Frectally speaking

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At the start of 2016, the Irish healthcare system, or better explained as systems (in both the North and South of Ireland) have both arrived at key milestones in their moves towards 21^st Century healthcare. They are of course separate healthcare systems, north and south of the border, as they are separate countries, but they both find themselves at a key point in their moves into the 21st Century, both with important decisions to make.

The important decisions relates to their moves into what we might call “21st Century Healthcare”, i.e. bringing healthcare into the information age. Now both North and South of Ireland are at different stages in this journey, but the decisions they face are closely related.

As eHealth Ireland has opened up a public consultation exercise on Electronic Health Records for Ireland, the time has come to publicly share my considered view.

The short version… if you’re after the bottom line is:

• Clinical leaders need support and guidance on the road towards 21st Healthcare
• Agile and Iterative Improvement towards integrated patient care is key
• Open Platform Technology allows for greater integration, collaboration, flexibility and reuse
• Investment is required but should be spent wisely…billions were wasted elsewhere, we can learn from this.
• Any other path risks perpetuating the current disconnects and related pressures.

Before we look into these 21st Century dilemmas in Irish healthcare, let us firstly look at the wider international landscape to give these Irish decisions some important context.

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Introduction- Healthcare under pressure

As an Irishman, an Irish doctor born and raised in an Irish medical family, now based back in Dublin, the Irish healthcare world is one I’m familiar with and care about. As a professional, a patient, a parent, what happens to the Irish healthcare system is of interest/concern to me and my family.

As an Irish doctor who has spent the last 15 years working to understand, improve and influence healthcare improvement with information technology at departmental, hospital, city, regional, national, international levels I feel obliged to share a considered view at this time.

My background is as an emergency physician and I have worked at the “coalface” /”frontline” of the health service for 20 years. I began that career in Dublin then moved onto train in the NHS in Emergency Medicine, with a years work in the US to see their healthcare system in action.

Some years on, it’s fair to say that Emergency Departments all over the world remain under real and increasing pressure. The EDs of the NHS are victims of their own 4-hour standard “success”, while my colleagues in Ireland-South still patiently work under very trying conditions with a national trolley crisis that has lumbered on unnecessarily for 10 years or more.

All healthcare systems, from the Irish, to the NHS, to the US and to Australia are under real pressure and all increasingly acknowledge that we need to work differently. Faced with an aging population, increased patient expectations and technical capabilities, one thing is pretty certain; that healthcare needs are likely to increase while funding is going to get tighter. Although healthcare has been late to the proceedings, the related need to modernise healthcare into the information age is now increasingly understood as critical to our future.

 

Healthcare Improvement Issue #1 For the patients

First and foremost, while patients patiently wait for health and social care to modernise, the current siloes of different teams with varied process and isolated information often make for a difficult and disconnected patient journey for those who attend for our care. Given these issues we need to move away from a paternalistic approach to health and care delivery and encourage citizens and patients to be more involved in looking after their own health and care. It is only through this movement into the new information age that a more effective partnership between patient and physician can be realised.

Healthcare Improvement Issue #2 For the staff

My early years in Emergency Medicine made clear the information intensive nature of this work, yet when I went to the US to train in Informatics back in 2000 it was because there was few if any opportunities for clinicians to understand how that might be improved.

Over the years of my work in Emergency Medicine, every shift I’ve ever done has reinforced the need to better support the busy staff. It also means that some of us need to lead on and tackle the real need for healthcare improvement projects, which is often critically dependent on information technology. As healthcare has grown increasingly complex the effort that both patients and professionals have to make on a day-to-day basis has become unnecessarily hard. We all need to find ways to work smarter, not harder.

 

A view from several angles: clinical + management + technical

So as an emergency physician drawn into clinical leadership and management roles aimed at healthcare improvements, I’ve also sought further education and qualifications in both management and information technology as a deliberate effort to understand these vantage points and those languages involved.

As a Consultant in Emergency Medicine in the early days of the transformative NHS 4-hour standard push, I was fortunate to witness a huge change in the way the NHS delivered emergency care. With investments in people, improvements in process and y leveraging the real power of information and technology we were able to drive down waiting time for patients. This ultimately enabled us to treat over 200,000 patients per year, across 2 departments, from arrival to discharge, in under 4 hours, 95 % of the time. It yielded a real transformation in the delivery of timely emergency care.

However beyond those local efforts in my own emergency department (setting up an ED information system etc) in Leeds lay more challenges than opportunities within the multibillion pound NHS National Programme for IT, also based out of Leeds, which then drew my work into the international world of health IT.

Roles within the NHS National Programme for IT from engaging with clinicians, exploring their ideas for new ways of working, trying to influence the requirements, design, build, and testing with a wide range of technologies to then tackling problematic NHS IT contracts taught a lot.

In establishing a NHS Clinical Content Service, which explored how the many varied clinical forms, pathways, guidelines etc across the service could be brought together to align the worlds of clinical practice and technical standards. Very quickly, the real disconnect between these worlds was laid bare.

The essence of those 5 years of national and international efforts in health IT was the very mediocre and entrenched nature of the health IT market was made clear to see. Despite billions of pounds and years of effort wasted, the NHS National Programme for IT held back progress in the NHS, clinically speaking, process improvement wise and in terms of local innovation that was squashed.

While certainly there are areas of healthcare than have already seen real quality, efficiency and safety improvements enabled with information technology, elsewhere many results are more mediocre. So though qualified in both medicine and information technology management, as a medical leader/clinical champion for health IT over the last 15 years, I might be expected to evangelise about the power of health IT. However the honest fact I need to relay is that the current state of health IT is very mixed, indeed I hold the view that current state of the health IT market is holding healthcare back.

 

 

Just what is this #HealthIT anyway? Towards a common language…

To understand the current state we find ourselves in in 2016 and the way forward, we need to explore a little.  One of the real challenges in this field of healthcare improvement with information technology, is the 3 differing cultures +camps +languages that you need to bring together around a table to get things done. i.e. clinical + management + technology. Too few of us have yet had that collective education.

So the art and science of informatics is still at such an immature state that hard definitions are hard to come by. This blended science that must transform healthcare yet doesn’t yet have a common clear frame of reference.

There are a few key principles that I’ve written up in a related “Book of Thoughts” that are essential to understanding how to make sense of it all.

Healthcare is a complex adaptive system, to be understood like an ecosystem, not just a complicated machine.

The case for change can be the common bond between clinicians, managers and technical folk in these efforts, yet the fusion of people and process and information technology takes time to get right and should be fostered to evolve rather than imposed.

Healthcare improvement requires tools that both support the core clinical processes that span all of healthcare yet allow for local flexibility and the vast diversity of this domain.

This article has been penned in response to this eHealth Ireland Electronic Health Record (EHR) consultation. Yet in that light what does an EHR for Ireland mean? I can tell you that at this point in the science and art of informatics, even the term EHR can and will be debated around the table.
Let’s start by being clear what an EHR is not. An EHR is not a piece of technical kit you can buy off the shelf and switch on… far from it. In my experience what an EHR programme inevitably involves is best described as a complex change challenge… the parts being people (including cultural issues of change), process (evolutionary change better than big bang) and technology.

The key challenge is to integrate those elements to effectively improve the care of the patients we serve and make easier the lives of staff at the frontline.

 

Integrating care for a patient doesn’t start or stop at the walls of any hospital, but it involves the patient themselves, primary care, secondary care (hospitals) as well as community, mental health and social care. The key point here is that there is no point “technologizing” the current state and current processes, a health IT/EHR programme needs to be seen as an opportune time to iteratively improve and reform care … which is best done around the patient… yet the current health IT market is holding that back.

 

The Health IT market malady: 3 key signs

In general terms, as every healthcare system and every part of every healthcare system suffers from the same challenge, we can explain 3 key signs/features of the health IT market for the last decades.

• A) A Myriad of Siloes- dozens/hundreds/thousands of siloed systems- these represent isolated clinical teams, their siloed processes and isolated information technology that pervade the department/city/nation you’re in – still an incredibly common feature in health IT
• B) Best of Breed (1.0) – which was/is a common middle ground between A & C – is an attempt to single out some of those technologies and bring them together into a more useful whole. Portal technology and integration engines really help here, but the architectural mismatch between systems limits what interplay can be done.
• C) Corporate/Conglomorate choice- a large monolithic proprietary solution from a single vendor. Here one is asked to give over ones clinical culture and process improvement methods to align with the values of single vendor, whose technology then dictates the practice of medicine thereafter. Vendors of this type usually insist on clinicians changing some of their practice to do it “the Vendor way”. Yet local control and ownership, interplay with other systems and at the boundaries (e.g. other clinical professionals within our “patch” or clinical neighbours nearby).. none are priority business models in this area of the health IT market.

These features can be explained as a by-product of the deep and perpetual misunderstanding of the interplay between clinical culture, generic clinical process and proprietary technology that remains at the root of these issues today.

I’ve examined these features/options in more detail in an earlier article elsewhere, but suffice to say that these limitations of the health IT market to date are certainly in some way responsible for the state of healthcare across the globe….beset by fragmentation, process improvement challenges, siloed information and technology.

 

The Health IT market malaise: 3 key symptoms

As a by product of these market features, 3 key areas of weakness that most impact the progress of healthcare improvement then deserve special mention

• Usability- This is where clinicians and clinical process meets technology at the frontline. The usability of Health IT is acknowledged to be particularly poor and a real barrier between patient and physician,  recently described as “treating the computer screen”, hence the birth of the clinical scribes industry. At the busy ED frontline the multiple applications and logins that one often has to juggle to get the information one needs is a real barrier. So too is the tedious “click heavy” layout of many health applications. Even more frustrating is having to wait for weeks, months, years for a vendor to make a change to your “clinical frontend” as it’s not their “business priority”.

• Integration- if the patients care record is scattered across multiple systems as it is in healthcare today that again impacts at the clinical frontline, where critical information takes time and/or is difficult/impossible to find, which impacts on the quality, safety and timeliness of care.
  For 20 years or more “messaging” and/or “interoperability” was meant to resolve the inadequacies of this mediocre and fragmented market. With due respect to those folk who have laboured on these standards, it was never going to be enough.
  With a very small number of systems point to point connections often evolve, yet if the numbers go up and you do the maths this is quickly unsustainable. In recent years an acknowledgement of the role of portal, integration and exchange technology has helped, yet most/all existing systems and many new apps and applications still struggle to usefully exchange clinical information. If you explore the world of Guideline based, Workflow Integrated Electronic Healthcare Records you’ll note such interoperability demands standardisation of clinical content (What), workflow (Who, Where, When) and rules (Why) between systems.
  The latest efforts generating interest (such as FHIR and related Application Programming Interfaces (APIs)) are improvements and are likely to be useful components going forward, but on their own they cannot and will not be enough to meet the needs of integrated healthcare in this 21^st Century.

• Flexibility – At the root of the problems in the market are the many proprietary technologies, applications and architectures that pervade healthcare. Some are stronger than others but many suffer from real challenges in terms of scalability and maintenance. As/when real time process changes/improvements are needed at the clinical frontline there is all too often a challenge to access the data, run that query or support that change. Either the aging system cannot be changed to meet this new need (difficult to maintain) and or cope with this new demand (difficult to scale) or the supplier will not make a timely change as they are too busy/it’s not a priority/doesn’t suit their business model.

So what is needed is a robust and open healthcare IT architecture that has the flexibility to accommodate local changes as/when needed.

Given that we know these are real problems for healthcare and are holding healthcare progress back.. approaches which perpetuate these current limitations simply keep healthcare back in the last century.. we now need to actively move on.

So there’s the rub… while a medical leader in healthcare improvement with information technology, I now find myself decrying the mediocre state of the health IT market and advocating for real health care IT market reform.

 

What’s the diagnosis Doctor? A second opinion..

Before I move on, let me make clear that I’m not alone with this view.

As Michael Porter explains in his push for “The Strategy That Will Fix Health Care” (2013) ;

“Historically, health care IT systems have been siloed by department, location, type of service, and type of data (for instance, images). Often IT systems complicate rather than support integrated, multidisciplinary care.”

As Enrico Coeira begins in his recent “A Modest e-Health Proposal to Government” (2015)

“Dear [insert country name] Government,
E-health is hard. I think we can all agree on that by now. You have spent [insert currency] [insert number] billion on e-health programs of one form or another over the last decade, and no one knows better than you how hard it is to demonstrate that you are making a difference to the quality, safety or efficiency of health care.”

Let me also quote from this recent (2015) book on the very subject;

“The Digital Doctor: Hope, Hype, Harm at the Dawn of Healthcares Computer Age” by Dr Robert Wachter, Chief Department of Medicine, UCSF, USA

“..Healthcares path to computerizations has been strewn with landmines, large and small. Medicine, our most intimately human profession, is being dehumanized by the arrival of the computer into the exam room”

“While someday the computerization of medicine will surely be that long awaited digital disruption, today it’s just plain disruptive: of the doctor patient relationship, of clinicians professional interactions’ and workflow and of the way we measure and try to improve things.”

 

21^st Century Healthcare – what might be needed?  

To look forward to the future of healthcare, let’s look for a moment at what a patient or clinician might reasonably need/want/expect in this the 21^st Century.

• Frontline Care- an integrated view of patient information, a patient centred health and care record. The role of technology should be supportive, not obtrusive here (e.g. recognising that patient stories blend important structure with vital narrative).
• Evidence Based Care – the means to ensure patients’ care across primary, secondary, community and social care is in line with evidence based guidelines.
• Managing Patient Cohorts – within a department/neighbourhood/city (e.g. oversight of those on a waiting list/ward/virtual ward) to ensure they get high quality, timely care.
• Healthcare Improvement – using system wide data, information and analytics to improve clinical practice in real time.
• Healthcare Research – integrating clinical and research practice such that information captured once at the point of care can, with consent, inform a relevant research study/trial.

We have not even mentioned personalised healthcare, the advent of genomic medicine and/or linkage to the world of bioinformatics….yet addressing even these core requirements in any typical healthcare system on the planet is currently out of reach given the current state.

Healthcare needs to catch up. For too long public sector and government ICT projects have run over-budget and not delivered on time. For too long, government and the public sector have procured “big, expensive, long­ term IT contracts that are too slow and cumbersome for today’s fast­ moving technology”.  To its credit the UK Government Cabinet Office has learned from this and is now providing international leadership on addressing these issues with its Government Service Design Manual. In supporting a move towards shorter, lower cost and more flexible contracts, in promoting the principles of user centred design, agile project management and software development in its Service Standard, in ensuring “digital teams build high quality [public] services”, all of these principles are an ideal fit for the complexity of the healthcare sector.

Those few long recognised as true leaders in the informatics field have often long understood these principles, with strong clinical leaders, local agile teams and iterative development. Naturally over time several have realised the limits of their own work and looked outside to collaborate with others. Of note, within that leading group, Dr Stan Huff, CMIO at InterMountain in Utah, is now involved in the setup of the Healthcare Services Platform Consortium.

So many roads are now pointing to the need for a new healthcare “platform” that will enable the transformation 21st Healthcare requires. This platform thinking may be new to healthcare but simply represents a catch-up with other industries that have been transformed in what is now known as the “Age of the Platform”. We have seen the positive disruption to other industries such as telecomms (e.g. Android), publishing (e.g WordPress), retail (e.g. Amazon), travel (e.g. AirBnB) and we in healthcare have been waiting for long enough …

In a related article on 21^st Century Healthcare: The Platform that will Transform .. 5 key features of this emerging platform (“Best of Breed 2.0”) are outlined

• Usability – healthcare IT needs optimal usability. Frontline tools must be very+ easy to use
• Integration – legacy systems & data needs to be accessible/APIs come to healthcare
• Clinical Kernel – clinical content- shareable & reusable- lego bricks for health IT
• Code & Community – open source fits the open scientific way of medical progress
• Governance & Leadership – balance of local flexibility and international standards

Could/should any one vendor supply this platform.. certainly not.. No one supplier can/will/should/ have control over this key global health need.

Certainly there is a common view that tasking one large multinational supplier should take up the effort, energy and risk that a “system wide”/ “enterprise wide” health IT system may offer.
Yet what to do if/when their service dips when the same multinational moves onto the next sale? What of those small requirements that pop up all the time til the end of time? Who will look after them? What of local industry? What of the boundaries issues? What of those who want to collaborate with others beyond the border? .. beyond the sea?

Rather than sink large sums into the old “Nobody got fired for buying IBX” logic.. the wider market is now moving us towards a more “services” oriented health IT market under pinned by a vendor-neutral Services Oriented Architecture and related open platform. In this world , catching up with the Software as a Service industry, suppliers compete on the service they provide, rather than the technology they firstly offer and then lock you into. Thankfully we are already seeing a range of commercial organisations, both large and small, who are interested in supporting this business model.

 

 

The good news: a 21^st Century Health IT remedy at last

Thankfully over the last 5 years we have seen the early signs of this major shift in the healthcare market.  My own learning journey started back in 2000 where I was fortunate to work with a small group of leading physicians with information technology expertise who were doing pioneering work on areas such as usability, portal and integration technology and clinical data analysis in the US.  Alongside my work at the clinical frontline, I’ve closely followed/been involved with the healthcare IT industry over the last 15 years so know it and its patterns very well.
Let’s look at some recent (personal & other) milestones on that road.

2001 Crossing the Quality Chasm: A New Health System for 21st Century (IOM, USA)
2001 openEHR Foundation established (UK & Australia)
2004-2011 (approx) NHS National Programme for IT/NHS Connecting for Health
2009- present Hi TECH ACT – EHR Stimulus in US Market
2010 UK Gov ICT strategy: Smarter, Greener, Cheaper – open source & standards strategy
2011 Open Source Electronic Health Record Alliance established (VA, USA)
2011 Leeds Takes a Lead – developing open source clinical portal
2012 Moscow city EHR programme selects open platform for city EHR programme
2013 NHS England “Safer Hospitals, Safer Wards” strategy highlights open source potential
2014 Healthcare Service Platform Consortium HSPC established (USA)
2014 Code4Health NHS initiative to educate clinicians & developers on open health platform
2015 ONC Report to US Congress on Health Information Blocking (USA)
2015 Leeds Care Record available to all hospitals, GPs and mental health services of Leeds
2015 Ripple Open Source Initiative set up by NHS England with Integration Pioneers
2015 Endeavour Health Initiative established to setup an open integration service in the NHS
2015 Apperta Foundation setup by NHS England to promote open platform in healthcare

 

What I’ve described elsewhere as Best of Breed (2.0) platform is a move towards a mix of open source, integration technology and an open standards based service oriented architecture (i.e. openEHR). Simply put healthcares B 2.0 platform push is an integration journey that can be commended as the best fit with the complexity and diversity of healthcare.

Having had difficulty promoting such as a push within the NHS NPfIT programme, I made a deliberate move in 2009 as Chief Clinical Information Officer (CCIO) of Leeds Teaching Hospitals, fostering an open platform approach to the Leeds EPR programme (PPM+) with clinical and technical colleagues across the four hospitals in Leeds.  Related needs beyond the hospitals led onto the setup of the related Leeds Care Record programme.

The Leeds Care Record now supports the care professionals in primary care, secondary care, mental health, community care and social care for across the city of Leeds with over 800,000 citizens. While engaging patients in the effort, the approach taken was clinically led, user centred design and agile development towards this open integrated platform. Importantly, good practice in patient engagement and information governance helped to gain the trust of the public. Related benefits to both patients and professionals are now emerging.

Now moving beyond Leeds the related Ripple programme is openly sharing related learning, information governance  and open platform tools (e.g. Plain English Guide to Information Sharing) with other Integration Pioneers across the NHS in England.

At the core kernel of this approach is a clinical “lego brick” (also known as an “archetype”) which is built to both support the key generic processes of clinical care but the infinite diversity of healthcare needs and wants at a “template” level (think of a smaller number of Lego Bricks and a wide range of Lego Toys). The archetype standard, methodology and related tools are aimed at supporting clinicians who wish to work collaboratively, while the open and vendor-neutral specification allows technical colleagues to support those needs. This related white paper on a “vendor-independent health computing platform” contains more than enough detail for those new to this field. This video gives an idea of the openEHR methodology and related tooling available.

 

So within the NHS this open platform approach is now recommended by Apperta Foundation, the Code4Health initiative and the Ripple community. Beyond the NHS, moves towards an international healthcare platform are now underway across the globe. From the work of Stan Huff with the Clinical Information Modelling Initiative and the related Healthcare Services Platform Consortium HSPC in the US market, to the related work of the openEHR Foundation this approach is now spreading from Australia to China and Moscow to South America.

 

 

BLS – Basic Learning Support: 10 top tips to survive 21^st Century Health IT
So at this point, lets distill some general principles;

Firstly some dragons to beware…

• Clinical engagement can be tokenistic, this needs informed authoritative clinical leadership
• Big Bang Change misunderstands the complex adaptive system of healthcare
• Waterfall style Programme Management (e.g. a 200 page Requirements Document and related contract) misunderstands the complexity of healthcare
• Poor Usability isn’t good enough. It will just get in the way at the frontline
• Reliance on “Interoperability”- to resolve the current limitations of health IT market is naive.
• Reliance on any one vendor.. the “One Throat to Choke” mentality is a recipe for later regret.
• Closed proprietary technology- is holding back progress towards 21^st Century Healthcare
• Sweet deals on offer of reselling to your healthcare neighbour- commonly done, part of the problem>solution

Then some survival tips..

• Healthcare should be understood as a complex adaptive system, this stuff is more than just complicated
• Healthcare systems need ongoing reform and improvements to meet 21^st century demands
• Change of this nature requires the right mix of people + process + technology
• Clinical Leaders- informed & educated in these issues need real authority to effectively lead
• Patient centred & evidence based care systems are the goal to aim towards
• Working Smarter/not Harder- will improve both care for patients and the lives of frontline staff
• User Centred Design is a key to top quality usability
• Agile Programme/Project Management and Software Development principles are good practice in this field
• Innovation and improvement needs to be fostered locally and at the frontline, not imposed
• Open Platform (B 2.0) is the direction that the health IT market is moving

 

 

Irish Healthcare at a 21^st Century crossroads : The road to take..

So it is within that wider international context that in early 2016 we can now examine the choices to be made in Ireland’s healthcare systems on the move towards the information age.

[Note: While this article explores universal issues in healthcare improvement with IT, its pointed at the current situation on the island of Ireland. To clarify certain points while making the article readable I will refer to to Northern Ireland as “Ireland – North” and the Republic of Ireland as “Ireland- South”. Hope this is helpful. Please excuse if not.]

 

Ireland-South

The state of the healthcare system in Ireland-South that will be most known to the public is the persistent problems with the Emergency Department Trolley Crisis. Of course while patients and colleagues suffer endlessly at the frontline, this crisis is symptomatic of the broader need for healthcare reform and improvement.

There is now an increasing acknowledgement of the important role of medical leadership (e.g. via the RCPI Quality & Leadership programme, Integrated Care & related programmes etc) and slowly but surely the science of process improvement (e.g. Lean thinking) is starting to spread.
On the information technology front, a high profile disaster in the form of the failed PPARS implementation meant that investment was very limited over the last decade (<1% of annual budget in the Ireland-South healthcare system).

For some time, it has been acknowledged that there are over 1000 disparate information systems across the Ireland-South healthcare landscape, so it is coming from a very fragmented base. In recent years, while lacking any national strategy for health IT, there have been efforts to roll out a national PAS system, a PACS/RIS system, now more recently a national contract for a Lab system, also a Maternity System, yet all of these developments have still happened in isolation…without a coherent overarching strategy/vision.

Back in 2011 I was involved in a focussed piece of work on the National Clinical Programmes: Aligning Process Improvements with Information Technologies within the HSE. The key recommendations made then including clinical leadership, focus on core clinical process, agile development, open platform, etc remain just as relevant (inc. to hospitals/hospital groups/community healthcare organisations/clinical programmes/national policy) now as then.

Clinically speaking there remains little knowledge/awareness of the role of informatics in any formal sense within the healthcare system in Ireland-South, which now poses a risk. Thankfully with the arrival of eHealth Ireland the arrival of the Council of Clinical Information Officers is a start, though real clinical leadership will require roles akin to Chief Clinical Information Officers to lead these changes from the front. However it is only fair to say that there are few/if any clinicians supported with adequate training and protected time for this work … yet.

The Ireland South health IT landscape is still best described as (A) Myriad of Siloes.
As of 2014 the first Best of Breed 1.0 (portal and integration) project arrived in Ireland-South into Temple Street Children’s Hospital. Other notable local innovation jewels continued to thrive, certainly the key work of the HealthLink messaging service deserves special mention as they host a key national integration service (and another key service the eReferrals system) which shows that local capacity and capability are vital ingredients in the way forward.

Then thankfully after decades of under investment as of 2015 there arrived a new sense of purpose in the air with the appointment of a Chief Information Officer at the HSE and the establishment of a new body called eHealth Ireland.

Published last year, the eHealth Ireland Knowledge and Information Plan and related National EHR: Vision & Direction paper show a good understanding of the generic clinical process in healthcare, plus a sensible acceptance of the need to confront the existing siloes and integrate key systems going forward. In essence this can be interpreted as a move towards a Best of Breed strategy (B 1.0) more widely with the establishment of a national Design Authority to explore how this might be done.

Following from that plan, there is now a related push for an “EHR” programme. eHealth Ireland explains that “An EHR for Ireland is the cornerstone of the eHealth Strategy”, so has now launched a public consultation on an EHR for Ireland. Indeed this article is a formal response to same.

In the past, back in 2005, a 10-year HSE deal to roll out one of those monolithic proprietary EHR systems bound up with the NHS NPfIT was done. As you may be aware that never did happen, so little value from that deal was realised, though some hawking of that solution still seems to be going on. Let’s hope we can learn some lessons from this?

Interestingly there is also now recent talk of the new National Children’s Hospital (NCH) being “born digital”, a noble aim and great soundbite. There are clearly lessons for the NCH to be learnt from the integration progress in Dublin’s Temple Street Children Hospital, though again the risk returns that a high cost “big bang push” for a proprietary monolithic EHR system is promoted to fill that need, (aka Corporate/Conglomerate choice) which risks skewing the health IT landscape across Ireland-South for some time to come. Given the lessons learned around this type of push from the NHS and US markets, the real risks in such tactics need to be out in the open.

 

Regardless, despite these risks, the diversity of the current Ireland South healthcare system (in its broader sense, with its “2 tier” or “public/private” split etc) will ensure that no one vendor ever can or will control the entire health IT landscape here. Given that fact, if an integrated healthcare delivery system centred around the patient is to be achieved then a move towards an  open (B 2.0)platform needs to begin now, as it is the only viable medium/long term road to take.

21^st Century healthcare for all the patients of Ireland-South is now a fair and important aim that will require healthcare improvements and an open health IT platform.

Such a goal demands clinical leadership with real authority, not just responsibility.
Such a goal requires patient engagement, good practice in both clinical care and information governance, aimed in the patients’ best interest,
Such a goal demands a collaborative and open approach to technology, inevitably crossing traditional health and care boundaries.
Such changes are inevitable in this century .. it’s just a question of when.

(FYI Now based back in Dublin, I’ve recently done some work with Dr Barry White, National Haemophilia Director at the National Centre for Hereditary Coagulation Disorders, based at St James’s Hospital, Dublin who have been the first to take a small lead on this push towards an open healthcare platform for Ireland  )

 

Ireland- North

In the Northern Ireland healthcare service, which I am admittedly less familiar with, in line with learning elsewhere in the world, efforts were sensibly started on a clinical portal and integration initiative back in 2009 and have already yielded great benefit in the form of the Northern Ireland Electronic Care Record (NIECR).

To their credit Northern Ireland has an active group of Chief Clinical Information Officers who symbolise the key role of clinical leadership in this field. They may now face a “once in a generation” decision that will have implications for their care system for years to come.

Having already taken that integrated care record step, they have already taken active moves to address the many siloes in their system. Some years into that journey it can expected that the limitations of a portal/best of breed approach have become apparent. Whether that be the perpetual rise of new requirements, the challenge of effective interoperability between component parts, data synthesis or analysis or the effort of maintaining such a system in the ever changing world of healthcare, they are now looking to make a next move.

So given their health IT journey thus far and where they are now at, it might be expected that Northern Ireland might move now to consider a turn towards an enterprise wide system from a large multi-national vendor, the Corporate/Conglomerate choice. There are real related risks.

So there is now a rare and important opportunity for the health service in Northern Ireland to look beyond that limited choice and to explore how they too could progress by building on this open health IT platform and join those leading the way towards 21^st Century care.

 

 

Beware the Dragons Ahead.. yet know the Opportunity too

So clearly this is decision time, potentially a decision for a generation, a key juncture for the health systems of both Northern Ireland and the Republic of Ireland.

So while pleased to see Ireland begin to make these moves …as an Irish medical doctor, an emergency physician, a medical lead in informatics for the last 10 years and someone who is personally committed to bringing Healthcare into the 21st Century, again I feel obliged to share a view. The facts are that healthcare is an industry that is still struggling to move into the information age, despite having billions of pounds and dollars been thrown at the challenge. Much of this is down to the complex adaptive system of healthcare, the immature science, art and language of the informatics industry and a health IT market that awaits major disruption.

The international forces at play in healthcare mean that the market is in the early stages of a move towards an open platform. Following the pioneering efforts of colleagues in the US (eg VHA, OSEHRA, HSPC)  and the UK (NHS England, Apperta, Code4Health) Europe (e.g. Norway) and elsewhere, Ireland should now join this international effort now, particularly at this key point in their proceedings.

The 21^st Century challenge here is an effective fusion of the worlds of healthcare, management and information technology. Does Ireland Inc. have an interest in developing both its healthcare systems and broader economy and international prowess in these areas? The IDA and InvestNI seem to think so. A real opportunity exists.

 

A Considered View and Recommendation – for the Record
So let me close with some short outright recommendations.

• Clinical leaders need support and guidance on the road towards 21st Healthcare
• Agile and Iterative Improvement towards integrated patient care is key
• Open Platform Technology allows for greater integration, collaboration, flexibility and reuse
• Investment is required but should be spent wisely…billions were wasted elsewhere, we can learn from this.
• Any other path risks perpetuating the current disconnects and related pressures.

Fast forward 10 years … do the Irish want to look back at this moment in time and say they ended up repeating the same mistakes that others have made before?.. that they had to learn the hard way..? Or do they want to look back at this time as a moment when they decided to take their place as leaders… international healthcare and IT leaders.. for the 21^st Century?

The healthcare systems of Ireland are now on the move towards the information age of the 21^st Century. Of course they need to invest further, they need to invest wisely.

 

 

Dr. Tony Shannon                                           January 31^st, 2016
MB BCh BAO, FRCEM, MSc ITM
Dublin, Ireland
Irish Medical Council Number 017678
General Medical Council Number 4263029

References/Links
Book of Thoughts- Healthcare, Complexity, Change, Patterns & the way forward
Healthcare: Generic Health Improvement Strategy
Healthcare: Generic Healthcare IT strategy: Options A/B/C
21st Century Healthcare: the Open Platform that will Transform
National Clinical Programmes: Aligning Process Improvement with Information Technology – strategic report
Leeds Care Record website
Ripple Open Source Initiative
Irish Care Record v0 site