Cross Talk on gunning the engines of telecare

In his first column of 2008, Mike Cross finds some unexpected parallels between the development of First World War fighter planes and an emerging healthcare technology.



Spring 1916. German Fokker fighter planes are clearing the skies of allied aircraft, thanks to their ability to fire machine guns directly forward through their own propellers.

After a few weeks of frantic work, the boffins of the Royal Flying Corps unveil an aircraft that can fight back. The BE9 has a second cockpit complete with machine gun in front of the pilot, mounted precariously on an extension of the propeller shaft. "In both respects, it's a useful model for the dangers that await efforts to transform public services through new technology – and especially healthcare."

Even by the standards of the Western Front, it was an unacceptable death trap. Aircrews refused to fly the "pulpit" and only a handful of prototypes were built. Eventually, the British saw the sense of copying the German solution, a mechanism that interrupted the machine gun for the fraction of a second that a propeller blade was in the way. The slaughter in the air continued, but on more equal terms.

Learning the lessons of history

The sad story of the BE9 is an object lesson in the "not invented here" syndrome: the temptation to produce a novel – if Heath-Robinson - solution to a given problem, instead of adopting something – better – because it was dreamed up by someone else.

It's also a warning of the pitfalls of trying to transform a system simply by bolting on a new bit to carry out a specific function. In both respects, it's a useful model for the dangers that await efforts to transform public services through new technology – and especially healthcare. “Telecare is the healthcare equivalent of being able to shoot straight ahead from a fighter plane… but we need to get it right.”

Telecare at twelve o’clock

Take telecare, for example. Nearly everyone who encounters the technology gets excited by the great things that can start to happen when we move information, rather than a physical person, to assess and monitor a patient's condition.

Rightly so: telecare is the healthcare equivalent of being able to shoot straight ahead from a fighter plane. We need to get it right, though.

We need to be sure that we are not building a BE9 by needlessly re-inventing an existing technology. Even more important, we need to be sure that the "tele" bolt-on does not unbalance the entire system. Most people with experience in telecare trials will have had experience of both.

Take the basic question of access to an essential underlying technology, broadband. The demographic profile of people with access to broadband is almost exactly the opposite of the demographic profile of people who would benefit most from telecare. "After several false starts, we seem to be getting the technology bit right."

Providing universal access will require a great deal of creative, holistic, thinking by the public and private sectors of a kind that hasn't previously been seen in British public policy.

Or take the softer, behavioural, aspects of telecare. It is well known that people's behaviour (and even physiology) change when they interact with a medical professional. Telecare can use this to advantage by collecting data that is unbiased by the "physician effect".

But is this the end of the story? What happens when patients consciously or unconsciously start to fool the system? What happens when doctors consciously or unconsciously start to make decisions based on some quirk in the technology rather than real symptoms?

What happens to a balanced and apparently well managed health system when telecare exposes a sudden and unexpected need for a new type of intervention?

Back in the real world…

Difficult questions. We can try to understand them by drawing on history, but we also need to remember that healthcare is more complicated than shooting down Messerschmitts.

After several false starts, we seem to be getting the technology bit right. With so much commercial off-the-shelf kit available, there is little excuse for re-invention (though we can hope that the burgeoning consumer market in electronic medical devices will be a good mother for design innovation).

The new world of interchangeable hardware and data technologies is at last achieving a rarely-discussed side effect. If IT and clinical experts can spend less time on the build process, then more resource can finally be allocated to that previously often forgotten issue: what the day-to-day user experience is actually like.

About the author: Michael Cross is a freelance journalist specialising in healthcare informatics and e-government. He is a member of the British Computer Society.