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6 December 2011
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Lessons from month three as a Clinical Fellow

This month’s lesson is about the importance of understanding the bigger picture, or trying to...

As the multibillion pound NHS National Programme for IT goes down the pipes and we fail to 'connect for health' clinicians, patients, and policy makers everywhere scratch their heads about how to drag NHS Health IT into the 21st,.  So how to get smart, digital, improve patient care, and save money?

If health care professionals and patients were connected to a big health network that allowed the exchange of digital health information, well, that would be a start. But how to set up such a network? Could an existing network we're all already connected to be used for this?

I think part of the answer lies within recent history and has to do with large general purpose networks and general purpose computing.

Trains were of limited use before a railway network, and telephones were of limited use before a telephone network. Fragmented point to point connections were a necessary, but not very useful, stepping stone on the way to the much more comprehensive, and useful, mature networks of today.

The realization that the telephone network once established could function as a general purpose network, the internet, and transmit any type data has been revolutionary. From voice calls, to fax, to text messaging and webpages, music and video, the general purpose network can serve them all and gain value in virtue of its general usefulness.

Of course, the general purpose network could not have arisen without a lack of restriction and control, openness and freedom have been essential to allowing innovation and unlocking the value of the network. This has broadly occurred despite digital restrictions management (DRM) seeking to control and limit the general network and the general computers for financial gain.

The emergence of the general purpose computer has been critical in unlocking much of the value of the general purpose network, numerous physical devices such as telephones, fax machines, vcrs, radios, televisions, books, and stereos, can all be replaced by applications on the general purpose computer.

I'd like to make an observation on the general purpose network and the general purpose computer:

1. Huge scales of economy operate, increased usefulness leads to more people using the technology which leads to more people investing in making the technology cheaper and improving its usefulness.

The corollary of this is that small scale implementations, or pilots, are unlikely to deliver significant value.

2. It is also worth observing that the implementation of new network applications such as email has not been evidence based, yet few would contest the usefulness and value of email as an additional communication medium.

So small scale, evidence based pilots, of Health IT networks might fail to demonstrate value.

But should a healthcare IT network run on the general network or develop its own railway?

3. It's time Health IT stopped being considered as a special case. Healthcare data is precious but so is health and for this reason Health IT needs to catch up with the 21st century. In my opinion, to be effective, Health IT must take place on general purpose computers attached to the general purpose network (the internet).

Overly rigid information governance, corporate IT staff resistant to change, and large proprietary software companies who lobby to maintain the status quo, must now be overcome in order to deliver effective Health IT.

We have the computers, we have the internet, we just need the applications. Adopting the Veterans Health Administrations open source and comprehensive electronic medical record system 'VistA' would be a good start....


  1. Adam Darkins (talk)
  2. Information Rules Carl Shapiro (book)
  3. Free Culture Lawrence Lessig (book)
  4. Cory Doctorow: Computer and Internet Regulation (
  5. Logging in and logging out: Patient safety on ward rounds Gordon Caldwell (;article=BJHCM_17_11_547_553 - paywall)

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12 years 2 months ago

Dear Carl,

Thanks for this. Insightful comments. The NHS IT debacle represents a catastrophic failure - not just for financial reasons but also for patients. It amazes me that this hasn't made more headline news.

As you say it is also amazing that given that the NHS has loads of computers (albeit slow), an information portal (N3 albeit overworked and with too many barriers) and loads of people looking for information we cannot use applications to solve both data protection and patient pathway problems.

One of the issues is vision and priorities. I know of trusts who won't allow a wireless network for their healthcare staff but are quite willing to provide a paid for one for patients. Not quite sure this is useful precedent.

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