Records, the universe and everything

Here is a surprising gem that I found this morning - "Records, the universe and everything" is part of a presentation entitled "Where is THE medical record?" given by David Markwell to the Primary Health Care Specialist Group of the British Computer Society back in September 1996.  Enjoy...

Carrie Byte sifted through the envelopes on her desk. She had already searched the practice computer without finding anything of interest. Her face was a picture of tired resignation. She was about to see Arthur Dent. She had never met him before, but her senior partner had once told her something about him. She could not remember what it was, but she did recall it was unusual. Without the record she would be at a serious disadvantage.

She lifted the phone and dialled.

"Hello, George. Mr Dent's record doesn't seem to be here."

George apologised and said he would look for it. As Carrie hung up the phone, there was a knock at the door and, almost immediately, in walked a nondescript man.

"Hello, I'm Arthur. I expect that you are Dr Byte."

Carrie agreed that she was, asked what she could do for him, and apologised that his record was missing. He smiled and said that he had been away for a few years.

"Your record is probably with the FHSA", she suggested.

"Perhaps the Vogons mislaid it when they destroyed the planet", he countered.

"What do you mean?" she asked.

"I admit the FHSA is more likely, but never dismiss the improbable."

"Good advice for a doctor - but tell me what I can do for you today", Carrie said, trying to regain control.

The smell of coffee percolated through the door and she wanted to get this consultation finished. After another knock at the door George entered, carrying three thick Lloyd George envelopes.

"I found it, Doctor."

Arthur noticed that Carrie looked more downcast by the size of the records than she had been by their absence.

"Bit of a trilogy, isn't it, Doctor?" he quipped.

She smiled and he continued "Don't panic! I only want to know the results of my last hospital visit. Your partner, Morris Oxford, referred me for an opinion."

Ten minutes later she had waded through letters, printouts from other practice computers and reams of notes and established that the hospital letter was missing. It took ten more minutes for George to find it in Dr Oxford's in-tray.

As Author left the room he turned and said "Just one more thing, Doctor." Her heart dropped.

"I have a friend who has really good ideas about piles of paper. He'd help you find the right information more easily and have time for a coffee break."

"Oh yes", she replied sceptically.

"Yes", he said emphatically. "You must meet him. One o'clock in the Frog and Sparrow, and bring a towel."

He spoke with such authority that she felt obliged to join Arthur and his friend at the appointed time. Arthur introduced Mr Prefect who frowned as he greeted her and said "No towel. You've forgotten the towel. Oh well, I suppose it doesn't matter."

He took from his pocket a small box with the words "Don't panic!" written on it. "This", he said, "is what Arthur was telling you about."

By the end of lunch break she was convinced. A week later her practice had installed the Instant Transfer Computerised Heath Hyper Record. At the heart of this system, known as the ITCH-Hyper Record, was the concept of the improbably distributed record. Few people understood it, but that didn't seem to matter. It promised an end to 'missing record' misery and it really worked. Within three months, every practice, every hospital and every community unit in the country had installed the ITCH-Hyper Record. Clinical information entered anywhere was seamlessly shared by everyone, subject to necessary and appropriate security constraints. The age of information sharing had arrived, dreams of patients outshining paper became reality, the wood was seen, the trees were spared and crocks of gold appeared under every rainbow.

Six months later Carrie started to worry. She was looking at a record which showed a high blood sugar result two days previously. She switched screens to check the advice on her decision support system. She returned to the record and the blood sugar was normal. The first time it happened she assumed she had misread the screen. The next day it happened to another patient's record, and then another. She queried it with the lab. They said there had been some errors in a batch of tests but insisted they were corrected immediately. Then why, she wondered, had she seen the erroneous results nearly a week later? Soon the medical press were full of stories of similar incidents. Ford Prefect explained by saying "The old record is cached and not refreshed until it is re-accessed. It's just a glitch: we'll fix it."

The next problems Carrie noticed were intermittent gaps in records. These were accompanied by ubiquitous "Don't panic!" messages accompanied by icons depicting sporting events. Enquiries to the support desk were met with the patronising response and brief explanation that the tennis racket meant a 'service fault', the rugby ball a 'line out' and the golf club 'open links'. These errors became more common and it was inevitable that before long the system acquired the less flattering nickname "The Glitch".

Just over a year after Carrie's meeting in the Frog and Sparrow, she was the defendant in the first court case in which two incompatible versions of a patient's ITCH-Hyper Record were presented as evidence. Both carried all the marks of authentication as the genuine record for the same patient. The judge asked for explanations. Ford and Arthur attempted to explain about caches, probability, post-dating, modification, repudiation and the importance of towels for galactic hitchhikers. The judge was unimpressed and asked a simple question: "Where is THE medical record for this patient?"

Ford asked for clarification and the judge obliged. "Where are the original records of the clinical information recorded by each of the health care professionals involved in the care of this patient?"

Ford regarded the judge as a child who wanted to open a television to look for the people inside. He made a contemptuous remark and was silenced.

Arthur came to the rescue. "It's like this, I think. It's sort of everywhere. Well, everywhere in the cyberspace defined by thirty thousand clinical systems in the UK. That is, it could be anywhere, but nobody knows where, and of course, nobody really needs to." The judge was silent for half a minute. During those thirty seconds several dolphins spontaneously appeared, unnoticed, in the courtroom. Then the judge spoke very slowly and deliberately: "I need to know and I need to know now. Otherwise, how can I determine which of these pieces of so-called evidence is genuine?" He paused, waiting for a response. As the silence continued, Ford and Arthur vanished, having hitched a lift on a passing Dolphinian space trawler. The silence resumed. The dolphins smiled and vanished, still unnoticed.

Then the judge summed up. "It is claimed that the medical record is everywhere. That it is distributed across what has been called cyberspace. Yet, since we find that in two places it differs, from a legal perspective there are at least two versions. Neither of these can be located and nor can they be separated or distinguished from one another, except by the factual differences in the statements they contain. It follows that I am unable to determine the legal status of either. Therefore, for the purposes of this court, I rule that this patient's medical record is located nowhere. Since something that is nowhere does not exist, I further rule that it is inadmissible in this court. This being the case, can anyone present any evidence that will help this court to reach a judgment?" There was another pause while the judge and others noticed the absence of the expert witnesses. He smiled and added: "I presume that Messrs. Ford and Dent are now distributed in a manner similar to their records. Is there a shred of evidence to assist us with this case?"

Carrie passed forward a page torn from her diary on which she had made a few rough scribbles. Her counsel rose. "If it please your honour, I have here a piece of paper written on by Dr Byte at the time. It appears to corroborate her account." The judge, having studied the paper, passed it to the plaintiff's legal team and asked if they offered any further evidence. After a hasty conversation with their client, they indicated that no more evidence would be offered and the case was dropped.

The profession was not always the beneficiary of this legal precedent. Patients who made their own rough notes immediately after consultations won otherwise absurd cases against doctors unable to cite admissible medical records. Within a few weeks most GPs were reopening their filing cabinets, brushing the dust off their pens and relearning elaborate hieroglyphics. The ancient art of doctors' writing was reborn. Years later, when Carrie retired, she cleared out her desk and found a perfect glass replica of a 3.5" computer disk. She didn't know where it came from, but it reminded her of the heady days of her youth when she really believed paperless practice had arrived.

Interesting to see a summary of the conference agenda and links from the proceedings still online and active.