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Previous Volume      Next Volume 

Volume 2. Nightmare Findings 

Volume Editor:  Rupert Fawdry

To see a sample page Click here

Current Master copy of Panel02 is with: RF (-11RF.pages) 

Discussion Links: http://eepd.org.uk/?p=487


"We will never get Medical IT systems to work effectively

until we accept the sheer size of the problem"



The remnants of my original massive attempt to document in a logical chronological sequence as many as possible of all those data items which some group, somewhere, has reasonably concluded to be so important that they merited being printed in a printed paper maternity or neonatal record or proforma, or to be included in a current official or proposed paper or electronic data-set.

This volume also includes a detailed analysis of a) Problems with Booking data in 1979 and b) exactly the same kind of problem as still identified in Caesarean Section Proformas in 2007. 

        RF (Updated 13 Nov 2010)



When I began what has now become the EEPD, I started over 30 years ago by sitting in a windowless outpatient records store in Edinburgh analysing on small paper filing cards all the data items which I found in existing paper records. This quickly led me to realise how locally variable such records could be and how complex the use of computers to help in maternity care would become.

My first IT paper, published in 1984, was entitled “Ante-natal records: What are we asking?“  (4 pages)

In summary, I discovered that, although more data is regularly collected from a greater proportion of humanity in the antenatal booking process than any other data collecting activity anywhere at any time in the whole world, it was clear that there were no universally-agreed logical criteria for deciding what we should or should not be recording.

For that paper I just analysed the items considered worthy of inclusion in the printed case-notes used for the initial assessment (”booking“) history in the 41 teaching hospitals in the United Kingdom.

571 different items were recorded; although the average number per hospital was 80 (Range 12 - 150).

Only 12 out of the 571 data items were universal!  Only 29 out of 571 data items were found to be present in more than 75% of case records and only 52 were present in more than 50% of records (http://www.fawdry.info/eepd/02_ngt/Percent.pdf).

Numerous items were only found in 1-5 records
(http://www.fawdry.info/eepd/02_ngt/Items.pdf (21 pages))

The final result of this analysis of paper records has been the theoretical concept of “The Nightmare Document”.  The aim of this would have been to list in a logical sequence all those data items which someone somewhere has reasonably concluded to be so important that they merited being printed in at least one printed paper maternity or neonatal record. 

In the event, the complexity has proved so great that the task has not been (and probably never will be) completed. But what quickly becomes apparent is that no-one would have the time to enter onto a computer database every proposed item regarding every expectant mother; and, more importantly, that no-one seemed to be addressing the question as to what criteria should be used to decide what should and what should not be entered. Selection and wording seemed universally to depend on the particular views of those directly involved in each different version.  In the past 30 years the situation has become, if anything, even worse - as can be seen from many other parts of the EEPD.

Owing to lack of resources, the existing nightmare list is by no means complete; however, even in its unfinished state it vividly illustrates the dilemma. 



No progress can be made in the logical creation of Electronic Patient Records without fully coming to terms with the existence, in every area of medicine, of such Nightmare Documents.  The reason for this and the potential solution is fully discussed in ”The Future of Electronic  Records in Acute Hospital Medicine: Coping with two unavoidable hybrids and a potentially infinite workload”

Only when those in the health care IT industry fully accept such complexity will we have a reliable foundation for future progress.  So far, the current situation still seems to be best illustrated by my chasm picture and my attempt to remedy the situation by my hills and mountains picture.

Rupert Fawdry  (Updated 15 Nov 2010)


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The EEPD by Dr. Rupert Fawdry is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/3.0/. Permissions beyond the scope of this license are available via http://eepd.org.uk/?page_id=56.
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