End of the Summer 2020, and time for the new term to start.

There is no doubt that challenges are ahead as we face into the Autumn and Winter of 2020.

As we do my sense is the best way to frame this time, is of one of opportunity. So lets not look at what we have lost or not able to do, but what we have and are able to do.

The world needed major changes at the start of 2020, it needs them now as much/more than ever before.

The time has come to Build Back Better…

P.S. as one small effort towards that end, see recent open source work from the Ripple Foundation – enabling Open Source TeleHealth– open for the wider world to use – and reuse..

Having grown up on the fringes of what was in effect a civil war, I have to mark the passing of the man who brought peace to this place.

When I was growing up in Ireland in the 1980s , it was a tough and hard place at times. The nightly news brought updates on the ongoing turmoil that was happening during The Troubles of the 1980s and the shocking senseless killings at that time became almost part of the routine. It was miserable at times and deeply sad.

The root of the problem was a division on this island between Catholics and Protestant, their religion and their culture.
As I recall of my time in the NorthEast of England when I worked between Newcastle and Sunderland, and I struggled to spot an iota of difference between the people in those fine cities (bar their accents which I still struggle to differentiate), folk can share 99%+ of their DNA, language, culture, etc etc but they tend to focus on what divides them ( in the NE of England , that is their football team).
In many ways so it was in Ireland at that time. Yes there were real important differences and injustices but the pity was that to some on either side of a fence, the other side were seen as the enemy.

John Hume who grew up in Derry/LondonDerry was different to others at that time. He knew deep down that the people of Northern Ireland shared much more than divided them , so he sought to build a bridge between them and work for peace..

For year after year, decade after decade, this message was the same, violence was not the answer and any divided factions have to negotiate compromise and peace. For many years we admired his tireless efforts and wondered how he kept going.

Those of us who call Ireland our home owe John Hume a great debt.

After decades of tireless advocacy , as well as very smart and important moves to establish the credit union movement in Ireland , plus linking the troubles/struggles to the Civil Rights movement in the US, a breakthrough came in the 1990s, a peace was negotiated, the Good Friday Agreement was signed, arms laid to rest and the civil war of that time came to an end.

When I was a young boy I recall driving up through the armed border from the “South” to the “North” of Ireland and a military helicopter sweeping down into a nearby field , soldiers jumping out, stopping our car, questioning my mother, before we were moved on and our trip to go shopping continued.
In recent years I have enjoyed some beautiful drives through Northern Ireland to visit its scenic Causeway Coast and instead the place was full of peace and open space.

We give thanks to John Hume for that.

May he Rest In Peace.

This paper by Health Education England is one that caught my eye.

The longer title is “ The Future Doctor Programme; A co-created vision for the future clinical team” but the short bottom line version is the doctor of a future is a generalist.

While we have seen major shift to specialisation and subspecialisation in healthcare in recent decades, when the pressure came on during the recent pandemic outbreak, it was the basic/general skills of doctors that was called upon. Ensuring it was safe to approach the patient, assessing patients for signs of illness, offering treatment (often simply Oxygen initially).

It was also a time when the value of generalists came into their own so the speciality of emergency medicine (where I hail from) came into its own , often as the front door for all cases where quick and urgent decisions had to be made, albeit and with due respect to anaesthetic/ICU colleagues.

Beyond the most recent crisis challenge though, this paper highlights some key issues going forward. Though this paper was in planning ahead of this crisis , the most recent crisis has made all the key issues more pertinent than ever. Here I have highlighted a few of the key points made

Patient-Doctor Partnership
Doctors in the future clinical team have the patient firmly front and centre to promote supported shared-decision making and enable patients to make the best use of available care and support

The Extensivist and Generalist
Future Doctors will have confidence in a greater breadth of practice across
disciplines and specialties due to a strong base of generalist skills, which will enable them to deliver complex, comprehensive care managing co-morbidities in changing healthcare environments.

Leadership, Followership and Team Working
Future Doctors will demonstrate compassionate and collaborative leadership and effective teamworking.

The Transformed Multi-professional Team
Future Doctors will espouse and promote a culture where each member of the multi-professional team is acknowledged, respected, valued and empowered to accept shared responsibility. Doctors will promote other healthcare roles to patients and the public.

Population Health and Sustainable Healthcare
Future Doctors will learn, while embedded in their local community, to better understand population needs and use resources optimally to improve the physical, mental and social wellbeing of the whole population. They will embrace a culture of stewardship and a sense of community responsibility.

Adoption of Technology
Technology will be employed by Future Doctors as an enabler for change in
clinical care and in education (e.g. remote supervision and care delivery and AI augmenting clinical decision making)

As a medical doctor/emergency physician who has evolved into an advocate for change/leadership/management, information technology and sustainable economics, I have to wholeheartedly endorse this view, doctors as generalists is the way to go!

As we move through the first wave of the global pandemic that the Covid 19/Coronavirus has unleashed upon the planet, it is time to quickly learn some lessons so we are better prepared for the next phase/wave/strain etc etc. As with the first wave its not a question of if but when…

If we have understood that we will need to live with this virus, then we need to find ways to contain its impact our society and economy, from both healthcare and economic dimensions.

So the issues we will be facing as we try to move forward will be how to balance the risks of reopening up our societies with the broader benefits. The most practical way we will be able to achieve that balance will be all dependent on one thing: Information.

Information on;

• Where covid cases are
• Who are their contacts
• How did they contact the virus
• Where, when, with who were they when they did
• How are they coping
• Whether they have symptoms
• Whether they need hospital/ICU care
• Whether they have longer term effects

Of course the other aspect of this will be the timeliness of this information, so rapid testing and tracing of this information will be paramount.

The good news is that all of this is essentially an information challenge.
That information challenge has people, process and technology dimensions.

To rise to that challenge people will need to think fast, work in an agile way and (while balancing genuine privacy concerns) understand that open data/information is in all our interests.

We have seen important developments in this regard with the open source release of a covid tracker app here in Ireland, based on open APIs made available by Apple & Google. Its a small but important start and the hopefully the beginning of a better way to manage information to save lives.

As the year of 2020 will be remembered by the rapid sweep of the coronavirus/ aka covid 19, lets hope that we will also remember the community and collaborative response that we have seen around the planet to this challenge.

Though we may have known that the world was due a global pandemic at some point soon, many of us have been shaken by the speed at which this one has spread across the globe, at speeds we didn’t imagine, most likely due to the interconnected nature of our globalised world.

Within the last weeks Ireland has gone from being on alert to cases due to arrive to a partial lockdown to a total lockdown within our homes (+/- 2Km) over the last days and weeks. So the threat is real and people recognise this as a public health crisis/emergency.

The health crisis goes hand in hand with a broader societoeonomic crisis that is intertwined, businesses have shut, hundreds of thousands made unemployed almost over night so this is challenging time for all.

Amidst this crisis, what has been nice to see is the quick, instinctive reaction of people that has followed the news.. i.e. people offering to help, to help with community and to collaborate in ways we haven’t seen before.

Some examples I have seen;

Community Level; Within days of a call for help, 150 volunteers signed up to help their community and their neighbours in the city village where I live.

City Level: Clusters of communities all springing up to do the same around the city, offering to help in any/all way people can to do good and help others, gratis.

Country level: Huge numbers of people volunteering to answer #IrelandsCall , again offering to help where they can.

Collaboration Internationally: the response of people all over the world to this crisis has been amazing to see. In particular see these global community efforts to build open source hardware and software to address the covid related challenges the world faces.

• The Open PPE project
• Helpful Engineering
• Open Source Ventilator
• African Covid Response team

These few examples of the efforts of others during this time of crisis show that when a crisis really happens, our human instinct is towards community and collaboration. Long may that continue..

With a background in emergency medicine and an eye on the news, the start, evolution and current state of the Coronavirus is of some interest.

To my eyes its a good way to understand the complexity of our world, our healthcare systems within and more than anything a reminder that we are not in charge of life on this planet, just one form of that life.

As I write at the end of February 2020, the main news of the year/decade that was climate change and its challenges has been knocked off by the story of the Coronavirus and its progress around the planet.
The WHO has just announced that earth is on highest level of alert about the potential spread of this viral disease.

Let me use the Cynefin framework as I have used it many times before to try to make sense as to what is happening around us. The Cynefin framework explains the world in 4 key aspects.. using the words simple, complicated, complex and chaos.

In simple terms the first case of CoronaVirus was officially reported to the WHO on 31 December 2019. It is alleged to have spread from bats to human in the Chinese city of Wuhan some time before than. It is easy to say, in retrospect, that in those first days the best possible chance to contain the virus was available, the reality of course was different, so it spread, as viruses tend to.

In complicated terms we then saw a hugely complicated effort by the Chinese government to contain the outbreak in and around the Wuhan City region, including a form of marshal law/quarantine that was massive its in size and scale, cordoning off a city of c 10 million people. That very complicated work (including the amazing construction of a new hospital facility within a few weeks) was largely possible to the culture of the Chinese people who were willing to make that effort for the greater good. It is worth considering if such a complicated containment effort to contain the virus would have worked in/around the city of Dallas, Texas for instance. Culturally I think not..

None the less despite all that complicate effort, the virus has continued to spread, beyond China and has now made its way to Italy and moving across Europe. We are now seeing a complex adaptive system in action, the key word here is complexity. Complex challenges are best understood by understanding the patterns within. The general pattern of disease transmission for viral illnesses is that those with the highest mortality rate (eg Ebola – up to 90%) are harder to transmit and spread than those with lower mortality rates (eg Influenza < 1%). We already know that the mortality rate of the coronavirus is low, < 2% and so is linked with a fairly high transmission rate as it can be passed on while the affected patient is very well. So this virus is clearly on the move and continuing to spread, despite massive effort to stop it.

So now we are at the stage where this outbreak is highlighting that the global healthcare system is a complex adaptive system.. that no one can control. Let me repeat that point, its is impossible to fully control a complex adaptive system as it is by definition made up of many parts and many interactions between those parts. We don’t hear enough of this complex adaptive systems science from the authorities, experts as to do so means that no one, not the Chinese government, the WHO , the US, EU or anyone else can control this outbreak now. In technical terms at this point we are seeing complex healthcare systems at the “edge of chaos”.

So we are looking into weeks/months of global chaos caused by this virus ahead of us. We are hearing talk of cancellation of events, of blocking the free movement of people, of shutting schools and colleges, etc etc.
What we know from Cynefin that chaotic systems require leadership. Clear leadership is required now to manage this situation but the leadership needs to be smart and understand the nature of the challenge we are up against.

My hope/instinct is that we will see this from the WHO very soon as/when we/they need to acknowledge that this virus is now reached the point of being outwith our capacity to contain it.. i.e. we are going to need to live with it.
Already I sense a slight shift in message telling people to focus on what they can do… wash hands, self care if symptoms develop, self isolate so as not to pass it on.. all good common sense advise, as we offer about all viral diseases of this type.

We’re seeing a fair bit of concern about the impact this will have in terms of illness and mortality from this virus for some while longer.. balanced against costs in economic terms. We will need to ask ourselves.. do we humans think we can control any/all other life forms on this planet.. do we need to change our lives at all?
We will not see a perfect response, more likely many imperfect choices, balancing risk and reward, decided in the face of complexity. We will need to learn as we go.
We are only human after all.

If you have being following the latest technical development in the software/web/internet for the last 10 years you will have noted a few star performers that have rocked our world.

• Javascript
• NodeJS
• NoSQL Databases (not forgetting other DBs too)
• Open Source

If there is one guy I know whose thinking has led these fields in this time its a gentleman you may not have heard of. I was very fortunate to be introduced to Rob Tweed some years ago and have been a major fan and advocate of his work ever since.

Though his style is his own and his work is not widely known, in my humble opinion his work is at the leading edge of 21st C software development in a very smart way. The Ripple Foundation has been fortunate to have benefited from his leading QewdJS technology as the key integration tier to our open platform push in healthcare, but his work has far wider utility and benefit to offer the wider world.

If you want to spin up a baseline version of his latest technology take a look here…. this smart stuff is a very useful starting point for a wide range of technology needs in the 2020s..

QewdJS – A Baseline Setup – Live in 5

There is a lot under the hood of this tech and perhaps one of the more interesting ways to understand its power is to dig and dive straight down… into data…
I say down into data as data, information, knowledge, these things run our world.. databases are the workhorses of 21st Century life.. but have you ever looked under the hood , do you think you understand them?

Now this material is only if you are technically inclined, but if you are, then imho this is mandatory viewing. What Rob has done in this presentation in London in early 2020, is explain a decades old data technology (known as Globals) and explain it in the context of the data & database driven world that brings his technology right up to date and could/should be relevant for decades to come.

Set in the context of a presentation to Javascript developers in London in 2020, this is imho a landmark presentation on the subject of Development and Databases from Rob Tweed.

If you are a computer science/information technology/software engineering student or any part in/interest in Javascript development I highly recommend this piece;

Technical Note: The discussion and demonstrations within will only mean something to you if you have wrested with the worlds of software development and database management that is so central to the 21st Century Information Society we all now live in.

This deep dive look into the world of databases give a taste of the power and potential that has been built into the QewdJS stack.. I recommend you take a look and learn.

As we reach the end of 2019 and the decade, I was invited to speak at an event in Cardiff, Wales , where open platforms were being explored and discussed.

Let me avoid any technical dimension to this discussion for now and say that we have been living in an age of consumption for a long time now, some decades, and we know that it is not all good for us.

We also know that humans are inherently creative people , who get as much joy out of creating as we do as consuming. Yet resources are limited so if everyone is “reinventing the wheel” that burns up scarce resources and we need to be mindful of this on our precious planet.

So as we are reaching the end of a decade will we see new energy and effort going into a third way, in the next decade, that of collaboration?

So the title of the presentation I gave in Cardiff was Consume, Create or Collaborate?

As the audience was healthcare related and the setting was Wales, I couldnt help evoke the memory of Aneurin Bevan and his visionary leadership behind a National Health Service.

Sometimes people swing to collaborate behind important ideas, visions and missions for the greater good..

As my journey from the clinical world into management and information technology has unfolded over time , I have had my ups and downs, haven’t we all…

It is widely understood that we all can and should learn from failures as well as successes and at this year Irish Association of Emergency Medicine conference I chose the chance to focus on the former, my failures, for a helpful change..

Yes I could have talked about the successes I have had, of which I am very proud, but I think its just as / if not more interesting/helpful to others to be open and talk about failures.

Often in the healthcare world, with its conservative and risk averse culture, people are discouraged from discussing things that can/have gone wrong. My own instinct is to be very honest about all the many complexities of a domain like healthcare and openly tell people that in a complex system that people and processes inevitably fail sometimes and that we could/should learn from that..

So over the course of a brief but I hope helpful presentation I explored a personal journey through medicine, emergency medicine, healthcare, complexity, health IT markets.. trying to change the world of healthcare & the health IT market…and finding myself failing (in part) against economic and political forces of our time etc etc..

None the less I finished on an optimistic note, citing a fellow Irishman;

“Ever tried. Ever failed. No matter. Try again. Fail again. Fail better.” (Beckett)

As I find a picture tells a thousand words, hope some of these slides speak for themselves..

In my last post I was briefly looking at some of the successes that the Ripple Foundation has enjoyed over the last few years. In fostering change in the field of healthcare and in promoting the role of open source, openEHR and an open platform in healthcare its been challenging work so great to see uptake of our ideas, methods and tools taken up and in action England, Scotland, Germany , Finland, India etc… hard not to be proud..

Of course we know that change in a complex system such as healthcare takes time and doesn’t happen overnight, we know there are many people challenges, process challenges and technical challenges on the way to further scale and further success.

We know too that our work is set within big picture issues of the societies and economies of our time. We recognise the brilliant work of Kate Raworth and her Doughnut Economics manifesto for a better world -resetting the relationship between the State, the Market, the Commons and the Household as the key players in any society/economy.

We want to make the world a better place and have been working to foster an open commons in healthcare for the last 5 years, seeding and supporting the development of open source tools in 3 key areas affecting healthcare… (1) usability of systems, (2) integration between systems and (3) persisting life long patient centred and vendor neutral data.

We have been developing open source code for quite some time now, sharing our work openly with the rest of the world. We can be understood as Makers. Our successes are framed in the context of those others who have taken our work and are using it to positive effect in healthcare settings around the world, in England, Scotland, Germany, Finland, India as I’ve mentioned.

So far so good.. we wanted and encouraged people to take our work and use it for their own needs to address health and care challenges around the world. Yet we have a problem, a failing so to speak, we aren’t getting contributions, in code or commercial support, we are not getting stuff back.

We expected that 1/10, 2/10, 5/10, 9/10 would be takers … so long as 1/10 see the bigger picture and is willing to give back. But our recent experience is that 10/10 are taking, without consideration for the ongoing maintenance of the open source tools they are leveraging and that is simply not sustainable.

Most importantly, we are not alone.. this challenge of Makers and Takers is a major challenge to the open source approach, to the right approach for healthcare.

We are aware of the Maker versus Taker challenge across the open source world as explained by Dries Buyteart of the global Drupal community.

We know that the global platform cooperative community, who are trying to build sustainable local services on open platforms are all up against challenges for investment and capital.

We know from colleagues in the open source world of healthcare, providing critical services in other parts of the world such as those that underpin the Global Goods agenda, that they do are facing the same sustainability challenges.

The reasons are clear enough..

At this time, the Market is ruled by shareholders rather than stakeholders, though it is now increasingly recognised that that needs to change.

At the same time, as the State has ceded significant aspects of its innovation agenda to the Market, in key areas it has neglected to look after the Commons, on which we all depend on for collaboration. In treating the work of healthcare information systems as just a commercial commodity and paying out for mediocre services on proprietary platforms, rather than quality services on an open platform, the lack of State leadership on this agenda is in fact a part of the problem. That too needs to change.

So we in Ripple Foundation need to take stock and consider what we do about it. As we do, we need to consider the bigger picture, the broader context of our work .. we need to consider the big movements of our day, from Doughnut Economics to We4All to Platform Coops and share our rethinking, shifting our ideas and our efforts more broadly.

Watch this space..

Back in 2010 my early Book of Thoughts writing was aimed at surveying the healthcare, management and information technology landscapes and looking for some key patterns across those.

We looked at complexity, people, process and technology issues and came back to focus on healthcare, concluding that open standards and open source technology architecture. That push has evolved over the last years for leadership in healthcare, the need for integrated care, more patient centred solutions

After related developments on the ground in Leeds the Ripple Open Source Initiative began in 2015 and moved into the Ripple Foundation shortly thereafter. In targeting the development of key open source components to address usability, interoperability and vendor neutral data persistence we have tackled some of the most difficult challenges in healthcare and shown how they can be addressed together, with tools that work.

Its gratifying to know that these tools have now been leveraged and are in use in projects in England, Finland, Germany, India , Scotland and more.. such is the power and potential of open source technology.

In Yorkshire, England, the open source Ripple stack has been key to the development of a Person Held Record for the Leeds and Yorkshire region, as well as key open source dimension to an integrating “system of systems” network to underpin that regions Yorkshire & Humber Care Record / NHS Local Health Care Record Exemplar (LHCRE) programme.

In Scotland, the open source Ripple stack has been central to their efforts to get up and running a National Digital Platform for the Scottish NHS. They started off their work with a series of sprints using the principles of user centred design, agile development and open source + platform technology to get their national plans underway.

In Germany, the HighMed consortium have taken a fork of one of the Ripple Stack tools , the openEHR compliant EtherCIS system and worked to improve it before recently giving it back to the open source community as EHRbase. This open source tool is aimed as being central to their Research & Development efforts across 14 partner organisations throughout Germany

In Finland, the national Una Core eHealth platform is also leveraging the open source openEHR tooling we have fostered to build the basis of their national integrated care record platform to serve the people of Finland.

In India, an innovative team has used the Ripple open source stack to build an information system to support the Ayurveda care system , know as AyushEHR.

We will look shortly at the challenges these initiatives face, each large regional/national efforts in their own right, for now at least as we close out 2019 we acknowledge these small stories as success stories and take a little pride in what we have started….

The launch of the Irish Health Service Executives Digital Academy Programme by Professor Martin Curley (Head of Innovation at the HSE) was an important effort to shift gears towards change in the Irish Healthcare system.

It was an important event for the Irish healthcare system, as it struggles from crisis to crisis with ongoing calls for improvement and reform. For now, the Irish healthcare culture and systems remain stuck in the last century, with little/no sign of shifting to the digital age to date.

Much of that is down to internal capacity and capability in the Irish public sector/ healthcare sector and the limited understanding of people , process and technology issues that are needed to develop a service fit for the 21st Century. So the push for a Digital Academy to tackle this lack of capacity and capability in the Irish health service is a good thing and full credit to the leadership of Prof Martin Curley for getting this important initiative off the ground.

Of note I thought it was worth pointing out several of the presentations that we’re made at the event as they shared an important message.

Dr Michael Harty , GP and Chair of the Healthcare committee and instrumental in the push towards Sláintecare made the case for a push for a more user centred design approach, agile development, a push for open standards and a call that 1% of current investment be used to progress these important principles to advance the digital aspect of the Slaintecare agenda that is required.

Professor Anthony Staines picked up a similar them with his clear call, “The Logic of Open” , again advocating a more open approach to health IT in Ireland and warning against proprietary technology that has failed elsewhere.

Here also is the SlainteCare Record demonstrator built for the event, on an open platform, to illustrate how an integrated care system could/should be developed in Ireland;

The Digital Academy will do well if it helps to educate the Irish healthcare work force in the key people , process and technology aspects of the changes required to bring the Irish healthcare system into the Digital Age, so we wish it well.

P.S. For those who have not been selected by their local Digital Academy to learn the basics of the elements involved.. you may find this resource of interest/value..

As a healthcare improvement/tech advocate am regularly willing and able to declare that the Electronic Health Record (EHR) market is not as good as it should be, at all, so we need an open collaborative approach, internationally, to make it better.

Some related articles that help explain the latest state of the EHR state of the market.

“EHR Sales Reached $31.5 Billion in 2018 Despite Concerns over Usability, Interoperability, and Ties to Medical Errors”

So big sales and increasing all the time, albeit with the usual caveats about the related challenges therein

#1 Interoperability as well as other common criticisms of EHRs cited include:

• Wasted provider time: a recent study published in JAMA Internal Medicine notes providers now spend more time in indirect patient care than interacting with patients.
• Physician burnout: EHRs have been shown to increase physician stress and burnout.
• Not worth the trouble: The debate continues over whether EHRs are improving the quality of care.
• Negative patient outcomes: Fortune’s investigation outlines patient safety risks tied to software glitches, user errors, or other flaws.

On a related noted, as if further evidence were needed that the main challenges in this field are people + process as much as technical.. check out this “Culture eats Strategy for Breakfast” type article on attempts towards a major EHR rollout in Denmark.

Lost in translation: Epic goes to Denmark

TLDR: the key points are perhaps best summarised by this Tweet by informatician of long standing Enrico Coeira

This month sees the publication of a most important paper on one of the most challenging issues of our time in the Western world and beyond , that of land ownership.

In “Land for the Many”, George Monbiot and others take a look at why and how the basics of land ownership as we know them today need to be challenged, fundamentally, to right a wrong.

In this related explainer article here Monbiot asks/explains
“Want to tackle inequality? Then first change our land ownership laws”

The issues are simpler that many would have you believe..
“Homes are so expensive not because of the price of bricks and mortar, but because land now accounts for 70% of the price”

There is a compelling argument that the market around land sales is clearly dysfunctional now and adversely impacting a whole generation of younger people.

So something needs to change.

Let me make that personal. I live in a nice part of Dublin, Ireland where property prices have escalated again in recent years. That might sound great, the value of our house has shot up, yet I take no pleasure in that/ wish it were not so, as our children and their children have a ridiculous challenge ahead of them in securing their own roofs above their heads.

If the answer to this is a land value tax and the greater public ownership of land (NB ownership of land rather than property is the key here) then bring it on.. needs to be done.

Young person trying to buy/rent a home? Please educate yourself by reading more on “Land for the Many” available here.

When moving at pace through a local bookshop in recent weeks, a title caught my eye..

What a title, what a question, I couldn’t ignore it

This is a hard hitting book, that pulls few /no punches in its scrutiny and examination of the medical profession in the early 21st Century.

As a medical professional myself, this could/should have been uncomfortable reading and yet I couldn’t help but agree with the main thrust of the argument herein.

It reminds me of a book about Eisenhower and his efforts to battle the Military Industrial complex in the latter part of his distinguished career from army general to US president.

So too is (Doctor) O’Mahony railing against the Medical Industrial complex that has sprung up in recent decades.

While his look back at the past of medical practice (which resonates as my own grandfathers were both GPs in rural Ireland of which he refers to in part) may be somewhat rose tinted, I believe this key point is a valid one.

That is something along that lines that the main value in medical science is in doing the basics well, midwifery for childbirth, vaccinations to prevent disease, trauma care to limit disability etc.

He challenges the status quo in modern medicine with its research and publication industry (and related publication bias) which rewards medical careers for publishing tons of papers often with little or no real clinical value as such.
He challenges the cancer research industry as absorbing much monies with relatively little return as well as the entire pharmaceutical sector, part of the medical industrial complex that is best understood as an vested interest with a primary focus on generating profit, lets call it what it is please.

If that isn’t uncomfortable enough reading he also calls out those medical professionals who effectively invent a disease so as to generate a related patient population, waiting list, funding etc etc, which if harsh+ has at least a grain of truth in it, at least in part, I believe.

With regard to the medical information industry, which I know well, he rightly challenges the move towards data capture for data captures sake which we know impacts the doctor-patient relationship at the frontline, so again I wouldn’t argue particularly with that point either.

While this book doesn’t particularly offer a lot of hope that the medical profession will have the insight to see its own conflicted role within the medical industrial complex that 21st Century medicine has become, it does at least provide a wake up call to those of us who believe in the essential need for medical leadership at this time. Leadership meaning “do the right thing” more than just “doing things right”.

So I welcome this soul searching book and if you are/know a medical professional I would encourage you to raise awareness of this most thought provoking and very timely writing.

Thank you Dr O’Mahony

Thank goodness for thinkers.

Amidst the world of political, economic and social turmoil that this decade is within , check out the bright ideas of one smart lady from New York.

They call her AOC, Alexandria Ocasio-Cortez and her idea whos time has come is being called the Green New Deal.

Check it out

For those of you with an interest in healthcare, then health IT you will be well aware of the huge interoperability challenge of our time.

The challenge of interoperability (aka getting health IT systems to talk to one another in an intelligible way) is perhaps the tech challenge that has got most attention in the sector in recent years.

Of course like any challenge in the complex system of healthcare, the interoperability challenge isnt just a tech one, but has real people and process dimensions too. Take the US Healthcare market where c 16% of GDP is spent on healthcare and competition between healthcare providers is rife.. an environment which doesn’t lend itself to data sharing as you may appreciate.

Back to the tech aspect of the challenge and the advent of openAPIs (open Application Programming Interfaces) from the rest of industry has finally hit the healthcare scene and HL7 the US based health IT standards body is promoting FHIR (Fast Healthcare Interoperability Resources) as the solution to interoperability. There is no doubt that the FHIR API movement is helping to move the sector in the right direction towards better sharing with the JSON syntax that is the most common approach bringing the challenge within reach of the average software developer.

For reasons that I wont go into in depth in this post FHIR is best placed as an interchange API approach to the existing healthIT market suppliers data, many of us who have looked under the hood and in detail believe that FHIR alone is not enough to resolve the interoperability problem in the sector. For that longer term solution, enabling the easier building, scaling and maintaining of health IT systems , esp towards a cradle to grave record, along with greater interoperability between systems (think swappable component parts) there is equal/greater potential from the world of openEHR as a future proof vendor neutral Electronic Health Record (EHR) architecture. openEHR is something I’ve written about before/for a long time and it is gratifying to see its growth slow and steady across the globe also unfolding.

If you are wondering if you need to dig deep to work out whether to use FHIR or openEHR for your next healthIT challenge, the short answer is don’t, the safe answer is that both are useful, can be complimentary and should be used together. If you would like to know more and look at this issue in more detail.. you may be interested to know that INTEROPen , the high profile interoperability effort in the NHS/UK has recently commissioned a paper exploring these issues which you will find here.

FHIRⓇ and openEHR

An excerpt from the Executive Summary may be useful here;

Poor interoperability between health and social care applications remains a critical barrier to the
effective digitisation of health and social care. Whilst HL7 FHIR Ⓡ is rapidly becoming established as the preferred data exchange standard in the UK, a number of NHS organisations and vendors are deploying applications built on the openEHR standard.

This paper outlines the differing approaches and goals of each standard, and suggests that both have a valid and complementary place in the challenges faced in digitising health and social care.
FHIR Ⓡ is more focused on data exchange between existing systems, whilst openEHR offers an alternative approach to building new systems and applications, which removes some of the barriers to interoperability in the first place.

I was glad to have the opportunity to input into this paper which we hope is of interest / benefit to others. Thanks of course to my colleagues Dr Ian McNicoll and Dr Amir Mehkar whose leadership made this paper possible.

This blog has explored issues from healthcare, to management, to technology over the last 10 years now and aimed to explore these at many levels.

If you are following the news in Ireland the story behind the attempts to build a new National Childrens Hospital, it presents an instructive example of a complex/change/healthcare programme going/gone wrong.

In brief, what started out many years ago as an aspiration to have a new Childrens Hospital decades ago, then became a political challenge around where to build it. While initial estimate costs were in the €400-600m range, it then jumped to about a billion euro, now in the last months up to €2billion, with no clear/good explanation of how things got so out of control.

When you look at it it appears a classic example of a complex systems challenge mismanaged. I have written before about the Simple/Complicated/Complex/Chaos in our lives and the misunderstanding many people have between complicated and complex challenges. Complicated challenges can be often handled with clearly defined plans.
Complex challenges need a more iterative exploratory approach.

Lets look at the essence of the National Children’s Hospital (NCH) aspiration/plan for a moment to understand some of the complexity involved. In Dublin there are at present 3 separate children’s hospitals of long standing and for many years those siloes have been seen as a problem, so the nation would be better served by one, integrated, national children’s hospital.

• Challenge #1 was always going to be the alignment of the people, processes and technology from 3 hospitals onto one new site.
• Challenge #2 was the oversight and coordination of this challenge, one of the biggest of its kind that the Irish State has taken on.
• Challenge #3 was the delivery of the related building programme, which was in large part, to be handled by “the Market”.

I call out the roles of the State and the Market early on here as we know that many of the challenges of our time are down to the politics & economics of the problematic relationship between Nations and Corporations (as we have explored in other posts).

We know that many states/governments talk about transforming this or that sector but often struggle with the organisational change involved. Many businesses/corporation/market forces face the same challenges, though may be able to keep their failings from the public eye.
Either way both the State and the Market fail to acknowledge that most change is evolutionary rather than revolutionary.

The rapidly escalating/out of control costs at Ireland’s National Children’s Hospital , now estimated at up to €2 Billion, show the limitations of both the State and the Market abilities to handle large scale Big Bang projects/programmes. While the State will get most of the blame, bear in mind that many leading business players from the Market have been brought in to help with this project and it is the tendering process to the Market and out of control costs post award of tender that are raising the alarm bells. There is a key lesson to be learnt here, that handing over the complexities of a programme from the State (government) to the Market (supplier) does not make the complexity go away.

You can foresee already that the key lessons to be learned here will involve people (esp leadership and governance issues) and process (around the project management/cost estimation/tendering of the work) issues, those recurring patterns will feature in the analysis.. that’s pretty much guaranteed amidst the complexity here..

It will be interesting to learn of the methods that were used to plan and cost the building of the Irish National Children’s Hospital. The Irish have been travelling around the world to help in the building industry for centuries, so regardless of the Celtic Tiger folly, this building challenge should have been manageable. As the investigations into what went wrong begin, keep an eye out for the use of Building Information Modelling (BIM) techniques to plan out the detail in each and every room of the projected build. There are varied levels to the detail available with BIM practice , including costs that could /should be included. Indeed the really important interplay between building designers and cost managers is nicely explored here.

I’m highlighting this #BIM discipline as it hasn’t been mentioned in coverage at all that I have seen, but as we know information is key to managing projects, so it could/should have been key to getting the costs right, down to the desks in the rooms, if it was done properly, iterating through designs/redesigns until design/cost agreement was reached, in advance of any tendering/ground being broken.

As it happens Ireland NCH was supposed to be a trail blazer of the BIM approach in Ireland (though I expect that either the initial designs were way off or the cost elements were not properly included for projecting the total building cost or else BIM just doesn’t work – either way there was a root cause issue here). This important approach has only just recently (2017) been recommended for use in projects across the State and it is clear there is a lot of learn about this on both the State and Market side.

Beyond the problematic building plans (Challenge #3, not #1), I’d like to bring attention to one of the most significant by products of the NCH cost problem now faced, that is the occasionally mentioned IT aspect of the project where we see these State/Market failures are being compounded.

It turns out that one of the addons to the project cost was €97 million that been put aside for IT in the NCH project. Whats €97 million in the context of €2 Billion I hear you say? 5%? Modest!
How didn’t they think of that before you may ask? The answer to that is tied up with the broader wider health reform plans such as the current thought leading SlainteCare programme and the related related (and risky) ask from eHealth Ireland for €875m to fund a 10 year Electronic Health Record (EHR) procurement/rollout plan.

What ever way you look at it, in the context of the Irish Healthcare system (which is largely paper based and stuck in the last century from an information management perspective) a potential investment of €97m is major, so all of HSE IT eyes are now trained on this opportunity for that investment.

Which is completely natural and understandable, until you consider that this NCH IT procurement of €97m focused on the acute paediatric sector is likely to consume/silo and skew the vast majority of the entire Irish Health IT spend and focus until now 2022/23 (i.e. until the NCH opens)… so just lets say the next 3/5 years.

In the context of the really really important stuff that Irish Healthcare needs (those major needs beyond a National Childrens Hospital), i.e. in the context of the SlainteCare programme of reform and improvement (whether you agree with it or not) around a patient centred healthcare system (based on need > ability to pay), this poses is a really big problem/risk.

Over the last couple of years I have been sharing information and ideas on how Ireland could /should embrace the challenging move to digital healthcare, as this is now the main focus of my work. In doing, so I have recently been warning of the risks of a waterfall style procurement towards a big bang spend on an EHR system/systems as the wrong way to do this. At this point in time, that’s exactly what the NCH IT programme looks set to do, another case of the State naivety of how to handle a complex challenge and hand the problem to the Market.

See Health Improvement in Ireland- for the Record(s) from 2016
and Irish HealthIT: It’s time to Innovate from 2017

As if that skewed NCH IT spend wasn’t problematic enough, the aforementioned Challenge #1 of the People (ie clinical staff from 3 independent hospitals) + Process ( 3 different ways to working across those 3 hospitals) + Technology (3 different tech landscapes) alignment between the hospitals hasn’t been done much at all, so a big bang change transformation is being teed up, that will force the alignment of organisational siloes, working practices and a ramp up of the information tech of the 3 independent hospitals, aimed at the promise of being “born digital“. I’m sorry to say it, but in my experience and opinion, this is a real recipe for a further big bang bungle.

You may not be believe me..
Well I’m afraid I’ve “been there, done that” during my 5 year time in the NHS as a medical doctor within the NHS National Programme for IT which spent up to £12 Billion (yes that’s billion not million) trying to bring Electronic Records to the NHS (between c. 2002-2016) and which floundered/failed on the acute hospital sector back in 2011.
Conversely, other work I later led in Leeds across the large multi-hospital Leeds Teaching Hospital group (which includes one of the UKs largest children’s hospitals) and then across the city of Leeds shows how this can be done better, at a fraction of the cost that is being considered here.

As a general rule, the answers to the challenges in 21st Century healthcare lie in clinically led, user/patient centred design and agile/iterative/evolutionary developments, rather than big bang programmes of revolutionary change.

We need to better understand how to tackle such complex challenges, so those in positions of responsibility within both the State and within the Market need to educate themselves on how to navigate and manage complex organisational change, where cooperation is as important as competition.

The story of the challenged delivery of the National Children’s Hospital in Ireland should be a wake up call in Ireland on that.

For those of you following the political/economic/societal turmoil all around us, you may appreciate this update article following the Davos elite as they gather to work out how to make the world a better place.

I recall recently hearing/reading of an executive advisor to the super rich who had routlinely been asked advise on how to get even wealthier.
Lately he explained that the tone of the help they were seeking was now changing.. questions we not longer about how to get richer/help the world but how to protect themselves in their enclaves as the current political turmoil gathers pace… when they aren’t sure they can trust the security guards at their gates..

Panic is on the agenda at Davos – but it’s too little too late

I guess the point being that “The results of the rampant inequality engineered by the global elite are finally catching up with them”….

For more on why you/we shouldn’t particularly trust the billionaire philanthropists of our age see here;

Winners Take All: The Elite Charade of Changing the World

My interests mean I dig about quite a bit looking for someone who’s doing a good job and building something that I think has a future.

The work we have done in the Ripple Foundation on PulseTile, our open source UX/UI framework for healthcare is work we are very proud of and based on the principles laid out in this blog and site.

Amidst complexity we look for patterns, and so PulseTile is a patterns based framework. Now the patterns we leverage may seem focussed on healthcare and indeed they are , but they are deliberately universal, leveraging patterns from the wider world.

So I was looking for good patterns based stuff in UX/UI, again and again

Material Design comes up… again and again.. Great Design.

Getting from Design to Development?
As we’re using ReactJS lately, I then come across Material UI.. 40K + stars on Github.. ie this development framework is popular+.

Then I find React Admin..

React Admin is;
A frontend Framework for building admin applications running in the browser on top of REST/GraphQL APIs, using ES6, React and Material Design. Previously named admin-on-rest. Open sourced and maintained by marmelab.

React Admin is very smart stuff, has lots in common with our design and development goals in PulseTile and going places with a smart leader and smart team behind it.

Nice work Francois, we’re in!

Atul Gawande is a respected doctor who has written some pretty useful stuff as books that have been well received, are thought provoking and made an impact already.

For those who dont know his work see here

The Checklist Manifesto: How to Get Things Right

and more importantly here

Being Mortal: Medicine and What Matters in the End

So when I noted his recent article online entitled

Why Doctors Hate Their Computers

it had to be read..

Now you might expect a medical doctor like myself who has moved into healthcare IT to be upset by his article. On the contrary, I was very glad to see it. The fact is this medical leader , who has no reason to pick a battle with the health IT industry has joined others who are calling the dysfunction of current healthIT out.

He takes aim at the Electronic Health Record industry and deservedly so, its decades out of date, behind the rest of the tech curve and holding healthcare back.

Several of us have been pushing for a new approach for some years now, one focussed on usability, integration and a good fit with the clinical process.. Its great to see others raise the volume on that call.

This blog started off as a set of pages, a Book of Thoughts

… with 5 themes and 5 articles within those themes

… which begat a monthly blog on related issues.

The bottom line of that writing was 21st C Healthcare demands an effective mix of people + process + tech (inc mix of open source & open standards).

Over time that analysis evolved from the positive potential of an open platform in healthcare, into open platform cooperatives, the commons, understanding the wider economy, the need for societal and economic change.

As times has changed the medium of video has becomes more useful, as its now easier to do, easier to share, is now a pervasive medium and a great way to learn.

So it seemed time to put some of the key thoughts & principles behind the work that have done for last while – down on video

So on behalf of the Ripple Foundation, which I’m a part of, working towards an open platform cooperative movement in healthcare…
.. I’m pleased to reveal our work on our Digital Commons Academy.

We are openly and widely sharing a set of 25+ five minute videos on a range of related issues.
You may be interested in the outline of the material covered below

If you would like to explore the Ripple Foundations Digital Commons Academy take a look over here.

Ripple Foundations – Digital Common Academy – educational material outline 

• Healthcare under pressure
• 21st Century Economics
• The Need for Medical Leadership
• The Future of the Professions
• Towards Patient Centered Care
• HealthIT : The State of the Market

Having identified challenges with 21st Century healthcare , we then delve deeper to try to understand these challenges better;

• Complexity & the Cynefin Framework
• Change = People + Process + Technology
• Emergency Medicine: Complexity + Patterns
• Management: Complexity + Patterns
• Info Tech: Complexity + Patterns
• HealthIT: Complexity + Patterns

We take the time to focus on 2 key areas in particular

• Process Improvement: Lean + Agile
• Information Technology: Open + Source

before we conclude that 21st Century Healthcare will be transformed by work now emerging from the Digital Commons;

• HealthIT Towards an Open Platform

Before we explore that future in more detail, we firstly explore some key concepts;

• Understanding Technology: 3 tiers UI- API -DB
• A for APIs – Exploring Messaging/APIs
• A for Alphabet- Exploring Terminology/Classification
• A for Architecture- Exploring Archetypes & Templates

We then focus on 5 key elements that need to be addressed on the road to 21st Century Digital Healthcare

1. Usability
2. Integration
3. Clinical Kernel
4. The Role of Open Source
5. Governance & Leadership

We look back at the background history to the story of “Self, Us, Now” behind the Ripple Foundation
We then look at its current & future work of the Ripple Foundation: Towards an Open Platform – in action

If you would like to explore the Ripple Foundations Digital Commons Academy take a look over here.

Look around and you’ll see that some years after the Great Recession of the last decade and in some parts of the planet  (inc Dublin, Ireland) where I’m based that its all talk of Growth again..

Yip, yahoo, GDP is back up.

Yet is you think about this GDO/growth obsession we have lived with for decades and ask “Why?”/”What does constant GDP growth mean?” you can come the conclusion that there is a Growth Delusion

Simply put, nothing natural grows for ever.
We live on one planet with limited resources, so there is only so much land, fresh air, water for us all.
Sure we can add some more billions of people to the planet, but not billions of billions, you get the idea of natural limits.
Now you might say Moon and Mars to me, but hold on a minute.. we cant just burn through all of earths resources and move on .. at least I wouldn’t want to.

No, we have to be smart and brave enough to acknowledge that we have one earth to look after and human consumption cant grow forever.. (for a long time yet, but not *forever*), so get our heads beyond this growth thing and think “grown up” steady state sustainability for a bit.

Then look around, look at this..

238 leading academics call on EU to prioritise a wellbeing economy

“For the past seven decades, GDP growth has stood as the primary economic objective of European nations. But as our economies have grown, so has our negative impact on the environment. We are now exceeding the safe operating space for humanity on this planet, and there is no sign that economic activity is being decoupled from resource use or pollution at anything like the scale required. Today, solving social problems within European nations does not require more growth. It requires a fairer distribution of the income and wealth that we already have.

…

The good news is that within civil society and academia, a post-growth movement has been emerging. It goes by different names in different places:décroissance, Postwachstum, steady-state or doughnut economics, prosperity without growth, to name a few. Since 2008, regular degrowth conferenceshave gathered thousands of participants. A new global initiative, the Wellbeing Economies Alliance (or WE-All), is making connections between these movements”

So enter the WellBeing Economy Alliance

The essense of their plan:

Connects and convene seven meta movements from around the world (both radical ones and those closer to the current system). These meta movements will be: businesses; faith and values groups; academia and think thanks; civil society organisations; governments; practitioners such as cities which are implementing wellbeing economy initiatives at scale; and institutional innovators.
WEAll will support their strategy, collaborations, dissemination and replication. 

This breakthrough movement is on the move.. the time is now

#WeAll

If you have an interest in the world around us and wonder where the world is going, you may be interested in this book.

SIMPOL – A new way to think about solving the worlds biggest problems

I’ve long been wondering about the simple patterns in our history, from tribes, to city states to nation states to empires and then the global units of the United Nations, the World Bank etc.

Yet we know that the globalisation has created a backlash across the globe, as the democratic nation states that have ridden that wave are now suffering, esp in the form of Brexit and Trump-it.

In answer to that, the SIMPOL analysis and idea may be very futuristic and perhaps a dream but its a very smart analysis and a very smart idea.

Simply put , the current political system has 2 organisational entities set against each other.

The Nation State versus the Business Corporation (aka the Market).

Nation States are being forced into a race to the bottom in terms of tolerating the movements of Corporations, such as those who move around to pay as little tax as they can (inc to Ireland).

So Nation States are unable to do the right things for the long term (eg protect their workers and the environment) as they are afraid that if they do, that the Market will flee to another Nation State.

So the *right* policy decisions are often ducked.

So  the solution is this..

Work towards SIMultaneous POLicy Implementation of the right policies (eg environmental protection across all countries together.

A pipe dream? Perhaps..

Yet part of the solution is;
getting you the public to sign up to the SIMPOL idea..
which then lets your local politician know you have signed up to sign up to the SIMPOL principles here..
which then suggests the local politicians does the same…. and many have, as they have nil to lose from signing up and something to lose ( a vote from a voter in their area( from not signing up
towards in time, a critical mass of voters and politicians open to the idea

Where this will go , who knows, maybe not far, but its an interesting & novel idea.

If, just if , enough citizens rowed behind it and got involved in online policy ideas, review (citizens assembly style) and enough politicians saw its long term potential, then there might, just might be something profoundly important to it.

Kudos to the Thought Leadership at simpol.org

July was a hot month in 2018.
2018 has been a hot year.
For most of us its been great to enjoy a warm summer, yet for many folk the temperatures are a wake up call to the state of Planet Earth.

You may have seen posts here on the challenge of living within the LifeRing,  i.e. meeting the needs of the earths population without destroying it. (aka Doughnut Economics)

We know that we are living through a time of turbulent change (Brexit and Trumpit) and its increasingly clear there is a mismatch between the key players of the State and the Market, that many Households are suffering, while the role of the Commons has been neglected/forgotten.

Indeed, you may not have heard much about the Commons, or consider that it belongs to a history lesson, but if you look around , you will see people coming together in new ways to collaborate and cooperate, just like they have done since the start of time.

In London, in July, in 2018 the second open platform cooperative gathering took place.
This was my first time to join this get together, the first one had happened in 2017, looked important and this one looked not to be missed.

So a gathering of people, from many walks of live, from many parts of the world came together for 2 days to bring their issues and ideas and work towards some common goals.

Most interestingly these were around the promise and potential of open platform cooperatives . Indeed open coop was founded on the purpose of ;

“building a world-wide community of individuals and organisations committed to the creation of a collaborative, sustainable economy”

Those attending were interested and agreed on the potential for

• People to cooperate and work together
• To tackle shared/common challenges
• via leveraging the power and potential of open platform technology

It was great to attend with colleagues and make new acquaintances from this wider world. A few things were clear to me from the event

• The energy and effort from those attending represents a new wave of thinking and working
• We are in the early stages of this movement.
• Many/most all attendees were convinced of the need to support Households with the Commons, yet many were unclear how to engage the State & Market in this shift
• Much of the tooling that is needed is indeed common, yet at an early stage, work towards an open platform in healthcare and related tools are indeed interesting models that others could learn from imho.
• There was an acknowledgement that as well as open source tools, that open standards were also going to be needed to achieve the change required at scale, which again fits with our experience in this field.
• That momentum will steadily build from here, this is very much a bottom up grassroots movement and look out for evidence of open platform + cooperative efforts sprouting up around you.

In essence, this is historic, game changing stuff, just getting started. If it appears radical, that because it is, its not business as usual neo liberal economics as we know it.

Will it thrive/survive? in my view the ingredients already sown and the complex adaptive systems nature of our world make this stuff unstoppable, though it will takes years of effort to see it fulfill its potential and the State and the Market may not know how to handle it, but the Commons is on the rise..

Some key links for the record.

https://open.coop/about/

https://open.coop/2018/08/30/open-2018-videos-workshop-space-sessions/

http://freeknowledge.eu/article/our-little-grain-sand-opencoop-2018

View at Medium.com

If you have an interest in the worlds of economics, healthcare or technology, here’s a story that’s emerged this month that is worth noting for the record books.

In the US, amidst the chaos of the Trump administration, yet another mistake has been made this month.  For the record, it is worth noting that the US Department of Veterans Affairs (VA) Veterans Health Administration (VHA) ended up with a contract for a large IT solution for the next 10 years worth about $10 billion as of May 2018. On the face of it that may appear to be unremarkable news: just another big expensive contract for an IT system.  Yet there is a part sad/part silly dimension to it that is well worth flagging up at this point.

Some history: The Veterans Health Administration and its transformation

To explain the folly of this recent move, it is worth understanding a bit of background to the VHA.

Whilst the USA may be the richest country in the world and spend more money than most on its healthcare system (c 16/17% of its GDP), it has some of the most mediocre healthcare outcomes. One of the exceptions to their problematic healthcare system was the VHA which is one of the few publicly funded systems in the USA.  The VHA is responsible for the healthcare of military veterans.

It wasn’t always that way. The story of the transformation of the VA from a dysfunctional healthcare system through its renewal as an efficient and effective beacon of healthcare in the US was nicely told in “Best Care Anywhere” by Phillip Longman.

Now I should say that I never worked in the VHA, so am commenting as an outsider, but my understanding is that one of the keys to this turn-around was the leadership by a fellow emergency physician: Dr Ken Kizer. My understanding is that his leadership was key to the improvements that  the VHA saw in the 1990s. Another key part of the transformation was the bottom-up IT innovation at the VHA, that created a comprehensive and extremely powerful Electronic Healthcare Record (EHR) known as Veterans Information Systems and Technology Architecture (VistA).

I won’t use this article to go into the pros and cons of VistA, but a mixture of clinical involvement, user centred design, iterative development and a unique technology known as Mumps are key elements.   If you have a technical interest you are likely to baulk at the mention of Mumps, which you are most unlikely to have heard of . Yet don’t dismiss it so fast.  From my understanding, and from what I’ve seen, its power stems from a unique combination of computer language and multi dimensional database.Sadly, it is not a technology that is widely understood or appreciated.

Anyway, times change, leaders move on etc, and so some years ago the VHA ended up under pressure to make further improvements and refresh its technology.  Such is the nature of change.

VHA IT Challenges: Leadership Steps

A range of options were explored for improving VistA in 2010 with a report known as the “VistA Modernization Report: Legacy to Leadership” and as a result, in my humble opinion, the VHA led the healthcare world when, in 2011, it made the brave decision to advocate an Open Source, Open Standards approach to the refactoring of VistA..  As part of this strategy, it established a separate organisation to oversee the Open Source efforts: the Open Source Electronic Health Record Alliance (OSEHRA)

It will only be in the fullness of time that the significance of that leadership move will be understood and appreciated, but for a range of reasons, though the intent was noble and right, the execution of this strategy was problematic.

Why those Open Source VistA efforts and the efforts of OSEHRA were not successful remains unclear, but my own considered view is that, given the size, scale and style of the VistA codebase that was Open-Sourced, it was always going to be challenging to build an Open Source community around VistA .

VHA IT Challenges: Mistakes Made

Cynically, one could argue that a key reason for the failure was because the approach taken to open sourcing VistA was more akin to an Open Source “code dump”, i.e. Open Sourcing an existing solution, without ensuring that the technology can be easily picked up by newcomers etc.  Indeed, this is one of the challenges faced when any legacy software is repackaged as Open Source. 

Additionally,  there appeared to be parallel refactoring efforts that , at least from where I was observing this story, were disconnected from building an Open Source community. I’m unclear whether this range of refactoring efforts – in particular VistA Evolution and eHMP – were meant to translate to a Healthcare  Open Platform for the VA and the wider world, but my perception was too much money being thrown at the problem, too many Powerpoint presentations of future architectures, and too few demonstrations of actual Open Source code deliverables to back the refactoring challenge up.

VHA IT Challenges: Opportunities missed

One opportunity that was surely missed, again in my humble opinion was some of the very smartest technology that emerged from the VistA scene, that of Enterprise Web Development by Rob Tweed, whose smart thinking recognised the power of M the database, whilst helping to migrate that technology towards the web age by forging very smart linkage with Javascript, the language of the web.

For reasons I cannot explain, the opportunity to exploit this innovative work was missed by those involved in the VistA refactoring, even though, somewhat ironically, Rob won OSEHRA’s first Innovators Award in 2014.  All was not lost, however: I should point out the interesting exploration we made towards an NHS VistA  by leveraging that smart stuff in the smallest possible way..

Another key blind spot the VHA had, and indeed the USA still has, is in leveraging the power and potential of openEHR.  The OpenEHR technology, with its focus on peer-reviewed, clinically-led  specifications and standards, presents a new and powerful model for health IT,  underpinned by the world’s leading research.

Indeed tt is safe to say the vast majority of those involved in Health IT in the US are completely oblivious to the international efforts focused around OpenEHR. that are, slowly but surely, building an Open Platform that is truly fit for 21st Century Healthcare.

VHA and the DOD: Interoperability dodged

The story, however, becomes even more messy and unsatisfactory, courtesy of , the US Department of Defense (DoD) who have close links to the VHA. DoD is responsible for the healthcare of active US military service personnel, but that responsibility switches to the VA when they become Veterans.  The linkage and transition of their health records between the DoD and the VA has long been recognised as a key requirement. The DoD’s solution to modernising their health IT was to take totally different approach: they awarded a large contract for a proprietary EHR in about 2015. Whilst both the VHA and DoD had shared some heritage in their earlier HealthIT (the DoDs earlier Composite Health Care System (CHCS) had its roots in VistA ) over the years they had  diverged, no doubt forpolitical differences of opinion as well as technical ones.

You won’t be surprised to hear that, for many years, there has been major political pressure to tackle the complex challenge of interoperability (within both the VHA (between the VistA instances spread across the many VA sites within the USA), within the DoD and of course between the VA and DOD). In recent years, all parties have struggled to achieve this.  To be fair, this is in common with most other healthcare sectors across the planet.

So, when the VHA IT refactoring efforts started to struggle, combined with the continuing  interoperability problems between the VA and DoD, a groupthink started to emerge: one that I have also seen in many other quarters in the past.

Rather than tackle the global interoperability challenge that healthcare faces by understanding, exploring and building a next generation open platform for healthcare, pressure came to bear on the VA to move away from VistA, and instead, replace it with another proprietary IT solution.  Not surprisingly, the perceived wisdom was to use the same IT vendor chosen for the DoD.

Now this post is nothing to do with the particular proprietary IT vendor involved in these deals.  However, many of us that have been around for a while have seen poorly informed customers purchase mediocre proprietary technology for years. Most of these vendors over-promise but under-deliver on interoperability, and an increasing number of us know that no one commercial organisation is going to own the platform that transforms healthcare.  The reality is that a more open, common-based approach to the platform challenge is needed.

Lessons from Health IT : Steps back in time

So my considered view is that now, in May 2018, the good work of the VHA as a true leader in the field of both healthcare and health IT for many years, is likely to take a step back in time.

The term “step back in time” is deliberate as this folly (polite term) is very reminiscent of the approach used during the failed NHS National Programme for IT of England (where I spent 5 years) of 2002- 2016. Safe to say that the initiative was a failure, huge sums of money were lost , much time was wasted andthe NHS is still trying to shake off the chains of the resulting proprietary health IT market.  If you look at this latest move by the VHA towards IT, the NHS in England has been there, done that, it doesn’t work.
Thankfully,the NHS is only now, years later, waking up to smarter moves towards an Open Platform approach.

Which brings me quickly to what I and others have meant by an Open Platform in healthcare (a term misused by some in recent years, who sense a paradigm shift in the health IT market is coming and are starting to jump on the bandwagon).   My own work and related writings have been towards a blend of open source and open standards for some time, towards what I’ve called The Open Platform that will transform 21st Century Healthcare.  To bring this up to date, please take a close look here at the “Defining an Open Platform” paper from the Apperta Foundation (Declaration: I’m a Director of the non profit Ripple Foundation as well as the non-profit Apperta Foundation.  Both organisations are working towards an Open Platform in healthcare. I also contributed to that paper)

So I wish the VHA luck with their new proprietary EHR contract, they are going to need it, especially if they wish to avoid the troubles the DoD now find themselves in with their latest EHR efforts.  What I honestly expect now is several years of effort by the VA to try to make that contract work before it ultimately grinds to a halt.  I can predict from my experience with the NHS National Programme for IT, that the report on why this VHA move to a proprietary EHR ultimately failed  will detail a mix of people, process and technology issues. My guess is that this report won’t be written and published  until about 2023….

Health IT: the world moves on to an open platform

Beyond this profound mistake, I look forward, in time (hopefully not too long) for the VHA to emerge from this costly experiment and make a move towards the Open Platform table.

The good news is that thanks to the leadership of the VA back in 2011, an increasing number of us are now actively engaged in Open Platform cooperativism around the planet., The push towards an Open Platform in healthcare is well underway, but, sadly, the VA will not be a participant.

So here endith this story, a mix of sad and silly folly by the VHA in the US, to the tune of some $10 billion.

Or maybe not… :o)

PS To give a taste of our Open Platform future, take a look at this open source and open platform work that has emerged out of the lessons learned by the NHS .., working with a tiny fraction of the funds that the VHA has been playing with and are now planning to spend.

PPS To get a sense of how the Open Platform push will grow, check out our 1% Open Platform push, the related responses we got, and this link to a world leading event.. open.coop.2018..

So back in time….

My student and early working life as a medical student/ junior medical doctor felt like a personal challenge, the need to learn to be able to do the job properly etc, by myself initially, then quickly as part of a team effort. Soon after I commenced work at the clinical frontline, it was clear that other areas of science were relevant, so aside from my training in emergency medicine, I took an interest in the principles of effective management and information technology.

That led onto a journey as a clinical leader in healthcare improvement with information technology and over time the realisation that the health IT market was holding healthcare back.
So after about 10 years in the field I began to push a somewhat uncommon view that healthcare needed a blend of open source and open standards based IT , later to be known as an open platform.

So that journey in healthcare has been interesting enough and felt again like a somewhat personal challenge, to learn to do lead that mission properly, initially fairly alone, then over time as part of a team effort.  What the last year has heralded, has been another great life lesson and stage of the journey when I think about it..

By way of further reading in other interesting disciplines (in particular a couple of sociology/economics texts that I have highlighted here) ;

• Doughnut Economics – by Kate Raworth
• The Common Good – by Robert Reich
• Principles of a Pluralist Commonwealth – from Gar Alperovitz
• as well as lots of other stories from across the globe..

In the last year or two it has become clear to me that there are major forces underway across the globe that are uniting, slowly , steadily, without any diktat or coordination from on high, but are clearly signs of a deep pattern that must be intrinsic to human nature I think.

These very disparate missions share a few key elements;

• Aimed at improving society for the greater good
• Aimed at challenging the (malfunctioning) economics status quo
• Largely bottom up efforts, not top down
• Most local>national in their outlook but at the same time, interestingly, plenty are international>national in their outlook
• Many can be explained as “Think Global: Act Local”
• Many are value driven and value the power of human cooperation (as much as competition) in tackling the grand challenges of our time
• Many understand the value of information technology and those revolutionary networks that the internet has enabled.

Though I am trying to describe a wide range of initiatives that I am seeing in greater numbers in many places that I look.. one term helps to encapsulate a large portion of these change agents.

In recent weeks that I have discovered platform cooperatives and “platform cooperativism“..

Some definitions:

“A platform cooperative, or platform co-op, is a cooperatively owned, democratically governed business that establishes a computing platform, and uses a protocol, website or mobile app to facilitate the sale of goods and services. Platform cooperatives are an alternative to venture capital funded platforms insofar as they are owned and governed by those who depend on them most—workers, users, and other relevant stakeholders. ”

“Platform cooperatives differ from traditional cooperatives not only due to their use of digital technologies, but also by their contribution to the commons for the purpose of fostering an equitable social and economic landscape.”

“Platform Cooperativism is an intellectual framework and movement which advocates for the global development of platform cooperatives. Its advocates object to the techno-solutionist claim that technology is, by default, the answer to all social problems. Rather, proponents of the movement claim that ethical commitments such as the building of the global commons, support of inventive unions, and promotion of ecological and social sustainability as well as social justice, are necessary to shape an equitable and fair social economy.”

Without needing to debate those definitions , it is great to see and start to understand this emerging platform cooperativism, as most of those involved seem to share a genuine interest in openness and sharing.

So now I see my own work, our work in the Ripple Foundation as one strand of many within an emerging network of;

• People who want to effect change in the world , as a group effort , ie a cooperative effort
• Aimed to tackling a problem/issue that requires smart minds to work together, i.e. cooperate with a touch of activism, cooperativism
• Understand the power of open source and open platform technology as a means to that network transformation, i.e. leveraging an open platform.

If this is as interesting and empowering to you as it is to me, start checking this very thought provoking material out , from an open coop meeting I didn’t know about last year.

Looking forward to open coop 2018 already!

Some months its not too clear what the main point should be..

Some months its very obvious.

This month, Robert Reich has just released a new book;

The Common Good

Principles of a Pluralist Commonwealth

My life as a student then became one as a medical student, then a doctor, then an emergency physician. For many years I was learning lots about important stuff like biology, anatomy, physiology, pathology , cardiology etc etc. Given how much knowledge there is the world it is easy to fill ones brain with any matter of subject areas.

Then working as a doctor, I became interested in /frustrated by stuff like the “clinical process” or the science of process improvement, and also the information and technology aspects of life at the clinical frontline. So I began to learn beyond Medicine, about Management and Information Technology. Which led onto work towards a shift in the healthIT market towards an open platform.

Yet once you lift your head up and look around you can’t help but noticing you are but one individual, one person, working away within a broader economy, a rich society, with a household to look after and if you lucky a commons to enjoy/partake in. So you get drawn into why change is hard, and drawn reluctantly towards the hard facts that politics and economics, for instance , are two more fields you need to better understand. So you read and read some more. You read a range of wide materials and patterns start to emerge in those fields too. Then you find a book and a writer who does a great job of summarising those key fields nicely in a great book such as “Doughnut Economics: 7 ways to think like a 21st Century Economist“.

You wonder if a great book is a single viewpoint and you keep reading and you find its not alone. Increasingly, slowly, steadily you find a growing number of views and voices that point to a new way of politics and a new way of economics , of healthcare, of education , of steering technology and towards changing the world.

This latest find , from the Next System project is written by a Gar Alperovitz and the Principles of a Pluralist Commonwealth is a powerful interconnected set of essays that rewrite the way the world is working. It is by no means an attempt to change the world from the top down, by imposing change on anyone. Yet is clearly and powerfully illuminates a set of component themes, thoughts and tactics that will reframe the way you see the world around you.

For now I will simply commend this work as another gem ( for a small donation I have a beautiful copy of the essays in book form) that I have no doubt will stand the test of time.

To whet your appetite, from the introduction;

Our time demands we meet the challenges inherent in an era of deepening despair and accelerating crises—political, ecological, and economic—that is also potentially the prehistory of transformative and fundamental systemic change. This requires a serious discussion of practical new economic efforts and organizing strategies as well as the steady development of both power and ideas that can help us move through and beyond the current emergency. The approach and model outlined here—the Pluralist Commonwealth—offers a trajectory and pattern for wide-ranging institutional change towards real democracy over the long haul, guided by a transformative vision beyond both corporate capitalism and traditional state socialism.

As we close out 2017 its fair to say its been a difficult year in Dublin. Between Brexit on the one side and Trumpit on the other, there is a lot of uncertainty in the air.
After the highs of the Celtic Tiger days, then the Financial Crisis of 2008, the lows of a bailout and recessionary times since then, it is increasingly clear that the political and economic systems around us are not fit for purpose.

We look at societies and political systems under strain in many directions (UK, US, EU) and note that some of the basics of the society around us that are creaking.
In particular in Ireland there is a housing crisis that highlights the growing gap between wealth and wages, which reflects the growing inequality in society i.e. the 1%/99% divide.

Looking at the root causes we see the growing power imbalance between the State and the Market and the real challenge of the 21st Century, the relationship between the Nation and the Corporation. While we are going away from (rather than towards) supra national states or anything like a global state , we are seeing the rise of the international and global corporation with the wealth to wield an almighty power in our lives, the rise of the frightful five being a case in point.

How can such a power imbalance be countered? How will this power play between State and Market end?

Thankfully there are 2 other forces at play that are often ignored but are starting to raise their game and likely provide the keys to the way forward. Kate Raworth highlighted them in her brilliant book of the year Doughnut Economics , the Household and the Commons.

We need to remember that how we live our daily lives, in our Households , has an impact, however small, as the choices we make all add up and they matter.
We also need to be aware that there is fantastic potential in the Commons , a concept that has been treated as a “tragedy”, then an area that has been increasingly enclosed and locked up, to now being better understood as a real potential force for good in the world.

As all this politics and economics is complex stuff, thankfully the stuff of complex systems and complex systems are slowly becoming better understood.
In another very helpful book I was introduced to this year was “Aid on the Edge of Chaos: Rethinking International Cooperation in a Complex World” , framed about international aid, but highlighting the issues with regards to top down change v bottom up innovation. He made one clear point that struck out about the way forward, amidst the complexity, “The Network is the Development”.. meaning the power to change lies in connecting people first to then work out the process and technology involved.

So much change depends on the networks that surround us. Some networks have more wealth, monies and influence than others, but each one of us is part of one network/more networks and it is by fostering, coordinating and harnessing the power of our networks that change happens.

So those of us that believe in the need for political change, the need for economic reformation, the need for a better world, the need for better tools , simply need to network better.
You and your network may be small in number at this point, but if the message and network effect is a positive one it will gain ground and take off .. around the planet.

So don’t wait for the State or depend on the Market to improve the world, 2018 looks set to be the year that “a commons network” near you starts to change the game..

Any journey toward deep and meaningful change is a long one that takes time.
Over time, indeed over many years at the frontline, I’ve grown into a mission towards improving 21st Century Healthcare with growing frustration with the current people + process + technology state, i.e the status quo.

It seems like a long wait for fundamental change in healthcare systems, most of which are slowly but steadily grinding up, with physicians under pressure, patient access and  care quality issues, as well as a archaic information infrastructure..

So it is always encouraging when other allies emerge to join the journey towards the changes that are required.
On that point, it is worth drawing attention to 2 key developments in recent months

One is a Key Paper/ Two is a Digital Square.

One: Open Paper:  Defining An Open Platform

The Apperta Foundation is an important non profit that I have mentioned in the past.. thanks to their leadership and the leading work of my colleague Ewan Davis, an important white paper to help outline a way forward for 21st Healthcare is now out in the open. It was my pleasure to be involved in contributing to this paper, and importantly joining other key allies on this journey in doing so. I’ve written in the past on this push, as in 21st Century Healthcare: the Open Platform that will Transform , our work on the Ripple Foundation is bringing this open platform to life and am pleased to be able to widely share this latest paper that aligns with earlier work while improving on earlier thinking..

This latest open paper outlines 8 key principles that should be widely read and well understood by anyone working to improve healthcare with information technology.

The essence of the paper can be distilled to the Definition of an Open Platform, required for 21st Century Healthcare.

An open platform adheres to the following principles in order to meet the need of all stakeholders:
1. Open Standards Based
2. Shared Common Information Models
3. Supporting Application Portability
4. Federatable
5. Vendor and Technology Neutral
6. Supporting Open Data
7. Providing Open APIs
8. Operability (as in DevOps)

The paper, known as Defining an Open Platform and has been brought to you by the Apperta Foundation.  If you have an interest in #healthIT please read it carefully and share it widely.

Two: Opening a Digital Square

The other key development in recent weeks is that of another internationally leading group from PATH.org . A non profit foundation,  PATH is an international health organization driving transformative innovation to save lives.

In recent weeks under the leadership of Lesley Anne Long , PATH has established the thought leading Digital Square.

In brief, Digital Square has been set up as “A partnership of the world’s leading digital health experts from 30+ organizations and countries working together to strengthen digital health systems in emerging economies.”

Very smartly they are working towards collaboration across the globe towards 21st Century healthcare, with 3 key aims;

• Coordinate investments in proven digital technology to maximize the impact of every dollar spent.
• Scale global good technologies that can be adapted to different countries and contexts.
• Create digital market readiness by building capacity with governments, local technology developers, and health workers.

In particular, their smart thinking and a focus on Global Goods could/should/will be game changing in this field. Their thought leading push around Global Goods is explained as coordinated investment to support the implementation of technical goods that are;

• Easy to implement and scale.
• Adaptable to different countries and contexts.
• Often, though not exclusively, open-source.
• Funded by multiple donors and supported by a variety of implementers.
• Interoperable across commonly used systems.

What is so gratifying is to see other allies emerge with such common aims and purpose, evolving and emerging from such different landscapes , yet towards the same end  the same goal… simply put, towards a revolution in 21st Century Healthcare…
The network is growing and we’re doing what we can to connect and grow the networks.. a tipping point is on theway..

As part of my work I’ve been advocating change in healthcare here for some time and have explained the elements needed as a blend of people + process + technology change.

Some time back I made the case that healthcare needed a mix of new technologies to support the change required, including a mix of open source and open standards based technologies.

Some time later I made the more explicit case for the open platform that we all await that will transform 21st Century Healthcare. In that case I identified 5 key elements of the platform required;

• Usability – healthcare needs great usability, poor Health UX has gone on too long
• Integration – the complexity of healthcare demands integration around the patient
• Clinical Kernel – there needs to be great fit between the process of care & the tech
• Code & Community – open source code – with community around it – is needed
• Governance & Leadership – this requires strong leadership and good governance

While waiting for others to emerge and lead on this challenge, it has been clear that I too should play my part. So following years of frontline clinical practice, clinical leadership roles and informatics effort…. many lessons learnt, from experiences ranging from the NHS National Programme for IT  to the more local Leeds Care Record , informed a focused push to begin the Ripple Open Source Initiative in 2015.

That has since evolved into the establishment of the Ripple Foundation, a non profit organisation supporting the move towards an open platform in healthcare, of which I am a Founder/Director.

Over the last 2 years, it just so happens that we have crafted most of the key components of the open platform that we believe healthcare requires. So as of the end of June 2017, the Ripple Foundation has now announced the launch of its Showcase Stack.

The Ripple Foundation Showcase Stack announcement & demonstrator is available here.

The key components include;

• PulseTile – Frontline UX/UI Framework
• QEWD – Quick Enterprise Web Development/Integration Framework
• EtherCIS – Enterprise Clinical Data Repository (inc openEHR support)
• All Open Sourced on Github under permissive Apache 2 license
• Leadership & Governance established by the Ripple Foundation

I’m very proud to have had the opportunity, support and the team around me to have been able to release these works to the world.
This announcement isn’t quite the end of a programme of work, more the beginning of a new phase…. a new open platform opportunity.

Our work is imperfect, flawed, with much room for improvement.
Yet it is an effort, an effort to make the world of healthcare a better place, for patients and professionals alike.

This Showcase Stack work of the Ripple Foundation and the components that make it up will either survive or thrive.
If it simply survives, a more capable set of open platform components/tools will emerge, make themselves known and go on to transform healthcare forever.
If they do thrive (and we hope they thrive) it will primarily be because these are helpful to others.

We hope they help.

Tony Shannon
30th June 2017

As we work to move healthcare into the 21st Century, much of the effort we see around us is piecemeal rather than pioneering.

An appointment of an individual here, a process improvement there, an app or application there, tweaks and twists in many cases, rather than significant steps forward. Such is the nature of all progress. Now and again an individual steps forward who does better than that, who shows how things can really be improved with a technical advancement that makes a real difference.

We hear a lot of about the pressure healthcare systems are under, we increasingly understand them as information intensive systems, we hear more about big data  and the forces of automation that will come and transform the professions, including healthcare. We see big showcase stuff like IBMs Watson as a taste of the future.

Yet a breakthrough in the field of healthcare and computing is happening around us that gets far less attention, that is the progress towards an open platform in healthcare.
One group that leads that field is the openEHR Foundation and one member of that group who leads the way is Dr Rong Chen.

Quietly, patiently, carefully Dr Chen (or Rong as I know him as) has been working towards a breakthrough in this area of healthcare, information, automation etc. That  is the gap between what I might describe as the information management aspects of healthcare (e.g. Joe Bloggs/John Doe and their Electronic Health Record material) and the knowledge management aspects of their care (e.g. latest evidence base on how to management their Hypertension, Asthma etc etc). This is known in the game as “Clinical Decision Support” and comes in a variety of flavours,.. passive decision support (eg publishing evidence, guidelines and pathways) and active decision support where you then build those guidelines into a computable format and try to support/influence the clinical decision making process.

Aside from the pros/cons of Active Clinical Decision Support ( there are both pros and cons) its fair to say this is tricky stuff to get right. In particular this is tricky stuff to scale and maintain. As I have written elsewhere I believe the solution to this and other challenges are a blend of open source and open standards and Rong has been working towards both.

Some years ago he outlined a proposal for GDL (Guideline Definition Language) which was related to /based on the openEHR ADL approach. This is not the first effort to tackle CDS, there has been Arden Syntax, PROforma etc beforehand, yet none have gone mainstream. In recent years he has been working away to progress this GDL work further. Then most recently he shared an update on this work..

https://gdl-lang.org/

https://github.com/gdl-lang/common-clinical-models

For many of your this will be dry technical stuff, but bear this in mind… over the space of 10 months, Rong, his team at Cambio and a handful of medical/informatics students at the Karolinska Institute in Sweden have put together 100 Clinical Decision Support Apps built on this technology. For that reason alone, I am optimistic about the potential future of this technology.

If you take just one example , eg Glasgow Coma Scale (for use in Emergency Medicine) take a look at the app here
https://common-clinical-models.cambiocds.com/km/views/execution/GCS.v1.dsv?token=4743532e7631:1546300799000:a13f234ff0cce0b9b3bd2b619fd380f3&language=en

and the underlying GDL here;
https://github.com/gdl-lang/common-clinical-models/blob/master/guidelines/GCS.v1.gdl

Again this is tough technical stuff but it will give you a good idea of the effort involved and tools required to deliver 21st Century Healthcare at scale, bridging the gap between the clinical frontline and technical command line..

Kudos to Rong and his team for this pioneering work. Thanks to his open and innovative work that we all march on, smarter together!

“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it’s the only thing that ever has.”

As the world turns between Brexit and Trump-it, we face uncertain times in 2017 and beyond.

We know that over the course of history patterns emerge and we see cycles at play. We have seen city states evolve into nation states and then great empires and yet just now we are seeing that trend in reverse, back towards a more nationalist/isolationist mindset. Some folk who have not seen the benefits of globalisation are, perhaps understandably, tempted to look after their own.

Those of us alive at this point in history, witnessing the forces of globalisation in action, note that one of its key components is being called out as “technology” as if it were a new and shiny thing, yet “technology” can be called “tools” and humans have been crafting and improving their world with tools since the dawn of time. The modern set of “information technology” tools unleashed in recent decades are like a genie out of the bottle now, for we know they enable folk to collaborate and cooperate across boundaries in a myriad of new and innovative ways. Open standards that have unleashed the power of the Internet and open source code has unleashed the likes of  Android, Drupal, WordPress, etc  and other open platforms that are changing the world.

Open international collaboration helped to give birth and foster the power of modern medical science as we now know it. If any sector is going to face increased pressure in the turbulent time ahead, it can be expected to be medicine and healthcare. Whether the natural tide of human migration is stymied or not over the next decade(s), as a sector that already requires 8-10% of GDP in most countries, expectations are that aging populations along with lower/more sustainable birth rates will force a narrower tax paying cohort to look after a larger number of people in the Western world. Many of those who have grown up in the West have grown used to/ now expect “cradle to grave” healthcare systems to look after them as they grow old, so expectations are on the rise while available resource is in decline.  

So we can expect that efforts towards healthcare reform and improvement will continue as a universal effort, tackled in a variety of ways (as befits a complex adaptive system such as healthcare) across the globe. For those of us that have spent some time in this field,we have learned that some clear patterns have emerged/are emerging from these efforts to improve on the current state of healthcare.

In particular we see the important potential of an open platform approach in healthcare to revolutionise the support of frontline of care delivery and its related transformation towards a more patient centred approach- where the patient will ultimately take greater control of their own health and care- as the only sustainable way forward.

In that context myself and my colleague Ewan Davis have just recently launched a bid towards a collaborative Open Digital Platform Challenge fund, based on a mere 1% of currently available healthcare IT funding. The rationale behind this is that the current health IT market is simply not good enough, with ample evidence of acknowledged limitations across the globe, from accessibility to interoperability to usability.

Our suggestion is to challenge the historical approach to this challenge and thereby the current state of health IT, we need to try something quite different.

Within our push we advocate important principles such as clinical leadership, agile development methodologies, regular review and assurance of both the process and the results, collaborative community building and ultimately a move towards an open platform for health and care that can be reused around the world. Indeed we specifically suggest that a key set of open source components could and should be used towards a more service oriented architecture in healthcare (which could most likely be reused by local government as well).

To that end our Open Digital Platform push is currently open for Expressions of Interest across England, Scotland, Wales, Northern Ireland and the Republic of Ireland. There is no reason why the ideas and principles involved here could not spread further and wider.

So if you sense there may be even a little common sense in such a tactic towards an open platform for healthcare, internationally, across borders and between collaborators…

….please get in touch. This work has begun.

“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it’s the only thing that ever has.”

Margaret Mead (1901-1978).  

Used with permission.

To give credit where due, leading economist David McWilliams has been ahead of several of the big calls of 2016, with a good nose for the way the political wind was blowing ahead of both Brexit and Trump-it.

In an end of year blog he explains 2016 as the Year of the Outsider which appears to be a good way to explain some of these historic events;

“An interesting and novel way of looking at politics — the politics of mature, wealthy, deeply democratic societies — is not through the prism of left versus right, rich versus poor, urban versus rural, Christian versus Muslim, conservative versus liberal or young versus old or whatever other face-off we like to talk about.
Insiders versus outsiders is more apposite and the recovery rather than the recession has crystallised the dichotomy.

“The insiders are those literally ‘on the inside’. They are the people with influence, with a voice at the table, those with a stake in society.  …  Their game plan is to gouge the state and extract as much rent as possible for their members and interests. Insiders are organised. They are part of the process of politics and their concerns are listened to by the state. In short, they have access to power and can influence the way it is deployed.”

“The outsiders in contrast, are those with no one to speak up for them. They have no stake in the political process and are thus on the outside. They are the self-employed small business person, the contract worker, the immigrant, the unemployed and, of course, the young. They are outside the tent, beyond the process and because they are not organised, their concerns are never felt.”
“More than anything, these parties and individuals have identified that the mainstream, traditional parties are in cahoots, trying to maintain a status quo, which is simply serving to featherbed the insiders.” 

“2016 was the year the outsiders said: “Enough!””

Lets hope 2017 is the year when an informed view of the right way forward for the “political system” starts to emerge.