The Case for the PCEHR

7 February 2012

On July 1st, 2012, the Australian government will launch the Personally-Controlled Electronic Health Record, which will be an online summary of your health and medical problems. Against the wishes of of consumer reference groups, doctors, and most of the designers of the system, it will be opt in; if you want one you'll have to ask for it.

In order to educate people about its existence and benefits, a number of scenarios have been devised to illustrate how it will work. Unfortunately, I'm not convinced they are particularly compelling. They include people going on holiday (domestically) and needing their gall bladder out, the sort of thing that is currently handled with irritation but without real difficulty, and which people won't see the benefits until after the fact.

Here's how I think it should be done: sign up for a PCEHR and avoid an unnecessary colonoscopy.

Now, nobody wants a colonoscopy, but they really don't want one they don't have to have. Yet up and down the country, when people move GPs or go to hospital or experience what they think is an unrelated problem, they have a conversation that goes "colonoscopy? Ooh. Three years ago. Or was it four? Did they find anything? Gosh, it all seems so long ago. I don't remember, but I don't think so..." and so their poor doctor sends them off for another scope.

Imagine if, instead, we could easily find out the last was two years ago, that the symptoms were caused by benign conditions, and that a repeat was recommend for five years time?

One in threeish Australians will need a colonoscopy at some point. Don't have more than you need. Get a PCEHR.

Another eHealth vignette

1 November 2011

A security researcher has devised an attack that hijacks nearby insulin pumps, enabling him to surreptitiously deliver fatal doses to diabetic patients who rely on them.

A few years ago I was trying to work out how I might be able to get to Black Hat or Defcon, both conferences where you really want to leave anything more complex than a wristwatch at home. I figured that attacks on medical devices might be an interesting talk, if a little ethically dubious. However, people have beaten me to the punch, with work some years ago on stopping people's pacemakers remotely, and so on.

Compare and contrast with my previous post - too much (or the wrong sort of) security or not enough.

An eHealth vignette

18 September 2011

How eHealth is supposed to work:

A busy orthopaedic registrar is able to review postoperative radiographs of yesterday's tertiary hospital patients from the peripheral hospital they are working at that day using a secure portable device or the in-hospital computer system.

How eHealth actually works:

A busy orthopaedic registrar texts his resident who looks up the images, takes a picture using their personal mobile and sends it by MMS over the public mobile network to the registrar’s iPhone.

People get really concerned about security and confidentiality of information when building new health information systems but the reality is that our inability to keep up with consumer-grade technology means official systems just get bypassed. I don’t know how to solve this problem, and I’m starting to wonder whether we can or should.

My least favourite IPv6 features

8 June 2011

It's world IPv6 day!

Having spent the last few years making IPv6 work at UCC whenever it breaks and trying to extend its reach inside and outside our network, I am often surprised by how many bad ideas there are involved. Most of these, I suspect, are because IPv6 was designed in the 1990s and now we're trying to implement it in a vastly different networking world.

My favourite thing about every single IPv6 presentation ever is that they spend the first four slides telling us about how many more address 128 bits gives us than 32 bits and conveniently forget the bit where there are only 64 bits for actual networks, with the second 64 bits dedicated to the host address. As far as I can tell this is to avoid having to do stateful autoconfiguration (DHCP) and also prevent widespread port scanning.

It turns out, though, that stateless autoconfiguration is not hugely helpful; your statelessly-autoconfigured address always contains the same host part, so you end up with the same host address on any network you plug into, and now every website you visit can uniquely identify your computer. You can turn on IPv6 Privacy Extensions, but then we're right back at IPv4-style autoconfiguration with duplicate address detection and so on. Widespread portscanning has also gone out of fashion since IPv6 was designed, mostly thanks to NAT and the near-ubiquitous deployment of firewalling; attacks against network systems have just moved on.

The reason I don't like this is because it is such a huge waste of prefix space; there's a whole 64 bits dedicated to the host address on each network, despite the fact that the most common identifiers (Ethernet addresses) are only 48 bits. Every point-to-point link wastes 63 bits of the IPv6 address. And if we invent a medium in which you need even close to 64 bits in a single broadcast domain in the lifetime of IPv6 I will be stunned.

Of course all this pales in comparison with the glorious ideological decision to make it effectively impossible for a host with only an IPv4 address to communicate with a host with only an IPv6 address, but still, happy IPv6 day! I could also go on to complain about IPv6 forward and reverse DNS, the lack of useful IPv6 debugging tools and advice, or everything involved with net.ipv6.bindv6only but it's the future; let's just make it work.

Day One

18 January 2011

Today was my first full day working as a junior medical officer or intern.

I've actually been employed for over a week but have been orientated, reoriented and disoriented by various organisations to the point where I was actually quite glad to get some real work done today. It was a bit of a long day so I thought I'd write down what I ended up doing. I work in a regional hospital in a team where there is just me and a consultant GP who spends all day in the hospital, which is pretty different from how the big tertiary hospitals work.

I walked onto the ward at about 0730. My first job was to acquire a list of patients, which is run off by the clerical staff in the regional hospital where I'm working. Most of the patients' names were familiar to me, so I spent a few minutes looking up the laboratory results of the patients who had been admitted to my team overnight. Because the pathology system isn't great, this took quite a while. Then I dealt with some more employment housekeeping and snagged a quick cup of coffee. I'm new on the ward, and my team hasn't had an intern before, so nobody is asking me to do things yet.

My consultant arrived about 0800. We check the list of patients together and decide how the day is going to work. He spent most of yesterday stabilising the sick patients, so today he decides that the first order of business is to send some people home. I leave him to do some of the work on the medical ward and go to the medical/surgical ward to find out why someone has disappeared off our list (they shouldn't have) and send one patient home. He is improving, although he is currently on intravenous antibiotics which you need to be in hospital for (with some caveats) - I work out the equivalent doses of pills, write a prescription and explain the follow-up arrangements to the patient.

I head back to the medical ward. I let my consultant know what's happened, tidy up a few pieces of paperwork and try and get my head around the new computer system (without success). Next, I chase up the report for a CT scan - sometimes this requires a lot of legwork but in my case I just look in the back of the filing cabinet to find it. Unfortunately, the CT report means that the patient needs to be seen by the surgical team, so I quickly review the case file, have a chat to the patient without trying to freak them out too much about surgery, then call the consultant surgeon. Calling consultants is great; registrars in general will do anything to avoid taking a patient, while consultants usually only listen for about fifteen seconds before saying yes. The patient I was trying to send home is having issues with pharmacy, so my consultant sorts things out and we drop the new scripts to the pharmacy department.

We move on to the geriatrics ward, stopping to search unsuccessfully for the rumoured free scones. We have a patient who needs to go to Perth reasonably urgently, which is something of a logistical nightmare - the nurses and the nurse manager are super-helpful here because they know all the local systems and the forms that need to be filled in. My boss finds a consultant in Perth to accept the patient and I write a transfer letter. The new computer system means I lose my draft twice, which makes me particularly cheerful. Then we see a couple more patients briefly to work out whether we need to do anything urgently. The nurses offer us a slice of cake, and it's getting pretty close to lunchtime so we graciously accept (read: stuff it into our faces Cookie Monster-style).

Around 1300 we manage to get back to the medical ward where one of our patients has developed an irregular heart rhythm. This is pretty concerning so we try some easy tricks to try and get her back into a normal rhythm; no success and we discover that this has been happening regularly at home. The nurses organise another ECG while I walk to the high dependency unit (the only part of the hospital that does continuous cardiac monitoring) to find out how we can get the patient in there. I have to ring the physician in charge of the unit, who comes down to see the patient, and there is a little bit of messing around. My consultant disappears and reappears with some more cake, the closest we have gotten to lunch, and we stuff it into our faces again while waiting for a decision from the HDU staff.

It's now time to start seeing the more complex patients, so I disappear to organise a psychiatric consultation for one of our patients who is struggling with mood issues. This involves reading the case file, seeing the patient for the first time, evaluating his mood state, writing some notes, making a recommendation to the consultant and filling in a form that the clerical staff fax to the psychiatrist, all of which takes the best part of an hour.

This sort of thing continues for the next few hours; I fill in forms, chase results, phone people, and make notes as my consultant sees patients. I haven't left the wards at all yet. Lunch, about 1500, is half of a salad roll that the boss locates somewhere; at 1600 I duck down to the psych wing where a mate is the intern, who offers me a muesli bar and a coffee, but I only sit down for a few minutes before getting stuck into it again.

At 1800, we are finally getting to the bottom of our list; the patient laughingly accuses us of standing around eating cake when we apologise for the delay in getting to him. We identify a couple of changes to medication charts, and then duck back to the medical/surgical ward to see a couple more patients, including one man who is new to the ward. My consultant finally disappears about 1845; I spend the next half-hour writing medication charts for our new patient and rewriting the chart for a patient who has filled theirs up, as well as doing some IV fluid orders for one of the nurses. 1915 sees me flop into the doctors' common room after having broken just about every "golden rule" of internship (eating, drinking and using the toilet regularly). The surgical intern is there waiting to review a patient, and we look at each other in amazement at having made it through the day! Once I sit down I don't want to get up, so it takes me half an hour before I'm on my bike heading home.

I think I probably spent about thirty percent of the day doing actual clinical work, which is probably more than many interns in the city; the rest of the time is taken up in communication, either via paperwork, making notes, phoning people, or discussing our plans with the nurses. I will get faster at just about all of it, but there's still more to do - discharge summaries, procedures, and admitting patients on my own. Here's hoping by the end of the year that I'm smashing through it all!