Delayed prescriptions in primary care.

large reference set accessible behind it. The sensitivity and specificity of computer triggering, whether it be for prompts to label the indication of prescription in the record4 or to present PRODIGY,9 can, and must, be improved. Until clinical systems adopt one standard nomenclature (which the NHS has decided will be SNOMED CT), which includes subsets, then it is unlikely the intelligent user interface will develop and present the appropriate subset (with access if more depth is required). In this interregnum knowledge authors have a laborious task and require supportive tools. The synthesis of knowledge that the computer can intelligently present is possible but needs to be based on a robust funding model and with a defined innovation model. Technically supporting multiprofessional, multiorganisational communication with the patient in ‘control’ is entirely possible now. In the near future, intelligent browsing of knowledge, within or without care pathways, with the addition of computerised review of clinical actions (to spot the bad habits and alert the clinician to potential mistakes or out-of-date activity) will also be a possibility.10 These are all part of second release of PRODIGY when the ‘Integrated Care Record Services’ (ICRS) concept is ready to plug it in.5 In addition, the National Electronic Library for Health is making great efforts in the integration of diverse knowledge sources to provide a National Knowledge Service. What is needed for progress is basic interoperability (i.e. for computers to be able to talk to each other), scalable knowledge bases, and intelligent interfaces that support what goes on in the consultation. The challenge is to align the technical, the social and the professional issues with the aim of supporting patient-centred systems that operate across the shifting organisational boundaries. Will the new national IT programme’s approach to procuring the ICRS succeed? For the first time in a number of years I believe the approach to the problems might succeed — although there are many who do not and I can understand some of their misgivings. ICRS success or not, be prepared! We need new interoperability standards, and converting what you code into your proprietary system data structures will lose some meaning when it is converted into the standard. For any practice that has moved clinical systems I don’t need to tell you that this loss of meaning needs to stop. The more the systems communicate the more it will happen, and for any progress to be made we need these new standards. In addition, as the new market develops who knows who your supplier will be? I have learned over the years that political conflict rarely leaves you further forward. We need a sensibly paced journey that develops the tools while iteratively learning from the experience of the clinical users and patients. Of course, clinical behaviour needs to adapt so we can continually learn, improve quality, and respond more to the patients’ needs while using new tools that support us.11 In addition, we need the time to consult with patients to reduce the more unhelpful short cuts we take, and spot the bad habits that can result. The tools of ‘knowledge management’ are more than a technical approach, they are also about human behaviours and mind-sets, and the language used is not just evidence-based: it is experience-based, too.