#EHRPersonas – blogpost on CCIO site

Here is a post on the CCIO website on the recent EHR Personas workshop organised by eHealthIreland:


The HSE’s Chief Information Officer and the Clinical Strategy and Programmes Directorate are currently developing ‘Personas’ and ‘Scenarios’ to support the introduction of Electronic Health Records (EHR). As part of this project, a series of workshops for those working in the health services and also patients/service users was held on January 31stand February 1st.

One of the challenges of developing an EHR is capturing the diversity of needs it must address. Even a seemingly straightforward clinical setting will involve multiple interactions with multiple information sources. Contemporary mental health practice is focused on the community, but at the same time acute psychiatric units now co-located in acute general hospitals, and mental health issues very commonly arise simultaneously with general health needs, there is considerable overlap with the hospital system. Mental health services increasingly integrate multiple models of mental health, not only a purely medical one; while simultaneously safe psychiatric practice requires access to laboratory and imaging systems to the same degree as other medical disciplines.

Mental health services are therefore interacting with hugely complex information networks. Capturing all this complexity in a useful form is a considerable challenge. Personas and scenarios allow the expertise of patients and clinicians to be synthesised and for assumptions about what an EHR is for and can do to be challenged.

As a participant in a service provider workshop, I naturally enough was grouped with other mental health professionals. Most of our team were mental health nurses – in the community, delivering therapies and liaising with general hospital staff. We also had representation from pharmacy and administration, and myself as a psychiatrist. Other workshops include the diverse range of health professionals that make up a multidisciplinary community mental health team.
The service user persona was Tom, a 19 year old student from Mayo who has recently started university in Dublin. Tom’s friends notice he is more withdrawn and generally “not himself” and are sufficiently concerned to persuade him to attend the college health services where he sees a GP. There a physical examination, blood work and a urine drug screen are performed. A referral is made via HealthLink to a community mental health team. However a couple of nights later Tom becomes much more distressed and tells his friends he needs to escape from black-coated men following him everywhere. Tom’s friends bring him to the local Emergency Department where he is medically assessed and referred for a psychiatric opinion.

The scenario attempted to address how an EHR would address multiple issues that effect current mental health practice – from communication between primary care and mental health services to the avoiding duplication of investigations and of questioning.

One of the most persistent items of feedback from mental health service users is the initial contact with services involving much repetition of the same questions – often including biographical and demographic data – at a time of distress and anxiety.There is also frequently repetition of investigations and physical examinations, even when these have already been performed.

In our scenario, the situation developed with Tom deciding to move back home to Mayo and re-presenting to his local GP. This brought up a whole range of issues around the interaction between primary care, student health services, the mental health services across different catchment areas and regions. In our group, we discussed how the issue of access to the National Shared Record could play out with various permutations of consent from Tom, and the impact this could have on his care.

The second persona focused on a community mental health nurse, Ann, on her daily routine of calling to service users across a geographically dispersed mixed urban/rural area, engaging with clients at various stages of recovery, and administering treatments such as depot injections of antipsychotic medication and centrally dispensed medication such as clozapine. In our scenario we introduced features typical of remote working in an environment where mobile connections are not always reliable. Features such as the ability to work offline and upload updated records when back online were discussed.

In both service user and clinician scenarios, it became clear that if technology is to improve how health systems work for the benefit of the patient, it is in many ways by becoming invisible, by making the clinical interaction frictionless and about the person at its heart. The need for repeated, intrusive and unnecessary investigations – and questioning – could be reduced, allowing therapeutic interactions to take place unhindered. Both personas, and both scenarios, reinforced for me that the health system must have the service user – such as Tom – at its heart, and the delivery of healthcare is ultimately by people – such as Ann.

At its best, technology can enable this ultimately deeply personal interaction, rather than acting as another barrier, another “system” to be navigated.

Behind the Heimlich manoeuvre – review of books by Henry Heimlich, Cecil Helman, Henry Marsh, TLS 15 October 2014

Probably the highlight of my writing career so far . Not only because of its place of publication (and its featuring on the website) but also because it is the most fully realised piece I have written. It functions well as an honest to goodness book review but has a personal perspective that my work often lacks. Or seems to lack.

I would love to explore the theme of the opening paragraph – about the general dissatisfaction many doctors feel, and how much of this is situation dependent, and how much is inherent to either the work or themselves – further.


978 1 61614 849 2

978 1 78161 019 0

978 0 297 86987 0

Published: 15 October 2014

In the Western world, at least, the medical profession generally enjoys high status. For sociologists, doctors incarnate various forms of power disparities. Medical science and medical technology have made spectacular progress since the Second World War; procedures such as LASIK laser eye surgery, to give just one example, that once would have seemed magical, are now near-routine.

And yet an air of discontent is evident in much of the discourse of modern medicine. Like many others, the medical profession is under question, if not attack, on a range of fronts. Complementary remedies are increasingly popular, often with practitioners as well as patients, despite the advent of evidence-based medicine and numerous books that have discredited their claims to efficacy. A succession of scandals in Britain and elsewhere has undermined public trust in doctors and nurses. Lewis Terman’s classic study of “gifted” individuals, published in 1954, found that physicians tended to feel inferior relative to those of comparable attainment in other fields, and the Grant Study, George Vaillant’s epic survey of adult development, following the Harvard Class of 1944, identified self-doubt as the feature distinguishing physicians from control subjects.

Henry Heimlich’s autobiography does not provide much evidence of self-doubt or of feelings of inferiority. The Heimlich manoeuvre is one of those medical interventions which have embedded themselves in public consciousness; so much so that I imagined the process was named after some nineteenth-century titan, like an anatomical feature such as the ampulla of Vater or the foramen of Magendie. Heimlich is not merely a historically recent figure, born in 1920, but is still with us. The autobiography opens in 1979 with a demonstration of the manoeuvre on Johnny Carson, on theTonight Show. Like Christian Barnaard, Heimlich was one of the celebrity doctors of the 1960s and 70s; an odd kind of fame, and one which seems to have evaporated. We do not lack for media medics, or doctors-turned-politicians, but a few sports surgeons aside, fame purely on clinical grounds is now unknown.

Heimlich grew up in New Rochelle, New York, overcame the anti-Semitism of the American medical school admission process, and, in January 1945, was drafted as a medical officer to the Sino-American Cooperative Organization, otherwise known as the US Naval Group, China. In Camp Four, at the edge of the Gobi Desert, Heimlich recounts his medical efforts with scant resources and support. He describes improvising a cream to treat trachoma, and is haunted by the death of a soldier whose gunshot-induced chest wound was impossible to drain. This death would inspire his later invention of the flutter valve, his other major medical innovation.

After Camp Four, and his establishment as a surgeon, the book’s focus shifts to medical innovations. Heimlich’s first claimed innovation is the Reversed Gastric Tube Operation, where a tube is created from the stomach to replace a damaged oesophagus. The book is most alive in recounting his innovations and the thought processes that went into them; there are significant gaps in the story between each innovation. While some of the more controversial aspects of his later career – such as an advocacy of malariatherapy for HIV and the removal of the Heimlich manoeuvre from the American Red Cross guidelines for choking – are addressed briefly, the reader would not discover from the book that Heimlich’s own son, Peter, has devoted himself, since 2002, to trying to discredit his father. At the very least, this sturdy, workmanlike account of steady advancement of medical knowledge and uncomplicated life-saving, in the face of opposition from the medical establishment, is not the complete picture.

Cecil Helman died from motor neurone disease in 2009. He was a GP in London, originally from South Africa, and after retiring from clinical practice in 2002 became Professor of Medical Anthropology at Brunel University. In this book, a successor to his Suburban Shaman (2006), Helman continues to advocate listening to the patient and attending to narrative. He repeatedly contrasts ideal practice with various brisk and efficient, and often technologically orientated practitioners. We meet Dr A, “an example of this new breed of doctor – the ones I call ‘techno-doctors’”. Dr A “likes nothing better than to sit in front of a computer screen, hour after hour, peering at it through his horn-rimmed spectacles”. Counterpoised to this is a practice rooted in listening to the patient, and recounting their story.

Each chapter is based on a vignette from clinical practice, related to a concept from the humanities – usually anthropology. For instance, Helman tells us of the pain of a patient which travels across his body, impervious to any intervention and without any discernible physical cause. This pain reminds Helman of the dybbuk, in Jewish folklore the restless soul of a dead person which takes possession of another. He later considers the power of diagnostic labels, the importance of a personal myth and how disease can undermine it, and various other concepts, always related back to his own clinical experience.

Helman’s book is discursive, and readable in the tradition of much medical writing. One suspects that Dr A is something of a straw man, and by putting listening to the patient in opposition to other aspects of practice, I fear that Dr Helman may have been stretching things to make a rhetorical point (surely one can make use of technology in practice, even be something of a “techno-doctor”, and nevertheless put the patient’s story at the heart of practice?) Furthermore, in its own way a recourse to anthropology or literature to “explain” a patient’s story can be as distancing, as intellectualizing, as invoking physiology, biochemistry or the genome. At times the anthropological explanations seem pat, all too convenient – even reductionist.

Nevertheless, there is considerable wisdom here, and one would have no hesitation in recommending this to medical students or doctors in training. In increasingly overloaded medical curricula, where an ever-expanding amount of physiological knowledge vies for attention with fields such as health economics and statistics, the fact that medicine is ultimately an enterprise about a single relationship with one other person – the patient – can get lost. Helman discusses the wounded healer archetype, relating it to the shamanic tradition. He is eloquent on the accumulated impact of so many experiences, even at a professional remove, of disease and death: “as a doctor you can never forget. Over the years you become a palimpsest of thousands of painful, shocking memories, old and new, and they remain with you for as long as you live. Just out of sight, but ready to burst out again at any moment”.

Henry Marsh, recently retired Consultant Neurosurgeon at St George’s Hospital in London, practised a speciality that seems abstruse and mysterious even to other medics. Do No Harm is almost an exemplar of Helman’s palimpsest image. Marsh trod the path from PPE at Oxford to medicine, rather than the Cabinet, and almost accidentally encountered neurosurgery (often not formally taught in medical schools).

Do No Harm is a difficult book to read, not formally or technically – Marsh has a fluid, informal style – but because of the sheer sense of exposure. Puns aside, neurosurgery is at the cutting edge of what it means to be, not only a doctor with limited power to cure or palliate, but to be human. Operations have the potential, even when they seemingly go well, to cause catastrophic effects. As Marsh weighs up the decision to enter the speciality, a neurosurgeon tells him “the operating is the easy part, you know. At my age you realise that the difficulties are all to do with the decision-making”. We accompany Marsh on his post-operative ward rounds, and while at times we read of a recovery and delighted gratitude, more memorable for Marsh and the reader are the times when the worst possible news has to be “broken”.

As a young surgeon, Marsh “lost the simple altruism I had had as a medical student . . . . I became hardened in the way doctors have to become hardened and came to see patients as an entirely separate race from all-important, invulnerable young doctors like myself”. This detachment fades in the later years of practice, and Marsh himself experiences cancer, divorce and the implacable workings of the NHS bureaucracy. This latter force is the subject of some of the most entertaining passages of the book; the world of targets, of endless managerial shell games based on the premiss that mere terminological changes will be enough to transform healthcare, emerges as one divorced from the messy realities of clinical care. The grandiloquent rhetoric about the NHS’s being “the envy of the world” (I’m sorry to inform British readers that the majority of the world doesn’t occupy itself with comparative healthcare enough to feel any such emotion) is also exposed as a continual attempt to plaster over deficiencies in care with words.

With one exception, each chapter is named after a neurological condition (“pituary adenoma”, “neurotmesis” etc) which relates to the clinical vignette around which the chapter is structured. The exception is the chapter entitled “hubris”, and Do No Harm could also profitably be distributed to graduating medical students as a warning against the arrogance so commonly associated with the profession.

We follow Marsh beyond the operating room and the wards. He is part of a National Institute of Clinical Excellence (NICE) technology appraisal, where he wonders “how many of the people sitting round the hollow square [of the meeting room] understood the difficulties and deceptions involved in treating patients who are dying, where the real value of a drug such as this one is hope”. He nevertheless sees these appraisals as important counterbalances to the power of pharmaceutical companies, and is amused that in the US healthcare debates they are seen as “death panels”. Reading a text on the philosophy of mind, he finds himself falling asleep, his conviction that what we are is determined by the clump of neurons that makes up the central nervous system unchanged.

Clearly Henry Heimlich’s account is, at the very least, contested: the use of malariatherapy to treat HIV and of the Heimlich manoeuvre to treat seemingly everything is far from evidence-based practice. In any case, its narrative of medical heroism is one that jars with the honesty and vulnerability displayed by Cecil Helman and, especially, Henry Marsh. The simple idea that doctors themselves are of the same flesh and blood as their patients, a fact often forgotten on both sides of the relationship, is at the core of both Do No Harm and An Amazing Murmur of the Heart. Not all of us are doctors, but all of us – including doctors – can be and will be patients. A wider acceptance of this idea, within the profession and society itself, might aid medicine in healing itself.