What next for electronic communication and health care?

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Abstract
What we learnt from the submissions The editorial announcing our theme issue resulted in the submission of nearly 100 articles—more than has been submitted for any other theme issue. The snapshot they provide shows that new media and communication tools are already transforming the way in which we communicate, learn, and think. The expansion of the internet, the launch of personal electronic assistants, and the penetration of wireless networks are making new relationships between doctors and the public possible. At the same time, they are exposing the weaknesses of our conventional approaches to clinical care, education, and evaluation of new interventions. We believe that we are just scratching the surface of the possibilities created by electronic communications. We can no more foresee the shape or extent of their effects on the health system than our ancestors could have foreseen the blossoming of science that followed the invention of the printing press.2 Impact on health: where art thou? Our original editorial solicited articles that shed light on how new electronic applications could improve people's health—yet many of the submissions reported process measures far removed from health outcomes. For example, several papers described clinical decision software but gave no information on whether its use actually improved patient care in practice. We discovered how new electronic tools are being used to perform old tricks (for example, data entry on to handheld computers rather than into paper records), but not adequate answers to the question, “So what?” Many of the submitted papers reported plausible clinical interventions but were rejected because they lacked any recognisable evaluation other than “acceptance” by patients or doctors. We learnt that assessing the impact of communication technologies might not be as simple as importing conventional methods of evaluation—such as randomised controlled trials. Although these could answer many of our evaluative questions, they may not have sufficient flexibility and power to handle the complex, dynamic, and rapidly expanding nature of the internet.3 Are the rapid developments in information and communication technologies outpacing our ability to judge their impact? The return of the human Although we expected the theme issue to be interesting mostly for electronic innovations, we found people's relationships with these of greater interest. A qualitative study of handheld computers was a case in point: despite almost identical equipment, doctors exhibited four distinct patterns of engagement with it—non-use, niche use, routine use, and power use (p 1162). We also learnt that when things go wrong—as they seem to do in more than half the cases—people tend to blame “the technology,” whereas social, behavioural, psychological, and cultural factors are the most likely culprits. In her editorial, Nancy Lorenzi argues that we cannot introduce new technology into a system without changing behaviour, and sets out the steps people need to go through (p 1146). Stephen Walsh brings a careful clinician's eye to the subject of electronic health records and contrasts the naive assumptions that they embody with how doctors actually work (p 1184). Warning bells are ringing for the NHS's new National programme for Information Technology. Michael Humber notes: “Its successful implementation will affect the ways in which people work and services are delivered” (p 1145), but the agency charged with ensuring its usability “continues to be concerned about the engagement of clinicians.”4 These same bells are tolling everywhere else. Enrico Coiera argues that the human element needs to be imported into health informatics. This will require a shift in its “sacred ground,” which is currently dominated by computers, the web, information architectures, and the creation of enormous taxonomies. To have a meaningful impact on health, health informatics must move closer to the profane world of politics, culture, persuasion, messy implementation, and user complaints. In short, the world of humans (p 1197). Other contributors to the issue looked at how some relatively simple technology could help with complicated human interactions. Daniel Klass's editorial on online learning and Jill Russell and colleagues' evaluation of the CHAIN network were both concerned with the transmission of “tacit” knowledge (pp p 1147, p 1174). This is knowledge that can't be transmitted in formal, systematic language; its personal quality makes it hard to formalise and codify. It is what philosopher Michael polanyi is talking about when he says: “We know more than we can tell.”5 Harnessing this tacit dimension will be decisive in the transformation of the health system in the age of the internet.2