Q We are upgrading our practice computer system and will be connected to both the NHSnet and the internet, and hope in time to have links to the local laboratory. Are there guidelines for dealing with the security threat, especially viruses?
A The NHSnet is a managed network, therefore only certain people are eligible to use it, and it can be more tightly organised than the internet.
Various safeguards are built into the NHSnet:
- Access is restricted to certain classes of people
- Individual users have to identify themselves to gain access
- The flow of information is subject to more stringent protocols than in the wider internet.
The BMA is still concerned about the implications of such a large network for the privacy and confidentiality of information, but many experts feel that the level of security offered by the NHSnet is now acceptable.
It is possible to reach the internet from the NHSnet, and benefit from the wider horizons of global information, but internet users cannot access the NHSnet.
On the internet itself, security is more difficult to achieve. No patient information will be transmitted using the internet unless an individual clinician chooses unwisely to send it by this route. Web browsers contain standard features to improve the security of the computer from which the internet is being accessed.
Linking general practices to laboratories is an important objective of government policy as laid out in Information for Health. The aim is to get at least some links in place to all general practices in the UK very quickly.
The security of transmission of pathology laboratory results will be governed by the rules of the NHSnet, because they will be transmitted using that network.
To guard against viruses, you should use standard software (such as McAfee or Dr Solomon's), set to come on every time the computer is switched on, and thus to scan automatically all incoming data, irrespective of the source.
New viruses are arising all the time so don't succumb to the temptation to save money by relying on out-of-date software to protect you. Software that is 6 months old is unsatisfactory, and software that is a year old is completely inappropriate.
Modern anti-virus software can be updated from web sites to ensure that the sudden emergence of cyberviruses does not have the same effect on computers as a new physical virus would on an unprotected population.
Q I am often asked to write legal reports, especially about injuries in road traffic accidents. Does the editorial board have any guidelines to share with me about how to prepare such reports? I'm never quite clear how much to charge for these either.
A There are a variety of sources of material which will help with legal reports. A number of good books have been published, the BMA has produced advice, the medical defence societies have produced booklets, and some GMC guidance is relevant.
The BMA suggests fees for various standard reports. If the report is not standard, you should estimate carefully the time you think it will take to read the relevant case material, make appropriate examinations, assemble relevant references, and write a clear and well-argued report.
The fee for this should be agreed in advance, and the charges for court appearances (for which there are also standard suggested fees) kept quite separate: many cases do not proceed to court.
It is particularly important not to underestimate the work, nor to skimp on it, and above all not to take on work for which you are not qualified.
Q Are you aware of any guidelines for requesting cervical spine X-rays? We are trying to reduce our request rates and audit has shown wide variation in individual request rates for the examination.
A The Royal College of Radiologists has produced guidelines about the use of chest X-rays (and others) in a range of clinical circumstances.These are published as a convenient booklet entitled Making the Best Use of a Department of Clinical Radiology: Guidelines for Doctors (4th edn, 1998), available from the College.
There have also been a number of relevant studies. Examples include:
- Brown S, Robertson C, Beggs I. The effect of introducing guidelines for cervical spine radiographs in the accident and emergency department. J Accid Emerg Med 1996; 13(1):38-40, 1996.
- Matthews I, Roberts C, Roberts G, Field S, Brindle M. Compliance with guidelines for choice of radiographic projections: a multicentre study. Clin Radiol 1994; 49: 537-40.
Wide variation is the norm. What is interesting is to look behind the fact of variation to its meaning. By understanding why the variation exists, we can understand what to do about it.
This may mean increasing low rates where need is not being met, or reducing high rates where some X-rays do not lead to improvements in outcome. But it may also mean accepting that much of the variation may be acceptable, if the indications are not absolutely clear cut.