Posted by: Tony Shannon | August 31, 2020

Time to Build Back Better

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..

Posted by: Tony Shannon | August 30, 2020

John Hume- an appreciation

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.

Posted by: Tony Shannon | July 31, 2020

The Doctor of the Future is a Generalist

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!

Posted by: Tony Shannon | June 30, 2020

Covid Containment Challenge = Information

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.

Posted by: Tony Shannon | May 31, 2020

WeGo – Ireland & Green Governance

As Ireland makes it way through historic times of a world wide pandemic, there is also the business of government to sort out, a new government, to be negotiated as the outcome of our recent general election (Feb 2020).

It just so happens that the Green Party did well here at the last election, reflective of an understanding of how important Green/Environmental/Sustainability issues are to this country.
The other message that came out of the election was the appetite for change and in particular in addressing economic injustice issues that are affecting many people, esp issues of housing, childcare and healthcare etc.

You might say that the wellbeing of both people and planet is now being recognised as critical to good governance of this country. Yet electoral history has shown that if any party pushes a “Green” agenda in the long term interest of people/planet, as the Green Party did here in their last time in government, they can be /were severely punished. With due respect to the electorate, they balance a range of issues, short, medium and long term and small political parties tend to get punished in coalition, no matter what their noble aims are.

So as the country is looking like it is moving to a new Government with a Green agenda, then the issue of Governance is key. To my mind this is where the important work of the WellBeing Economic Alliance and its WeGo arm is key. The WellBeing Economic Alliance is something I have mentioned in the past as being , as its name suggests an alliance of those who want to encourage societies and economies to promote wellbeing of people and planet.

The WeGo movement is an emerging alternative to the G20 and encourages like minded governments from around the world to cooperate and collaborate to pursue well-being as a goal rather than simply pursuing growth in GDP at all costs.

With that end in mind, in my opinion this would be a very good time for the Irish Government to join that effort, as a team effort, rather than go alone, hence this related opinion piece encouraging the new Irish government to join this movement to help pursue a “WELLBEING ECONOMY AGENDA FOR PEOPLE AND PLANET”.

PS. thanks to co authors Dr Peter Doran, Katherine Trebeck and the Village Magazine for their help in publishing the article

Posted by: Tony Shannon | April 30, 2020

Whats coming next? Amsterdam goes for the Doughnut

While the world moves apace to handle the difficulties posed by the covid coronavirus, people are already starting to ask “whats coming next”? Most importantly they are asking what kind of a world will we get back to after dealing with the current pandemic challenge?

When forced to consider the options, many people are already clear that we do not want to go back to the way we were, to people and the politics and the planet that we we’re living with pre Covid.

Where to then? Well the city of Amsterdam has a clear and smart plan in place already for their post covid future..

Amsterdam has decided to embrace the ‘doughnut’ model to mend their post-coronavirus economy. As the Guardian reports “Out with the global attachment to economic growth and laws of supply and demand, and in with the so-called doughnut model devised by Raworth as a guide to what it means for countries, cities and people to thrive in balance with the planet”.

“The inner ring of her doughnut sets out the minimum we need to lead a good life, derived from the UN’s sustainable development goals and agreed by world leaders of every political stripe. It ranges from food and clean water to a certain level of housing, sanitation, energy, education, healthcare, gender equality, income and political voice. Anyone not attaining such minimum standards is living in the doughnut’s hole.”

“The outer ring of the doughnut, where the sprinkles go, represents the ecological ceiling drawn up by earth-system scientists. It highlights the boundaries across which human kind should not go to avoid damaging the climate, soils, oceans, the ozone layer, freshwater and abundant biodiversity.”

“Between the two rings is the good stuff: the dough, where everyone’s needs and that of the planet are being met.”

“.. the model will be formally embraced by the municipality of Amsterdam as the starting point for public policy decisions, the first city in the world to make such a commitment.”

“The world is experiencing a series of shocks and surprise impacts which are enabling us to shift away from the idea of growth to ‘thriving’, Raworth says. “Thriving means our wellbeing lies in balance. We know it so well in the level of our body. “

“This is the moment we are going to connect bodily health to planetary health.”

Posted by: Tony Shannon | March 31, 2020

Community & Collaboration in Crisis

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.

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.

Posted by: Tony Shannon | January 31, 2020

2020: New Year: New Decade: New Approach/Action Needed

As the New Year of 2020 opened the gates on a new decade, the 2020s, there appeared to important message to us all being sent by the planet from Australia.

The Australian bush fires which had been burning for months reached a peak in January 2020 bringing scenes many of us has not seen before, of devastation to humans, animals and wildlife that we had not seen before. Or at least we hadn’t paid as much attention before.

Anyway, the world can’t say it didnt get notice from the planet that there is a real important job to do this year and this decade which is to get on with tackling climate change and….

I say “and….” as of course climate change is interlinked to a range of other challenges that 21st Century people and planet face… best explained in a book I’ve referred to here many times before.. Doughnut Economics, as well as the broad WellBeing Economics Alliance that is getting this message out far and wide and aimed at the emerging WellBeing Governments of the world.

A new approach has been needed for some time and this ideas time has most certainly come… 2020s is now time for Action.

Posted by: Tony Shannon | December 20, 2019

Consume, Create or Collaborate?

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..

Posted by: Tony Shannon | November 29, 2019

Failing Better: A Journey of Change, Healthcare, IT

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..

Posted by: Tony Shannon | November 25, 2019

Ripple Foundation: A Story of Makers & Takers

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..

Posted by: Tony Shannon | October 30, 2019

Ripple Foundation: Stories of Success

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….

Posted by: Tony Shannon | September 28, 2019

HSE Healthcare Digital Academy launch

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..

Posted by: Tony Shannon | August 15, 2019

Currach off Kerry

Posted by: Tony Shannon | July 31, 2019

Lost in Translation : EHR State of the Market update

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

Posted by: Tony Shannon | June 29, 2019

Land for the Many: Land Ownership explored

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.

Posted by: Tony Shannon | May 10, 2019

Can Medicine Be Cured?

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

Posted by: Tony Shannon | April 30, 2019

A Green New Deal

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

Posted by: Tony Shannon | March 26, 2019

INTEROPen : FHIR & openEHR paper

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.

Posted by: Tony Shannon | February 8, 2019

NCH Ireland – State/Market failure in action – (inc the IT)

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

Posted by: Tony Shannon | December 20, 2018

Material Design and React-Admin

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!

Posted by: Tony Shannon | November 30, 2018

Why Doctors hate their Computers

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.

Posted by: Tony Shannon | October 30, 2018

Introducing the Ripple Foundations: Digital Commons Academy

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.



Posted by: Tony Shannon | September 30, 2018

WeAll: Building a WellBeing Economy

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, Postwachstumsteady-state or doughnut economicsprosperity 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







Posted by: Tony Shannon | August 31, 2018

SIMPOL idea for a better world

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



Posted by: Tony Shannon | July 31, 2018

Open Coop 2018 – Making history in London

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.

View at


Posted by: Tony Shannon | June 27, 2018

Big Sky Break

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 2018On 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..

Posted by: Tony Shannon | April 30, 2018

Discovering Platform Cooperativism

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) ;

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!


Posted by: Tony Shannon | March 30, 2018

How to Solve 21st Century Challenges: Discuss!

In the 21st Century we know there are great opportunities and great challenges all around us. These are exciting times, yet with so much going on, where do you focus your efforts?

A good book as you know can be a great way to improve your understanding of the world and reading is hard to beat as a means to better yourself.
When you find a great book, you often want to discuss it with others and so it was with “Doughnut Economics: 7 Ways to think like a 21st Century Economist” which I’ve been recommending to everyone I meet.

Indeed a great book often means you’d like to connect to the author to pass on your thanks, feedback, ideas etc.  When I did make contact with the Kate Raworth, the author of that great book to do so, I wasn’t at all surprised to get an email bounce-back explaining how busy she was, very naturally so. Yet I wanted to discuss the key ideas within a lot, from a range of angles, with others too.

So a seed was planted to explore how to connect with Kate and the many fans of her work around the work.. through , you might have guessed it (esp if you have read the book) the Digital Commons. An ideal tool immediately fitted the bill, Discourse, a tool for civilized discourse, is the “100% open source discussion platform built for the next decade of the Internet”. My colleague and fellow open source in healthIT champion Dr Marcus Baw was the expert guru who had recommended it to me in the past and kindly offered to lend a hand.

So it was that in March 2018 a small group of us helped Kate launch to the world.
It’s a great medium to discuss some of the biggest challenges facing us in the 21st Century… come & discuss!




Posted by: Tony Shannon | February 28, 2018

The Common Good – by Robert Reich @RBReich

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




Posted by: Tony Shannon | January 31, 2018

Principles of a Pluralist Commonwealth

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 . 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..







Posted by: Tony Shannon | October 22, 2017

Irish HealthIT: It’s time to Innovate

If you’ve come across this blog before you’ll have noted a few things.
As an Irishman, an Irish doctor with broad interests, I’ve been reading and writing quite a bit about stuff called Economics lately.
Now Economics sounds dry and dull, but the more good books I’ve read on the subject, the more obvious it is that understanding it is key to lots of stuff.
We certainly know that understanding economics is important to us, as the risks posed by Brexit and Trumpit are significant threats to Ireland’s future,… we need to box clever at this time.

So I’m going to add a further post here to 2 earlier posts about Ireland , #1 about Ireland’s #1 crisis which is housing, #2 about Ireland’s healthcare challenge to come to #3

It’s 2017,  Ireland needs to improve its healthcare system – its time to take an innovative path forward with better #HealthIT.

So here we are looking at Ireland/ its healthcare system/ its need to get digital in the 21st Century and the related need to innovate our way there.
(NB If you’ve come to this blog in the past you will know that the move to bring healthcare into the information age is now the main focus of my work hence topic#3.)

We mentioned the Irish healthcare system needing reform in our last post and the potential of the SlainteCare plan therein.
We know the SlainteCare report called for a transition & legacy fund of £3 billion of investment over the next 6 years as part of a 10 year reform programme.
We also know the Budget of recent weeks failed to find the funds to kickstart that programme, just yet.
On the issue of moving the Irish health service into the information age, we know that large parts of it have years/decade of catching up to do.
We know that eHealth Ireland’s related plan to seek €875m over 10 years to fund a related Electronic Health Record programme has been in waiting for some time now.
We also know that ask for €875m made that it into the SlainteCare report and for better/worse the funding request could/may be linked within the SlainteCare programme.
We also know there are real and substantial risks when planing to spend that sum of money on healthIT, billions were wasted elsewhere, so we can learn from this.
So lets tease out some of the key issues on Ireland’s move to digitise healthcare, again re-exploring the key aspects via the approach taken in “7 Ways to Think like a 21st Economist“.

The key (bottom line TL;DR) points are

The State which is essential- so make it accountable – needs to educate and build capacity/capability & be v careful what it procures
The Market, which is powerful , so embed it wisely – we need to move the market towards user centred digital services based on an open platform in healthcare
The Household, which is core, so value its contribution – the patient should be at the centre of healthcare – so build a patient centric platform
The Commons, which are creative, so unleash their potential – so nurture an open digital commons in healthcare to transform


The State which is essential- so make it accountable

So lets start by looking at the role of the State in this move to digitise healthcare.

Its been clear for years that the Irish healthcare system has not yet made the move towards a digital health service in most areas of practice. Aside from Primary Care/GPs where there is a high level of computerisation, the majority of community, hospital, mental health and social care is supported with paper records. Simply put Irish healthcare is still in the information dark ages.

We know there has been report after report over many years to try to move that agenda on, yet the legacy of PPARS cast a long shadow and so there was very little innovation in healthIT for a long time here. That began to change when eHealth Ireland was set up in 2015 and the team involved have worked hard and done some good stuff. Where things have gotten stuck of late is in move towards the adoption and rollout of Electronic Health Records (EHR).

Now I’ve been on the record for some time, to suggest caution when tackling Electronic Health Records projects/programmes as I guess its probably fair to say this is now my particular area of expertise, based on over 15 years in the field of informatics at departmental/hospital/city/regional/national/international levels. You may be interested in some key suggestions made as part of the eHealth Ireland public consultation on EHRs, early in 2016.

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

Nevertheless, sometime later last year eHealth Ireland appeared to be moving down the traditional “big procurement” approach to buying EHRs, i.e.
€875m spend on EHR over 10 years made up of 4 key parts ; an acute EPR; a community EPR; an integration platform; and a national shared record provided via a portal

Now we know from experience (including some of my own) in large national eHealth/EHRs pushes in the NHS and the US that there has been billions wasted on EHRs before.
At that time and since that time, indeed for too long, I have seen “poor customers” make poor decisions in this space on behalf of the taxpayer, on behalf of the state.My own experience and looking at the leaders in this field internationally, one needs a small/highly educated/experienced group across clinical/managerial/technical disciplines to make good decisions on EHR decisions and the norm is to make mediocre decisions, i.e. I’ve seen many teams make naieve mistakes and then admit sometime later they have learnt some of these lessons the hard way..

To explain further why I start here, it is important to acknowledge the relatively immature state of informatics as a discipline in healthcare. Up until this year there was no recognised training body in the UK for Clinical Informatics . In fact the Faculty of Clinical Informatics in the UK has just appointed its very first Founding Fellows in recent months, which gives you some idea of the level of digital literacy in the medical profession at this point in time.  The NHS Digital Academy has been announced, but has yet to get started.  To reinforce the same point locally, there is simply no formal training or recognition of the science/art of clinical informatics in the Republic of Ireland. None.

So there is a major educational gap in the professions and indeed across our universities and so a real need to ensure staff have the right level of understanding of the complex people + process + technical aspects that are involved in digitising healthcare. Simply put Ireland has a very limited informatics capacity at this point in time.

In the context of that environment, where experience with EPRs is very limited in Ireland, then any EPR/EHR project is by nature going to be risky here, so the key is to start small and be agile and iterative in the approach taken. So the key to getting this right is to tackle the knowledge gap on the “state side”, to allow small teams to develop their skills and expertise in this area before taking on projects of increasing scale.

Its also clear this knowledge gap isn’t confined to the healthcare sector, but applies across the public sector (eg PULSE System in the Gardai etc is known to have related challenges), so the level of knowledge in Government of handling large IT projects needs to be tackled. Thankfully (though perhaps I need to be careful how I put this during these days of Brexit looming) the Government Digital Service team in the UK Cabinet Office, having learned the hard way with several high profile IT disasters in the public sector, has done an internationally leading job on sharing good practice in this regard and lessons can be learned from elsewhere, via their Digital Service Standard.
If you think the Digital Service Standard is some hokie-cokie public sector cook book, then take a closer look, it is very well aligned with good practice from the rest of the digital industry in terms of User Centred Design, Agile Development, Reuse of Open Source, Open Standards etc.  If this good practice  is happening on the ground within the Irish State sector, its hard to see it, certainly none of this level of thinking is publicly evident within the Irish public sector.

In recent years some governmental bodies world wide have neglected to build up internal capacity and capability to lead on critical Digital Service developments. In tackling digital service development (such as an Electronic Health Record) many have preferred to outsource the challenge and procure the promise of a solution from a third party vendor/supplier. The mindset is explained as “Nobody ever got fired for buying IBM“. .. what some folk crudely call the “One Throat to Choke” tactic.

So moving to a substantial procurement (e.g for an EHR) from the market in advance of building up your state side capability and capacity to handle the very complex process of procurement but especially implementation is fraught with risk in my view. Let me convey one simple reason, from past experience. During the days of the multibillion pound NHS National Programme for IT, I was witness to large groups involved in the very expensive procurement process and then some months later .. other large groups involved in the challenge of implementation of the same technology. Were these groups aligned and agreed? Certainly not.
So any large procurement (“waterfall style”) rather than user centred & iterative (“agile style”) development runs that risk. Indeed by the time the state goes to implement these technologies the folk involved in the original procurement may be long gone..

So in that vein, if , in the context of limited finances in the Irish states coffers, there is to be a shift/push for a National Childrens Hospital EHR procurement ahead of an capacity/capability building and an agile development team to prototype and understand EHR architecture, scalability, maintainability etc could be a costly mistake.

You may well ask, is there another way towards an EHR besides an expensive one off procurement? Indeed there is… again from personal experience, after leaving the travails of the NHS National IT programme, I took up a role as Chief Clinical Information Officer for Leeds Teaching Hospitals in 2009 and then Leeds City in 2012. Working with a great clinical/management and technical team (split internal/external) we developed towards the Leeds Care Record as it is today, a city wide integrated care (EHR) record system serving the professionals in primary/community/acute/mental health and social care systems to support nearly a million patients. Built on top on the internally (“state” side) developed PPM+ platform along with partner supplier (“market” side) the work involved was done in waves, with the EHR development to roll out across the city cost in the order of £2m over 3 years.. i.e. pretty good value for money. So there is another way.

The Market- which is powerful , so embed it wisely

So as we turn to the roll of the market in this challenge we repeat the words of Kate Raworth again here..

The Market:  which is powerful , so embed it wisely

As we explained that the science of informatics is in its early days, so its fair to describe the health IT market is relatively immature.

The healthIT market is both dominated by a large enough number of large proprietary monoliths who promise a holistic EHR as well as by thousands of small, niche, specialist systems who offer a fragment of an EHR. The business model that most all suppliers in this market are based on depends on selling proprietary software licenses based on closed software code, rather than services oriented market based on open code.

Now if you go to look at the rest of the software market you will note that such proprietary tactics are going the way of the dinosaur…  with most/many leading tech companies  (even ones such as Microsoft and Apple) open sourcing their work, while other leaders such as Google and Facebook creating entire ecosystems of development based on their open source tools.

Indeed if you look beyond the vendor lockin problem in healthcare IT, to look at key issues of poor interoperability and woeful usability you will find a market that I have described as dysfunctional, ie its holding healthcare back. If you’d like to get another view, check out The Digital Doctor by US based Dr Bob Wachter;

“The Digital Doctor: Hope, Hype, Harm at the Dawn of Healthcares Computer Age” by Dr Robert Wachter, Chief Department of Medicine, UCSF, USA (2015)

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

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

So here we make/stress the point again, if the State cedes leadership and control of your informatics destiny by tieing itself to a proprietary EHR architecture/vendor you do so at risk.
So we need to be very careful about any major EHR procurement in 2017/18, the National Children’s Hospital being a case in point.

If you want to see the future of the EHR market, you may need to consider the future of the ERP (Enterprise Resource and Planning Market) (sidenote : PPARS was built on legacy ERP provider SAP), what Gartner have called the post modern ERP strategy.
If you’d like to understand that in a healthcare context, see this excellent article on Post Modern EHR thinking

The bottom line in terms of where the market needs to move towards and is slowly moving is that based on an open platform.
If you believe that buying an EHR system that ticks the standards box will do the trick, be very careful, you’re likely to be naieve..

Without dwelling on the details that is meant by an open platform I suggest you note this technical summary from Garnter and read more here if you want more information.

from the Gartner paper “Healthcare Provider CIOs Need to Rally Their Enterprise Architects Around Citizen-Centric Care Delivery” (2017)

Gartner believes that truly effective and sustainable open architectures will need a capability for vendor-neutral data persistence, such as utilizing a common schema or set of archetypes and rules for managing structured and unstructured data (for example, a VNA, openEHR or IHE XDS repository in combination with services for trust/consent, ecosystem governance and oversight, and reuse of data and processes for secondary purposes, such as research and population health).
Providing open messaging standards (for example, FHIR, HL7) for data exchange in specific use cases will only go so far in meeting the architectural challenges of digital citizen-centric care delivery.”

This shift is already underway with a move to an open platform evident from Brazil to Finland to Norway to Moscow to Salford, so the key point to take aware here is that in 2017 Ireland should avoid buying into proprietary software licenses for its EHR software.
Rather than falling into the trap of being beholden to some proprietary EHR vendor for years to come, Ireland should aim break free of its economic dependence on Foreign Direct Investment by cultivating the growth of an enterprise sector aimed at supporting the leading the future direction of the healthIT market, not its past.

Is this really possible you may ask?
Well take a look at this work from 2 years ago (2015) built on this internationally leading open platform technology towards an Irish Care Record prototype.. the time involved? 1 month. the team involved? 6 people. The cost? €25,000.  (If you’re a software type you’ll know exactly what can be done in 2017).

The Household which is core, so value its contribution

Having explored the pressures across the Irish healthcare system in our last post we made clear the real need to ensure the patient is much more actively involved in their own care.
Historically and currently it has been/it is too difficult for patients to navigate the healthcare system, so a paternalistic rather than cooperative and collaborative approach to healthcare delivery prevails. One of the real barriers to getting patients more involved in their healthcare is that their health and care information is scattered across the system, some in the GP record, some in the hospital record, some in the public system, some in the private system etc. etc, a painful mess with consequences..

There is therefore, very much inline with the SlainteCare push and indeed pushes long before that towards integrated care…
.. any EHR procurement in 2017 should be aimed towards building on a patient centred record platform, i.e. not simply procuring an organisation centric record such as a hospital or community EHR system, hoping to wire them up later.
Simply put, for too long healthcare systems have been stymied by siloes of information and information systems, we could/should be actively avoiding that.

Forgive me for spelling out in technical terms what that means, taking from the same recent Gartner 2017 report to make the same point from another direction.

Healthcare Provider CIOs Need to Rally Their Enterprise Architects Around Citizen-Centric Care Delivery, Gartner 2017
Gartner believes that truly effective and sustainable open architectures will need a capability
for managing structured and unstructured data (for example, a VNA, openEHR or IHE XDS
…providing open messaging standards (for example, FHIR, HL7) for data exchange …
will only go so far in meeting the architectural challenges of digital citizen-centric care delivery.”

 So any EHR procurement effort should be going into a citizen/patient centred record effort.  Am aware that some of the good folk at eHealth Ireland already get this point, they simply need to get more publicly vocal about it.
Here again its worth highlighting that a primary focus for the next 3-5 years on the National Childrens Hospital EHR rather than wider capacity/capability building around such a patient centric EHR platform across the rest of the system has real disadvantages, especially if the aim for any EHR is to support healthcare from cradle to grave..
So building on the earlier demonstration of what can be done towards an integrated Irish Care Record prototype, an early move towards a Personal Health Record on an open platform could/should be addressed at this time..

The Commons – which are creative, so unleash their potential

We now turn to the 4th angle on which to examine this challenge.

We have already said that the healthcare/public sector capacity/capability in large scale IT procurement is limited and needs to be addressed.
We have already highlighted the immature state of the healthIT market and the need for change.

In healthcare, for most of us educated in medicine, with the ethics and morals that go with that, many of us believe that healthcare information/knowledge should be shared between peers.
To be clear that is not to say we should improperly sharing patient information, this is simply to say that healthcare improvement will only come about at scale if we share our learning (aka “public or perish”) and our tools (e.g. it’s common to share care pathway documentation for reuse between teams etc etc)
In that spirit many of us believe that open source is the only way forward for medicine to move forward into the 21st Century.

Here we flag up the lack of a “digital commons” in Irish healthcare. What do we mean by that? Well for instance.. consider any/all of the learning that has gone into the EPR efforts in Ireland to date… is a related open place to learn and leverage from?
I might cite examples of an open digital commons such as wikipedia in the mainstream, to open access journals in healthcare, to the world of npm if you’re a software type.

Despite the presence of most of the large software suppliers in the based in Dublin, and despite the fact that many/most now support open source development ie contribute to the digital commons in healthcare.. the “digital commons”/open source scene in Ireland is fairly low profile, especially from the State side.
Some of this may be explained by inclination the the IDA towards a “knowledge development box” to encourage external companies to invest here and lock up their IP.
Now for many industries there will be no issue with that. Yet in healthcare that poses a real problem.

Let me declare here that I believe healthcare needs to be properly funded with the right level of staffing having access to the right tools at the frontline.
Let me also declare the view that healthcare monies should not be wasted again and again on poor healthIT tech with poor usability/interoperability, there has to be a better way.

So my current work, after years at the frontline in Emergency Medicine, is as a director of the non-profit Ripple Foundation, working to educate and support those people who understand this need for a digital commons in healthcare, where we work openly and collaboratively to improve healthcare with open technology.

In working towards this mission, I’m actively involved in a related 1% open digital platform push, suggesting that across the 5 Nations on these islands (Rep of Ireland, N Ireland, England, Scotland and Wales) ..and indeed beyond) that 1% of the millions of regular health IT spend could be put to better use towards this open commons goal..
Though eHealth Ireland have not actively responded on this, we know there is a real interest in this approach and a new wave of innovation on the horizon..

Thankfully this mission isn’t confined to these 5 nations either, if you look at the work of our colleagues on the recently launched Digital Square initiative based in the US and aimed across the globe, a movement has begun towards the transformation of healthcare in this century by means of openly collaborating towards a digital commons in healthcare.  To explain with an excerpt from their open source mission in healthcare;

“For over a decade, PATH’s Digital Health program has been a leader in the application and use of scalable digital products and services globally and at the country level. We build on that legacy by pledging to encourage co-investment among partners and donors to support countries in seamlessly connecting their digital health systems, sharing better data, and reaching better health outcomes,” said Dr. Fleming.

As a part of this commitment, PATH is pleased to announce Digital Square. The new initiative, comprised of 40+ partner organizations, encourages more efficient investment in digital health technology solutions …. through an innovative co-investment model. “Co-investment is a simple but powerful concept. Development dollars are scarce; by coordinating them, we can maximize the impact of our financial investments,” …

It is fair to say that done right, a push towards a digital commons in Irish healthcare could not just help educate our students and professionals, transform our healthcare services, but stimulate a wave of innovation and enterprise in Ireland that would have benefit across the world too…

So its 2017, and its time to innovate our way forward in healthcare in Ireland with better healthIT.

In summary

The State which is essential- so make it accountable – needs to educate and build capacity/capability & be v careful what it procures
The Market, which is powerful , so embed it wisely – we need to move the market towards user centred digital services based on an open platform in healthcare
The Household, which is core, so value its contribution – the patient should be at the centre of healthcare – so build a patient centric platform
The Commons, which are creative, so unleash their potential – so nurture an open digital commons in healthcare to transform

Posted by: Tony Shannon | October 17, 2017

Irish Healthcare: 4 ways to look at it & SlainteCare

Further to our last post examining some of those key elements that make up the society and economy of Ireland with a focus on the most acute issue confronting in 21st Century Ireland, i.e. housing people… we now use the same principles to delve into another area that is often a cause for concern/discussion in Ireland, that is supporting the populations healthcare needs.

We’re going to look at the healthcare system using the same lens that we looked at last time around, based on an approach to refreshing our worldview by Kate Raworth and her “7 Ways to think like a 21st Century Economist“. Now if someone says that healthcare doesn’t have anything to do with economics, please think again. I may have had that view myself way back in medical school through lack of knowledge, but some years later I know that healthcare has plenty to do with the world of economics.

As a baseline, we make the point that healthcare delivery in Ireland is often hitting the headlines with a range of negative stories/concerns in the news. The ongoing criticism it receives reflects the pressure to meet expectations of what a modern healthcare system should deliver, while also posing a real challenge to morale at the frontline. To my mind the state of our healthcare system is another “canary in the mine” of a society and economy under pressure.

To give some context as to the extent of the problem across Irelands healthcare system, the single best way to explain/expose it is to point out that few countries in this developed part of the world have endured  the pain of a National Emergency Department Trolley Crisis for the best part of 20 years, with little/no progress to speak of , month after month, year after year. Why such a crisis, why so long, why unsolved you may ask? You may well ask and you’ll find the usual mix of people, process, information and technology issues that face healthcare across the globe that we have explored elsewhere

If you look at any healthcare system you will see that they all are closely related to the politics of place, each system reflecting the culture within which they reside.. from the individualist “sort yourself out” of the US to the “free for all” of the UKs NHS. Does the national shame of a trolley crisis which has eluded the Irish healthcare system for at least a decade reflect poorly on the culture in Irish healthcare? Certainly it has frustrated the politicsl order for some time….

So in order to avoid the swings in policy/ decision making that have beset the Irish healthcare sector for a decade of more, within the last year the political machinery in Ireland has made an unprecedented effort to try to forge a new way forward.  If you want to get right up to date on the latest healthcare policy in Ireland, you can check out this latest 192 page tome released in May 2017, named the Committee on the Future of Healthcare : Sláintecare Report“.

I’m not going to get into the nitty gritty detail of this report here, but simply to say this is historic stuff, ie it’s the first time that there has been cross party political consensus on the way forward for the healthcare systems in Ireland in my living memory and it’s a comprehensive plan for 10 years of reform, no matter what you/I may think of that detail.

Now all of this exploration is very timely, as cross party endorsed SlainteCare was approved in May 2017, with a clear implementation plan to begin in July 2017, which would suggest that it should feature strongly in the following budget, i.e. within last weeks in October 2017, aka “Budget 2018”.

So aside from the # 1 issue on housing that needed to be tackled, where does the key concern of healthcare reform (i.e. this newly minted SlainteCare plan) feature in the numbers?

The short answer is that Budget18 was not the one to bite the bullet of healthcare reform that is SlainteCare, i.e. in the Budget 18 Financial Statement Slaintecare did not get a single mention. So with one move, already the SlainteCare plan is in the territory of risking sitting on a shelf. So if such a key/historic opportunity/move towards healthcare reform has not been grasped… why so?

Why would such a key building block to addressing/improving that most sacred of efforts, healthcare, be put on hold or only implemented in part?
The answer, though those of us with a healthcare background may not wish to admit it, is that there is quite simply much more to a society/economy than just its healthcare system, therefore there is a limit to the % of spending that a nation wants to put towards its healthcare and the budget ask for SlainteCare was too much to swallow on this occasion. Fair enough you may say, based on the significant % of GDP that Ireland already spends on its healthcare systems…there needs to be a better return on that spend.

So let’s use this key juncture between political will for healthcare reform, yet financial constraints in doing so, to look at 4 key societal/economics elements from our 21st Century thinkers picture in Kate Raworth’s excellent Economics book and consider some of the key issues at stake more closely.


In brief summary , the key points/ideas here to move on affordable reform include;

The State which is essential- so make it accountable – professionals should lead reform/ state should commission care wisely
The Market, which is powerful , so embed it wisely – disclose & tackle conflicts of interest while harnessing the private sector
The Household, which is core, so value its contribution – have honest discussion with public about realistic medicine and allow them to support their own care
The Commons, which are creative, so unleash their potential – tap into the potential of collaboration and reuse in pharma and medtech sectors



The State

In this time for reflection more generally on the role of the nation state, I’ll begin by suggesting that surely one of key roles of the state is to care after its most vulnerable in society? ie the sick and injured, those in pain etc, those requiring emergency care for instance?
Well if so, how has the interminable Irish  ED trolley crisis shame be tolerated for so long?
There is no doubt that the ED is the “canary in the mine” highlighting the broader failings of the Irish healthcare system, fitting a pattern of healthcare usage that is being seen in EDs across the globe.  Sure, some of the issues in Ireland are down to those broader forces but given the level of funding into Irish healthcare (Ireland has a relatively high % spend on healthcare compared to our neighbours and the health budget is already the largest % of state spending per department) some issues must surely reflect the structure and governance of our healthcare system.

Who leads the state on healthcare is an interesting question right now. Our Taoiseach is a young qualified doctor with some interest in healthcare, our Minister is a younger hard working man making an effort to do the right thing amidst a political system fixated on the next year/two, he means well by promoting longer term thinking that is SlainteCare, he doesn’t quite have the money. The Department of Health is the civil service branch that oversees policy etc, while the unpopular Health Service Executive fulfils the vital role of health service delivery. Can they swing into SlainteCare reform mode without the extra money?

Which raises a question about who should be leading this reform anyway?

The vital medical, nursing and other allied healthcare professionals who make up the large  numbers and the essence of healthcare delivery on behalf of the state is the essence of public service as most of us know it. The health and care professionals are the ones at the coal face of the health service and under the intense pressure that goes with that. So how do they feel about the need for this SlainteCare reform?

To that we need to look to the professional leaders, their unions you may say. OK lets look at what they say.. there in lies an immediate issue, who represents the professional leaders of the health service, the doctors for instance? The IMO, NAGP, IHCA? You will quickly note the profession is somewhat split. You may also note that support for SlainteCare from these professional bodies is by no means clear, i.e. simply put, the Irish medical profession is not leading on the rollout of this cross political healthcare reform programme from the front.
Let’s consider why not by switching hats and looking at this challenge from another perspective, that of the market.

The Market

“The Market is powerful, so embed it wisely.”

If you are looking at the Irish healthcare “system”, it doesn’t take long to notice its unusual mix  that is the spread across 2 “systems”, the public and private healthcare systems. In clearer terms that can be explained as healthcare delivery spanning both the “state” (public sector) and the “market” (private sector). In fact is the split between the public & private sector and the wish to focus on reform and improvement of the public sector alone that is fundamental to the SlainteCare report/recommendations.

Ireland unusual healthcare mix involves many staff spanning public/private sectors which is an unusual arrangement in any sector and it’s this involvement across the public/private divide which is seen as a potentially problematic conflict of interest. In particular for those medical professionals whose practice involves public and private practice. i.e. what incentive do they have to improve the public healthcare services if that may impact on their private practice? Whether the staff involved do/don’t feel that conflict, such perceived conflict is an unspoken dimension of the healthcare system which would be intolerable in other industries.

Why has this split developed and what is the SlainteCare plan aiming to do about it?
To answer that it is helpful to understand some background history. Healthcare delivery a century ago was delivered largely by stand alone doctors whose practice some patients were able to pay for and some were not. When the state/public sector system then came along to take greater care of people and doctors became salaried, they were expected to ensure a set/minimum number of hours were set out to cater for their public patients and in their spare time they could see additional private patients, a perk of the job perhaps in some eyes, or a way to cater for extra demand in other eyes. To the modern day it is widely known facet of the Irish healthcare system that some of it is delivered by the state (public system) and some by the market  (private system). Many doctors practice on both sides of that fence. We know that the casemix in public settings is generally more varied and challenging than in the private sector. We also know that staff seem to find more frustrations working within the public sector, less so in the private sector. Human nature being human nature, and with no malice intended, one can see how and why a subtle but important conflict of interest emerges from the mix.

So the SlainteCare plan aims at uncoupling that conflict and focussing reform on the public provision of healthcare in Ireland, seeking to lessen the need for private healthcare, remove private healthcare out of the public healthcare facilities – thereby reducing the overall spend on healthcare, while making the system more equitable in terms of access & outcomes etc.

So let’s not dodge that difficult issue that is perhaps the elephant in the room with regards to SlainteCare. Let me state it clearly here, if the essence of the SlainteCare report is aimed at reforming and improving the public healthcare system, while quietly sidelining the role of private healthcare system in Ireland, what are the chances of those Irish medical professionals who span that divide leading the related changes required? In my own humble opinion, this key issue needs to be brought out and dealt with for real reform to happen.

State v Market in Irish Healthcare –  tackling the conflict..

Now thats out in the open, let’s quickly explore how this potential conflict could/should be avoided?

Though the range of alternatives were not within the scope of the SlainteCare report, there has always been/will always be a range of solutions/approaches to the provision of healthcare.

The range spans from state led and tax funded healthcare provision to market let and generally insurance funded healthcare provision on the other hand. We know Ireland has a problematic mix of both. We know that a move towards a market led/ universal insurance based provision of healthcare was dismissed here in recent years with the mishandling of UHI (Universal Health Insurance) push . On the move towards a universal service such as healthcare, there is one important perhaps interim option that needs to be more widely discussed and understood, which may be explained as the “commissioner/provider” split in the healthcare delivery.

To explain how this might work let me simply suggest that this state led universal healthcare Slaintecare model could morph towards;

  1. state led and tax based funding model of healthcare.. where key services are commissioned by the state.
  2. state provision and market provision of healthcare.. to fulfil those key service requirements set out by the state.

On the commissioning side… Ireland already has some of that mix in place, i.e. the structure that is the HSE was/is to be replaced by a form of Commissioning Body at least in some shape/form. The commissioning arm of the state healthcare service could/would be absolutely vital. Indeed if the essence of the State is to protect its citizens, if the provision of healthcare is vital to that, who should be accountable/for what?
It could be argued that the role of the State is as vital in the effective commissioning of the good quality healthcare as it is to the provision of quality healthcare.
If healthcare commissioning is understood and embraced it should lean heavily on the learnings from the NHS (warts and all), the key feature being that Primary Care Professionals are the key decision makers in how monies are spent in their area. The SlainteCare report already spells out the vital role of Primary Care/GPs for a sustainable healthcare service. It makes brief mention of commissioning, yet it doesn’t go far enough in my view to put GPs in charge of the commissioning of services in their area.

On the provision side… as Ireland already has self employed GPs and many healthcare staff working in private setting, hospitals etc. It strikes me that this capacity should be leveraged by the state rather than sidelined.
While the inherent conflict of interest in the present state would not go away any time soon, this could /should be managed by professionals being registering a public register of interests. They could/should clarify if their work involved;

  • State side Public commissioning of healthcare services
  • State side Public provision of healthcare services
  • Market side Private provision of healthcare services.

Most of the medical professionals I know are highly motivated people who wish to do the right thing and do it properly. My view is that as healthcare reform is required that medical professionals should be leading that from the front.
Regarding the conflict of interest issue, some potential conflict across those lines is unavoidable, particularly in the short term, so should be openly disclosed. At the very least such open disclosure would encourage folk to better understand the relationship between the state and the market in Irish healthcare and allow all parties to work together to improve on that in line with the SlainteCare framework.

If these issues are not confronted proactively, I would suggest that attempts to actively implement SlainteCare without the active leadership of the medical profession here could/will spell trouble ahead.
If these issues are confronted and dealt with, I would suggest this is a rare opportunity to move towards a new approach to healthcare delivery in Ireland.. one that anyone enduring a long wait on an ED trolley would say is long overdue.

The HouseHold

Now from yet another angle, one of the key changes that is required in the Irish healthcare system and outlined in the SlainteCare report is a shift to place the patient at the centre of their healthcare. Going back in time we know that in the past family doctors were able to provide cradle to grave healthcare. Then over time came a shift to centralise care, delivered in hospital more often, with a specialisation of the medical profession and a more team based delivery of modern healthcare, to the point we are at today where patients often have to do deal with a wide range of healthcare professionals and often a somewhat disconnected patient journey through the system.

We now know and the SlainteCare report acknowledges that we need to integrate the delivery of care, around the patient, i.e. a big push to deliver Integrated Care. To do so will involve a shift from the paternalistic approach to healthcare that we have seen in the past, were patients are told what to do, towards a more engaged and collaborative approach between professional and patient, towards shared decision making etc.

Having worked in the National Health Service in England for many years and seen the fantastic service delivered free at the point of care, in particular my years as a Consultant in Emergency Medicine there, caring for patients from arrival to discharge in line with the 4 hour ED standard, it was a revelation in how good healthcare can be, yet the real related challenge to be sustainable for years on end. I say sustainable in that as good as we were able to provide emergency care in such a timely fashion, the EDs in the NHS became victims of their own success, with ever greater numbers of attendances year on year, pointing to what some folk explain as an insatiable level of demand for healthcare.

If you look internationally at models of healthcare provision you will see a wide range of differing models, from state led /tax based systems towards more market led/insurance based systems and a wide range in between. Of note from Singapore is an interesting approach, whereby the state provides a MediShield (aka catastrophy insurance (in case of car accident or cancer)) along with a MediSave (savings account) which encourages and empowers individuals to take greater interest in their health and care with a view to using it wisely, ie spent on the gym etc, though a degree of choice too (eg cosmetic surgery) but the point is the individual has to take responsibility for their health and care, thereby helping to reduce demand on healthcare services and control costs (Singapore spends <7% of their GDP on healthcare with some of the best outcomes internationally.

The Chief Medical Officer in Scotland has been lauded for her push towards what she calls “Realistic Medicine“. So lets flag up the need to have an honest conversation with the people of Ireland on what is realistic to expect from a health service and a related conversation with professionals to encourage a shift from a paternalistic approach to healthcare to empowering people to more actively engage in looking after their own health and care.

Aside from looking after ourselves, we need to consider the vital valuable role of carers. When we think of the economy and the role of “the household” it is often ignored, not appreciated. When calculating our GDP figures we count the work of men and women in factories and offices yet not in their homes? How come? Is the cost of caring for our unwell and elderly in healthcare buildings a significant cost? Certainly so. Is caring for our unwell and elderly in homes free of cost? Hardly. These issues are explored in thought provoking ways in Kate Raworth great book and worth again mentioning here. If we think the role of the household doesn’t count in economic terms and the “value of work” /or cost of caring depends on where its delivered and by whom, then for now its suffice to say we need to think again.


The Commons
The terms “the commons” is not one hear spoken/mentioned in Ireland much, and in our last discussion we explored potentially better use of the physical commons, in the last exploration of housing and land in Ireland, we now consider the “knowledge commons”.

If Ireland has a low level of discussion/understanding of the physical commons then for a “smart economy” it has equally another blindspot on the importance of the “knowledge commons” in the 21st Century.

In the next post I will specifically look at the expansive knowledge economy aspect to the software sector of Ireland’s economy and the small profile that an open knowledge commons has here. In advance of doing so, let me tackle another elephant in the room that is worth exploring, the knowledge commons with regards to pharmaceutical & medical devices.

Bearing in mind that we need to contain costs in healthcare around the world and bearing in mind that most innovation in healthcare is done within/alongside the publicly funded healthcare systems there are many questions to be asked about the relationship between the pharmaceutical & medical devices industries and what they could learn from the open source world.

Considering that pharmaceutical & medical devices industry has become a hugely important employer, one should tread carefully here perhaps. As I do, let me first raise the question to you the reader as to whether you believe that;

  1. the healthcare industry should be understood as an essential industry, which is needed to ensure a healthy population can go about leading happy and fulfilled lives… while the cost of healthcare could/should be contained to reasonable limits so other monies can be spent on housing, education, transport, etc etc
  2. the healthcare industry could/should be understood as a very promising “growth industry” where the aging population of the planet means that industry provides an opportunity to chase a greater market share of the pie on offer, greater GDP growth etc.

If you have any doubt about a) and  think b) is the right answer, I sguggest you now go elsewhere. If on the other hand you think a) may be reasonable.. have you considered how much Ireland pays for its medications and/or medical devices?
Did you know that despite/because the pharmaceutical industry is such a powerful player in Irish industry that the Irish Healthcare service has an inordinately high pharmaceutical bill, low rates of generic drug prescribing etc?
Do we know the major cost of medical devices in use in Ireland? Internationally, the average doctor does not.
Is there an argument that innovations in healthcare should be made widely available at reasonable cost and to a global healthcare commons? I would argue so..
Does that mean that innovators and suppliers shouldn’t make good money and profit from their ideas? Certainly not. Does that mean that Big Pharma & Med Tech shareholders are more important than other healthcare stakeholders? I don’t think so.

While there will always be innovations at the frontiers, in pharmaceuticals/medical devices/other industries that will be well rewarded, the question for Irish healthcare, as elsewhere, is shouldn’t we be innovating ourselves and sharing our efforts and ideas in better ways?

Perhaps in days gone by when money was aplenty such profligate spending in these areas could be justified, but with a country so heavily in debt and an healthcare system would costs are so hard to control?

Here are 2 ideas to throw into the mix;

While Ireland has a history of dependency on Foreign Direct Investment in these areas, where are the Irish men and women in these sectors with some creative flair that want to change the world in new ways along these lines?

We will return to this theme, with a focus on a digital commons to revolutionise Irish healthcare in our next post.


So we have done our tour of duty, we have explored the Irish healthcare challenge and opportunities in new ways.

The SlainteCare Report of 2017 marks a historic opportunity to reform the Irish healthcare system.
It has some key strengths, other weaknesses, some opportunities and some gaps.
I believe that the Irish medical profession should seize the opportunity and embrace this chance for reform .

We need to improve our society and our economy.
In these challenging times of Brexit and Trumpit in 2017, the best way to do that is to look at the world in new ways, with affordable healthcare reform a noble case in point.
To sum up let me go back to the book where some of these new perspectives came from and repeat some of the key lines that may resonate, as we look forward.

The State which is essential- so make it accountable – professionals should lead reform/ state should commission wisely
The Market, which is powerful , so embed it wisely – disclose & tackle conflicts of interest while harnessing the private sector
The Household, which is core, so value its contribution – have honest discussion with public about realistic medicine and allow them to support their own care
The Commons, which are creative, so unleash their potential – tap into the potential of collaboration and reuse in pharma and medtech sectors

Posted by: Tony Shannon | September 30, 2017

Ireland : Society & Economy: Land & Housing

As the autumn arrives to Ireland at the close of September 2017, we use this “back to school” time to take stock of where things are at here at this place and at this time.

Without wanting to explore things that are completely new and disconnected from earlier posts, rather this post directly follows on from recent posts on new ways to look at the world, new ways to look at our economies in particular , aka 7 ways to think like a 21st Century Economist (based on the thought leading book by Kate Raworth), this time in an Irish setting.

So the idea here is not to look at Ireland/ Economics or the Irish Economics in particular, but at a broader range of issues, albeit framed on one island, they are global in nature.

To help frame the discussion am going to reuse a helpful picture that we can hang the discussion points on. I’m not calling this a diagram, as to do so would suggest this was a fixed representation of worldly things. Rather this is a picture, as the author Kate Raworth recognises the importance of pictures to stimulate thought and encourage more pictures..!



So we start with Society.. what is Irish society like?

Sat on Planet Earth…. conservative yet innovative some might say.. Ireland is shaped by its geography.. with the powers of Europe to our east and the powerhouse of the United States and Canada big influences to our west.. Ireland is also shaped by our history, indeed as the island of Ireland is divided into North & South, our long and complicated history with our nearest neighbour has a profound influence on us.. and after some time we now have a very good relationship with our neighbours, despite the challenges of yesterday and today.



The Irish are well known to punch above our weight on the international stage. How so? Perhaps its because we are a nation of emigrants where pretty much every family have members who have been/are overseas, so our diaspora is broad and wide and we see the world with international eyes..


Within our society , in terms of our Economy, what do we see? 

A global facing and open economy is one of the ways that the Irish economy is explained these days, so very far removed and much progressed since its days as an agrarian/agriculturally based economy for centuries. One of the interesting facts about Ireland is the population of this island, around about the 6 million mark these days of 2017. Remarkably for a developed/Westernised nation we are one of the very few that has fewer people now than we did pre 1850, when the Great Famine struck. A trip to the west of Ireland will show you show small and subdivided the land became , forcing folk to live off smaller and smaller farms until catastrophe struck. Even so Ireland largely bypassed the Industrial revolution so was a primarily an agricultural economy until recent times.
With an agricultural oriented economy until very recent decades the shift to a modern services based economy that you see across Ireland today has been transformational to say the least.

With that change we have seen a steady and significant population shift from rural to urban areas. As the economy shifted in the 1970s with Irelands membership of the EEC/now EU we began to see a series of investment from outside Ireland by globally oriented businesses, especially US businesses that wanted a presence in Europe, where our English speaking and well educated population was ready to meet that need. As a result Ireland has seen a lot of Foreign Direct Investment (FDI) from a wide range of multinationals (inc from the software and pharmaceutical sector) . One of the other attractions (or perhaps a minor detail ;o)) has been the relatively low rate of corporation tax (12.5%).. which has helped attract investment though is now under some threat from efforts to align tax regimes internationally. The pros/cons of that tack in relation to general income tax is a point we may return to later.


Lets split that Economy up.. first the role of the State

So one of the 4 key elements of the Economy is the important role of the state. As Kate Raworth exposes  it in her thought leading book, the issue here is not an either state or market dilemma in any economy, its always an issue of the state and the market, i.e. you simply cannot have one without the other. Internationally in the last decades the essential role of the state has been downplayed, she exposes  the “State, which is incompetent, so don’t let it meddle” type of mindset that grew fashionable in western circles. Indeed she would rather now reexpress it as “The State, which is essential, so make it accountable”. If we consider the State ie the nation state of the Irish Republic, it may be understood as the political parties and governmental bodies that run the state (the Dail and Senate) between electoral cycles as well as the civil/public service than run public service functions for the long term. The split between these arms of the State are important, with Government begin accused of short termism and chasing the next election, while the public service regularly being accused of conservative, change averse class, resistant to reform.

Regardless many/most all agree that the State plays a vital , if often criticised role in Irelands economy, running the Department of Educations, Jobs, Health etc etc, all crucial roles not just to an Economy but more importantly the Society that contains that Economy.

How are the state run sectors of Education, Healthcare and Justice perceived (to name just 3)..  “In need of reform” would be one common form of reply..
What expectations are reasonable of these sectors in 2017? Just what should the state provide? What instead should it guide?
Importantly the interplay between the role of the State and the other key economics factors we will look at ..  the Household, the Commons and the Market is generally poorly understood across these sectors..
In a future post we’ll be taking a look at the Healthcare sector which I know well and looking at the challenges faced, with these important if neglected perspectives..
Before we do that lets look more closely at some of the other dimensions we mention to better understand them.. you know them well, even if not looked at them together this way..

Lets move now to the HouseHold .. have you considered it before?

So consider this, whats the original meaning of the word economics?  Well the tome “Oeconomicus” is explained as “one of the earliest works on economics in its original sense of household management”. (Wikipedia:Oeconomicus). Yet we hear the Economy being spoken about in terms of $/£/€ and GDP(Gross Domestic Product) etc with little no measure or regard for any of work done within households. Why so? I’m certainly unclear and Kate Raworth explores this in a very smart way.. Ask yourself this, is Childcare free? Can you get a meal cooked for free? Can cleaning your house cost money? Does caring for our elders have a cost? All of these important questions are explored in her book, yet I raise it here to make a simple enough point.

There is a lot of work done across the Households of Ireland, with many households needing 2 adults at work all week to pay for the cost of running a household. Here is the rub.. the cost of buying a house/making a home in Ireland has risen so much that Dad and Mum both need to go to work all week to make ends meet. Wages have not risen in a big way for some years now midst/post recession, yet house prices have gone up again. As house prices have risen, so have house rental costs. With wages relatively flat and housing costs on the rise, a modern day tragedy of increased homelessness has become a shameful dimension to modern Irish life.

Therein lies an issue at the heart of modern day societies/economies.. Wealth versus Wages. i.e owning Capital may becoming an easier way to make money that earning a Revenue/Income for working. We have arrived at perhaps the heart of the most challenging issue of our times..and the explanation for every growing 1%/99% divide..

Which brings us to the Commons.. whose land is it anyway?

Now you may note that the commons is a key player in our picture of the 21st Century Economy, yet its not a term you hear about in Ireland much. What we do know is that the Irish have a real link “to the land” and land ownership is a big issue in these parts. (If you want to watch 1 movie to explain that culture, check out “The Field“).

So back to the commons, in bye gone times, our ancient ancestors generally walked the earth treating the land as a resource “in common” where folk hunted and gathered and then moved on. Sure enough folk then began to settle down then make a farm , a house etc and so the concept of land ownership began to be understood. Who owned that land then became an issue of power and money.. with lands being owned by tribes, then kings, then church and sometimes state etc. The Irish have a history of trouble with a landlord class which led up to the Land League which worked to establish a fairer relationship between landlord & tenant. In any event the moves of 1916 and a push for Irish independence meant a group of men and women wanted ownership of their own land and a right to rule themselves. Ireland back in 1917 remained part of an empire but that was to change with the Treaty of 1922 and a split between Ireland North and South.

While most of Irish lands were privately owned by owner occupiers, unlike in Scotland where huge estates were the norm, the State became responsible for just a few lands and parks, the designation of National Parks only came to Ireland around 1969 and there are still only 6 in the Republic of Ireland. None of that was a real issue until the time that a certain Celtic Tiger came to town and with a wash of cheap money from the euro zone, and decades of being a poor relation, the country “went mad” buying land and houses, thinking “this time would be different” and blissfully unaware of the bubble in plain sight.

The price of land

As we consider this challenge, consider this for a moment, a billboard from the US in 1914. (Image from Doughnut Economics).


There is an important story here.. most land, taken from the commons way way back, is in private hands/ownership. That land is understood as wealth, as capital on an accountants balance sheet. That land which cost $3600 was to remain unsold until the owner gets $6000. The owner makes clear they will do no work to earn that $2400 profit, but the value of that land will simply accrue from the presence of the community the land sits in and the enterprise of its people. The land and the value of its location, location, location is down to others, to other people, people, people.

The rising price of houses can always be traced back to the rising price of land and while land prices rose across the land, a great wave of “one off houses” have been  built in Ireland in recent years, continuing a trend of poor planning that had been going on for decades related to weak governance and local politics. One sad aspect of this has been a great spread of development across “commuting counties” that adjoin key cities. Increasingly framed as a growing split aka the rural/urban divide, Ireland has seen the international pattern of movement to the cities alongside a hollowing out of smaller towns and villages with a scattering of houses in between…  all of those changes having had a resulting impact on Irish society.


The price of housing..
As night follows day, so a housing price collapse duly followed the housing bubble and lessons were learned .. or were they??

As monies from the ECB (Eu Central Bank) have kept credit lines open across Europe to stave off a recession, so the lending for building and property has begun again with land and house prices are on the rise.

Are wages on the rise to match? Not so.. the Wealth v Wages tension has taken off again.


P.S. The price of water
Aside from the challenge of providing shelter, another challenge has hit the headlines in recent years.. the provision and supply of water..
Water you ask? Doesn’t it rain a lot? Indeed it rains, enough. Yet the Irish Water story tells another story of the misappropriation of the commons in Ireland.
There is a challenge in supplying water in Ireland for the simple reason that water is seen as a classical common good, that nobody seems to want to pay for..
Arriving on the scene to semi-privatise the challenge of investing in infrastructure to look after this common good, Irish Water turned into public enemy #1.
While folk didnt hit the streets to protest about a decade long trolley crisis in the countries Emergency Departments, they turned out in big numbers to say “no way, we wont pay- for water”.
Except they will have to pay, not via an Irish Water bill based on how much water you use but through general taxation .. most likely on income. A price worth paying?


.. and so to Market, to Market we shall go. 

So thence the Market, what way is the market working for the Irish Economy and Society? By the way who controls the market? No one, nothing you say, the free market reigns?
Yet again, to reinforce the point, there is no such thing as a free market, as fellow renegade economist Robert Reich makes clear in his related book “Saving Capitalism: For the Many Not the Few”.  The only way that a market exists is if the conditions are set for market dynamics by the state, within the economy, within the society of a nation.  So societal values could/should influence the game. Lets ask the question, could/should the market be influenced to improve the health and well being of a nation? Eh.. why not, I hear someone say…

So lets ask this.. what can be done in Ireland in 2017 to the market/economy to improve society?

Should wages/income tax go up or down? Should wealth tax go up or down?
Do you agree with the assertion by Irish economist David McWilliams when he suggests “A real Republic of Opportunity? We’d have to tax land to the hilt” 
Turning back towards the commons, do you know that South Korea, slightly larger in size than Ireland has a National Land Bank controlling more than half of residential land development? Have we given enough thought to related developments in the UK towards Community Land Trusts? Should the Irish National Asset Management Agency be repurposed towards this work?

The key question here is whom should the Market serve?.. in the past it was understood to be all of us , we “stakeholders” in society.
Lately that key principle seems to have shifted a little too, far as we here far too often about the key aim of the market is to satisfy the “shareholders”.. i.e. shareholder purely in the monetary sense of the word…


So now may be as good a time as any to resetting Irish Society and our Economy and look forward to changes from the State, in the Market, within the Household, leveraging the Commons….
… to improve the economy …. towards a better society..

The future direction of this country has been painted in “Boston versus Berlin” thinking in the past.. which way do we turn?
Indeed in these times of Brexit and Trump-it the next steps that Ireland takes are particularly important.

We have a new young leader, in post now for no much more than 100 days..he has choices.
More importantly Ireland is a young country.. with young minds.. who should be keen to learn, think and thrive..they/you have voices..


(NB for the sake of reading I have referred to the Republic of Ireland as Ireland, as thats what I call home. I hope neighbours, colleagues & friends in Northern Ireland will understand that shortcut.. many of the same principles apply “Up North” too.)









Posted by: Tony Shannon | August 31, 2017

Life Ring (aka Doughnut) Economics for the 21st Century

So, having made it west to the #WildAtlanticWay armed with a great book, time to recount the key lessons learnt, from a book that is already changing the way I think…

With one book, Kate Raworth is offering her fellow citizens of the world a new world view.. Framed in the context of fixing the “dismal science” of economics that she acknowledges is broken from the start, while this book is all about “7 (new) ways to think like a 21st Century Economist” the breadth and depth of her efforts to learn from across the spectrum help to explain why this is such an important book and certainly not just for budding economists.

Already I can sense that the way she suggests reframing the world we live in is bound to attract scorn and derision from those with any vested interest in the status quo, yet whatever your political persuasion, her new ideas are surely well worth spreading, if only to stimulate the debate and discourse needed by societies to improve our lot.

One could of course suggest as others have done that we have already reached “the End of History” and that the human race has reached the pinnacle of its time on earth, with no further room for improvement, so switch on the TV and sit back…

Somehow I don’t think so, for although many of us are living comfortably (including myself) in a safe part of the world with more creature comforts than our forefathers could have imagined, if we really look around us we see modern society under threat and in danger in many ways. Based in Ireland as I am, I need only look to Brexit and Trumpit to see 2 of the worlds leading nations at the edge of political +/- economic crises of their own making. Why is that so? What is at the heart of the challenge we face as a human race and what way forward?

In her book “Doughnut Economics: 7 ways to think like a 21st Century Economist” Kate Raworth proposes a new visual way of looking at the challenges we face, in a more holistic frame than any I have seen before. She uses the term doughnut to explain an inner ring , a foundation of basic human living standards that everyone aspires to, alongside an outer ring, a ceiling of human activity and impact beyond which there is compelling evidence of long lasting impact to the planet we live on.  She uses the term Doughnut to symbolise this new human compass for the 21st Century . (I would have rather use the term Life Ring or something else, as I fear the Doughnut term will distract/detract from the message) and the key idea is to share a visual that sticks in the mind. Here is key visual #1


From many angles and at many levels, be it at an individual, family, city, nation or planetary perspective, there is plenty work to do to ensure we shift human societies to within these basic/reasonable/essential boundaries.. if you have any interest in your common man today or the generations to come hereafter.
If you aren’t interested yet and sense this is all about green sandal wearing environmental stuff, do read on, this read and the important message is far broader than that suggestion alone…

Kate understands the complexity of our world far better than most authors I’ve read of late, and appreciates the power of patterns, of pictures and of stories/narrative. She introduces 2 versions of a grand play with the key actors, in a way that resonated strongly and are well worth sharing here.
From current economic thinking/which influences our current world view.. the key players in our world and their roles on the stage;

THE MARKET, which is efficient – so give it free rein.
BUSINESS, which is innovative – so let it lead
FINANCE, which is infallible – so trust in its ways.
TRADE, which is win–win – so open your borders.
THE STATE, which is incompetent – so don’t let it meddle.
THE HOUSEHOLD, which is domestic – so leave it to the women.
THE COMMONS, which are tragic – so sell them off.
SOCIETY, which is non-existent – so ignore it.
EARTH, which is inexhaustible – so take all you want.
POWER, which is irrelevant – so don’t mention it.

Then a new 21st Century oriented script, with the key players and their adjusted roles;

EARTH, which is life-giving – so respect its boundaries
SOCIETY, which is foundational – so nurture its connections
THE ECONOMY, which is diverse – so support all of its systems
THE HOUSEHOLD, which is core – so value its contribution
THE MARKET, which is powerful – so embed it wisely
THE COMMONS, which are creative – so unleash their potential
THE STATE, which is essential – so make it accountable
FINANCE, which is in service – so make it serve society
BUSINESS, which is innovative – so give it purpose
TRADE, which is double-edged – so make it fair
POWER, which is pervasive – so check its abuse

To help explain this new world view and how we can frame related discussions she offers another helpful visual;


Some of the many important points that I’ve taken away from this world view.. aren’t radically new, yet they are more cohesive together when framed in the new ways that Kate suggests we can all contribute to a new way of looking at the world around us.

For instance, an affirmation of the important, nay essential role of the State in shepherding change and progress in a fair and equitable direction.  Equally, the essential role of Business with a purpose and the related Market in our world. She draws attention to the importance of both the Household we all take for granted alongside the Commons that has been neglected and pillaged for too long. In exploring the current obsession with measuring a nations success in terms of GDP and growth she sheds light on the broken elements of the politico economic system that has tolerated such a narrow mindset for so long, very easily explained by the small number of powerful actors on the world stage that are quite happy with that current state and the status quo, you guessed it, the 1%..

I mentioned in my last post about the 7 key ways to rethink for the future, frankly brilliant insights worth repeating here and well worth delving into in the book.

  1. Change the goal: away from GDP Gross Domestic Product to sustainability and well-being.
  2. See the big picture: not just a self-contained ‘market’, but rather an ‘embedded economy’ which takes account of households, common property resources, the natural environment.
  3. Nurture human nature: and not just ‘homo economicus’, recognising that people are interdependent social beings, enmeshed in the web of life.
  4. Get savvy with systems: recognising complexity, challenging equilibrium economics, and learning to work with the grain, as gardeners not engineers.
  5. Design to distribute: tackling inequalities in wealth, land, and money.
  6. Create to regenerate: building a circular economy, reshaping the state, and raising the standard of business responsibility.
  7. Be agnostic about growth: not just decoupling growth from environmental resource use, but learning how to live without growth.

Perhaps the beauty of the book is that she is not calling for revolution on the streets to enable a radical reset of the global politico economic system that needs a rejig. A revolution in thinking perhaps, but no bloodshed required! It is all too clear from her writings that a retreat to the shelter of nationhood to sort out these challenges, currently on exhibition in the form of Brexit and Trumpit, isn’t going to really sort any nations ills out for long.  We have arrived at the time for planetary economics for our planetary household and already a global evolution in the right direction is underway.

That evolution she sees happening and ahead of us is something I’m already a witness too.. in fact as she suggests as she closes, “We are all economists now” .. [many of us involved in an] Economic Evolution: one experiment at a time”;

One promising way of redefining the meaning of ‘economist’ is to look to those who have gone beyond new economic thinking to new economic doing: the innovators who are evolving the economy one experiment at a time. Their impact is already reflected in the take-off of new business models, in the proven dynamism of the collaborative commons, in the vast potential of digital currencies, and in the inspiring possibilities of regenerative design. As Donella Meadows made clear, the power of self-organisation – the ability of a system to add, change and evolve its own structure – is a high leverage point for whole system change. And that unleashes a revolutionary thought: it makes economists of us all.

If economies change by evolving then every experiment – be it a new enterprise model, complementary currency, or open-source collaboration – helps to diversify, select and amplify a new economic future. We all have a hand in shaping that evolution because our choices and actions are continually remaking the economy and not merely through the products that we do or don’t buy.

We remake it by: moving our savings to ethical banks; using peer-to-peer complementary currencies; enshrining living purpose in the enterprises that we set up; exercising our rights to parental leave from work; contributing to the knowledge commons; and campaigning with political movements that share our economic vision.

So kudos to Kate Raworth for bringing some new vibrant and deeply insightful thinking to the economic table… call it Doughnut Economics or a new Life Ring for 21st Century thinkers.. I have no doubt there is major merit in this modern cookbook/survival guide.
In fact, if I was a betting man, methinks Kate will be in the running for a Nobel Prize , such is the potential impact of this stuff on the policy makers of the world.
In fact put me down for a tenner.

Please get this book and spread the word.

Posted by: Tony Shannon | July 31, 2017

Seven Ways to Think Like a 21st-Century Economist

As summer is here and a break beckons, I’ve been looking out for a good book.

With a broad interest and trying to understand the world of Brexit , Trumpit and all the confusion in the air, I’ve been looking a fair bit at some economics stuff. Not always easy reading but important material to brush up on these days.

So I’ve come across this interesting looking text, which looks like it should be entitled “Seven Ways to Think Like a 21st-Century Economist”

The long title is actually “Doughnut Economics: Seven Ways to Think Like a 21st-Century Economist” by Kate Raworth, though I’m immediately wary of the doughnut in the title, as a potential barrier to get the masses to open their minds to a new way of thinking.

Here is a taste of the contents around “7 key ways to think like a 21st Century Economist”

  1. Change the goal: away from GDP Gross Domestic Product to sustainability and well-being.
  2. See the big picture: not just a self-contained ‘market’, but rather an ‘embedded economy’ which takes account of households, common property resources, the natural environment.
  3. Nurture human nature: and not just ‘homo economicus’, recognising that people are interdependent social beings, enmeshed in the web of life.
  4. Get savvy with systems: recognising complexity, challenging equilibrium economics, and learning to work with the grain, as gardeners not engineers.
  5. Design to distribute: tackling inequalities in wealth, land, and money.
  6. Create to regenerate: building a circular economy, reshaping the state, and raising the standard of business responsibility.
  7. Be agnostic about growth: not just decoupling growth from environmental resource use, but learning how to live without growth.

So far so good, am very interested , got the book and will read on..

Is there a way to look after our own interests, tackle inequality, while looking after the long term interest of this planet?
Lets hope so… will report back with a view in a month..


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;

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








Posted by: Tony Shannon | May 31, 2017

Healthcare. Knowledge. Decision Support. GDL.

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..

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

and the underlying GDL here;

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!





Posted by: Tony Shannon | April 30, 2017

WWW: CERN: .. Choices re Property/ Monopoly/Contracts..

As the final day of April arrived and a reminder for my monthly blog update…this tweet arrived.

Read that (30th April) headline one more time…

On this day in 1993: World Wide Web is made free to everyone by CERN.


Last month we were looking at a few key concerns in a world struggling with Brexit and Trump-it.
We mentioned Property, Monopoly and Contracts.

Ask yourself these 3 questions please.. why didn’t CERN take the World Wide Web and try to
1) wrap the tools that underpinned the WWW up with a proprietary software licence and “protect their intellectual property“?
2) leverage the monopoly they held at that time on these WWW service/tools and try to gain some millions of dollars in additional revenue/income etc?
3) sell/rent/resell the tooling via a set of commercial contracts with those who would have been willing to pay for such a service/set of tools as the WWW provided?

Then consider what the implications of the WWW would have been had they secured their intellectual property via commercial contracts and enjoyed their monopoly for a few years?

I ask these questions to ask folk to consider what makes some organisations take the path that CERN took and others to take others?

Does the answer lie in the difference between “public” organisations and “private” organisations.
Do all “public” organisations behave this way?
Do all “private” organisations avoid this behaviour?
I think not..

Reich mentions the difference between Shareholder Capitalism and Stakeholder Capitalism in his Saving Capitalism book in a chapter called..
“Reinventing the Corporation”.
There is something to that…
Could the world of healthcare benefit from some of that thinking for instance?
Again, more to follow…




Posted by: Tony Shannon | March 31, 2017

Economics: Human Constructs: The Government, The Market

Economics… sounds like a dry word.
In fact its neither a hard science or just a dark art, but a human construct of ideas to describe how we humans live our lives..
To understand Economics, we need to understand it in terms of ideas made by man.
Then we can talk about the “Government”, we can talk about the “Market”.

In Robert Reich’s Book Saving Capitalism for the Many not the Few .. he exposes 5 key human concepts and constructs for further analysis.



The concept of property ownership is a human construct.

We own land, houses, money , shares and other assets, but though it was “legal” and widely practiced for centuries we don’t own people (i.e. slaves).
In recent years intellectual property has become a huge international business now involving pictures, to moving pictures, to songs, written work, software etc etc.
So our ownership of what can and cannot be owned is subject to change over time.

We know that there is an increasing issue of late, with the wealthy able to acquire capital/property/assets and the poor less able to. It has ever been this. However the gap between the richest 1% and the rest, the 99% continues to grow to the point that folk are not content to stand idly by any longer.

Reich explains;  “In sum, property—the most basic building block of the market economy—turns on political decisions about what can be owned and under what circumstances. Due to the increasing wealth and political influence of large corporations, as well as the subtlety and complexity of the contours of intellectual property, these political decisions have tended to enlarge and entrench that wealth and power. The winners are adept at playing this game. The rest of us, lacking such influence and unaware of its consequences, often lose out.”

Survival of the fittest is a feature of life itself, yet the human concept of monopoly and our tolerance for it is based on a human construct. Simply put a monopoly is a feature of a human activity, when we allow some folk to have more control and power over certain aspects of our lives than others.

The West has lived through periods of monopolisation of property, power and money before. We have seen boom and bust before and seen the consequences of this when the roaring 1920s and depressing 1930s brought the world to war.

Reich states with concern that in recent decades a new group of monopolists have taken control, from Pharma to Finance.

“Unlike the old monopolists, who controlled production, the new monopolists control networks. Antitrust laws often busted up the old monopolists. But the new monopolists have enough influence to keep antitrust at bay.”
“We are now in a new gilded age of wealth and power similar to the first Gilded Age, when the nation’s antitrust laws were enacted. The political effects of concentrated economic power are no less important now than they were then, and the failure of modern antitrust to address them is surely related to the exercise of that power itself”


So the 3rd issue flows from the second. Yet again, contracts are a human construct.

Yet again, following on from the earlier construct .. modern monopolies affect and influence the next key construct, that of contracts.


“The new contracts do not result from negotiations between two parties with roughly equal bargaining power. They are faits accomplis, emanating from giant corporations that have the power to demand acceptance. Mortgage applicants are required to sign a small mountain of bank conditions to qualify for a loan, even though they may thereby forfeit their right to go to court alleging predatory lending practices. Lower-income borrowers must agree to double-digit fees and interest rates if they fail to pay on time, even though they rarely know they’re accepting those terms. Students seeking college loans have no choice but to waive certain claims. Small-business franchisees must sign agreements setting forth their obligations in such detail that parent corporations can close them down for minor violations in order to resell the franchises at high prices to new owners.”

“When large corporations have disproportionate power—not only over what’s sold, but also over the rules for deciding what contracts are permissible and enforceable by law—those who are relatively powerless have no choice. The “free market” is not, in this sense, free. It offers no practical alternative.”


If the role of Government is seen as looking after one thing in a market economy, it is the setting and enforcement of the rules and regulations that make up the market.
If we see the role of government as nothing else, we see again that government and governance is yet another human construct.
Talk of big or small government, left or right government is somewhat irrelevant here. The issue is that humans, from hunter gatherers, to tribes to city states, nation states and beyond are defined by the borders and boundaries that their respective human collectives set. Without such governance there are no city/nation states, Without such governance there is no market.

“The [next] building block of the market is enforcement. Property must be protected. Excessive market power must be constrained. Contractual agreements must be enforced (or banned). Losses from bankruptcy must be allocated. All are essential if there is to be a market. On this there is broad consensus. But decisions differ on the details—what “property” merits protection, what market power is excessive, what contracts should be prohibited or enforced, and what to do when a party to an agreement is unable to pay. The answers that emerge from legislatures, administrative agencies, and courts are not necessarily permanent; in fact, they are reconsidered repeatedly through legislative amendment, court cases overturning or ignoring precedent, and changes in administrative laws and rules. Every juncture in this process offers opportunities for vested interests to exert influence. And they do, continuously. They also exert influence on how all of this is enforced. In many respects, the enforcement mechanism is the most hidden from view because decisions about what not to enforce are not publicized; priorities for how to use limited enforcement resources are hard to gauge; and the sufficiency of penalties imposed are difficult to assess. Moreover, wealthy individuals and corporations that can afford vast numbers of experienced litigators have a permanent, systemic advantage over average individuals and small businesses that cannot.”


Lastly we turn to the bottom line, the topic of money , credit/debt and the issue of bankruptcy. Yet again, another human construct.

Bankruptcy is a human construct aimed at allowing folk a second change.. to avoid years of penury.. for when they have made an honest mistake/miscalculation and cannot pay the debt they owe.
The last years have taught us a few things on this score.
#1 While some banks and other financial corporations went to the wall, others were deemed “too big to fail”, so their debt was passed onto tax payers in many cases.
#2 Many of those people who were involved in developing the capital/asset/property bubble were given the protection of the courts and able to walk away.
#3 Many others, of lessor means have been/unable to get the same protection so we are seeing home repossessions that have laid the ground for the political backlash that has since followed.


“Bankruptcy is the system used in most capitalist economies for finding the right balance—allowing debtors to reduce their IOUs to a manageable level while spreading the losses equitably among all creditors, under the watchful eye of a bankruptcy judge. The central idea is shared sacrifice—between debtors and creditors as a whole, and among the creditors. Here again, the mechanism requires decisions about all sorts of issues, and these decisions are often hidden in court decisions, agency directives, and the sub-clauses of legislation. For example, who gets to use bankruptcy, and for what types of debts? What’s an equitable allocation of losses among creditors? And what happens when bankruptcy isn’t available? These questions and hundreds of others related to them have to be answered somehow. The “free market” itself doesn’t offer solutions. Most often, powerful interests do.”


In these 5 key aspects we see the building blocks of economics, of human lives, of “government” , of the “market”.
We also see the key elements that can help explain some of the key failings and frustrations of the modern age, from Brexit to Trump-it.

More to follow..


Posted by: Tony Shannon | February 28, 2017

For the Many, Not the Few: Saving Capitalism

Now and again a book comes along that helps you see the world in a clearer light.
On a trip away I stumbled across a bookshop  with a book that caught my eye.

Saving Capitalism: For the Many, Not the Few   – by Robert Reich.

I bought it .. it may be the most important book I’ve come across in some years.


First published in 2015 but only recently available here, it was written before Brexit and Trump-it but is a wholly important examination of our current times.
The material within merits significant exploration and exposition which I hope to do in future posts.
For now I wanted to share the 5 Building Blocks of Capitalism that it explains.

  • Property: what can be owned
  • Monopoly: what degree of market power is permissible
  • Contract: what can be bought and sold and on what terms
  • Bankruptcy: what happens when purchasers can’t pay up
  • Enforcement: how to make sure no one cheats these rules

Now these key aspects of the world we live in may seem to be written in stone.. far from it.
The key point I’ve already taken away from this book is that these are all human constructs, not defined by the laws of nature or the universe.
In teasing these key elements apart Reich ably demonstrates why were in the state we’re in and what we need to do to get out of it.

More to follow…





“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.

Posted by: Tony Shannon | December 30, 2016

The Year of the Outsider

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.

Posted by: Tony Shannon | November 30, 2016

2016 Q4: Democracy v Capitalism

Well 2016 has certainly turned out to be a most interesting year.

  • 2016 set out to be the 100th anniversary of Ireland’s bid for independence from Britain in 1916, which failed at the time but set a cultural shift in motion that led to independence for the Irish Republic a few years later.
  • 2016 was the year that the British public voted for Brexit , i.e. an exit/independence from the European Union.
  • 2016 was the year that the US public voted for something, though its not yet clear what. On the face of it they seemed to have voted for unqualified racist chauvinist so he can become their next president… though perhaps Mr Trump is simply completely misunderstood?

Either way there is something going on in 2016.  Irelands leading economic commentator David McWilliams recently interviewed Paul McCulley (of PIMCO Investment Management background/fame) who nicely explained what was going on ..  thats is the inherent tension between two governance systems;

  • Democracy; based on 1 man/1 vote – aimed  at fairness & equity
  • Capitalism;  based on $1 ; 1 Vote – aimed at efficiency

When all is going well in recent decades, the combined forces led to a shared prosperity which the masses enjoyed.
Right now, things are not going so well and as he said the “sharing stinks”. So we should see this historic vote for Trump as related to a set of broader forces at play

  • Rich V Poor
  • Insider V Outsiders
  • Layman v Political Elite
  • 1% v 99%
  • City V Rural
  • Democracy v Capitalism

Of all those dimensions, this evident tension between capitalism and democracy has now become apparent, in 2016 – for the first time since the end of WW2, the fall of communism and ascent of capitalism and faith in the free market.

Yet Trump doesn’t look likely to reverse the tide of capitalism with a new flavour of democracy any time soon. More likely that history will note the sharp irony in this silver spooned billionaire ascended to the US presidency by appealing to the common man with the help of a baseball hat and then helping himself. Time will tell. What he will do, no ones knows, it simply seems fair to say that now we have a better idea of what it felt like during the troubling 1930’s.

So we the people must look to learn and educate ourselves as to the issues at play here. No one demagogue , good or evil, will sort this out for us. So start reading and get thinking.

To consider then : How will this battle between capitalism and democracy pan out? How could/should it?  We don’t yet know but we do know that unfettered capitalism is causing revolt/revolution at the ballot box in the most unexpected of places.  We do know that the mechanics of democratic forces alone are struggling to manage this. We can expect more trouble to come.

One particular area to watch is the growing tension between nation states vs corporations – in terms of taxation for instance, or the gains to be made from intellectual property from public investment.

Can our social networked generation support a social movement to inform smart  government policy and good corporate behaviour? We live in hope.

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