Informatics 97nov6

Journal of Informatics in Primary Care 1997 (November):15-17


Articles


The Case for Integration of JANET and NHSnet: a pragmatic proposal for its implementation

Simon de Lusignan and Robert Whitelaw

The Doctors Desk Project, General Practice, St George’s Hospital Medical School and Woodbridge Hill Surgery, Guildford

Correspondence to Dr Simon de Lusignan, Woodbridge Hill Surgery, Guildford, GU2 6AT, Tel: 01483 566234, Fax: 01483 301132, email: slusigna@sghms.ac.uk


Abstract

The NHSnet, to achieve public and professional confidence, needs to be secure. In order to achieve this, its code of connection requires general practices to remove any Internet connections they might have including connections to JANET (the Joint Academic Network). Whilst this rationale is understandable, other pressures are pushing undergraduate medical education into general practice. An increasing part of medical student learning is self-directed and computer-based. Tutors working in general practice need both to be able to access patient data, as well as to communicate with their educational peer group at their University Department. This paper sets up a pragmatic staged process whereby a practice could in a secure way access both email and educational material at its medical school, whilst at the same time linking to NHSnet.


Introduction

NHSnet, through its Code of Connection[1] requires practices to drop any Internet or JANET connections. The authors have had first-hand experience, through their Doctors Desk project[2], of the difficulties of setting up in a practice a link to an NHSnet server whilst also needing to keep resources for medical students who come out from St George’s Hospital Medical School to attend an Outreach Firm[3]. The only way this could be achieved within the current rules has been to connect the link to the Medical School to our branch surgery, so that students can only access the Medical School resources from there, and to connect our main surgery building to NHSnet. This keeps within the rules laid down by the Code of Connection, but means a walk to the branch surgery to look at your email rather than, as before, having it available over any machine on the practice network.

This sorry state of affairs has led us to wish to argue the case as to why there should be some degree of integration between JANET and NHSnet, and to suggest a pragmatic way by which that might be achieved. The first section of this paper sets out why we believe this is such an important issue, and the second part, how it might be achieved.

Part 1: The Case for Integrating JANET and NHSnet

Central policy changes make it inevitable that practices involved in teaching and training will need to be connected to both JANET and NHSnet. One of the pressures to do this comes from the Dearing Report[4]. One of Dearing’s main thrusts was the necessity to provide appropriate communications and information technology (C&IT) at all sites at which higher education was provided. The importance of C&IT is stressed in almost every chapter of the Dearing Report. Dearing also suggested an appropriate ratio of PCs to students of one to five. It could be surmised from this that there should be at least one PC connected to the Medical School network for each group of five students visiting a primary care teaching site.

The General Medical Council has reinforced this theme in its document Tomorrow’s Doctors[5]. Here, the GMC stress the importance of reducing factual burden on students and stressed the importance of computer-based learning (CBL). Medical students should have a greater emphasis on learning where to find information, than purely learning facts. Most University networks provide access to key information. The Medical Act 1993 has been amended to remove some of the obstructions that have prevented the development of house jobs in general practice. The GMC has made a set of recommendations about the educational input needed in the pre-registration year[6]. These will be more easily met if house officers have access to their Medical School network and CBL (Computer Based Learning). The National Health Service Executive (NHSE) has a policy of encouraging a primary care led NHS[7]. This policy, along with shifts in primary care towards evidence based practice further reinforces the need for quality information sources in General Practice.

Table 1: Policy changes requiring JANET connections in general practice

  • The Dearing Report ‘Higher Education in the Learning Society’
    • Appropriate C&IT at ALL HE sites
    • Ratio of students to PCs 5:1
  • GMC Tomorrow’s Doctors
    • Less factual burden
    • More CBL
  • House Officers in General Practice
  • Primary Care Led NHS
  • EBM

The teaching hospitals are less able to provide the clinical experience needed by undergraduate students. Part of the reason for this has been the shift of work into primary care, but also the work done in these tertiary centres has changed.

Table 2:  Why less undergraduate teaching can occur in tertiary hospitals

1.   Increased number of day cases
2.   Reduced length of stay of inpatients
3.   Greater pressure on consultant staff
4.   Sub-specialisation means less broad-based experience
5.   Shift of work into primary care

There are also a number of positive reasons why a JANET connection can be of benefit to both students and tutors based within primary care.

Table 3: Benefits of JANET connection to teaching practices

  1. Email/newsgroups for medical students’ links with their peer group
  2. Student access to Medical School library, CBL and self assessment
  3. Opportunity to combine undergraduate and postgraduate learning
  4. Allows academic GPs to maintain links to their University Department

Part 2: A Pragmatic Proposal for Integrating JANET and NHSnet

We believe that it should be possible to pilot a stepwise process of linking JANET and NHSnet. We believe that the first step in this process should be a secure SMTP email gateway with restrictions on the attachments allowed. If this can be shown to run in a secure and reliable way, then progressively the newsgroups, specific standalone CAL packages, and then eventually greater access to medical student computer networks, could be allowed. The proposed solution is discussed under the following headings:

  1. A secure gateway from JANET to NHSnet
  2. The link from the secure gateway to the practice network
  3. The link from the practice network to NHSnet
  4. A solution for a single PC able to access both JANET and NHSnet

A secure gateway from JANET to NHSnet

JANET is not synonymous with the Internet. It should be remembered that there are filters, and in some places firewalls around JANET which provide a limited degree of security. Stage 1 of producing a gateway from JANET to NHSnet should be the provision of a router and firewall, identical in specification to that which protects the NHSnet currently, to be arranged to allow simple mail transfer packages (SMTP) to pass from JANET to NHSnet. These would go into a ‘post office’ where they would be virus scanned and all attachments which contained a .exe, .zip or possibly other attachments would be excluded. The remaining SMTP would then be allowed to pass into NHSnet. The NHSnet already allows downloading from the Internet and this process would be comparably secure.

If this gateway can be shown to be secure, then progressively greater access to Medical School computers could be provided.

The link from the secure gateway to the practice network

The bridge and ISDN line would access to the practice network. A certain number of machines in that network, which are used for undergraduate teaching, would have IP addresses which allow them to access the Medical School network. Hardware filtering, at MAC address level, would be provided, linked to the hexadecimal identities of the Ethernet cards in these machines, and conversely to authorised machines on JANET/NHSnet. When more than SMTP mail was accessed from the Medical School, then these machines would use anonymous browsing to prevent unwanted email. It should therefore be possible to isolate a small number of machines within a practice network that are able to access the medical school network. Alternatively, routers could be used for this stage of the link allowing full firewall implementation, complete with anti-spoofing filters.

The link from the practice network to the NHSnet

The link to the NHSnet would be from separate ISDN line or other linkage. The router (which the NHSnet Code of Connection requires to protect the practice network) can also operate to protect NHSnet from any penetration via JANET, through the use of a firewall, and a packet filter installed at the router. The PCs in the practice that can access NHSnet will have IP addresses that belong to NHSnet. In this way, the two systems can be kept completely separate.

A solution for a single PC able to access both JANET and NHSnet

A PC able to access both NHSnet and JANET: Windows NT™ allows a computer to have a dual IP address8. When an NT machine is set up in that way, it effectively links to two separate networks. It would be possible to provide GP academics an NT machine that would allow them to access their email education resources on JANET via a Medical School IP address, at the same time as accessing NHSnet resources using an NHSnet IP address. This may sound like heresy to NHSnet purists but it is a straightforward practical solution for GP academics.

Conclusions

The NHSnet has become hung up because of fears that connections with JANET would be a major breach in security. An SMTP data flow would enhance, not diminish the NHSnet. Microsoft Exchange, and other software, will allow messages to be sent either as an SMTP message or in X.400 form where needed within the NHSnet. The need to link teaching practices to both JANET and to NHSnet will not go away. Until encryption or other forms of security come along, a pragmatic approach to this problem, such as the one identified above, needs to be piloted, preferably sooner rather than later.

Acknowledgments

The Doctors Desk project is funded by NHSE South Thames Research and Development Directorate.

References

  1. Confidentiality and Security using NHSnet. NHSE IMG, Birmingham, 1997
  2. de Lusignan S, Brown AMA, Douglas BM. What is the Doctors Desk? Proceedings of the Annual Conference of the Primary Health Care Specialist Group of the British Computer Society, 1997 (in press)
  3. de Lusignan S, Hilton SR. Report of the Piloting of a Specialties (Eyes, ENT & Dermatology) Firm in General Practice,. Association of University Departments of General Practice, 26th Annual Scientific Meeting, Dublin, 1997
  4. Higher education in the learning society. The Dearing Report, HMSO, London 1997; also on the WWW at http://www.leeds.ac.uk/educol/ncihe/
  5. Tomorrow's Doctors. GMC, London, 1993
  6. The New Doctor. GMC, London, 1997
  7. Developing a Primary Care Led NHS. NHS Executive, Leeds, 1995
  8. Microsoft Windows NT™ Workstation Resource Kit Multi-homed Devices. Security for Internet Clients, pp 969,1009,1033

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