to identify specific potential developments and should be alert to the possibilities presented by the increasingly flexible and sophisticated technology available I searched three databases (Medline, PsychLit, and BIDS) for references to …

Objective: To review research into patient satisfaction with teleconsultation, specifically clinical consultations between healthcare providers and patients involving real time interactive video. Design: Systematic review of telemedicine satisfaction studies. Electronic databases searched include Medline, Embase, Science Citation Index, Social Sciences Citation Index, Arts and Humanities Citation Index, and the TIE (Telemedicine Information Exchange) database. Subjects: Studies conducted worldwide and published between 1966 and 1998. Main outcome measures: Quality of evidence about patient satisfaction. Results: 32 studies were identified. Study methods used were simple survey instruments (26 studies), exact methods not specified (5), and qualitative methods (1). Study designs were randomised controlled trial (1 trial); random patient selection (2); case-control (1); and selection criteria not specified or participants represented consecutive referrals, convenience samples, or volunteers (28). Sample sizes were20 (10 trials),100 (14), >100 (7), and not specified (1). All studies reported good levels of patient satisfaction. Qualitative analysis revealed methodological problems with all the published work. Even so, important issues were highlighted that merit further investigation. There is a paucity of data examining patients9 perceptions or the effects of this mode of healthcare delivery on the interaction between providers and clients. Conclusions: Methodological deficiencies (low sample sizes, context, and study designs) of the published research limit the generalisability of the findings. The studies suggest that teleconsultation is acceptable to patients in a variety of circumstances, but issues relating to patient satisfaction require further exploration from the perspective of both clients and providers.

Objectives: To characterise the information needs of family doctors by collecting the questions they asked about patient care during consultations and to classify these in ways that would be useful to developers of knowledge bases. Design: Observational study in which investigators visited doctors for two half days and collected their questions. Taxonomies were developed to characterise the clinical topic and generic type of information sought for each question. Setting: Eastern Iowa. Participants: Random sample of 103 family doctors. Main outcome measures: Number of questions posed, pursued, and answered; topic and generic type of information sought for each question; time spent pursuing answers; information resources used. Results: Participants asked a total of 1101 questions. Questions about drug prescribing, obstetrics and gynaecology, and adult infectious disease were most common and comprised 36% of all questions. The taxonomy of generic questions included 69 categories; the three most common types, comprising 24% of all questions, were “What is the cause of symptom X?” “What is the dose of drug X?” and “How should I manage disease or finding X?” Answers to most questions (702, 64%) were not immediately pursued, but, of those pursued, most (318, 80%) were answered Doctors spent an average of less than 2 minutes pursuing an answer, and they used readily available print and human resources Only two questions led to a formal literature search. Conclusions: Family doctors in this study did not pursue answers to most of their questions. Questions about patient care can be organised into a limited number of generic types, which could help guide the efforts of knowledge base developers. Key messages Questions that doctors have about the care of their patients could help guide the content of medical information sources and medical training In this study of US family doctors, participants frequently had questions about patient care but did not pursue answers to most questions (64%) On average, participants spent less than 2 minutes seeking an answer to a question The most common resources used to answer questions included textbooks and colleagues; formal literature searches were rarely performed The most common generic questions were “What is the cause of symptom X?” “What is the dose of drug X?” and “How should I manage disease or finding X?”

Objectives: To explore general practitioners9 perceptions of effective health care and its application in their own practice; to examine how these perceptions relate to assumptions about clinicians9 values and behaviour implicit in the evidence based medicine approach. Design: A qualitative study using semistructured interviews. Setting: Eight general practices in North Thames region that were part of the Medical Research Council General Practice Research Framework. Participants: 24 general practitioners, three from each practice Main outcome measures: Respondents9 definitions of effective health care, reasons for not practising effectively according to their own criteria, sources of information used to answer clinical questions about patients, reasons for making changes in clinical practice. Results: Three categories of definitions emerged: clinical, patient related, and resource related. Patient factors were the main reason given for not practising effectively; others were lack of time, doctors9 lack of knowledge and skills, lack of resources, and “human failings.” Main sources of information used in situations of clinical uncertainty were general practitioner partners and hospital doctors. Contact with hospital doctors and observation of hospital practice were just as likely as information from medical and scientific literature to bring about changes in clinical practice. Conclusions: The findings suggest that the central assumptions of the evidence based medicine paradigm may not be shared by many general practitioners, making its application in general practice problematic. The promotion of effective care in general practice requires a broader vision and a more pragmatic approach which takes account of practitioners9concerns and is compatible with the complex nature of their work.

Objective: To examine the effect of the method of data display on physician investigators9 decisions to stop hypothetical clinical trials for an unplanned statistical analysis. Design: Prospective, mixed model design with variables between subjects and within subjects (repeated measures). Setting: Comprehensive cancer centre. Participants: 34 physicians, stratified by academic rank, who were conducting clinical trials. Interventions:Participants were shown tables, pie charts, bar graphs, and icon displays containing hypothetical data from a clinical trial and were asked to decide whether to continue the trial or stop for an unplanned statistical analysis. Main outcome measure:Percentage of accurate decisions with each type of display. Results: Accuracy of decisions was affected by the type of data display and positive or negative framing of the data. More correct decisions were made with icon displays than with tables, pie charts, and bar graphs (82% v 68%, 56%, and 43%, respectively; P=0.03) and when data were negatively framed rather than positively framed in tables (93% v 47%; P=0.004). Conclusions: Clinical investigators9 decisions can be affected by factors unrelated to the actual data. In the design of clinical trials information systems, careful consideration should be given to the method by which data are framed and displayed in order to reduce the impact of these extraneous factors.

Objective: To describe, and to test against trial data, a simple and flexible computer program for calculating cardiovascular risk in individual patients as an aid to managing risk factors and prescribing drugs to lower cholesterol concentration and blood pressure. Design: Descriptive comparison of actual cardiovascular risk in randomised controlled trials of cholesterol reduction with risk predicted by a computer program based on the Framingham risk equation. Comparison of the program9s performance with that of tables and guidelines by means of hypothetical case examples. Main outcome measures: Average risk of coronary heart disease and myocardial infarction. Results: The computer program accurately predicted baseline absolute risk in a UK population as well as the relative and absolute reduction in risk from cholesterol lowering for primary prevention of coronary heart disease. The program also allowed a more refined estimate of absolute risk of coronary heart disease than some existing tables and enabled the impact of prescribing decisions to be quantified and costed. Conclusions: This simple computer program to estimate individuals9 cardiovascular disease risk and display the benefits of intervention should help clinicians and patients decide on the most effective packages of risk reduction and identify those most likely to benefit from modulation of risk factors.

Objectives: To investigate the variability of patients9 length of stay in intensive care after cardiac surgery. To investigate potential interactions between such variability, booked admissions, and capacity requirements. Design: Mathematical modelling study using routinely collected data. Setting: A cardiac surgery department. Source of data: Hospital records of 7014 people entering intensive care after cardiac surgery. Main outcome measures: Length of stay in intensive care; capacity requirements of an intensive care unit for a hypothetical booked admission system. Results: Although the vast majority of patients (89.5%) had a length of stay in intensive care of ≤48 hours, there was considerable overall variability and the distribution of stays has a lengthy tail. A mathematical model of the operation of a hypothetical booking system indicates that such variability has a considerable impact on intensive care capacity requirements, indicating that a high degree of reserve capacity is required to avoid high rates of operation cancellation because of unavailability of suitable postoperative care. Conclusion: Despite the considerable enthusiasm for booked admissions systems, queuing theory suggests that caution is required when considering such systems for inpatient admissions. Such systems may well result in frequent operational difficulties if there is a high degree of variability in length of stay and where reserve capacity is limited. Both of these are common in the NHS. What is already known in this topic Booking systems for hospital admissions have considerable potential benefits for patients in terms of peace of mind and planning their lives, but these benefits are dependent on having a low cancellation rate What this study adds Variability in length of stay can have a major impact on hospital operation and capacity requirements. Operational research techniques can be used to explore this impact If variability in length of stay is substantial, as is common, then booked admission systems may require considerable reserve capacity if cancellation rates are to be kept low

Effective programmes for management of chronic disease are invariably supported by information technology. These have typically been developed within secondary care, with limited access available to primary care. The British government's white paper The New NHS clearly states that a dedicated NHS network service (NHSnet), linking information systems in primary and secondary care, will be working by 2002.1 Although this could improve the flow of information between primary and secondary care, thereby improving patient care,1 there are, quite rightly, grave concerns about the security and confidentiality of patients' data both in terms of who has legitimate access and who has illegitimate access to the data. 2 3 Furthermore, it cannot be assumed that all general practitioners will be willing to spend the time and money necessary to connect to NHSnet and to conform to its code of connection,4 especially as more than one in eight general practitioners are already connected to and familiar with the internet5 and, increasingly, internet service providers are free of charge (apart from telephone charges). Users of NHSnet, however, will be charged for connection and use, the costs of which are not yet known. These are major concerns for general practitioners and may be a reason for the poor uptake of NHSnet by general practice.5 In addition, although NHSnet could increase hospitals' and general practices' access to patients' data, this information will still not be available within the patients' homes. This is exactly where general practitioners, seeing sick patients whom they may not know, need immediate access to this information. Internet technology could also allow patients access to their own data, thereby empowering them to allow appropriate healthcare professionals access to their data. We suggest that the internet will be as good, if not better, an integrating network as NHSnet, providing …

The government white paper The New NHS has suggested that all general practices will be connected to NHSnet, the NHS computer network, by the year 2002.1 NHSnet is a secure private network based on internet technologies. It will be the largest public sector project to connect computers in this country since the early 1980s, when the Joint Academic Network (JANET) was created by the universities and research councils. The policy decisions relating to security, networking products, and funding that were taken when JANET was created are pertinent to NHSnet and require deeper consideration and wider discussion. ### Summary points The Joint Academic Network (JANET) and the NHS network NHSnet are both large, widespread computer networks in the United Kingdom, and the lessons learnt in creating JANET should be considered for NHSnet Policy decisions about security, connectivity, and finance have a great effect on the type of network that is created Confidentiality is of paramount importance in NHS communications, and it is vital that NHSnet has secure safeguards built into it Connecting a computer to thousands of others must make it less secure; security has to be the remit of end users The Computer Board for Universities and Research Councils was formed in 1966 in response to difficulties in funding computing resources in the tertiary education and research sector.2 The board initially concentrated on funding computers in individual universities but increasingly came to focus on the provision of shared regional systems to allow access to large scale computing. The board also fostered the development of computer networks, primarily to provide access to powerful shared facilities that were being set up in the 1970s. In 1975 a working party recommended a rolling programme of investment in network services and the creation of a unit to oversee developments to facilitate networking. With this encouragement, …

The government white paper The New NHS , published in December 1997,1 reaffirmed the NHS Executive's commitment to an NHS-wide electronic network. The network was originally conceived in essentially administrative terms, but it is now to be used to support clinical work. Now is therefore a good time to consider the future direction of NHS networking. This article focuses on the economic and political issues of electronic networks in primary care and considers two questions. Firstly, can the benefits of networks outweigh the costs, or are they simply poor investments? Secondly, if a case can be made, then what problems will need to be addressed in the new networking strategy? #### Summary points The NHS computer network, NHSnet, was originally oriented towards administration but is now to be designed to support clinical work It is possible to construct a positive case for a large scale network for healthcare settings, based mainly on economic arguments It is also possible to identify conditions that need to be met before the positive case can be translated into reality Some of these conditions could be met in the near future, but others will require changes in attitudes and values that will have to be tackled in the longer term Assessment of the chances of success of an NHS-wide network is hampered by a lack of empirical evidence about the costs and benefits of networks in health care Implementation of the 1992 information management and technology strategy2 was slower than the NHS Executive originally hoped. 3 4 Concern has been expressed about elements of the strategy, notably about data security5 and the failure to show that the investments made to date have been worth while.6 It has been claimed that the strategy will save £100m a year,7 but after five years there is …

Odds ratios are a common measure of the size of an effect and may be reported in case-control studies, cohort studies, or clinical trials. Increasingly, they are also used to report the findings from systematic reviews and meta-analyses. Odds ratios are hard to comprehend directly and are usually interpreted as being equivalent to the relative risk. Unfortunately, there is a recognised problem that odds ratios do not approximate well to the relative risk when the initial risk (that is, the prevalence of the outcome of interest) is high. 1 2 Thus there is a danger that if odds ratios are interpreted as though they were relative risks then they may mislead. The advice given in many texts is unusually coy on the matter. For example: “The odds ratio is approximately the same as the relative risk if the outcome of interest is rare. For common events, however, they can be quite different.”3 How close is “approximately the same,” how uncommon does an event have to be to qualify as “rare,” and how different is “quite different”? #### Summary points If the odds ratio is interpreted as a relative risk it will always overstate any effect size: the odds ratio is smaller than the relative risk for odds ratios of less than one, and bigger than the relative risk for odds ratios of greater than one The extent of overstatement increases as both the initial risk increases and the odds ratio departs from unity However, serious divergence between the odds ratio and the relative risk occurs only with large effects on groups at high initial risk. Therefore qualitative judgments based on interpreting odds ratios as though they were relative risks are unlikely to be seriously in error In studies which show reductions in risk (odds ratios of less than one), the odds ratio …

Objective To describe where papers come from in a systematic review of complex evidence. Method Audit of how the 495 primary sources for the review were originally identified. Results Only 30% of sources were obtained from the protocol defined at the outset of the study (that is, from the database and hand searches). Fifty one per cent were identified by “snowballing” (such as pursuing references of references), and 24% by personal knowledge or personal contacts. Conclusion Systematic reviews of complex evidence cannot rely solely on protocol-driven search strategies.

Since 1948 the NHS has provided universal coverage that is free at the point of use, funded largely from taxation. Reforms have come and gone, but until the late 1990s they had been applied similarly across the four countries of the UK. Although the NHS has never been homogeneous, in practice the policy differences between the countries have been marginal compared with the similarities. However, in 1998 the Labour government devolved power to an elected parliament in Scotland, an elected assembly in Wales, and, until it was suspended in 2002, an elected assembly in Northern Ireland. Although the powers of each political body differ, each has important freedoms with respect to NHS policy. As a result, in England, the emphasis has been on national targets to improve performance (particularly reducing waiting times), increasing capacity, and sharper market-style incentives. In Scotland, the 1990s quasi-market has been abolished and steps taken to build a professionally led, integrated system based on concepts such as managed clinical networks. In Wales, the focus has been on improving the public health through partnership working between the local NHS, local government, and communities, and in Northern Ireland, developments have been stalled by political uncertainty.1 2 What is the effect of these differences in emphasis of policy? We used routine data on performance of the NHS in each country to compare health indicators for 2002-3 with those in 1996-7 (before devolution). The baseline data were from a previous study by one of the authors.3 We present six sets of indicators relating to health, per capita expenditure, inputs (such as staff and beds), activity (such as inpatient and day case rates), rates of selected operations, and other outputs (such as waiting times). After collecting the data, we tried to contact people with overall responsibility for health statistics …

OBJECTIVES: To describe the context for implementing the national programme for information technology (NPfIT) in England, actual and perceived barriers, and opportunities to facilitate implementation. DESIGN: Case studies and in depth interviews, with themes identified using a framework developed from grounded theory. SETTING: Four acute NHS trusts in England. PARTICIPANTS: Senior trust managers and clinicians, including chief executives, directors of information technology, medical directors, and directors of nursing. RESULTS: The trusts varied in their circumstances, which may affect their ability to implement the NPfIT. The process of implementation has been suboptimal, leading to reports of low morale by the NHS staff responsible for implementation. The overall timetable is unrealistic, and trusts are uncertain about their implementation schedules. Short term benefits alone are unlikely to persuade NHS staff to adopt the national programme enthusiastically, and some may experience a loss of electronic functionality in the short term. CONCLUSIONS: The sociocultural challenges to implementing the NPfIT are as daunting as the technical and logistical ones. Senior NHS staff feel these have been neglected. We recommend that national programme managers prioritise strategies to improve communication with, and to gain the cooperation of, front line staff.

Objectives To determine how often reprints of scientific publications are shared online, whether journal readership level is a predictor, how the amount of file sharing changes with the age of the article, and to what degree open access publications are shared on non-journal websites. Design The internet was searched using an application programming interface to Google, a popular and freely available search engine. Main outcome measures The proportion of reprints of journal articles published between 1994 and 2004 from within 13 subscription based and four open access journals that could be located online at non-journal websites. Results The probability that an article could be found online at a non-journal website correlated with the journal impact factor and the time since initial publication. Papers from higher impact journals and more recent articles were more likely to be located. On average, for the high impact journal articles published in 2003, over a third could be located at non-journal websites. Similar trends were observed for the delayed or full open access publications. Conclusions Decentralised sharing of scientific reprints through the internet creates a degree of de facto open access that, though highly incomplete in its coverage, is none the less biased towards publications of higher popular demand.

To identify features of clinical decision support systems critical for improving clinical practice.Systematic review of randomised controlled trials.Literature searches via Medline, CINAHL, and the Cochrane Controlled Trials Register up to 2003; and searches of reference lists of included studies and relevant reviews.Studies had to evaluate the ability of decision support systems to improve clinical practice.Studies were assessed for statistically and clinically significant improvement in clinical practice and for the presence of 15 decision support system features whose importance had been repeatedly suggested in the literature.Seventy studies were included. Decision support systems significantly improved clinical practice in 68% of trials. Univariate analyses revealed that, for five of the system features, interventions possessing the feature were significantly more likely to improve clinical practice than interventions lacking the feature. Multiple logistic regression analysis identified four features as independent predictors of improved clinical practice: automatic provision of decision support as part of clinician workflow (P0.00001), provision of recommendations rather than just assessments (P = 0.0187), provision of decision support at the time and location of decision making (P = 0.0263), and computer based decision support (P = 0.0294). Of 32 systems possessing all four features, 30 (94%) significantly improved clinical practice. Furthermore, direct experimental justification was found for providing periodic performance feedback, sharing recommendations with patients, and requesting documentation of reasons for not following recommendations.Several features were closely correlated with decision support systems' ability to improve patient care significantly. Clinicians and other stakeholders should implement clinical decision support systems that incorporate these features whenever feasible and appropriate.

Objective To evaluate the effect of implementing comprehensive, integrated electronic health record systems on use and quality of ambulatory care Design Retrospective, serial, cross sectional study. Setting Colorado and Northwest regions of Kaiser Permanente, a US integrated healthcare delivery system. Population 367 795 members in the Colorado region and 449 728 members in the Northwest region. Intervention Implementation of electronic health record systems. Main outcome measures Total number of office visits and use of primary care, specialty care, clinical laboratory, radiology services, and telephone contact. Health Plan Employer Data and Information Set to assess quality. Results Two years after electronic health records were fully implemented, age adjusted rates of office visits fell by 9% in both regions. Age adjusted primary care visits decreased by 11% in both regions and specialty care visits decreased by 5% in Colorado and 6% in the Northwest. All these decreases were significant (P < 0.0001). The percentage of members making ≥ 3 visits a year decreased by 10% in Colorado and 11% in the Northwest, and the percentage of members with ≤ 2 visits a year increased. In the Northwest, scheduled telephone contact increased from a baseline of 1.26 per member per year to 2.09 after two years. Use of clinical laboratory and radiology services did not change conclusively. Intermediate measures of quality of health care remained unchanged or improved slightly. Conclusions Readily available, comprehensive, integrated clinical information reduced use of ambulatory care while maintaining quality and allowed doctors to replace some office visits with telephone contacts. Shifting patterns of use suggest reduced numbers of ambulatory care visits that are inappropriate or marginally productive.

In the second of their two articles about using existing routine data to assess performance in the NHS, the authors make practical suggestions about using data for mental health care, potentially avoidable deaths, and forecasting coronary heart disease outcomes, and raise issues about assumptions and technical aspects for discussion

Objective Firstly, to assess the completeness of ascertainment in the National Congenital Anomaly System (NCAS), the basis for congenital anomaly surveillance in England and Wales, and its variation by defect, geographical area, and socioeconomic deprivation. Secondly, to assess the impact of the lack of data on pregnancies terminated because of fetal anomaly. Design Comparison of the NCAS with four local congenital anomaly registers in England. Setting Four regions in England covering some 109 000 annual births. Participants Cases of congenital anomalies registered in the NCAS (live births and stillbirths) and independently registered in the four local registers (live births, stillbirths, fetal losses from 20 weeks' gestation, and pregnancies terminated after prenatal diagnosis of fetal anomaly). Main outcome measure The ratio of cases identified by the national register to those in local registry files, calculated for different specified anomalies, for whole registry areas, and for hospital catchment areas within registry boundaries. Results Ascertainment by the NCAS (compared with data from local registers, from which terminations of pregnancy were removed) was 40% (34% for chromosomal anomalies and 42% for non-chromosomal anomalies) and varied markedly by defect, by local register, and by hospital catchment area, but not by area deprivation. When terminations of pregnancy were included in the register data, ascertainment by NCAS was 27% (19% for chromosomal anomalies and 31% for non-chromosomal anomalies), and the geographical variation was of a similar magnitude. Conclusion The surveillance of congenital anomalies in England is currently inadequate because ascertainment to the national register is low and non-uniform and because no data exist on termination of pregnancy resulting from prenatal diagnosis of fetal anomaly.

Electronic communication promises to revolutionise the delivery of health care. In the first of two articles considering the potential for email consultations, Car and Sheikh summarise the evidence about their use for preventive health care, health education, and managing non-urgent conditions

Dr X is back from her annual leave. Dr Y, the locum doctor, reports on the patients he saw during her absence, including a 40 year old teacher who had sprained her right ankle. Returning from a conference, she had stumbled while walking down the stairs with a heavy bag. Examination revealed a moderately swollen lateral right ankle. The patient was able to walk but was clearly in pain. Her breath smelt of alcohol. Dr Y had applied the Ottawa ankle rules—decision rules designed to exclude fractures of the malleolus and the midfoot—and found no bone tenderness.1 He had previously visited the website of a centre for evidence based medicine2 and printed out a list of diagnostic tests that can rule out, or rule in, the condition in question without requiring further investigations. The probability of disease, given a positive or negative test result (post-test probability), is usually obtained by calculating the likelihood ratio of the test result and using formulas based on Bayes's theorem (see box 1), or a nomogram,3 to convert the estimated probability of the suspected diagnosis before the test result was known (pretest probability) into a post-test probability, which takes the result into account.4 Likelihood ratios indicate how many times more likely a test result is to be expected in a patient with the disease compared with a person free of the disease and thus measure a test's ability to modify pretest probabilities. David Sackett and others have argued that such calculations are unnecessary when a test is highly sensitive or highly specific.4–6 In this situation the likelihood ratio of a negative test will generally be very small, and the likelihood ratio of a positive test very large. A negative test will thus rule out, and a positive result …

To look for evidence of a relation between antibiotic resistance and prescribing by general practitioners by analysis of prescribing at both practice and individual patient level.Repeated cross-sectional study in 1995 and 1996.28 general practices in the Ninewells Hospital laboratory catchment area, Tayside, Scotland. SUBJECTS REVIEWED: 8833 patients registered with the 28 practices who submitted urine samples for analysis.Resistance to trimethoprim in bacteria isolated from urine samples at practice and individual level simultaneously in a multilevel model.Practices showed considerable variation in both the prevalence of trimethoprim resistance (26-50% of bacteria isolated) and trimethoprim prescribing (67-357 prescriptions per 100 practice patients). Although variation in prescribing showed no association with resistance at the practice level after adjustment for other factors (P = 0.101), in the multilevel model resistance to trimethoprim was significantly associated with age, sex, and individual-level exposure to trimethoprim (P0.001) or to other antibiotics (P = 0.002). The association with trimethoprim resistance was strongest for people recently exposed to trimethoprim, and there was no association for people with trimethoprim exposure more than six months before the date of the urine sample.Analysis of practice level data obscured important associations between antibiotic prescribing and resistance. The results support efforts to reduce unnecessary prescribing of antibiotics in the community and show the added value of individual patient data for research on the outcomes of prescribing.

To attract internet users to an educational website on colorectal cancer, the US Centers for Disease Control and Prevention (CDC) posted advertisements on Yahoo!, an internet search engine used by 232 million people worldwide.1 The six week campaign included 12 advertisements in four formats (“east module,” “north banner,” “large rectangular,” and “streaming video large rectangular”—see bmj.com for examples) posted in locations throughout Yahoo!. Exposure to the advertisements was limited to health professionals and selected lay populations. Through a hyperlink, a software function that transfers users from one internet location to another,2 3 those who selected or “clicked” on an advertisement were transferred to the SFL website (Screen for Life: National Colorectal Cancer Action Campaign) (www.cdc.gov/cancer/screenforlife).4 5 The first phase of the campaign on Yahoo! lasted five weeks, from 29 April to 2 June 2002, and the advertisement space was paid for by the CDC. In …

Objectives To explore the process of knowledge exchange in an informal email network for evidence based health care, to illuminate the value of the service and its critical success factors, and to identify areas for improvement. Design Illuminative evaluation. Setting Targeted email and networking service for UK healthcare practitioners and researchers. Participants 2800 members of a networking service. Main outcome measures Tracking of email messages, interviews with core staff, and a qualitative analysis of messages, postings from focus groups, and invited and unsolicited feedback to the service. Results The informal email network helped to bridge the gap between research and practice by serving as a rich source of information, providing access to members' experiences, suggestions, and ideas, facilitating cross boundary collaboration, and enabling participation in networking at a variety of levels. Ad hoc groupings and communities of practice emerged spontaneously as members discovered common areas of interest. Conclusion This study illuminated how knowledge for evidence based health care can be targeted, personalised, and made meaningful through informal social processes. Critical success factors include a broad based membership from both the research and service communities; a loose and fluid network structure; tight targeting of messages based on members' interests; the presence of a strong network identity and culture of reciprocity; and the opportunity for new members to learn through passive participation.

The rise of the internet as a communication tool has resulted in the creation of ehealth interfaces as a service for those with illness. We describe how two online discussion lists for patients with chronic myelogenous leukaemia affect the health care of patients both individually and worldwide. The Chronic Myelogenous Leukaemia International Support Group was formed in 1998 by Robert Neill after his mother was diagnosed as having the condition. The list has 1500 subscribers and averages 28 new postings a day. A major feature of list discussions is the sharing of information and experiences of patients undergoing treatment for disease (figure). Random sampling of topics covered over five years by Chronic Myelogenous Leukaemia International Support Group In 1999, imatinib (Novartis), a drug in the …

The central Hampshire electronic health record (CHEHR) was constructed by linking several electronic patient records.1 Its two main objectives were to test the clinical usefulness of the electronic record in supporting emergency and out of hours care and to determine whether clinical data could be extracted and used to assess patient care. A clinical committee was established to determine access protocols for staff. All stakeholders were represented. Access to the central Hampshire electronic health record, training in its use, and consent conditions applied to several staff (box 1). The pilot ran from January to March 2003. Staff who used the system were asked to complete an evaluation form at the end of their shift. Overall, 148 forms were returned, mainly from eight staff (two senior house officers, two nurse advisers, two practice managers, and two general practitioners) who between them had accessed the system on more than 260 occasions. The senior house officers used the system most often. They had been partially funded by the project for the purpose of evaluation so they became expert, and fellow clinicians used them to access patient details. For social services access was restricted to patients' personal details, their registered general practitioner, and the social service record. Health service staff were allowed more access to the social services record and could access details of patients and residential or non-residential care. The social care plan is not held electronically and was therefore not available for the pilot. As only three practices participated in the pilot there were numerous occasions when there was no general practice record available for a patient in hospital. Patient records were found on only 47% of attempts. Even when records were found, they did not always contain useful information. Only 20% of forms reported finding the information being sought, but …

EDITOR—Ziebland et al investigated how the use of the internet affected patients' experience of cancer.1 The experiences reported by the patients they interviewed are certainly consistent with those that patients and families on the wards tell of internet use and are similar to findings of two surveys of Australian patients with cancer in Sydney.2 …

Objective To investigate whether information on mammographic screening presented on websites by interest groups is balanced, is independent of source of funding, and reflects recent findings. Design Cross sectional study using a checklist with 17 information items. Setting 27 websites in Scandinavian and English speaking countries. Results The 13 sites from advocacy groups and the 11 from governmental institutions all recommended mammographic screening, whereas the three from consumer organisations questioned screening (P = 0.0007). All the advocacy groups accepted industry funding, apparently without restrictions. In contrast the three consumer organisations acknowledged the risk of bias related to industry funding, and two of them did not accept such funding at all. Advocacy groups and governmental organisations favoured information items that shed positive light on screening. The major harms of screening, overdiagnosis and overtreatment, were mentioned by only four of these groups, but by all three sites from consumer organisations (P = 0.02). In addition, the chosen information was often misleading or erroneous. The selection of information items for websites did not reflect recent findings, apart from the consumer sites, which were much more balanced and comprehensive than other sites (median of 9 information items v3 items, P = 0.03). Conclusions The information material provided by professional advocacy groups and governmental organisations is information poor and severely biased in favour of screening. Few websites live up to accepted standards for informed consent such as those stated in the General Medical Council9s guidelines.

Objectives To describe the multicentre clinical databases that exist in the United Kingdom, to report on their quality, to explore which organisational and managerial features are associated with high quality, and to make recommendations for improvements. Design Cross sectional survey, with interviews with database custodians and search of electronic bibliographic database (PubMed). Studies reviewed 105 clinical databases across the United Kingdom. Results Clinical databases existed in all areas of health care, but their distribution was uneven—cancer and surgery were better covered than mental health and obstetrics. They varied greatly in age, size, growth rate, and geographical areas covered. Their scope (and thus their potential uses) and the quality of the data collected also varied. The latter was not associated with any organisational characteristics. Despite impressive achievements, many faced substantial financial uncertainty. Considerable scope existed for improvements: greater use of nationally approved codes; more support from relevant professional organisations; greater involvement by nurses, allied health professionals, managers, and laypeople in database management teams; and more attention to data security and ensuring patient confidentiality. With some notable exceptions, the audit and research potential of most databases had not been realised: half the databases had each produced only four or fewer peer reviewed research articles. Conclusions At least one clinical database support unit is needed in the United Kingdom to provide assistance in organisation and management, information technology, epidemiology, and statistics. Without such an initiative, the variable picture of databases reported here is likely to persist and their potential not be realised.

How is Africa to build up the medical research it needs? Doctors in African research communities are starved of access to the journals and texts their colleagues in more developed countries regard as fundamental to good practice and research. Isolation, burden of practice, and resource limitations make education and research difficult, but the rapid spread of access to the internet reduces these obstacles and provides an increasingly attractive means to disseminate information and build partnerships in education and research. The role of electronic health information in building local capacity to find, publish, and implement solutions has been emphasised recently in Science,1 Nature,2 the Lancet,3,4 and the BMJ.5 The Global Forum for Health Research gives priority to interventions designed to build research capacity in developing countries and correct the disparity in health research.6 The Coalition for Global Health Research (Canada) has recently reported how a major effort now can make a substantial difference.7 Access to reliable health information has been described as “the single most cost-effective and achievable strategy for sustainable improvement in health care.”8 We are interested in helping to build research, teaching, and clinical capacity for neglected yet substantial problems such as injury, which kills 5.1 million people annually.9-11

The authors are well known proponents of evidence based medicine and introduced the concept of patient oriented evidence that matters (POEMs) and disease oriented evidence in the early 1990s. The current study claims that the two main POEMS from the United Kingdom prospective diabetes study (UKPDS), namely that for patients with type 2 diabetes blood pressure control is more important than glycaemic control and that metformin should be first line therapy, are not well presented in review articles. It is odd, therefore, that they choose …

Objective To evaluate systematically the review literature on type 2 diabetes to assess transmission of the findings of the United Kingdom prospective diabetes study (UKPDS), an important source of recent valid patient oriented evidence that matters (POEMs). Design Inception cohort analysis of the recent medical literature. Studies reviewed Thirty five reviews on treatment of type 2 diabetes. Main outcome measures Presentation of three types of information from UKPDS in review articles: recommendations based on patient oriented outcomes of study; recommendations contradicted by patient oriented outcomes of study; and recommendations based on disease oriented outcomes for which no patient oriented evidence exists. Results Only six of the reviews included the POEM that tight blood glucose control had no effect on diabetes related or overall mortality. Just seven mentioned that metformin treatment was associated with decreased mortality. Most (30) of the reviews did not report that diabetic patients with hypertension benefit more from good blood pressure control than good blood glucose control. No review pointed out that treatment of overweight patients with type 2 diabetes with insulin or sulphonylurea drugs had no effect on microvascular or macrovascular outcomes. Thirteen reviews recommended drugs as first line treatment for which we do not have patient oriented outcomes data. The average validity assessment score was 1.3 out of a possible score of 15 (95% confidence interval 0.9 to 1.8). Conclusions Review articles on the treatment of type 2 diabetes have not accurately transmitted the valid POEM results of the UKPDS to clinicians. Clinicians relying on review articles written by experts as a source of valid POEMs may be misled.

Objectives To determine whether paperless medical records contained less information than paper based medical records and whether that information was harder to retrieve. Design Cross sectional study with review of medical records and interviews with general practitioners. Setting 25 general practices in Trent region. Participants 53 British general practitioners (25 using paperless records and 28 using paper based records) who each provided records of 10 consultations. Main outcome measures Content of a sample of records and doctor recall of consultations for which paperless or paper based records had been made. Results Compared with paper based records, more paperless records were fully understandable (89.2% v 69.9%, P=0.0001) and fully legible (100% v 64.3%, P < 0.0001). Paperless records were significantly more likely to have at least one diagnosis recorded (48.2% v 33.2%, P=0.05), to record that advice had been given (23.7% vs 10.7%, P=0.017), and, when a referral had been made, were more likely to contain details of the specialty (77.4% v 59.5%, P=0.03). When a prescription had been issued, paperless records were more likely to specify the drug dose (86.6% v 66.2%, P=0.005). Paperless records contained significantly more words, abbreviations, and symbols (P < 0.01 for all). At doctor interview, there was no difference between the groups for the proportion of patients or consultations that could be recalled. Doctors using paperless records were able to recall more advice given to patients (38.6% v 26.8%, P=0.03). Conclusion We found no evidence to support our hypotheses that paperless records would be truncated and contain more local abbreviations; and that the absence of writing would decrease subsequent recall. Conversely we found that the paperless records compared favourably with manual records.

Objective To establish current practice in the use of Read codes for diabetes. Design Cross sectional study. Setting 17 practices in the Battersea primary care group in southwest London. Data sources Computerised medical records. Main outcome measures Number of codes in use in all practices; variation in the use of codes between practices; and prevalence of Read code use in diabetic patients. Results At least 9 separate Read code groupings and 25 individual diabetes codes were in use in the 17 general practices. Only one Read code (C10, diabetes mellitus) and its subcodes was being used in all 17 practices, but its use varied from 14% to 98% of patients with diabetes. The use of other key Read codes for monitoring the care of patients with diabetes also varied widely between practices; for example, < 20% of practices used the code for the location of care. Less than half of patients (45%) with diabetes had their type of diabetes coded, and even fewer (21%) had measures such as the examination of the retina coded. Conclusions The use of Read codes for diabetes needs to be standardised and coding levels improved if valid diabetic registers are to be constructed and the quality of care is to be monitored effectively. Until all patients with diabetes have the C10 Read code recorded, clinicians will have to use a wide range of Read codes and prescribing data to ensure that diabetes registers are complete.

Patients have a right to information about their care. Information allows better understanding and greater involvement and enables patients to make choices if they wish.1 Information is also crucial to the concept of consent to treatment.2 Food and drink are withheld from people undergoing routine general anaesthesia, traditionally from midnight on the day of surgery. Recent evidence indicates that prolonged fasts are unnecessary in healthy people; one typical guideline allows a light meal six hours before and clear fluids up to two hours before induction of anaesthesia.3 How is this information presented to patients? We carried out a survey and textual analysis of materials gathered from 267 anaesthetic departments in the United Kingdom as part of the Royal College of Anaesthetists' patient information project.4 We noted the length of fast recommended, the …

Summary points: Implementation of a hospital information system in Limpopo Province, South Africa, failed. Problems arose because of inadequate infrastructure as well as with the functioning and implementation of the system. Evaluation using qualitative and quantitative methods showed that the reasons for failure were similar to those in computer projects in other countries. Reasons for failure included not ensuring users understood the reasons for implementation from the outset and underestimating the complexity of healthcare tasks. Those responsible for commissioning and implementing computerised systems need to heed the lessons learnt to avoid further waste of scarce health resources.

Objective: To assess whether transferring knowledge from specialists at centres of excellence to referring doctors through online consultations can improve the management of patients requiring specialised care. Design: Retrospective case review of the first year of internet based patient initiated consultations between referring doctors and consulting specialists. Setting: US teaching hospitals affiliated with an organisation providing internet based consultations. Participants: Doctors in various settings around the world engaging in internet based consultations with specialists. Main outcome measures: New recommendations for treatment, change in diagnosis, and turnaround time for consultation compared with time to see a specialist. Results: 79 consultations took place. 90% (n=71) of consultations were for services related to oncology. 90% of consultations involved new recommendations for treatment. The most common recommendation was a new chemotherapeutic regimen (68%, n=54). Diagnosis changed in 5% (n=4) of cases. The average turnaround time was 6.8 working days compared with an average of 19 working days to see a comparable specialist. Conclusions: Internet based consultations between specialists at centres of excellence and referring doctors contribute to patient care through recommendations for new treatment and timely access to specialist knowledge. Although change in diagnosis occurred in only a few cases, the prognostic and therapeutic implications for these patients may be profound. What is already known on this topic Telemedicine could improve health care by transferring knowledge from centres of excellence to patients9 doctors Few studies have systematically assessed the value of such internet based specialty consultations What this study adds Patients can benefit from internet based consultations between their doctor and consulting specialists New recommendations for treatment were discussed in 90% of cases, and change in diagnosis occurred in 5% of cases Patients can access a specialist9s opinion more quickly than waiting to see a specialist