Dr. John Bryden was the executive officer of European Federation for Medical Informatics for a decade between 1998 and 2008. When he retired from active work within the federation, he was awarded an honorary fellowship. In one of his early papers from the 1960s, he described how some relatively novel machines called computers might replace the punched cards that were being used at the time. He saw, before many others, that computers could be used for the care of individual patients and even more so for groups of patients. He implemented a unique patient identifier (community health index) which has enabled Scotland to link electronic medical record data for clinical management of chronic disease deterministically. An example was the development of the Glasgow Coma Scale. One benefit of demonstrating significant value in projects such as this at an early stage of record linkage was that the governance framework for the use of data became relatively permissive. Another major success was diabetes care; it became possible to apply insights from the aggregate data to improve services and make them more efficient. Scotland has developed safe havens for data where not only the physical environment but also the people, mechanisms and projects are all subject to control to ensure safety and confidentiality. Similar moves are under way in Europe. TRANSFoRm (www.transformproject.eu) led by King's college in London is mainly focused on primary care data. Excellence in medical informatics is possible as a result of the work of its pioneers, including John Bryden's first paper suggesting that computers might be useful.

Falls in older Australians are an increasingly costly public health issue, driving the development of novel modes of intervention, especially those that rely on computer-driven technologies. The aim of this paper was to gain an understanding of the state of the art of research on smart homes and computer-based monitoring technologies to prevent and detect falls in the community-dwelling elderly. Cochrane, Medline, Embase and Google databases were searched for articles on fall prevention in the elderly using pre-specified search terms. Additional papers were searched for in the reference lists of relevant reviews and by the process of 'snowballing'. Only studies that investigated outcomes related to falling such as fall prevention and detection, change in participants' fear of falling and attitudes towards monitoring technology were included. Nine papers fulfilled the inclusion criteria. The following outcomes were observed: (1) older adults' attitudes towards fall detectors and smart home technology are generally positive; (2) privacy concerns and intrusiveness of technology were perceived as less important to participants than their perception of health needs and (3) unfriendly and age-inappropriate design of the interface may be one of the deciding factors in not using the technology. So far, there is little evidence that using smart home technology may assist in fall prevention or detection, but there are some indications that it may increase older adults' confidence and sense of security, thus possibly enabling aging in place.

The 1999 Institute of Medicine (IOM) report To Err is Human alerted the healthcare industry and the public to the lack of consistency in the delivery of quality care to the US population. Clinical decision support systems (CDSS) have become a leading response to this report, and to the growing demand for the promotion of standards-based care delivery. The objective of this paper is to evaluate the recent literature for both the types and effectiveness of electronic CDSS in the primary care setting. An electronic search of the literature was conducted utilising MEDLINE (1996-2006), CINAHL (1982-2006) and all EBM Reviews--Cochrane DSR, ACP Journal Club, DARE and CCTR. The search included various combinations of the MeSH search terms 'clinical decision support systems', 'primary health care', 'ambulatory care' and 'practice guidelines' and was limited to articles published from 2000 to 2006. Studies were selected for review if they involved either non-randomised observational or randomised controlled trials (RCTs) utilising CDSS as a single intervention, were performed in an ambulatory primary care setting and included quantifiable outcome measures. Seventeen studies were included in the review, including five non-randomised observational studies and 12 RCTs. Thirteen studies (76%) found either positive or variable outcomes related to CDSS intervention with four studies (24%) showing no significant effect. Although there is validation that CDSS has the potential to produce statistically significant improvement in outcomes, there is much variability among the types and methods of CDSS implementation and resulting effectiveness. As CDSS will likely continue to be at the forefront of the march toward effective standards-based care, more work needs to be done to determine effective implementation strategies for the use of CDSS across multiple settings and patient populations.

Recent evaluations of IT innovations in primary care have highlighted variations between centres and practices in uptake and use. We evaluated whether structural characteristics of a general practice were associated with variations in use of a web-based clinical information system underpinning a Managed Clinical Network in diabetes, between the years 2001 and 2003. Using a computerised audit trail, we calculated the numbers of web-based operations that occurred in each practice, stratified by staff type and year, and adjusted for the numbers of registered diabetic patients. In regression analyses, we determined whether total use was associated with structural characteristics of the practice (total list size, training status, numbers of GPs (general practitioners), mean age of the GPs, numbers of female GPs, level of deprivation of the population and whether staff had received advanced training in diabetes care). Initially there were a few practices which made very frequent use of the information system, with relatively high numbers of practices using the facility infrequently. However, overall use gradually became more evenly spread. This effect was particularly evident among nurse users. Frequent use by GPs was evident in only a small number of practices, with mean GP use decreasing over the three years. In linear regression analyses, none of the general practice variables were associated with online use, either overall or stratified by staff type, except for the numbers of diabetes-educated staff. This was consistently associated with increased use by nurses and GPs. The analyses show that structural characteristics of a practice are not associated with uptake of a new IT facility, but that its use may be influenced by post-graduate education in the relevant clinical condition. For this diabetes system at least, practice nurse use was critical in spreading uptake beyond initial GP enthusiasts and for sustained and rising use in subsequent years.

Landmark reports suggest that sharing health data between clinical computer systems should improve patient safety and the quality of care. Enhancing the use of informatics in primary care is usually a key part of these strategies. To synthesise the learning from the international use of informatics in primary care. The workshop was attended by 21 delegates drawn from all continents. There were presentations from USA, UK and the Netherlands, and informal updates from Australia, Argentina, and Sweden and the Nordic countries. These presentations were discussed in a workshop setting to identify common issues. Key principles were synthesised through a post-workshop analysis and then sorted into themes. Themes emerged about the deployment of informatics which can be applied at health service, practice and individual clinical consultation level: 1 At the health service or provider level, success appeared proportional to the extent of collaboration between a broad range of stakeholders and identification of leaders. 2 Within the practice much is currently being achieved with legacy computer systems and apparently outdated coding systems. This includes prescribing safety alerts, clinical audit and promoting computer data recording and quality. 3 In the consultation the computer is a 'big player' and may make traditional models of the consultation redundant. We should make more efforts to share learning; develop clear internationally acceptable definitions; highlight gaps between pockets of excellence and real-world practice, and most importantly suggest how they might be bridged. Knowledge synthesis from different health systems may provide a greater understanding of how the third actor (the computer) is best used in primary care.

We set out to investigate the feasibility of incorporating a computer-tailored health behaviour program into routine care in a group of primary care practices in Rhode Island. Two existing computer programs (physical activity, smoking) that tailored text and graphical feedback to survey responses were combined and adapted for use in primary care directly by patients. Ten primary care practices were recruited and worked closely with project staff to develop a practice-specific plan for incorporating the program into the workflow and office routine. Feasibility was measured by the percentage of patients who used the program during the day of their visit. Only one of the ten offices was able to successfully incorporate the program into their office workflow and delivery of routine care. The main categories of barriers to incorporating the computer program into routine care included: the program was viewed overall as inconsistent with practice workflow, the staff was inexperienced with the program, technical problems with the computer and/or printer, the program placed an additional time burden on staff who already felt overworked. Suggestions for improving the program or the way that it was incorporated into routine care included: shortening the program, modifying the program's orientation to a target population (such as patients with hypertension) and incorporating decision-support feedback to help physicians manage the target condition, modifying the program to include other programs pertinent to primary care (for example, depression screening), selecting patients to use the program, rather than asking all patients to use it. After working closely with ten highly motivated primary care offices, we were unable to fully implement a point-of-care health behaviour computer system for patients and providers. Suggestions for disseminating computer-tailored health behaviour communications in primary care settings are discussed.

Electronic patient records and access to electronic information resources are the cornerstones of delivery of modern primary care, and they will be necessary to deliver effective evidence-based patient care, provide needs-driven health care, assist research and improve quality of services. However, prison health needs assessments carried out in the South East region suggested that modern information technology was lacking in prison primary care. This is despite the fact that the principle of 'equivalence of care' has been guiding the recent prison healthcare reforms in response to concerns about quality of prison healthcare services. We visited all four male adult prisons in the Thames Valley area and conducted one-to-one semi-structured interviews with healthcare staff to investigate the information available to them, the quality and uses of the data, and their current information systems. We also ran a workshop with prison healthcare managers and other healthcare staff from prisons in the Thames Valley area. Primary care staff in prisons record almost all clinical data on paper and do not have access to electronic clinical records nor to the internet. The main perceived barriers to implementing health information technology in prisons were concerns about potential breaches of security and discipline in prisons, anxiety about data security and a culture that gives low priority to health in prisons. To provide 'equivalence of care' for prisoners, primary care trusts need to implement full electronic clinical records in prisons and ensure staff have access to resources on the internet.