And there is that Leviathan
The 17th century political philosopher Thomas Hobbes
believed passionately in the need for a strong central power as an
absolute prerequisite for the creation and continued existence of
civilised society. To create this power in the first place, he envisaged
(as did Rousseau a century later) a coming together of the population and
emergence of an agreement both to create the power and to select,
irrevocably, who was thereafter to wield it. Without such a concept, human
nature was such that there would be anarchy. “Life without Leviathan”, he
maintained in a stark aphorism, “would be nasty, brutish, and short”.
In this exceedingly compressed snapshot of Hobbes’s political thought,
there are a number of interesting parallels to be drawn with the
development of standards within healthcare and, in particular, within
healthcare computing. In the early stages of a new technology, there often
occurs a diversity of approach. In the early stages of sound recording —
for example, when Emile Berliner began in 1894 to manufacture the flat
discs that were soon to replace cylinder recordings — there was some
disagreement about the speed at which the disc should revolve. For both
The Gramophone Company and Victor, 78 rpm was the choice; for Columbia 80
rpm seemed better. The difference continued into the 1920s when, with the
emergence of electrical recording techniques, Columbia finally moved to 78
rpm. (In passing, and on the basis of personal observation, the 2 rpm
difference makes no difference at all to the listener!) When video
recording became commercially available in the late 1970s, a choice of
formats was available: Betamax and VHS. VHS soon became the format of
choice even though some regarded it as technically inferior. Both in the
case of the record industry and the video-recorder industry, the move to
standardisation was driven by a complex of reasons: the desire for
competitive edge, obviously, but also the realisation that agreement over
basics had far more to offer than disagreement. Hobbes was right: not only
in society, but in the marketplace, anarchy was destructive and ways had
to be found to combat it.
The same process of coming together — in the understanding that it has
more to offer than anarchy — has been occurring in computing and is
gathering pace. Interoperability, and the associated need for standards,
is becoming increasingly necessary on two grounds. In stark contrast to
the past, current perceptions of healthcare emphasise a continuum of care
that revolves around an individual patient/client record, rather than on
records based in particular organisations or at a particular level. To
achieve this, interoperability is vital. Secondly, developments in the
European Union actively promote the concept that healthcare may be
obtained anywhere within it and emphasise the growing need for
interoperability.
This issue of the Journal examines a range of issues that stem
from the move towards interoperability and the development of, and need
for, the standards that make it possible. Ray Rogers, who has a long and
detailed involvement in international standards in informatics, describes
the major strands of work that are in hand. He explains both the need and
the difficulties in obtaining co-operation, not only at national, but also
at international level. In his article, Tony Brooks, a management
consultant from Fox IT Ltd, sets out the role that a newly adopted quality
standard has to play in IT-service management. BS15000 aims to make
contracting easier and to improve the effectiveness of managed ICT
services. Barry Barber, who also has long experience in international
standards work in healthcare informatics, points to an area of increasing
concern: the absence to date of safety standards in information systems
and, consequently, the potentially growing risk to patient safety. In
their article, Amy Downing and Richard Wilson demonstrate one of the
practicalities of interdependence. Their study of routinely collected A&E
department data — needed for healthcare planning, in this example — shows
areas where quality and completeness of data require improvement, but
where the incentive to do so is not yet present. Our final article, by
David Grigsby, reviews the challenges to ICT inherent in cross-sector
collaboration and ways in which some of those challenges are being faced.
In some ways, it is easy to accept Hobbes’s view that a strong central
power is necessary to ensure order and the proper conduct of affairs. But
where both Hobbes and Rousseau gloss over the difficulty is on precisely
how to arrive at that level of agreement. This issue’s authors show some
of the problems that arise in healthcare where agreement over order has
yet to be reached. Encouragingly, however, the articles also show that,
laborious and time consuming though agreement may be, it is indeed
possible. We must all hope that those engaged in the task continue to
succeed.
Michael Fairey
