Posted by: Tony Shannon | October 22, 2017

Irish HealthIT: 2017: 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

21stceconomicactorsV2

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

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Posted by: Tony Shannon | October 17, 2017

Irish Healthcare: 4 ways to look at it/ SlainteCare: 2017

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 . There is one more 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.  http://www.irishexaminer.com/business/columnists/joe-gill/to-fix-health-we-have-to-treat-it-as-a-growth-industry-439635.html

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: 2017: taking stock of a Society & an Economy

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.

 

ireL_map2017

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

DonutEconomicsPic#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;

21stceconomicactorsV2

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..

https://gdl-lang.org/

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

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

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

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

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

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

 

 

 

 

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.

 

 

Property
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.”

Monopoly
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”

Contracts

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.”

Enforcement

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.”

Bankruptcy

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.

Posted by: Tony Shannon | October 31, 2016

Beyond Wachter: 1% for the 99%

Beyond Wachter: 1% for the 99% was originally published on DigitalHealth.net

Beyond Wachter: 1% for the 99%
Ewan Davis and Tony Shannon say there is a lot to like about the Wachter Review, but identify some worrying gaps between its approach and NHS policy. They call for an open platform and a challenge fund to secure digital transformation for all, and not just for the exemplars.

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As the NHS looks forward to another/perpetual winter, it has the Wachter Review to read. This is the outcome of the review of NHS IT (actually acute IT) that health secretary Jeremy Hunt asked US ‘digital doctor’ Robert Wachter to undertake last November.

We broadly welcome Watcher’s recommendations, but they don’t go far enough. So far, their main impact has been to encourage Hunt and NHS England to announce a programme of investment focused on a few “exemplar” trusts, which Hunt has described as an ‘Ivy League’ for others to aspire to.

In combination, we don’t see any sign of the radically different approach that is required if digital technology is going to enable the radical transformation the NHS requires.

The good points

Complex, not complicated: Healthcare has been misunderstood as a complicated endeavor for too long. Complicated machines, such as aircraft, are engineered to have a predictable relationship between the switches in the cockpit and the connected component parts.

A typical hospital is a good deal more complex than that. It is much better understood as an ecosystem than a machine. The Wachter Review, thankfully, acknowledges that healthcare is a complex “adaptive system”, in which evolution rather than revolution reigns supreme, and says that digitising healthcare should be understood in that context.

IG and training: Digitising healthcare for the right reasons and at the right speed, working with patients to promote an effective balance between data sharing and effective privacy controls, and developing a professional workforce properly trained in informatics good practice are further key principles that it sets out that are well worth advocating.

Smart recommendations: The ten related recommendations are mostly smart, too. They Include a push for trained clinical informaticians with resource and authority at board level, along with a push for local networks to share learning, and a call for the NHS to join the international push for greater interoperability.

Missing pieces and policy gaps

Hospital centric mindset: The forward looking ‘Five Year Forward View’, issued by NHS England chief executive Simon Stevens to try and close a £30 billion gap between NHS funding and demand by 2020-21, rightly focuses on the need for integration across health and social care communities.

Indeed, it goes further in calling for the creation of accountable care organisations (which it calls primary and acute care systems). The focus of Wachter and NHS England seems to be on a few acute hospitals and the new programme of global and national digital exemplars.

Lack of patient centred thinking/care: The Forward View also recognises the importance of engaging patients and their informal care networks and putting these at the centre of care. Watcher has little to say about patient engagement and the exemplar programme’s focus on hospitals with 20th century megasuites does little to create the digital ecosystem required to enable innovative patient faces apps and services.

Platform approach: It’s widely recognised that open platforms have been key to digital transformation in other sectors and that the creation of such platforms is essential if we want to see digital transformation in health and care. Yet there is nothing in Watcher or in subsequent announcements that gives support to open platform approaches.

 

Given that the well-respected global consultancy McKinsey http://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/how-healthcare-systems-can-become-digital-health-leaders tells us that ‘Open Innovation Platforms’ have the potential to save more than 11% of total healthcare costs, and that this view supported by Accenture, which describes platforms as creating a “(R)evolution” in healthcare”, this seems to be both a surprising and unforgivable omission.

 

So what are platforms and what do we mean a platform approach?

A platform provides an information infrastructure; a set of shared services based on common standards, on which developers can build applications that work together. By using standard components, and providing services that offload common tasks from application developers, they enable those developers to concentrate on the unique features of their application, delivering more quickly and providing a spur to innovation.

Attempts to create a platform for health go back 20 years. Initial efforts by suppliers focused on attempts to own the platform but, while some still seek that monopoly, there is now a growing consensus that only an open platform approach can succeed in healthcare.

In the end, governments, healthcare systems and market participants will not accept monopolistic/proprietary ownership of the platform. By an open platform, we don’t just mean some proprietary systems with some open application programming interfaces, but rather implementations that:

  1. Are based on open standards
  2. Share common information models
  3. Support application portability
  4. Are federatable
  5. Are vendor and technology neutral
  6. Store data in a common open format.

These definitions align with the forward thinking ‘Digital Supplier Standard’ now emerging from Gov.uk https://www.gov.uk/government/consultations/supplier-standard-for-digital-and-technology-service-providers/supplier-standard-for-digital-and-technology-service-providers By taking this approach vendor lock-in is eliminated, as one platform implementation is easily replaced with another and applications are easily portable across different implementations.

The use of a common open data format ensures vendors work towards the goal of an integrated patient centred record architecture, meaning data does not get locked into a proprietary format and is easily shared, simplifying interoperability and cross-border flows.

Open platforms go further than closed platforms in that they facilitate international cooperation while moving the market away from vendor lock-in and towards a market for services that add real value. There are a number of approaches that might support such an open platform but we believe that the most promising is, openEHR.

This both meets these principles and is already being successfully implemented on a large scale to enable integrated patient centred care elsewhere in the world; perhaps most notably in Moscow. http://www.woodcote-consulting.com/moscow-ehealth-a-model-for-the-uk/

A call to action: 1% for the 99%

Even if McKinsey’s view of the potential of open platforms and their estimated savings to the NHS of £14 billion (11% of the annual £130 billion NHS spend) are grossly overstated, the potential is clearly such that it is amazing that that open platforms don’t feature at all in the NHS’s latest plans.

We recognise that open platforms in healthcare will take time to embed. However, the technology on offer is already mature and has the support of a global community of clinicians and vendors.

Therefore, our challenge to the NHS is to try something different to investing in the “usual suspects” and to shift just 1% of the £4 billion planned investment in NHS IT over the next five years to proactively stimulate innovation.

We think that £40 million should be used to create an ‘Open Platforms Challenge Fund’ open to small and medium sized enterprises partnering with health and social care providers. Open it up, and let’s discover what this group can do.

To the skeptics, we’d suggest a look at the results delivered by the recent very small investment by the NHS in initiatives like Apperta’s Code4Health Programme and the Ripple Open Source Initiative. To the visionaries, we’d invite you to join us on our journey, one we believe is destined to change healthcare and bring it into the 21st Century at last.

We want 1% for the 99% beyond the Ivy League…

About the authors:

Ewan Davis has worked in digital health since 1981, and now works for Woodcote Consulting. woodcote-consulting.com He works closely with the HANDI Health CIC, a not-for-profit organisation established to help the health and care app community, and writes regular columns for Digital Health on open source, open platform, and other IT issues. @Woodcote_Ewan

Dr Tony Shannon has worked in frontline clinical practice for 20 years, with ten of those as a consultant in emergency medicine in the NHS, where he has also held the CCIO roles for Leeds Teaching Hospitals NHS Foundation Trust and Leeds City, leading on the Leeds Care Record. www.leedscarerecord.orgHe is the director of Frectal www.frectal.com and of the Ripple Foundation, which has been set up to foster a community of health and social care pioneers in England by collaborating around an open Integrated Care Record platform. www.rippleosi.org @frectally

Published on DigitalHealth.net on 12th October 2016

Posted by: Tony Shannon | September 30, 2016

Making IT work in the NHS: … working for who?

Earlier this month at the NHS Expo, the latest in a long line of reviews and plans was unveiled to guide the future of the NHS and its Information Technology.

“Making IT work: harnessing the power of health information technology to improve care in England”  was primarily authored by Dr Robert Wachter, a leading hospitalist from the United States and author of “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age

If your interested in healthcare & technology this review is worth a look. Certainly some very good observations and recommendations are well made..

Digitising for the right reasons, at the right pace, the push for interoperability, the need to share data, the push for User Centred Design are all great observations and points to make.

In particular the push for a better educated workforce (inc. many more clinicians properly trained in Informatics  :o)) and the understanding that this is all about adaptive change in complex environments… all good stuff..

Then come the recommendations, again several great ideas.

However there are some key gaps.. can you spot them?

Will be back here with an update asap…
Tip: Think 1% … and the rest…

Posted by: Tony Shannon | August 31, 2016

The Future of the Professions..

During a break away in August, I was able to read through a book that had caught my interest called “The Future of the Professions” by father and son team, Richard and Daniel Susskind.

The full title is actually  “The Future of the Professions: How Technology Will Transform the Work of Human Experts” so its remit is broad and wide….

As the Irish writer George Bernard Shaw wrote in past “All professions are conspiracies against the laity”, so his argument is one that I’m familiar with.
The book is a most interesting read and pretty well balanced too which begins with a similar point, outlining the Grand Bargain between the professions and the public. The opening chapters allow them to make a fair case that this relationship has served a key purpose until now but the times are a changing….

They essentially make the case that the supply/cost of professional services (i.e. services by the professions) cannot meet the growing demands/resource of the average citizen and so with the arrival of the information technology revolution that we are living through, that this unequal relationship has to/will fundamentally change in the years and decades ahead.

The authors then take a broad look at areas such as healthcare, law, education, journalism, management consultancy, accounting and wisely and carefully look for patterns amidst that complexity. To their credit though their original research was based in the legal profession they understood their were more generic patterns at play, which is why this smart book deserves some attention.

 
After making the case for the change in the first part of the book, in the second they turn to a decent look at the theory that underpins their case. This theory is simply aimed at understanding two key fields, that of information and knowledge management. The point is well made that though most professionals don’t necessarily see it that way, that the professions are, by and large, information intensive industries. On this point, as a medical doctor by profession and an emergency physician by clinical background, I might be expected to challenge that key declaration, yet to be fair (as my work and related writings elsewhere on this blog makes clear) I very much agree with them.

In deconstructing the key patterns that underpin professional work to the core/generic processes that underpin them, which inevitably align to core/generic information and knowledge management processes, the essence of this book makes a very important point. Essentially all the professions, as we now know them, will inevitably be very significantly impacted by technologies that will indeed “transform the work of human experts”.

It may be useful to offer one key compliment and one key critique here..

To their credit they make a profoundly important point when they say “we argue that professional work should be decomposed, that is, broken down into its constituent ‘tasks’—identifiable, distinct, and separable modules of work that make it up. Once decomposed, the challenge then is to identify the most efficient way of executing each type of task, consistent with the quality of work needed, the level of human interaction required, and the ease with which the decomposed tasks can be managed alongside one another and pulled together into one coherent offering”.

In doing so they are highlighting the key people, process and information technology challenges that I believe face healthcare and have explored elsewhere in my writings. In fact their suggestion also aligns well with an international push already underway towards an open information platform in healthcare, known as openEHR, which essentially aligns with their argument.

In terms of critique what I think this book doesn’t quite expose as much as it could or should is the art of professional service. The focus is rather on the scientific decomposition of the element parts, which is of course a very useful exercise. Yet patients know that is is the art of medical practice (communication skills, surgical suturing skills etc ) that matters as much as the science (logic and reasoning). To the authors credit they address many of these points as well as they can, exploring the value of personal interaction and empathy in a fair way in later sections.

One other point worth noting is that they say “Very often, after we give talks on our ideas, we are approached by individuals who argue that what we say applies right across the professions except in one field—their own.”
Again, as an emergency physician I might be expected to play that card. I choose not to. I found that I largely agree with the authors on the thrust of this book, if not all the detail..

 

The implications of this upheaval are explored in the third section of this book, which wisely exposes and addresses some of the inevitable skepticism that their claims are bound to be met with. For the most part they address many of these head on and deal with them fairly. As the book closes there is a slightly ominous sense of foreboding as to what the future will look like, in line with the directly related and equally powerful message delivered elsewhere online as “Humans Need Not Apply” .

To avoid a doomsday ending, they helpful conclude with a call to action rather than inaction, in tackling the future proactively, man with machine…

 

This is a brave, bold book which may make for uncomfortable reading for many professionals. No more than myself, my instinct is that we professionals need to understand the past and present to create the future. It goes without saying that change is inevitable…its the only constant in life..

Objections to/denial of the key messages in this book are to be expected. Yet methinks this book will stand the test of time and could be referenced in the 21st Century history books for a long time to come.

 

 

 

 

 

 

This month marked the sorrowful passing of a real clinical leader.

I had never met the lady, though her name and her reputation were well known in the NHS were I worked.

Her name was Dr Kate Granger, but she probably would rather be known as Kate.
Struck cruelly by an aggressive cancer, far too young in life, she saw medicine from both ends, both as a medical consultant and a patient.
During her care, she noted that the personal qualities of the staff that cared for her were occasionally missing a little something, like a polite introduction, “Hello My Name is….”.
I’m sure I must have been guilty of that myself sometimes, this simple yet key point was made clear enough to medical professionals in the past.

So she did something powerful about it. She acted locally and started a #HelloMyNameIs campaign where she worked, introducing herself to her patients to set an example and then a simple namebadge to go with it…

From her own local action, real change spread and spread and so the campaign has grown across the NHS and now to the Irish health service too.
She died on the 23rd July 2016 at the tragically young age of 34.
I expect the momentum behind her campaign will grow and grow. It is so simple and has proven to be so effective I expect it will continue to change the world of healthcare and make a real and meaningful difference to patients lives.

I never did have the honour to meet Dr Kate Granger, but by her actions I have to say that she has done more in her all too brief time on earth than most of us to make the world a better place.
The world of healthcare has lost a real leader, she was indeed the epitome of a clinical leader, as well as a lady, who changed the world.

May she rest in peace.

 

 

 

Posted by: Tony Shannon | June 30, 2016

Brexit- Global versus Local – Making sense of the tension

Brexit- Global versus Local – Making sense of the tension

As we close out the month of June 2016, there could be no other story to mention than that of #Brexit.. That is the decision of the people of the UK to vote to leave the EU in their recent referendum.

As an Irish citizen who studied, lived and worked in England for 16 years, the result made me sad. Sad in the sense that it felt/feels like losing someone/something that I had known all of my life.. that is the UK/Great Britain and its leading place in the world, in particular its reputation for tolerance, which I had many years of direct experience of, amidst the many many good people of England, Wales, Scotland and Northern Ireland that I know and admire.

Yet beyond that sadness, what can we all learn from this #Brexit vote by the British people?

Let’s start by taking the long view of human history for a moment.
A quick rush through human history shows that humans evolved from hunter gatherers to tribes to chiefdoms, then principalities and city states and most recently nation states. Though the nation that we know as the UK is over than most, nation states are relatively new.. it is worth acknowledging that the vast majority of the current 195 nation states in the world have been established during in the 1800s and 1900s.
Beyond nation states, we are also familiar with empires. As the second world war saw the mantle of empire pass from the British to the United States, it also saw the establishment of the United Nations, World Bank, then some decades later the European Union, so a new age of superpowers beckoned.
One could have been forgiven for interpreting this as simply the march of human progress, towards a small number of superpowers to rule the world and towards “globalisation”…

Hence why this unexpected move by the UK to exit the EU stage left appears to be an abrupt reverse gear, to challenge that march of the superpowers such as the EU? Clearly the EU is a flawed organisation that needs major changes including a more democratic link to the European people, many of whom see it as an ivory tower. Yet why would the British not want to stay within and lead those reforms?
Several commentators have interpreted the Brexit result as symptomatic of a broad and wide malaise, a reaction to the march of globalisation. In particular a reaction to the growing inequality in a country like the UK, the rise of the 1%, at the expense of the 99%., the insiders versus the outsiders..

If so then we are likely to see more of the same reaction, as personified by the uncomfortable rise of characters like Trump in US politics as well as extremists in other parts of the world. The globe has just been through the major financial crisis of 2008 with a lot of collateral damage. When people are doing well, are busy and optimistic for the future the world progresses. When folk are threatened and concerned for their future, they often look for who to blame… hence the tension in the air.

So what is the future of the relationship between individuals and local communities across the globe and what is the role of the nation state a broker between local and global?

Lets first admit that we have one globe, one planet earth, with a growing population and limited resources. The keyword there is limited, i.e. finite. Now I’m the first to admit that I’m one of the lucky ones, one of the privileged, with a good home, in a safe country, with a good education and never been hungry or needing shelter. Others are not so lucky.
Indeed more than anything else we know that the world is an unequal place. Interpretations of the Brexit result highlight that it is a cry from those who have lost most/gained least in the last 10 years of globalisation.. Furthermore all of the tension that has built up between local, national and supranational/global forces in recent decades was offered a route out via this recent referendum.

Although the world has always been unequal  (and always will be, such is the nature of life itself) we can indeed all do something about reducing in-equal-ity. Regardless of your politics, the evidence (as per an excellent book named The Spirit Level by a couple of British authors) highlights that more equal societies (on key measures like health, education, violence, imprisonment etc) do better for everyone. This issue of in-equal-ity isn’t confined to any nation state, it is of course a global issue, as highlighted by the United Nations with their powerful campaign towards global goals we can all share.
http://www.globalgoals.org/

So though no one says life is fair, we can at least make it fairer for one another. Let’s start that with a more honest aspect to our political discourse. Of the role of the individual in their own lives, on the role of the nation state, on those threats and opportunities that span the globe. To suggest that a retreat to isolation within a nation state as the answer to problems locally appears naive in the highly connected 21st Century. Yet the subtext to Brexit is that super powers such as the EU are not delivering for folk locally, so such many political institutions need to wake up and change and better explain their worth.

Of course we can all act in splendid isolation, yet the march of human endeavour is both forcing and encouraging us to work together. Indeed no matter where you establish boundaries (around England, the UK, the EU) you can’t really have all the “advantages” of a connected world (e.g. free movement of people and their ideas) without the mirrored “disadvantages” (e.g. free movement of people and their ills).
While some may wish to put barriers up during this period of change, am sure many of us are keen to build bridges beyond any such barriers..

Let us look for a moment at 3 unrelated movements, from local to global.

ChangeX – “allows you to discover proven ideas and provides all the information and support you need to join or start these ideas in your local community.”

Smart Cities – “The goal of building a smart city is to improve quality of life by using technology to improve the efficiency of services and meet residents’ needs.”

Global Goals – “Goals are unique in that they call for action by all countries, poor, rich and middle-income to promote prosperity while protecting the planet. They recognize that ending poverty must go hand-in-hand with strategies that build economic growth and addresses a range of social needs including education, health, social protection, and job opportunities, while tackling climate change and environmental protection.”

Do initiatives such as these really need the backing of a particular nation state to make progress? Can human progress be held back by tensions within the ranks of the political bodies that surround us? What is stopping us tackling these ambitions locally and build networks of change globally?

Of course one might argue that the role of the nation state is to broker the local versus global forces that are often at play… supporting and addressing local needs while cognisant and mindful of the bigger picture issues… yet their is often a natural tension there… its not possible to offer everything to everyone, so an honest conversation is needed in that brokering role… how can the nation state support its people in what they need versus what they want?

During this soul searching time, let’s all relook at what we can do as individuals.
Start by finding the change you want to see in the world around you and start local action.
If you think/consider there may be a global dimension to your need, then look broad and wide and consider the power of collaborative innovation that the 21st Century enables.. Efforts towards an open source platform in healthcare is a case in point in my own work.
Consider how a blend of thinking global and acting local can make this world a better fairer place for us all.

This brief essay is not aimed towards a utopian vision. It’s simply about highlighting that despite all the noise and the angst, the change we need in the world is something we can tackle ourselves, we need not wait for our politicians to do for us. The big changes required are not confined by borders and the global solutions needed will not be halted by a move like Brexit.

There is much work to be done, in smart cities like Dublin, Belfast, Leeds and London and far beyond. Lets get to it…

Having attended the Health Reform Alliance launch event in Dublin earlier in May and aware of the timely announcement of a 10 year cross party plan for Healthcare… I thought it would be useful to share some ideas on the future of healthcare in Ireland.

To begin, its worth a few words about the broader issues of governance and politics in Ireland.
As Ireland is recognised as being very globally connected, so the politics here is now influenced by a range of ideas, from Birmingham to Boston and to Berlin. The Irish are acknowledged to be a fairly worldly aware, reasonably patient yet industrious lot …. a moderate people. Still less than a century old as an independent nation, the politics here may have swung left and right over the last decades but at this stage the politics here is probably described as fairly centrist..  perhaps a little more centre left/centre right depending on your point of view.

From a healthcare perspective, in common with many other “western” countries, Ireland has a health system that has been on the edge of crisis for a long time now. In many respects the well known symptom of this malaise which is the perpetual Emergency Department trolley crisis in Ireland reflects a wider global issue of “healthcare under pressure”, yet there some particular issues local to Ireland seem to have held meaningful progress back.

One particular issue that gets a lot of attention/criticism is the “2-tier” nature of the Irish health service, that mixes public and private provision, with differing experiences and outcomes based on ones ability to pay. Other dimensions that have been at play has been the close relationship between church and state in the historical delivery of healthcare, plus the relative immaturity of the primary care sector alongside the more established hospital sector.

A very brief/rough guide to the history of Irish healthcare

Over the life time of the Irish nation , a national health service grew out of local GPs and hospitals to being coordinated at a regional health board level, to then the establishment of a national Health Service Executive (HSE). As healthcare is a complex adaptive system, delivering healthcare at a national level is a highly complex endeavour. So along with every other western healthcare system the challenge of scaling and maintaining high quality, low risk, timely, cost effective healthcare has not yet been met. As the public’s awareness and understanding of these issues has grown, so too has dissatisfaction with the HSE which for a time became a bit of a public punchbag. While many people know that pockets of excellence exist throughout the system, the ongoing public narrative involves the pockets of crisis.

While there has always been a blend of public and private provision of healthcare in Ireland, over the decades that mounting pressure on the public healthcare system has led to an increasing percentage of the population taking out private insurance, essentially aimed at safe guarding their healthcare. The take up of health insurance in Ireland had reached up to 50.9%  before financial crash, yet despite that crash and related recession that figure never fell far below 40% and is back at 45.9%which indicates how dearly it is being held onto.…”for dear life”..

As the public healthcare system has lurched through a series of crises and in the context of that high uptake of health insurance, the last government made an attempt towards healthcare reform with a move towards a Universal Health Insurance (UHI) model, based on a European model of healthcare (the Netherlands to be precise). However well intention-ed this push was, the details of its delivery were never made clear enough, it was essentially poorly handled from a public communications perspective and quickly fell out of favour with the political establishment.  Since the end of the Universal Health Insurance push in the last 2 years there again been a move in the public discussion, a swing back to the merits of return back to a tax based approach to healthcare funding… though little discussion on the pros/cons.. or how that might fit within a particularly Irish context.

 

Post crash Irish politics has mobilised the public in a manner not seen in Irish politics for some time. Yet while folk have come together onto the streets about water bills, the need for healthcare reform has not progressed as a public movement for change in any meaningful manner. Perhaps this can be explained by the complex nature of healthcare reform and the challenge in aligning the effort and energy of the many agendas involved.

 

Engaging the nation on the road to (healthcare) reform?

5 noble principles to aim for

So how can this need and appetite for change in Irish healthcare be directed to engage the public and politicians alike? The Health Reform Alliance are gathering a diverse group of stakeholders from the bottom up and are keen to get public opinion behind this common cause. A first glance at their 5 key principles suggest a very good effort, a short and punchy attempt to focus the mind of these important issues . Yet the gap between policy aspiration and reform reality will always be hard to bridge, so let’s take a quick look and then delve a little. Here are the 5 key candidate principles of Healthcare Reform Alliance in Ireland.

1. The health and social care system treats everyone equally.
2. The health and social care system is focused on the needs of all social groups in society.
3. People have an entitlement to health and social care, free at the point of access.
4. The different elements of the health and social care system work together and are connected.
5. The health and social care system is a universal, publicly funded system

Short and punchy, they are noble ambitions and should help focus minds and actions.

 

2 Challenges to be confronted

Yet can these noble ambitions translate into actions? There are 2 issues I sense need to be tackled early on here to get this right for an Irish context.

.
Firstly and most importantly perhaps , “People have an entitlement to health and social care, free at the point of access”.
With a background of 15+ years in emergency medicine in the NHS, I like the idea of course, its very noble indeed. Yet to be blunt we all (doctors and others) now need to challenge the notion that all forms of healthcare can be delivered to everyone, all of the time, for free. Its not that its the wrong motive, its simply that those of us that live on this planet need to accept we are a planet with limited resources, so like it or not we cannot spend everything on healthcare. I say that simply to acknowledge that housing and education and transport and other public services are needed to, so we need to have some limit on healthcare spending. We also need to acknowledge that there is an insatiable appetite for healthcare if we all think we can live forever, which we can not. So between public demand and professional services we need to make clear that healthcare can and should be delivered very well, but there are limits to what can and should be done in the name of healthcare.
Therefore, though it may be a bit unpopular to say so (?) , along with the peoples entitlement to health and social care, we need to make clear a related responsibility.. particularly for people to take greater responsibility for managing their own health… by managing their diet, exercise etc etc. In doing so we can and should empower people to take more control of their own healthcare too.
Now to be clear, my view is that if people are unwell or injured, they should of course have an entitlement to quality, timely health and social care, regardless of their ability to pay. Beyond that they have a responsibility to look after their own health too. More on how these issues can be addressed shortly below..
Of course this issue isn’t local to just the Irish setting , these is universal truth which needs to be declared more openly, so patients, doctors and politicians can have a more honest and frank discussion on how to deliver good quality, timely healthcare from a fair % of a nations monies. That is the only sustainable future for healthcare.

Secondly, “The health and social care system is a universal, publicly funded system”.
Once again with a background of 15+ years in emergency medicine in the NHS, I’d happily agree to same. Yet in an Irish context, given the Boston to Berlin dimension, this risks being particularly divisive I fear. What this principle doesn’t acknowledge is the 40+% of those people who have private health insurance, for the reasonable reasons we noted earlier. Nor does it factor in the private healthcare providers that are already a significant feature of the admittedly 2 tier Irish healthcare service. So my instinct is the noble aim here needs to be teased out alongside an option to achieve that in the Irish setting, more on this below…

 

2 ideas from abroad

So…. while these 5 principles are a really great start towards healthcare reform in Ireland, I’m now going to quickly introduce 2 other axes to this discussion, which I sense may be key to resolving the gap between aspiration and actual implementation here.  These 2 key aspects to healthcare policy debate are ones I’ve picked up from my understanding of other healthcare systems in both the UK & Singapore. There are many others axes one could explore, but to keep this discussion focussed I’m introducing just these 2.

Commissioning and Provision – recent moves within the NHS

In the NHS in England, as the UK began to grow a world leading National Health Service, the primary care physicians (General Practitioners/GPs) began to take on a crucial role responsible for their patients health from patient to grave. Their strength in primary care is widely acknowledged to be a strength within the system, the antithesis to the (specialist led and therefore more fragmented and costly) US Healthcare system. In recent decades their power and influence has increased with the advent of “GP fund holding” in the 1990s and since then the split between the commissioning and the provision of healthcare.

The key issue here is that GPs now lead Clinical Commissioning Groups and as GPs are well placed to take a holistic view of their populations needs and commission health and care services on their behalf. Most of those services will be provided by public providers (e.g. NHS trusts and local authorities) though others services are provided by the private sector. The patients involved don’t necessary want or need to know about this split, but as far as they are concerned their care is taken care of by the NHS. So you have in effect a universal/egalitarian healthcare system with a mix of public and private provision, well regarded with good outcomes in many areas for about an 8% spend on their GDP.

Translated to an Irish setting one can see that if a universal health insurance model doesn’t hold up, that commissioning from the public purse might be the only other option? In doing so it could help ensure principles around quality, timely and equal access for serious illness and injury are built into that process…while a mix of public and private provision deliver the health and social care required.

 

Healthcare Rights and Responsibilities- lessons from Singapore

Over on the other side of the world, if we look at Singapore we look at another interesting approach to healthcare. Singapore city state story also took off after the second world war, under the benevolent but firm hand of Mr Lee. Their healthcare system which provides good outcomes for about 6 % of their GDP is another interesting approach.

The most interesting dimension here is the split between rights and responsibilities. As an emergency physician I’m an advocate of an egalitarian system, that treats based on clinical need rather than ones ability to pay, to ensure a basic human right to quality timely healthcare.

The Singaporean approach  takes an interesting twist on that universal right. Its offers universal healthcare to all those who suffer in a form of “catastrophe” insurance (e.g if affected by a car accident or cancer) known as MediShield so no one is left to suffer needlessly or financially.

Along with that right to healthcare is a related responsibility.. via a compulsory medical savings account known as MediSave.. so that citizens understand they need to spend that money wisely on looking after their health.. My understanding is that can be spent on going the gym, a health check-up or an elective procedure perhaps, which gives the patient a good degree of choice in how their personal budget is spent.

Translated to an Irish context this may equate to universal healthcare protection to all those who suffer a “catastrophe”, i.e. serious illness/injury in the public healthcare system. Alongside that by re-imagining private health insurance as a health and social care savings account, with state subsidy for those who cannot afford it, citizens are encouraged and empowered to get more involved in the looking after their own health and care. The key here is to shift the emphasis to preventative health care measures, underpinned by good primary care, which might also be supplemented by the private sector for beneficial elective investigations, procedures etc..

 

My instinct is these 2 key axes, the split between the Commissioning/Provision of Healthcare and clear healthcare Rights/Responsibility are key to the future of the Irish Healthcare system.

5 Fair Principles to action?  
Now that we have outlined the 5 Health Reform Alliance principles and highlighted some challenges that can be expected, lets look at those 5 key principles with some related modifications to see if they hold up/seem reasonable/may help with the important debate needed in this area.

So here are the Health Reform Alliance five principles that underpin their Charter for reform of the Irish health & social care system, with some small but hopefully useful tweaks..

1 The health and social care system treats everyone equally

2 The health and social care system is focused on the needs of all social groups in society

3 People who are unwell/injured have an entitlement to quality health and social care, with a related responsibility to look after their own health while they are well.

4 The different elements of the health and social care system work together and are connected

5 The health and social care system offers universal, publicly funded, health and care protection to citizens, alongside a health and care savings scheme to incentivise better population health.

 

To discuss….

Related Links

Health Reform Alliance
http://healthreformalliance.ie/wordpress/

NHS Commissioning
https://www.england.nhs.uk/commissioning/

Affordable Excellence : The Singapore Health Care System
http://www.brookings.edu/research/books/2013/affordableexcellence

Posted by: Tony Shannon | May 6, 2016

Think you need an IDCR? Think again…

[Repost from RippleOSI.org]

Think you need an IDCR?  Think again..

The letters IDCR are currently used in the NHS in England as an abbreviation for Integrated Digital Care Records, part of the latest push to transform health and care in England in the 21st Century towards more holistic, integrated, patient-centred care,  supported by the right healthcare IT.

The abbreviation IDCR is the latest in a line of health IT abbreviations or keywords to symbolise the information technology that healthcare needs/wants/requires. Those include EPR (Electronic Patient Record), EHR (Electronic Health Record), portal, SCR (Summary Care Record), CDR (Clinical Data Repository), patient registries, etc, etc. Though such terms and abbreviations might suggest that the health IT “buyer” has a range of technical products from which to choose, it is increasingly understood that any of these tools are simply technical artefacts amidst a sea of change.

That 21st century healthcare change that is upon us is a “complex change challenge” made up of people, process, information and technology. We also know that to make such complex change happen we need a mix of clinicians, managers and technical team to work together, for the greater good, for the patient.

Involved in such change over the last years, I’ve seen many related change efforts and am aware of the significant challenge in aligning clinical, managerial and technical language and purpose effectively towards these noble goals. There is often an inherent tension between the clinical/business change desired and the technical tools on offer. Ideally a well informed clinically led team will have a deep understanding of the process they want to improve and access to/control of a technical tool that meets that clinical/business need.  More often these multidisciplinary teams are convened towards a common health improvement goal, yet a little/lot unclear on how the IT will get them there. In many cases this desire for change ends up as a clinical and business push ends up tied to a likely technical product. The current push in the NHS around Integration Pioneers and Vanguards and Integrated Digital Care Records is a case in point.

Clinicians who join these explorations and discussions often struggle initially for a reference point. They may cite the health IT system that they themselves know and/or love/hate, it may be a clinical guideline (or related proforma) that they have a particular interest in having supported in this new world, or a particular clinical report that they want/need to support here and now. They use these as reference points as these are the healthcare information and knowledge artefacts that they know.

In bringing clinicians together around a healthcare improvement/IT project (e.g. EPR, IDCR, Registry etc etc) to gauge their “clinical requirements”,  then analysing those requirements to generate a related system design etc, significant clinical time and real intellectual effort is required by all those involved.  If the aim of these efforts is about patient centred healthcare improvement, the focus of these efforts could/should involve a look at clinical guidelines, forms, reports etc to inform the approach. Yet if one teases apart just one clinical guideline, one discovers the rich tapestry of information and knowledge embedded within. Splitting a single guideline apart in technical terms into the clinical content, workflow and clinical/business rules involved helps explain how and why traditional approaches to programme and project management struggle at scale in this field. The lengthy, detailed documentation that can result from such efforts to elicit “requirements” does little to contain the challenge here. Indeed such an approach to procurement and the related documentation can become a key part of the change challenge… and so a key gap between clinical need and technical direction can begin to emerge..

 

Is there an alternative approach to this “complex change challenge”? We think so.

Firstly we emphasise the word complex, to reinforce that this change challenge is about managing complexity, more akin to curating an ecosystem than crafting a machine. We offer the following tips based on our experience of these challenges at scale and with some reference to the helpful Gov.uk Government Digital Service standard.

Tip #1
Q: How to quickly scope a clinical change project with health IT?
A: Put the user in charge of these (clinically led) proceedings, with the support of an agile design team.
Follow the principles of User Centred Design and Agile Development with early “wireframes”/”mock-ups”/prototypes.   The tools involved might be as simple as a sketch on paper, a PowerPoint slide or an online mockup tool (e.g.Lumzy.com). Either way this allows the clinical teams to express their needs and wants in terms of usability.. perhaps the most critical factor in health IT adoption. If their ambitions are big and dreamy, so be it, it’s a vision to aim towards. Of equal value, these visual designs help management and technical colleagues discuss and establish what is “do-able” within the time and budget available. Such prototypes are perhaps the simplest and most effective way for clinicians, managers and technical folk to communicate the scope of the change involved. A picture tells a thousand words.

 

Tip #2
Q: Where to focus the early effort in a major healthcare improvement project with health IT?
A: Focus the diversity of the clinical community involved around its common interest in core/generic clinical content.
One of the main challenges in bringing a multidisciplinary team together is the difference in culture, language and agendas in the room. Such discussions are full of rabbit holes for the unwary. (Try agreeing a consensus definition in such a room on terms like “Care Plan” or “Care Pathway” if you want to while away some time). Aim your focus on getting the clinicians in the room to find their common ground.. the needs they both/all share. These common needs are invariably linked to the core generic processes in health and care, although this is often poorly understood by those in the room. On a related note, focus firstly on the shared clinical content that is required, but not the workflow or rules involved.  While consensus on clinical content can be gathered more easily (via openEHR archetyping for example), clinical workflow and clinical rules are generally less amenable to early consensus.

 

Tip #3
Q: Who should own this requirements & design process? The healthcare customer or IT supplier?
A: The healthcare customer, aka the clinical lead and core clinical team involved, supported by “in house” project management and technical architecture expertise.
In our experience there is a compelling case that the process of requirements analysis and the related design authority should be overseen/owned by the healthcare “customer”. This should ensure that these key aspects are guided by the clinical need, not by the supplier want.
We would go further to suggest that you aim to ensure the key clinical requirements captured in this process are opened up and widely shared. That could/should include both the visual mock-ups (e.g. JPGs etc) and clinical content specifications (e.g. openEHR archetyping helps again here) –  so that you have captured and kept these in a vendor neutral format for supplier engagement purposes, while other clinical colleagues can learn from, reuse and recycle this same material.
The natural extension of this thinking is to suggest an Alpha “Discovery” phase to bring early health IT requirements to life in an open source reference implementation. The potential benefits here are at least three fold, its serves as (1) method of engaging the healthcare change project team with proof of what can/cannot be easily done (2) a means of bridging the significant gap between local frontline health change agents and national health IT standards setters (3) a means towards a “bi-modal” health IT strategy – keeping your future options open/avoiding vendor lock in

 

Experience in Leeds has highlighted these 3 key tips in a real life setting while illustrating the nature of such change. What began life as the Leeds Clinical Portal project morphed over time into the Leeds Teaching Hospitals EPR platform (named Patient Pathway Manager +). That in time became the platform that has served/is serving the Leeds Care Record, an Electronic Health Record for the people of Leeds. That journey from portal to EPR to EHR was not about swapping technical artefacts in and out, it was about change in a complex environment. Change that was clinically led, user centred in design, agile and evolutionary in development. That journey continues today in the ethos and form of the Ripple programme.

So if you think you are in the market for an IDCR… think again.

 

Posted by: Tony Shannon | April 28, 2016

Economics Rebellion- Teaching the Science + the Art

While working on something completely different, a podcast on Economics recently caught my attention.
Entitled “Economics Rebellion” it had just been broadcast on BBC Radio 4 , the blurb exploring “Why is there so much dissatisfaction about how economics is taught at universities? ”
It went on to say that “Since the financial crash, many students have been in revolt in the UK and overseas, determined to change the content of their courses. They are not alone. Employers and some economists share many of their concerns.”.

Now I am no economist, I have never studied the subject in any depth, yet I was curious so I listened in.  What surprised me wasn’t that economics as a subject was in such an agitated state, but rather I noted a few important missing links that no one seemed to mention. Please let me explain…

Though I have no formal training in economics whatsoever, I sense/believe that economics as a discipline is suffering from problems that are familiar to me from the rest of my work. I’m a medical doctor, with additional education/training in management and information technology… but not economics… yet here are the parallels that I see.

  • Firstly economics is an important subject, but not particularly well understood by the layman.
  • Secondly, like politics , management, healthcare…  economics is a discipline under scrutiny and trying to both progress and explain itself in the 21st Century to a public who sense all is not well.
  • Thirdly, though some of us may have assumed there were economics professors or masters who “knew it all” , the financial crash of 2008 suggests that no one individual has a complete grasp of the discipline, so increasing number of us are skeptical about the “science” involved.

Those “limitations” about the state of economics could also be pointed at modern medicine, management or software engineering disciplines. An experience of my own, working through the NHS National Programme for IT, billed at the time as “the biggest computer programme in the world…ever”,  also highlighted real shortcomings/ key knowledge gaps in these other/unrelated fields.

One of the key points missing from that recent BBC Radio 4 analysis of Economics was a look at economics from a “complex systems perspective”… this sounds esoteric, but bear with me, there are important parallels at play here.  As I’ve learned about medicine, management and information technology I’ve picked up on the importance of “complex systems” thinking which seems to me to apply at least as equally to economics…

To begin without any controversy, I might suggest .. some of economics may be “simple”, more is “complicated”, it appears frequently “complex”, then may at least occasionally exist on the “edge of chaos”.
Those 4 keywords  (simple/obvious, complicated, complex, chaos) come from a highly useful framework that has helped much of my thinking, named the Cynefin framework. This framework, helps us make sense of the world, came from the original thinking of Dave Snowden and I’ve see it grow in appeal across many disciplines over the last several years that I have been following it… yet not widely enough in economics.

Cynefin

To explain further I might try to explain the world of Economics as I see it myself..;
(NB Amateur attempt here, but here goes. Comments to improve these examples are most welcome)

Simple (Obvious) Stuff.
(They say Simple Stuff can be taught in about 10 hours)
e.g. Definition of an Economic Profit.
An economic profit occurs when the Total Revenue  (TR) less the Total Cost (TC) is greater than 0.”
My instinct is that no one wishes to argue about this stuff. Its simple .. or obvious.
(If trying to work through this simple stuff the tactic here is simply to Sense, *Categorise* and Respond.)

Complicated Stuff
(They say Complicated Stuff can be taught in about 1000 hours.. 6 months of full time work… perhaps a year of education?)
I’ve never looked at it but assume this is where Mathematical Economics comes in… plenty of deep maths that looks complicated to learn but given enough time can be mastered, perhaps with an Economics degree, perhaps after a year or so working in this full time in banking etc? Sure they may be more than one way of doing mathematical economics, am sure there are many many ways, but one would at least expect some good practice in this field has been agreed on?
This might perhaps be explained at the basis of “the science of economics”? The Economics Rebellion piece mentioned “physics envy” as a factor in economics education pulling towards the “hard” sciences.
If maths & economics are to be intertwined as a science that certainly that fits with the “Sense, *Analyse* and Respond” approach that underpins this aspect of the Cynefin framework.
Now that complicated stuff is all very well but I would suggest that only takes our understanding of economics so far. So we must move on…

Complex Stuff
(They say Complex Stuff takes 10000 hours to master.. 5 years of full time work)
To explain…. “Complex Adaptive Systems” are by definition made up of many parts, with many interactions between those parts. Such systems are open, difficult to explain, hard to put boundaries around or control. In many ways they are a very good way to explain what economies are and behave like… yet this is rarely said or explained properly.. indeed this understanding was strangely missing from discussions of economics in the media.. e.g. the aforementioned Economics Rebellion piece…
Why isn’t Economics explained more often as a Complex Systems challenge? Are we expected to believe that its all about men with calculators in central banks that are working it all out along perfect mathematical models alone??  Lets hope we get some discussion on that.
Regardless of how economics is taught, my sense is that experienced economists must/do understand this dimension to this discipline, even if they don’t routinely articulate this or talk about it. Experience is the key here.. understanding the complexity takes time… This is where the years of experience comes in , where those who have done there time see patterns and trends at play.
I guess if they work in the stock markets or elsewhere and they are good at what they do, they will spot these patterns earlier than their peers and may move to “buy” or “sell”. If they work in policy (eg IMF, World Bank, Central banks) you would hope they can harness and use their understanding of the  key patterns at play to influence the economics climate they govern.

How to deal with complexity ? Probe, Sense and Respond
If this sounds all too abstract , consider this…we all know at least one key pattern and means at influence at play here in controlling economies around the world … that of the interest rate mechanism.
If economic growth is low my understanding is that interest rates are cut to try to stimulate growth.
If economic growth is too high, then the opposite is used, interest rates are raised to try to limit that growth.
Of course these are not perfect tools but may be the best that can be used in a complex adaptive system? The interest rate acts as a probe into the economy, then indicators are sensed/looked for… is it working? does the rate need to respond by adjusting up or down? The central banks Probe, Sense, Respond… an ongoing and continuous iterative cycle of adjustment is the only way through…
This complex systems aspect of economics, is I sense best explained as “the art of economics”.

One of the best ways to explain patterns within complex systems is to use narrative rather than numbers. To his credit my fellow Irishman (and imho global thought leader on economics) David McWilliams has a real talent for explaining complex economics with narrative and related stories.  My sense is his deep and meaningful understanding of economics helps him identify the key recurring patterns at play and how to convey complexity with narrative better than anyone else I’ve seen.

Chaos
(Some say there is no training you can get for handling chaos, its a leadership trait you either have or not)
After the financial crash of 2008 we should be better able to understand that economies are complex systems “on the edge of chaos”.  Such days are full of unpredictable turmoil and we see them at regular enough intervals when markets surge or tumble.
The key to getting out of such chaos is the need for leadership and action… any action… (see above .. Act, Sense , Respond)
We know that at the height of the 2008 crisis, “in a dramatic meeting on September 18, 2008, Treasury Secretary Henry Paulson and Fed Chairman Ben Bernanke met with key legislators to propose a $700 billion emergency bailout of the banking system. Bernanke reportedly told them: “If we don’t do this, we may not have an economy on Monday. ”
One might argue that any ongoing EU economic malaise is due to the wrong form of leadership or indeed the lack of real leadership?

 

Here end’th a brief discussion on Economics, Complexity and the Cynefin framework.. for now at least. I’ve been looking for others to bring these subjects together for a while and not found any, so here’s hoping someone else picks this one up and takes the thinking further…

Any efforts to improve my/your/our understanding of the important yet misunderstood discipline of Economics are appreciated in advance..

 

 

 

 

 

“This is the practice of medicine…” begins Dr Larry Weed , back in 1971.
He is holding a set of patient case notes in his hands.
“.. it’s intertwined with it…” he continues to his Medical Grand Rounds audience.

On a rare, deep and meaningful day…. this visionary physician takes a look at the humble patient case notes and dissects them out to explain the intimate connection between the science/art of medicine and the information therein.

Thankfully this lecture was captured in video at that time and has now been shared online with the wider world. As a physician with an interest in these issues I’m surprised I hadn’t come across it before as its been online for a few years already.
Thanks to Dr Ian McNicoll of freshehr who brought it to my attention at a series of openEHR workshops we’ve been running together recently around England and Ireland.
While the video is in black and white, clearly dated from the time of its taking back in 1971, the pearl in this unusual medical lecture is the brilliant mind at play.. that of Dr Larry Weed…. of some medical fame. Though his name is known for SOAP notes and POMR, I expect you may not have heard of or know what they mean …why would you .. they sound like dry and dusty acronyms.

However this video expose helps expose his important deep thinking further…
In teasing apart the medical case notes in his hands, he simultaneously shows how;

  • Medicine is an information intensive discipline
  • Good medical practice and good information management are intertwined
  • The quality and safety of medical care  – can only be judged from the medical information.
  • Our aims towards evidence based medicine, high quality research and related innovations – are critically dependent on the medical information.

In brief his work is heralding the arrival of medicine into the information age… such that much that has gone before it could appear like alchemy…
His thinking is so far ahead of his time that his words will still have implications for decades to come.  Its a rare insight… worth teasing out in more detail in future..
If you are interested in medical history this is worth a watch.
More importantly if you are interested in the future of medicine, this may become essential viewing…

 

 

 

Posted by: Tony Shannon | February 29, 2016

Integrated Care & Digital Records – A Maturity Model

As an update to the Ripple OSI effort, this month I’ve published an article entitled “Integrated Care & Digital Records – A Maturity Model“.

Building on the principles outlined in “21st Century Healthcare: The Open Platform that will Transform“.. the article outlines the approach that Ripple offers to the effective union of key elements  i.e. (1) clean and simple user interface design, (2) integration with existing/other systems and the path to the (3) clinical kernel oriented platform approach.

The article steps through several levels of integrated care enabled by digital records and illustrates that people need to work through a process to develop patient centred care.

As another reference point the key slides are available here.

 

 

The main “Integrated Care & Digital Records – A Maturity Model” article  is available now on RippleOSI.

 

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pdf

 

Posted by: Tony Shannon | January 31, 2016

Health Improvement in Ireland- for the Record(s)

~~~~~

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

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

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

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

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

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

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Read More…

Posted by: Tony Shannon | December 21, 2015

Human Culture: Nations v Networks: Tension & Tools

Human Culture: Nations v Networks: Tension & Tools

As we look around the world, as we see endless creativity and never ending crises, we naturally look for ideas and principles that help us make sense of it all. Faced with complexity, a search for the patterns at play is often most fruitful. One of those key patterns that can be seen all around is the natural tension inbuilt in the human endeavour – that inherent tension between the hierarchies and networks of the world.

 

Human History: Hierarchies vs Networks

Human history has taken a scenic course, from nomadic hunter gatherers to settled farmers, then onto those families who grew into tribes, then small city states and over thousands of years evolved into the nation states as we know them today. Most/all of us have grown up with the accepted power of the nation state, those geographically defined borders that help define who we are, what tribe we belong to, the core culture we individual humans value.

The theory that surrounds the state is that they are hierarchical in structure, our leaders were/are to be trusted and respected, so could/can make decrees from on high that we all should follow. Indeed in recent decades we have seen the rise of super states, such as the EU and the UN, the IMF, that are an extension of the same principle. As these bodies are newer yet larger organisations they are often seen as much more detached from our daily lives, perhaps an evolutionary step too far?

Anyway the theory generally continues that the nations’ leaders, be they princes or prime ministers, serve the people that have gifted them this high office. If they do not serve that role well, the theory goes that the people will rise up.

 

Yet another even more powerful influence pervades our culture.
Ingrained in our existence as humans is another powerful force, explained by what we call the network effect, or more recently known as the “social network”. This networked world is nothing new to human life, rather in many ways a more natural fit with the human experience, even if now seen as an alternate slice through human organisation. Networks as we understand them take many sizes and shapes, from our friends and neighbours, to our local village, community council, to our professional peers and to most recent international movements such as facebook, twitter etc. etc.

Networks are well understood as more informal organisational forms, agile yet influential. They are perfect examples of complex adaptive systems, without any single point of control, but made up of many parts and many interactions between those parts. They therefore self-organise, exhibit perpetual novelty and are an essential source of both innovation and disruption.

 

While we expose these two differing aspects of human culture we note that many organisational entities span this range of organisational forms. From the past, ancient religious groups such the Christian church has grown to reach from the Vatican to the multitude of prayer groups that now span the globe. So too are many modern business corporations, who have head offices and regional offices at a national and international level that exhibit a hierarchical form, yet also display the features of a social network that spans international boundaries with a range of cultures within.

 

There is of course an inherent tension and challenge between these 2 organisational forms of hierarchy and network that lies at the root of the many challenges humans have always faced.

 

Today at the highest level if we look at the challenges such as climate change or international terrorism, we also see both of these forces at work, sometimes in union, sometimes against each other.

Most modern nation states are well aware that they face the real threat of climate change yet struggle to take meaningful action. Networks within and around nation states vie to wield influence over the decision makers.  On one side, the climate change lobby network are keen for more action on climate change. On the other, the networks of large oil and corporations are rather less keen.

Many nation states also face some level of threat from international terrorism. On one side humans naturally flee from terror, over borders etc, using their networks to guide them where and when to travel. On the other side, the terrorists using their own networked tactics to scare and monger.

 

What can nation states or supernations do-  to “do the right thing” in this networked world?

 

Certainly nation states can bring their cultural might to bear and can rally their people into action, we certainly see this happen during times of an outside threat, i.e. in times of war. During peacetime it’s a little harder but they can use the cultural value of stories and weave a narrative that is also very powerful, such as “the birth of the NHS”. When called to action, nation states can bring legislation and funds to bear and yield their formal power to mighty effect.

Yet while people change in a range of ways, they are most especially influenced by the network of people around them and they usually fall into one of the following categories.. a few are early adopters of change/ more form an early majority/more still the late majority…while few enough want to be seen as the last to change.. the laggards.

So networks are absolutely vital and key to real change, yet we know they are naturally “complex” rather than just complicated, so are harder to control. On their own they own lack the benefits that stable hierarchies provide such as pooled financial resources, legal structures, etc.

 

So what balance is to be had here? What are the patterns that can and do unite these hierarchical forces of nation states and the diverse force of networks towards common causes?

Read More…

Posting a copy of my slides at yesterdays HISI2015 meeting in Dublin.

It was an important day for eHealth in Ireland, with a session on visioning the future of Healthcare and a serious look at the role of Electronic Health Records therein.

Having been asked to speak about my time as an Emergency Physician and a Clinical Lead for IT/CCIO in the NHS over a period of 10 years, I shared a few key lessons learnt.;

 

Healthcare pressures mounting in the 21st Century. Reference: ED Trolley Crisis in Ireland and the NHS Winter crisis earlier in the year.

Importance of Clinical Leadership, including doctors like myself to stand up and speak out about the need for change. With true clinical leadership goes some authority, not just responsibility.

The Integration Challenge in Healthcare, as the current system is far too fragmented with many siloes of people + process + info tech operating in isolation, resulting in a very challenging journey for patients to navigate, not to mention the quality, safety, cost and timeliness issues.

The advent and arrival of an Open Platform in Healthcare, which will have a profound effect on the health IT market and thereby in healthcare in this 21st Century.

Lastly to make the point that while “change is inevitable, progress is optional“. We have seen significant effort in the UK and US Healthcare settings with IT in recent years, but limited progress. To make greater progress in this field, it is up to us.

Related Slideset is here;

Related videocast is here;

 

Last week I enjoyed the opportunity to present at the inaugural joint conference between the Royal College of Emergency Medicine and Faculty Of Medical Leadership and Management.

I was asked to explore  “Technological solutions.. Achieving quality and performance. What leaders need to know?”

Needless to say that challenge is a complex one, a mix of people, process and technology, as I’ve explored from many angles here before in this “book of thoughts”.

In brief, rather than exploring the detail on one/other of the Emergency Department Information Systems on the market..I explored some of the bigger issues as I see it..

#Healthcare under pressure/in crisis around the globe.
Emergency Departments feel this pressure more than anywhere else.

#The need for medical leadership of healthcare reform/improvement
Emergency Physicians as action oriented/problem solvers/team players and a very broad clinical knowledge and skillset –  well as medical leaders. We practice medical leadership and we value it.

#The complexity of the related Change Challenge (People + Process + Technology)
Emergency Physicians are very familiar with healthcare as a complex > complicated challenge, sitting on the edge of chaos.. they are good at pattern recognition and the key changes needed to positive disrupt a system.. think ABC in Resuscitation.
The “value” that comes out of any patient encounter or any emergency department is a balance of quality, safety, cost and time (performance) aspects, some of which can be measured. Getting that balance right…. is part of the art of emergency medicine…

#The poor state of the health IT market (inc EDIS)
Emergency Medicine is very information intensive, much time and effort is expended by the EM troops at the frontline that could be better supported with better Health IT.

#Update on international moves towards an open platform in health
Emergency Medicine is of course a global effort. As the principles and the practice of Emergency Medicine grows around the world, so too will the need/appetite/community grow for an improved Emergency Medicine “platform”.. tools for the 21st Century. Its not a question of If. Just when..

You may be interested in the related slides below

During last weeks St Lukes Symposium at the Royal College of Physicians in Ireland, I was exploring a few slightly challenging themes including;

21st Century Healthcare under Pressure.. an international issue around the globe.

The related need for Medical Leadership, i.e. medics are best placed to lead the way forward, though need to get out of their comfort zones to do so.

The challenge of Complexity in Healthcare. i.e. Healthcare is a great example of a complex adaptive system , the key to handling such systems is seek and then leverage common patterns within, eg ABC in Trauma Management.

The promise of an open platform in healthcare. i.e. the current state of healthIT is holding us all back and we need to collaborate as never before with a new generation of open tools.

The related slides (inc. one of my GP grandfather in action) are available here…

Posted by: Tony Shannon | September 30, 2015

A paper, a proposal.. to share..

One of the most common things you notice as you look around at healthcare is the business of “reinventing the wheel”.

reinventWheels

Whether you look at local efforts in a healthcare department, a hospital.. whether its a regional or national push.. what you see is many healthcare people trying to improve a process/service with a blend of technology . It’s happening all around the planet, yet many efforts are in isolation… building user interfaces, integrating healthcare systems, clinical data modelling etc etc… with little if any effective collaboration and/or reuse.

Now healthcare can be /should be explained as a good example of a complex adaptive system, so diversity is to be expected and indeed to be welcomed..yet when you’ve been in healthcare for 20 years you can’t help spotting the common patterns at play… and mindful of the real waste inherent in the current approach.

However there is no point just preaching at people, nor suggesting they get better educated in the clinical/management/technical world to gain a better understanding of 21st Century Healthcare to work as one. Of course more related education and a better understanding is needed across the globe to avoid such divided/siloed effort and foster good practice, yet what will make as much/more of a difference is to offer folk better tools.

Now by tools here I mean that in the broadest sense of the world.
Tool : definition: Anything used as a means of accomplishing a task or purpose.

Hence the approach taken by the Ripple programme, in offering a suite of open tools that others can use/reuse towards health & care improvement in the 21st Century. Of those tools, its worth drawing your attention to one in particular this month, a paper, a proposal… an open source business case for health IT investment.

The thinking here is that as many folk are tackling health & care improvement projects around the planet, when that first spark of an idea wants to turn to reality, they will move to seek funding, resource and support for their effort. In the modern world of healthcare, to get much done, like it or not, a business case is often required.

We’ve taken the basic outline of a standard issue business case and applied some healthcare improvement thinking to it.. it’s up online as a draft health IT business case for review/comment/improvement/reuse. Within the business case template some key learning is distilled within, such as the recommendation to fund related development of an 21st Century healthcare  platform.

If such tools help folk progress their efforts towards health & care improvement with just a little less reinvention of the wheel then it will have fulfilled its purpose.. Please feel free to share..

Posted by: Tony Shannon | August 13, 2015

Intermission & related Image

BigBlueBreak

Posted by: Tony Shannon | July 22, 2015

Design: Healthcare: IT

After a very useful couple of days last week at the NHS CCIO Summer School..

..one of several nuggets I came across was thanks to @marcus_baw as we were chatting about his push for improved health IT usability.

He mentioned an online lecture I hadn’t heard about.. from last year.. at Gresham College.

Without further ado, I have to wholeheartedly recommend this as well worth a watch.. if you are anyway interested in healthcare/improvement/technology and the intersection between these fields.

Designing IT to make Healthcare Safer by Prof Harold Thimbleby is an important contribution and clearly states that to resolve Healthcare in Crisis we need to design our way out of it..

 

Screenshot 2015-07-22 at 09.50.06

Posted by: Tony Shannon | June 30, 2015

ClinUiP – Clinical UI Patterns – an update

As I’ve mentioned many times, the world is a complex place.

The field I’m most involved in, Healthcare is a complex endeavour, and the health IT industry I know well is complex. At the frontline the look and feel and usability of many health IT applications is overly complex.

So as we work to move forward and address the complexity of health IT and improve usability, one of the keys is to look for key patterns amidst the complexity and harness their power.

To improve usability in healthcare I’m sure that we need to identify and harness several key UI patterns… certainly within my own work I’ve found  few key patterns which hold up as a useful Clinical UI Pattern framework in a range of settings and technologies;

Back as an Informatics Fellow in Washington Hospital Center I spend time coding an application within a related framework that blended record navigation, structured data & narrative.. issues that remain pertinent to usability today.

ClinStateBuilderTS_2

During my time in Leeds a brief session towards a related UI framework with my colleague Dr Geoff Hall laid the foundations of the look and feel of the PPM+ platform and the Leeds Care Record.

Early ClinUiP work and NHS VistA work

The same approach has held up during exploratory efforts around a refresh of the open source VistA stack.

and now the same UI pattern is holding up well in the context of the Ripple OSI effort.

This update seemed in order as I’ve penned a related article for the Ripple Open Source Initiative, introducing its UI/UX framework… so you may be interested in checking that article out here..

Posted by: Tony Shannon | May 31, 2015

Plain English Guide to Information Sharing

One of the challenges I see in my work across healthcare, management and technology is the varied languages that these varied professionals and disciplines bring to the table when trying to work together. I’ve written before about the need for some of us to work across boundaries and work towards a common language if we are to collaborate on challenges such as healthcare improvement together.

The challenge of improving health and social care services to citizens and patients is all around, yet one of the particular aspects to that challenge which might surprise you is that around information sharing.

You may/may not be surprised to discover that healthcare organisations have a tendency to work in siloes, where teams can work in isolation from each other, with varied processes and disparate information technology that does not connect. So the citizen/patient has to navigate the healthcare “system” by themselves and they get confused/bewildered when they are asked the same questions again and again, see that services are not well integrated, find that information about their care does not flow seamlessly around the “system”.

 

A key part of the problem has been the reluctance to share information about the patient between differing parts of the healthcare system, ie Primary Care (your GP), the Hospital (the Emergency Department or clinic or ward) , the Specialist … then with limited information sharing between these siloes it results in delays/duplication/errors in patients care.
Of course most patients assume that information about their care could/should/does flow between these healthcare providers… yet part of the current problem is that some healthcare providers are overly protective of this information, suggesting that they should own/guard/control patients information and quickly cite concerns about information sharing, when in many cases that attitude is simply holding healthcare improvement back. Indeed there are increasing calls that the only way to resolve this is to put the patient in charge of their own information, which is certainly likely to be the medium/long term answer, especially for this digital generation, though will take time to unfold.

 

Meanwhile of course there are many good reasons why we have to be careful about information sharing in health care and so the specialist field of information governance has arisen to craft related good practice in this area. However for many people the language of information governance bewilders and confuses them too.

So as a part of the Ripple Community effort I’ve been involved with crafting a “Plain English Guide to Information Sharing“. Using a  Who, Where, What, Why, When  and How  approach, the idea was to craft some material that makes this issue a whole lot easier for people to understand and help to eliminate some of the unnecessary confusion in this field.

There are clear moves now to actively encourage health and care professionals in better information sharing in the best interests of improved patient care across the globe.

Hopefully this Plain English Guide to Information Sharing can help.

 

Posted by: Tony Shannon | April 30, 2015

Change: Story #3: The Story of Now – Opportunity

This post is the third in a series of 3 … building on my earlier Story of Self and then a Story of Us, is the related followup Story of Now.
As the next step on the road I’m travelling, I’ve recently been involved in the start up of a community effort known as Ripple, aiming to quietly but positively disrupt the health and social care scene.
This latest post is taken from RippleOSI.org to explain the real opportunity that is now on offer to bring health and social care into the 21st Century.
(Reposted from the original with some very minor tweaks to help explain the context of this push)..

The Story of Now – Opportunity

The word ‘opportunity’ is defined as ‘a time or set of circumstances that makes it possible to do something’ which help to introduce our story of now.

As one of 25 Integration Pioneers, [Leeds has] been given the opportunity to blaze the trail for change and new ways of working to support Health and Social care. With [a] successful bid to NHS England’s Integrated Digital Care Fund (IDCF), as mentioned in [an] earlier story (the story of us), [there is now] the opportunity to work with and support Integration Pioneers and the wider community on their own journeys towards integrated digital care records.

Across health and social care organisations, the top priority is to provide the very best care for people, to improve their care outcomes and ultimately to improve the lives people lead. [It’s] recognise that to do so we need to support the practitioners working across health and social care by giving them better information and better tools in order for them to provide the very best care.

Integrated digital care records therefore play an important role in the drive towards improving care. They bring together information from various care settings to provide a more joined up view of a person’s care. Without, there is a disconnect in care journeys as the information doesn’t flow between care settings, causing delays, inefficiencies and potentially impacting the care provided. With this technology change begins as people and process evolve to truly deliver integrated and thereby improved care.

The 25 Integration Pioneers [across England] on this journey recognise the need for integrated digital care records, as an important part in this change equation, allowing staff to work smarter to provide improved sustainable care in their respective cities and regions.  Each are at different stages on this road, some just starting out and some well on their way. There are two common patterns appearing in the early work we have undertaken with Integration Pioneers in this area;

  1. the disconnect between the pressing need for change and the maturity and capability of care systems to meet these demands
  2. as pioneers, we are each doing our own thing, ploughing our own unique path and potentially encountering the same problems, when actually we all have the same core need – we need to work together

An open, collaborative and joined up approach is needed in the journey towards integrated digital care records. As Integration Pioneers an open approach allows us to act together, tackling the problems and learning once and sharing with all so everyone can benefit. [So has]  begun the Ripple community effort to support this approach. Key to that community effort, .. experience has shown that there are six core components needed to support the delivery of an integrated digital care record system, explained here along two key themes outlined below:

Foundations

Open Requirements – Working with Integration Pioneers, … identify the common requirements and capabilities needed for an integrated care record, along with their associated benefits. The identified aspects will be shared with all Integration Pioneers to save time and effort and to provide a consistent strategic direction to the community.

Open Governance – .. work with Integration Pioneers to standardise the governance arrangements for the sharing of information across care settings. At the moment this is seen as a real barrier to progress. Working with Integration Pioneers and with the support of NHS England …will provide standard governance templates and guidance to ensure the right arrangements are available and shared across the Pioneers and this emerging community across England.

Open Citizen – .. work with other Integration Pioneers on citizen engagement in sharing care information. It is essential to build trust as well as talking about care records openly, communicating widely and clearly. Working with Integration Pioneers and their respective communities,… provide the common information and core tools  needed to support engagement in and communication of care record initiatives. In addition to this ….undertake.. citizen engagement with the Integration Pioneers around the needs and requirements of a personal health record (citizen access to an integrated care record) and other key healthcare apps as a demonstration of this community effort in action.

Open source platform

Open Viewer – based on the Open Requirements identified by pioneers … develop and deliver regular enhancements for an open source viewer for the community to use. As ease of use is critical at the front line of care, .. work..towards an Open Source care record viewer that makes the navigation around care records intuitive.

Open API –  In between the viewing and the storage aspects of any platform is an important element of bringing information together from the various systems Pioneers currently work with. To meet this need, ..will be .. an Open Source Integration Engine which will be connected to those core systems that emerge from the Integration Pioneer analysis delivered by a series of related Open Application Programme Interfaces (Open APIs) to the community.

Open Architecture – Learning to date has shown that many clinical groups require similar elements of clinical content, although they use them in slightly different ways to meet their own local need.  The current market offers a huge number of applications to accommodate this however these are very difficult to integrate. To move away from this approach and into the 21st century we need a more adaptive, modular, building block approach that allows the community to collaborate. Working with the pioneers ..will provide a collaborative forum to develop these key building blocks, in line with international best practice, known asopenEHR. With this in mind, [work will go ] towards an open source storage mechanism to support this approach.

Why open source?

Open Source and Open Standards are key to innovation and an alternative to traditional ways of purchasing systems from software suppliers.  Open source is owned by the .. community, though it can be reused by others across the health and care community. The key features of an open source approach to Healthcare IT as;

  • Unconstrained Innovation – Ideas and ambitions can be shared by collaborators who work in different ways, in different organisations, different communities and different skills and experiences, including those not directly employed in healthcare IT
  • Transparent credibility – Allowing immediate detailed scrutiny immediately boosts credibility within the community
  • Decentralized control – amendments and improvement come from the community, bottom up

.. All the deliverables will be made available in the public domain under a recognised open licence.

Now is the opportunity to deliver a real change to care in the 21st century, to remove the barriers to progressing and to give the practitioners the tools they need to deliver more joined up care.

The Ripple programme has begun, the community effort has started.

## Repost from Ripple Community Site ###

 

There is a widely held view that 21st century care is under pressure, in a state of near-crisis in many places (ref #NHSwinter) where the burden of disease and the limitations of current health and social care systems are becoming ever more apparent.  We know that at the frontline, staff are already working under immense pressure, in unsustainable ways and that change is needed. We must find ways to “work smarter, not harder”.  So we must also find ways to improve the quality, safety, timeliness and cost effectiveness of 21st century care.

Of course,  the change that 21st century care needs will require strong leadership and changes in the way staff work at the coalface, and one question that presents itself is around the role of technology and specifically information technology.

Health and care commentators are, for the most part, all agreed that Information Technology is a key driver for change, while many are also aware that its great potential remains untapped. The gap between the hope and the reality of the promise of improving care via effective IT remains one of the key challenges facing us today.

In exploring this challenge, there is a view that the health and care IT market is not as good as it could be, lacking leadership and a mixed bag of technologies on offer with vendor lock-in a real issue.

Quite often it is still too hard to;

  • share citizen and patient information between providers and across city and district boundaries
  • adapt care pathways in a way that combines Lean thinking with a flexible information system
  • support the audit of care and research which for the most part is done by duplicating effort with cumbersome “back-room” processes.

It would be hard to contest the fact that the current state of the health IT market is holding us all back from the advances that 21st Century health and social care demands.

So is there an alternative path?

Leeds is one of 25 integration pioneers chosen to lead the way on the integration of health and social care through; new ways of working for staff, process redesign and integrated digital care records. Many are at early stages for this work but all with the same focus to improve care and work smarter.

Leeds, as part of an effort to positively disrupt the market, has ploughed its own pioneering path in this field via a mix of open source and open standards to underpin the Leeds PPM+ platform which now powers the Leeds Care Record. Great progress continues to be made on both fronts and positive feedback from both users and citizens alike is emerging, but Leeds believes it would benefit by contributing to and working with a broader community.

Recognising this need for change, to collaborate and to support integration pioneers, Leeds City Council on behalf of the city and with the support of the integration pioneers submitted a successful bid for the second phase of NHS England’s Integrated Digital Care Technology Fund. With the clinical leadership of Dr Tony Shannon, we are now reaching out to work with those 24 other integration pioneers who want to be part of Ripple community which is focussed along 6 open strands:

  1. Open Requirements
  2. Open Governance
  3. Open Citizen
  4. Open Viewer
  5. Open API
  6. Open Architecture

We hope that in sharing our challenges, our learning and our efforts, we can kickstart a real health and social care community effort. We are keen to collaborate with all others who recognise this story and share this vision, who choose to take this path together.

Posted by: Tony Shannon | February 28, 2015

Change: Story #1: The Story of Self

Change: Story #1: The Story of Self

My first blog of 2015 mentioned a word that is key to all change – culture.

Cultural change is a challenging thing and yet if we examine history, there is a noticeable pattern across all human culture over countless generations, from tribes to chiefdoms to city states to modern nations; the power of a story.

Often, scientific training teaches us that facts come first and therefore ones initial reaction may be to dismiss the power of stories. They can’t be scientific; there may be few specifics, no hard numbers or evidence base involved. I have many years of scientific training yet I realised as important as a scientific discipline is, any medical doctor will be able to recount a “good clinical case” – an individual patient story – that had a very important influence on their medical training and education.
Certainly in the early part of my medical career I could not quite reconcile the power of these stories with the factual evidence base that we were trained to focus on and refer to. However as time progressed, I began to appreciate the real power in stories and what is also called “narrative” as an important element of the art and science of fields such as medicine or management. Clearly, there must be something about stories that we need to better understand.

So when I heard of a recent webinar by the Faculty of Medical Leadership and Management on “Stories of Us: …. using public narrative to …. inspire change” I was keen to tune in. The series of webinars run by a medical colleague Dr Claire Marie Thomas (who did a great job) brought an approach to my attention which immediately resonated. Exploring the “Story of Self, Story of Us, Story of Now” it was quickly clear that, as a means of leading change and particularly cultural change, such an approach to stories and narrative offers invaluable help..

The principle, as I understand it, is that all real change starts with one person, who leads and takes on that change. To do this they need to tell their own story, a Story of Self. For that person to work with others to achieve real change, that story of self needs to become a Story of Us, and for that change to begin to gain momentum the story needs to become a Story of Now.

So if you’re sitting comfortably, then I’ll begin … my own short story, my Story of Self.

My own background is from a deeply medical family in Ireland, my great-grandfather on my mother’s side was a doctor, both my grandfathers were doctors, both my parents were doctors, all of my uncles are doctors, my only brother is a doctor. Within that environment I did consider taking other paths, including a look at engineering in my last year in school, yet in the end I also wanted to become a doctor and graduated in 1993 from medical school, University College Dublin.

Once qualified, my first job was in emergency medicine and although I considered a variety of other options I quickly realised that in terms of clinical practice, emergency medicine was the most challenging, diverse, stimulating and rewarding of all clinical environments – nothing else came close to holding my interest and attention and so I chose it as my own medical field.

While doctors are understood as a privileged profession who work hard, most enjoy the push and the pressure that goes with the work, especially as it so readily offers a way to “give back”, in looking after your fellow man, your patients’, as a real means to make the world a better place.
Certainly there are few places on the planet quite like an Emergency Department/Emergency Room, where “all of life is here”, literally from cradle to grave, where rich and poor are equal and care is provided based to whoever has the greatest need. The most moving moments in this intense setting.. are not those dramatic moments of the life or limb saved, but those moments after the event when patients and partners or family come together, quietly aware of what could have been, they are special moments to witness and stories not to be forgotten.

Over 20 years practising in Emergency Departments I can explain them as perfect examples of “complex adaptive systems” where you are constantly juggling patients from major resuscitation to minor injuries and everything in between, never sure what will come in next, always working to balance issues of the quality, safety and timeliness of a patients care.

Within that complexity and over time, I noted patterns emerge. Every emergency physician on the planet will know what I mean by the A/B/C approach to resuscitation, a simple yet vital tool to guide a team involved in the complex care of a patient by looking after: A – Airway, B – Breathing, C – Circulation. This process is essential to bring order from the edge of chaos. Another pattern I found involved asking a few key questions with every patient encounter: Was there anything I hadn’t covered? Had they any questions? Were they happy with their care plan?

One key pattern that leapt out from my early days as a doctor was the information intensive nature of work at the frontline. Every shift I have done has reinforced the point that to bring emergency medicine into the 21st century, we need much better information tools to allow staff to work smarter, not harder. My interest in this challenge meant that I slowly and steadily moved into medical leadership roles in Informatics and I have worked between emergency medicine and Informatics for most of the last 10 years.

So over the last ten years I have worked to lead and represent my clinical colleagues in the changes many of us believe are now required across healthcare in this 21st Century. I have listened to their stories whilst aware of my own and it has become increasingly clear to me that we are being hindered from making major progress in this field by the state of the health IT industry.
Those who know me, who have heard my story before, will have heard me say that I believe the industry has much to offer and I know there are many good people working in health IT, but that the health IT market is way behind the rest of the software industry and holding us back. Simply put, we need better Health IT.

Today, in 2015… many patients journeys through our health systems are too cumbersome and time consuming. Today in 2015, clinical staff often find it difficult to work effectively with current health IT solutions, it remains hard for disparate clinical groups to deliver integrated patient centred care and it is too hard for clinicians to keep up with the latest evidence based practice without better information and better tools. In essence the Health IT market needs major change to deliver and develop those systems which are required to support 21st Century high quality, safe clinical care and self-care.

In recent years I have moved to lead on some of the change required by promoting the role of open source and open standards in work that has underpinned the development of the Leeds Teaching Hospitals PPM+ platform and the related Leeds Care Record. I think that this work has gone well and thankfully in recent times we have seen the market starting to change.

Yet there is much more work to do and it has become increasingly clear that my journey needs to take this mission further and wider, to support the development of an enabling “open platform” that I believe will transform 21st century healthcare. So it was with that mission in mind that I completed my last shifts in Leeds ED last weekend, a new journey is in store, a new chapter in the story of self.

Posted by: Tony Shannon | January 30, 2015

Healthcare Change: Clinical Documentation in the 21st Century

Every so often an article comes across your desk that is worth sharing more widely. Of course in this day and age news doesn’t hit your desk as much as reach your smartphone and via a tweet.

So thanks to a recent tweet from @IanMcNicoll, I came across an article that was worth a mention.

Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians
Thomson Kuhn, MA; Peter Basch, MD; Michael Barr, MD, MBA; Thomas Yackel, MD, MPH, MS, for the Medical Informatics Committee of the American College of Physicians*
Ann Intern Med. Published online 13 January 2015 doi:10.7326/M14-2128

Now policy statements aren’t usually particularly interesting but I liked the 21st Century long view this paper was taking from the start. What may seem like a very niche subject goes to the heart of the challenge that 21st Century Healthcare faces. That is with regards to my own work across healthcare/ process improvement/ information technology this policy paper has enough good material that it seemed worthy of sharing and bringing to other people’s attention…

It’s a pretty lengthy paper which suggests its unlikely to get wide readership, so to be able to share the essence of it more widely I’ve culled/cut/moved quite a bit to emphasise the key points and am otherwise replaying them verbatim here (so clearly the rest of the material remains the copyright of the ACP etc) from their (thankfully free) online article ;

On the Background to “Clinical Documentation”;

“Observe, record, tabulate, communicate.—Sir William Osler (1849–1919)”

“The medical record was first used by physicians to record their findings and actions and as a vehicle to communicate with other physicians who might care for the patient in the future. Physician notes were concise, were handwritten or dictated, varied in length and detail, and typically reflected the personality and style of the physician.
.. This was the documentation style of physicians until the early 20th century, when leading hospitals began to require structure and the use of forms to organize what had been essentially free-form notes in order to perform analyses of their medical records and improve quality. “

“Over time, clinical documentation has evolved in response to other pressures outside of the desire to improve systems of care in hospitals and care for individual patients. The medical record also became an essential legal document with requirements for nonmodification and retention, a vehicle for education of medical students and trainees, and the defined work product for which physicians were paid. “

“In 1968, Lawrence L. Weed, MD, published a seminal article on the subject of clinical documentation, “Medical Records that Guide and Teach” (8). Weed observed then (decades before the emergence of the EHR as a tool outside of select academic centers and computer laboratories) that paper-based clinical documentation was confusing, scattered, repetitious, and sometimes even directly responsible for diagnostic and therapy errors. His response was to argue for a new style of documentation that focused on problems and how they should be managed and documented “:

“Weed’s work was widely read and appreciated and, by the mid-1970s, became the standard by which American medical students were taught to document.”

On “Evolving Purposes and Drivers of Clinical Documentation”;

“Increasing Demands for Structured Data”

“As with the rise of the quality movement in hospitals in the early 1900s, the current shift from volume-based to value-based payment models is driving the need for more structured data. “

“The laudable goal is to be able to extract data automatically from patient records, compile the data into reports, and export them with the click of a button. This process, if it worked well, would be far better than the current process of manual chart abstraction; additional data entry at the point of care; “
“Many “e-measures” are in the early stages of development and thus have not been fully implemented in EHR systems. These measures often require physicians and other health care professionals to enter additional data into the appropriately structured fields. It is unlikely that entering accurate and complete data into structured fields will become a high priority unless doing so becomes easier and more efficient than it typically is.”

On “Opportunities and Challenges of Clinical Documentation With EHRs”

“Electronic health record documentation is always legible; is always available anytime and anywhere, except during system downtime; and can be accessed by multiple persons, including patients, at the same time in different locations. However, legibility and availability do not necessarily result in efficiency and usability”.

“The primary goal of EHR-generated documentation should be concise, history-rich notes that reflect the information gathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up. Technology should facilitate attainment of these goals in the most efficient manner possible without losing the humanistic elements of the record that support ongoing relationships between patients and their physicians.”

“Data Display”

“A common complaint from users is that EHR interfaces are unnecessarily cluttered and require too much navigation for too little value.”

“Data Entry”

“An examination of paper-based records from most physicians clearly shows that the nature of medical documentation—other than the patient narrative—tends to be controlled and standardized with respect to documenting normal or expected findings. One-click templates and macros to generate findings from a normal physical examination or review of systems are time-saving functions that replicate what physicians would otherwise have to handwrite in paper-based records and should be acceptable as long as the final, signed documentation accurately reflects what occurred during the patient–physician encounter.”

“Capture and Use of Structured Data”

“For many types of information, properly formatted structured data are of enormous value and greatly aid clinical care, especially through well-designed CDS and flow charts that highlight opportunities for improving the health of individuals and populations. However, not all clinical data lend themselves to structured documentation.”

“The ideal note would facilitate hybrid documentation by allowing physicians to efficiently capture the patient narrative and supplement it with context-sensitive, template-driven data that enhance rather than detract from the clinical record’s relevance as a communication tool. Furthermore, the EHR should account for the concept of synthesis of information over time.”

“Policy Recommendations for Clinical Documentation

“Clinical documentation, whether on paper or in an EHR and regardless of other drivers, should strive to effectively and efficiently serve the purposes of documentation as described by Sir William Osler: “record, tabulate, communicate.”

“The College strongly supports the use of EHRs in clinical medicine on the basis of the potential to improve quality of care provided to individuals and populations.
The College strongly supports the use of new capabilities within EHRs and other health information technology to enhance the efficiency and accuracy of documentation as well as the transformation of the medical record from predominantly a reflector of gathered information to a dynamic, team-oriented communication tool that serves the entire care team, including patients and families. To these ends, the College offers the following policy recommendations.”

“The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.”

“The primary purpose of clinical documentation is to facilitate excellent care for patients. Whenever possible, documentation for other purposes should be generated as a by-product of care delivery rather than requiring additional data entry unrelated to care delivery.”

“The EHR should facilitate thoughtful review of previously documented clinical information. Ready review of prior relevant information, such as longitudinal history and care plans as well as prior physical examination findings, may be valuable in improving the completeness of documentation as well as establishing context.”

“The clinical record should include the patient’s story in as much detail as is required to retell the story.”

“To preserve the integrity of the patient narrative, requirements for capture of structured data should be kept to a minimum. Structured data should never take the place of narrative comments.”

“Structured data should be captured only where they are useful in care delivery or essential for quality assessment or reporting.”

“Ultimately, billing requirements should be adjusted to accept accurate documentation generated for clinical purposes. “

“As value-based care and accountable care models grow, the primary purpose of the EHR should remain the facilitation of seamless patient care to improve outcomes while contributing to data collection that supports necessary analyses.”

“To the extent possible, metrics designed to support analyses of quality and value should leverage data collected in the usual course of patient care, with appropriate attention to privacy and other ethical concerns, rather than requiring clinicians to take extra time to collect structured data not essential to patient care. When data are required beyond those that are generated as a consequence of care delivery, clinicians, practices, and health care systems should be compensated for time spent collecting these additional data.”

“Patient access to progress notes, as well as the rest of their medical records, may offer a way to improve both patient engagement and quality of care.”

“Policy Recommendations for EHR System Design to Support 21st-Century Clinical Documentation”

“EHR developers need to optimize EHR systems to facilitate longitudinal care delivery as well as care that involves teams of clinicians and patients that are managed over time.”

“Important elements of documentation, such as the patient narrative and differential diagnosis, cannot be lost as a consequence of overstructuring or underdesigning the user interface . The needs of medical practice should drive the development of EHRs and not the reverse “.

“Clinical documentation in EHR systems must support clinicians’ cognitive processes during the documentation process.”

“Electronic health record systems must enable collection of data and interpretation of information from multiple sources by clinicians as appropriate and necessary, including nuanced medical discourse, structured items, and data captured in other systems and devices “.

“Summary”

“Electronic health records should be leveraged for what they can do to improve care and documentation, including effectively displaying prior information that shows historical information in rich context; supporting critical thinking; enabling efficient and effective documentation; and supporting appropriate and secure sharing of useful and usable information with others, including patients, families, and caregivers. “

“Physicians must learn to leverage the enormous and growing capabilities of EHR technology without diminishing or devaluing the importance of narrative entries. Failure to do so will inevitably influence the way we think and teach, to the detriment of patient care.”

“Cooperation is needed among industry health care providers, health care systems, government, and insurers to continue to improve the documentation. We must work together to fundamentally change the EHR from a passive recipient of information to an active virtual care team member.”

For any further detail I can commend the full text of this article here.

Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians
Thomson Kuhn, MA; Peter Basch, MD; Michael Barr, MD, MBA; Thomas Yackel, MD, MPH, MS, for the Medical Informatics Committee of the American College of Physicians*
Ann Intern Med. Published online 13 January 2015 doi:10.7326/M14-2128

Posted by: Tony Shannon | December 30, 2014

Culture: Change / Number 1

At one of those quiet times of the year, when reflecting on the year past and the year ahead, one key issue stands ahead for 2015 and it surrounds the word “culture”.

When younger and in the midst of a largely scientific training it occurred to me that this word “culture”, given mention every so often, hailed from the arts field and the softer side of life so wasn’t relevant or applicable … at the time. As the years go by and as ones work evolves and involves change at any level this word “culture” just keeps coming back.. it seems key to understanding the past and unlocking the future.

To explain .. am thinking of the word “culture” in the context of;

My local community,  how we may /may not make progress with change as we begin to explore establishing a 10 year vision for the area. What are the cultural issues and values that are important to this community, what does it want to promote and support.?

My home city Dublin and country Ireland, which is in the midst of a decade of commemoration of those key events a century ago.
While the world is working to learn from the lessons of the “War to end all Wars” of 1914 -1918, Ireland is in the midst of a “decade of centenaries” and soon to begin commemorating 100 years since its landmark moves to independence began in 1916…
As part of that reflection and in the context of a nation that some say has “lost its way” and needs to redefine its place and purpose in the world, the country could/should begin a period of self examination of its culture.. what it means to be a citizen.. what rights and responsibilities do we have.. how can we make a change that makes society and the nation a better place?
Thankfully a related Peoples Conversation has begun as a means to foster that important Big Conversation about the meaning of citizenship, which is surely an important key to the future and a route to the cultural change that is now needed across society.

My own profession, the medical profession, which is under a form of real strain..almost its’ own “doctor crisis“, as healthcare stresses under increasing pressure internationally. What does it mean to be a physician in the 21st Century, how can the profession leads on healthcare reforms that are needed rather than simply guard its own interests?
Many challenges abound.. how can we do more with less, how can we manage expectations, how can we treat patients with dignity but not “medicalise” their last months, weeks, days, hours? how can we offer a fair, equitable and quality service for all?

Here too the important culture issue is raised.. how can one effect change in healthcare… the medical profession is renowned more for its conservative culture than its ability to innovate and lead change. Patients expectations have rightly increased yet when things go wrong a “compensation culture” exacerbates the strain rather than helping with shared partnership and decision making required to progress. So some form of culture change seems required to make progress..

My own work.. in frectal .. promoting and supporting medical leadership, process improvement amidst complexity and work towards an open platform to support the transformation of 21st Century Healthcare. How can any individual hope to impact on these significant challenges when major cultural challenges abound?

In each and every one of these spheres of interest.. the word “culture” seems to come increasingly to the fore.

How can one person help themselves , work with colleagues around them, towards common goals for the common good? So often the process of change, the information, the technology elements all come up against one key challenge.. understanding people and leading, driving and supporting cultural change?

How to define “Culture”?

“the ideas, customs, and social behaviour of a particular people or society”
.. is one of many definitions.

How to change “Culture”?

As I’ve read elsewhere culture is a bit like the weather, you can see it feel it but its can’t necessarily grasp it and it very hard to control it.. a complex thing..

So my New Years resolution for 2015 is to continue to study & understand & work on this issue even more than before.
Its perhaps the #1 change challenge; Influencing People & Impacting their Culture.

All change has to begin with number 1.

Towards an Open Platform: NHS Open Source Day at the Races… and they’re off..

The great city of Newcastle in the North of England hosted a landmark event this month. Newcastle is a proud city famed for its industrial heritage and its warm hospitality and was where I spent formative years as a trainee in Emergency Medicine based around the Northern Deanery. So it was great to be back for an all important event hosted by NHS England on Open Source in the NHS. The NHS England Open Source event at Newcastle Racecourse appeared to be a great success, full to capacity with a good size crowd of the pioneers in this movement and others who had come along to look and learn.

 

To give some of the context and background of this important event, one must acknowledge where the NHS has come from in recent years.. i.e. only a couple of years ago the NHS ran the largest civil IT programme in the world (based down the road (and one of the reasons I moved to work) in Leeds) named NHS Connecting for Health/NHS National Programme for IT which did some good work but in other ways ran aground against the complexities of the healthcare ecosystem.

Since then the approach to NHS Health IT has swung in the opposite direction, allowing “a thousand flowers to bloom” as the recent NHS Five Year Forward report put it. The talk since the demise of the National Programme for IT lately has been of the promise of “interoperability” and standards as the preferred way forward to join up all the many disconnected people/process/technical systems of the NHS. However simply waiting for the right standard to make it all better fails to understand the disconnect in the current Health IT market where frontline innovators, vendors, eHealth bodies and the Standard Development Organisations (SDOs) are often working in isolation from one another, without a common platform on which to build.

 

Thanks to the enlightened leadership of those of the top of the health reform with IT agenda at NHS England (Bev Bryant, Richard Jefferson, Peter Coates, Andy Williams, Ewan Davies, Indi Singh to name just a few of the key players (apols to the many others/& those behind the scenes :o)) my sense is the NHS is now moving towards the cusp of a much smarter way of doing things.

 

On the face of it this event was simply about opening the eyes of the NHS to the power and potential of Open Source software to positively disrupt healthcare. As healthcare is conservative part of the public sector and the public sector is a conservative part of industry, it has taken some time for the NHS to catch-up on this. The significance of this pivotal shift should not be underestimated, though we are only in the early days. One of the key stats mentioned on the day was that 1/3 of all NHS hospitals trusts had submitted a recent bid to the NHS Tech Fund with an open source interest, which heralds an important shift in dynamics of the market.

Importantly and interestingly at the same time, the range of open source solutions on offer to the NHS has rapidly ballooned over the last year with solutions/projects such as Open Eyes, Open Dental, Open Minds, OpenPACS, Open EDRMS, OpenEPR, OpenMaxims, openEP etc all being exposed to the audience.

 

Yet perhaps the most important part of the whole event was the parallel launch of the NHS Code 4 Health platform, with the HANDI HOPD platform as central to this. Here the principle is to offer the basis of an open platform, based on a healthy blend of open source and open record architecture (i.e. openEHR) to the NHS clinical/coding community.

This move towards an “open platform” could be /should be a game changer in the NHS and have implications further afield. Though it will take time to tell, the idea is that NHS clinicians and coders can now begin to collaborate with a set of tools that will allow for scalable, maintainable and well- constructed health applications based on good informatics practice from elsewhere in the world. In my opinion this blend of open source and open architecture and open tools is key to the way forward with the promise of aligning the efforts of innovators, vendors, eHealth bodies and SDOs alike.

Thankfully this approach fits well with the work being done within Leeds – on the Leeds Teaching Hospitals PPM+ platform, the related Leeds Care Record initiative and most recent Integration Pioneer plans … all being built towards the same open platform end. FYI Related slides on Connecting Leeds: Work towards an open platform below and here.

 

It’s great to see the happy and healthy development of such an enlightened community. A colleague remarked that the 100 or 150 folk present were only a tiny fraction of the 1 million+ NHS staff. Fair point indeed, but it’s with small innovative communities such as these that real change begins.
My sense is there is no going back now, the race towards the open platform that will transform 21st Century Healthcare has begun…

After several years away, I was back within my alma mater, the environs of University College Dublin Medical School at the Mater Hospital in Dublin earlier this month to present at an interesting Contemporary Issues in Hospital Practice workshop for their emerging Ireland East Hospital Group organised by my colleague Dr Leo Lawler.

My own presentation entitled “Medical Leadership: Complex Systems: Open Data”was aimed at stirring up some thinking in a few areas;

Starting by acknowledging healthcare under pressure/in crisis in Ireland and across the globe. Then the related “Doctor Crisis“, with the medical profession being adversely impacted by this healthcare crisis. As Healthcare is now a team effort we doctors need to forgo some of our sacred clinical independence for the greater good. In essence there is a need for medical professionals to better understand the science and art of effective management and work with both nursing and management colleagues to achieve change. Indeed there is a real need for medical professionals to lead the changes required in healthcare from the front and even be prepared to take on roles such as the CEO of the hospital in line with international medical leaders elsewhere.

Healthcare needs to be understood as a complex rather than just complicated system (note a brief introduction to Cynefin), and in doing so we should look for simple patterns that can be harnessed for change. An example is the universal people+process+technology elements needed to achieve any change – such as the 4 hour standard in Emergency Medicine in the NHS/ the ATLS approach in Trauma Care/ many other service designs in healthcare.

Within healthcare we need to appreciate the value of open data in driving change. “If you cannot measure it you cannot improve it”. To deliver on that what is universally needed to transform 21st Century Healthcare is an “open platform” centred around the patients healthcare (i.e. not around a single institution). Finally a suggestion to my UCD colleagues to think about joining forces with other international leaders in this field and help lead on this approach within the Irish system and across the globe.

Related Slides available here

Posted by: Tony Shannon | November 10, 2014

EHILive 2014 Conference update

After last weeks EHI Live of 2014 am posting up related presentations.

 

#1) Connecting – Leeds- Care Record update

To the CCIO network this update explored the :
History that Leeds has come from , including the formation of the powerful PPM+ platform that aligned with Leeds Clinical Portal strategy.
Current Leeds Care Record progamme, now being rolled out across Leeds to support Health & Social Care improvements across the city.
Future plans to work with Integration Pioneers towards an open platform.

 

#2) 21st Century Healthcare: the Open Platform that will transform

To the Skunkworks network this presentation based on an earlier related article here, explored;

The healthcare crisis internationally
The case for an open platform to underpin transformation across the industry
5 key features of that platform
Whos who & related leadership in this field.

 

Related videocast here;

 

Posted by: Tony Shannon | October 31, 2014

FAO Medical Leaders: Cynefin: A Leader’s Framework

 It’s become a complex world…an introduction to Complexity

In our last post on medical leadership we spoke of the need for a framework that aligns medical , management and technical disciplines towards the improved delivery of 21st Century Healthcare.. before we closed by introducing the Cynefin framework.

Before we get into the broad and valuable framework of Cynefin ( which looks at the world from 4 useful perspectives -from simple to complicated to complex to chaos) lets me delve initially into one that deserves particular mention in this exploration, i.e. complexity and the world of Complex Systems

As history has unfolded human civilisation has inexorably moved from a relatively simple hunter gatherer/agrigarian life towards the development of more complicated skills and expertise and we now find ourselves in the complex world of the 21st century.

The word complex is one that is bandied around all the time.. yet what does it mean to you? Have you heard of complex systems science? Well if not, you may be interested as while its relatively new, it’s already pretty useful.

The principles of complex systems..

A complex system is one that;

-is made up of many parts with

-has many interactions between its parts

-cannot be completely understood

-cannot be completely controlled.
…so rather than trying to understand and control the whole system you look for the simple patterns and simple rules that emerge from the system and you harness those then the rest of the system will self-organise…

Certainly from my perspective, that is a perfect description of one of  the places I’ve spent most of my career, i.e. an Emergency Department and I’m eternally grateful for being introduced to the subject by Dr Mark Smith of Washington Hospital Center ED.

Over time I realised that it was also a very good way to explain hospitals.. and local health economies .. and healthcare systems in general too!

Moving beyond clinical practice,  I ventured into further studies, then took on more Leadership and Management roles. Whereupon it was quickly apparent that many/most projects I was involved with fitted the same “Complex System” description. As has any of the management programmes I have been/am involved in. So it became clear to me that Complex Systems have a very good fit with Management science too.

Furthermore, as more of my work became involved with the Information Technology field, over time I began to understand most software quickly moves away from being complicated (its rarely simple) to being complex too, especially if issues of scalability and maintainability are examined. So yet again, I believe there is a good fit between complex systems science and the world of information technology/software engineering. If you would like an example of a complex system in the context of Information Technology… think Internet..

So though I’ve just mentioned 3 differing fields, I can explain that complex systems science applies to just about anything you can think of, from biology to mathematics, ecology to evolution, social science to economics, from military strategy to medicine.

If you have  an interest in that tiny taster in the subject of Complex Systems, I can recommend “Making Thinks Work” by Yaneer Bar Yam of the New England Complex Systems Institute as a very good introductory book on the subject.

That’s all very well.. but how does that fit with..?

For a time I was finding the principles of complex systems of interest and useful to my work while wondering how to reconcile these principles with the rest of my education and knowledge base. While I was wondering how to fit complexity into the rest of my thinking, I got some very useful help from Kate Silvester, a fellow medical doctor who introduced me to looking at complexity within the broader Cynefin framework.

Thankfully this framework is a relatively simple yet effective way to reconcile many of the challenges in the modern world. While it has emerged from the leading work of Dave Snowden from the knowledge management industry I believe it has very widespread applicability. Within this field there are a number of related and valuable schools of thought including work by Ralph Stacey (Agreement & Certainty Matrix) and adaptations by Brenda Zimmerman et al (Edgeware).

Very briefly the Cynefin framework explains the world across 4 key states, from simple to complicated to complex to chaos. Thankfully I find this framework a relatively simple yet effective way to reconcile many of the challenges in the modern world. I hope in spreading the word, this just might help you too…

Chaos-Complex-Complicated-Simple and the Cynefin Framework

After a formal education in medical school, I was armed with the related medical vocabulary. Yet that language is very different to that used by the management and software engineering folk I now work with.

Understanding the differences and commonality in languages and mental frameworks between disciplines is in many ways key to tackling multidisciplinary challenges (e.g. Healthcare reform) today. In the modern world differing folk with differing backgrounds increasingly need to come together to tackle challenges together.

Over time I have found myself looking across these disciplines for some common patterns that span across disciplines and found some common ground that I think may be useful to share.

One of the key aspects of that common ground is that all 3 disciplines can learn from the patterns in the Cynefin framework which is very much a multidisciplinary approach to making sense of the world and aiding leaders with decision making.

Simple

You began your education with the basics of reading, writing and arithmetic. While challenging at the time, you likely take these challenges for granted now and might class them as “simple” to do.

Complicated
Further along your education you most likely will have chosen a path that you enjoyed/preferred for a variety of reasons. While your chosen field may have appeared a “complicated” at the outset, requiring years of study and effort, over time you will have got a very good grasp of the subject. Indeed you may be a master in that field. Those from a scientific background will be familiar with this domain.

Complex
Regardless, there is for all of us, stuff that appears more than complicated, complex even, that stretches our ability and it can be hard to explain how, but some how we get through these challenges. Within the complexity, patterns emerge and can be distinguished and harnessed, which may be understood as the art within many disciplines.

Chaos
At the edge of complex challenges, occasionally lies chaos… a bad day, an organisational mess, a challenge so unwieldy that chaos is the only word that fits..

In brief, the Cynefin principles of how to deal with each of these domains can be summarised as follows..

Simple: Sense, Respond, Categorise (Best practice)

Complicated: Sense, Analyse, Respond (Good practice)

Complex: Probe, Sense, Respond (Emergent Practice)

Chaos: Act, Sense, Respond (Novel Practice)

In our next post we will delve into the common ground between three disciplines, Healthcare, Management and Information Technology, using the Cynefin framework which should help to explain and illustrate its real value.

Reference:

A Leader’s Framework for Decision Making by David J. Snowden and Mary E. Boone
Harvard Business Review, November 2007
http://hbr.org/2007/11/a-leaders-framework-for-decision-making/

NB This post is adapted from a series of articles in my Book of Thoughts

Medical Leadership – moving from the dark side towards the age of enlightenment

As medical, management and technical fields collide in 21st Century Healthcare… a common language and framework is required for medical leaders to steer the way forward.

1200- Establishment of the first Medical School Faculty in University of Bologna, Italy
1908- Establishment of the first MBA programme in Harvard University, USA
1987- Establishment of first Software Engineering degree in Imperial College London, England

As the world’s economies continue their tumultuous ride through the early 21st Century, the many varied healthcare systems of the world are exhibiting strain in many forms. Yet a look across the globe makes clear that a simple increase in percentage spending on healthcare is not the simple solution it might appear (note costs versus outcomes alone in the US versus Singaporean system alone as an illustration). If so… where is the future of healthcare, where are we heading?
Medicine has rapidly evolved in recent years from the age-old profession it once was, pursued by our forefathers as single handled practitioners that served their communities from cradles to graves. Delivering Quality & Affordable Healthcare in the 21st Century is acknowledged to be amongst the most complex of human endeavours on the planet, a multi-disciplinary team sport that requires medical, management and technological expertise and so is one of the grand challenges of our age. Given that context, is there any surprise that with such complexity comes a cultural and cognitive challenge across such diverse teams? Though our human species has thrived on earth thanks to our innate problem solving skills, over the course of the 20th Century the specialisation of our labour has resulted in so many camps, cultures and codes that collaboration can be difficult. We need to regroup and regain our common purpose.

So why don’t clinicians understand/appreciate the field of management?
Raised in a medical family where medical matters often came up over dinner, the world of management was mentioned, though more in passing than in a way we really understood. With no mention of the management field on my medical school curriculum it wasn’t until I entered the field of Emergency Medicine and met informed mentors and colleagues that my training and understanding of Leadership and Management began. Thankfully leaders within my College of Emergency Medicine had the foresight to make this educational element key to our curriculum , a useful precursor to the transformation that has been seen across Emergency Medicine over the last decade in the NHS. Even internationally the movement to drive forward medical leadership and education took until 1975 to see the important landmark of the establishment of the  American Association for Physician Leadership (previously named the AAMD and just recently the American College of Physician Executives) and in the UK the Faculty of Medical Leadership and Management  has only just recently been founded in 2011. So considering the age of medicine as a profession we must recognise that these are still relatively “early days” in the field of medical leadership and management as a movement for change. As we emerge from the “dark ages” where the majority of our profession have not understood the vital role of leadership and management in healthcare, but rather seen such moves as towards the “dark side”… so we now need to educate our all colleagues, demystify the science and art involved and offer a related lexicon that enters the everyday medical vernacular.

Have you ever attended a management meeting with some perplexing vocabulary in the room?

The challenge with communicating and broadening the appeal of leadership and management to our medical colleagues can be at least in part explained by recognising the differing culture and languages across the clinical and management worlds.
Our medical school education imparted long established fields of anatomy, physiology and pathology to us based on well-established tomes that underpin their scientific basis with a robust vocabulary that can be universally understood (e.g. left, radial, arterial, capillary refill, etc, etc).
Yet the relatively young field of management, our understanding of management science and related MBA curricula are changing at a considerable rate, with a related vocabulary that is still on the move. Management disciplines as business strategy, organisational management and economics are still evolving as scientific disciplines. Lest that is in doubt consider the globes most recent economic crisis and ask yourself can the field of economics be considered as a solid science yet?
In terms of culture, for some of our medical colleagues this implicit lack of scientific rigour suggests an alien culture. Of course most of us recognise that doctors blend a mix of science and art across our work. We might like to consider that medicine is more science than art , that management appears more art than science but few would argue that good health care requires a mix of both.
In terms of language, given the different disciplines involved.. depending on those attendees in the room, there is often an early mismatch in vocabulary between clinicians and managers, i.e. while clinicians can quickly relate using the vocabulary we were all taught at medical school, another language is needed to communicate to management colleagues which the MBAs of this world have not managed to standardise yet.
So in consequence we have separate cultures and languages that are holding us back.

Why do health IT projects run aground when your smartphone could power Apollo 11 to the moon?
As time moves on, it is increasingly clear that healthcare is an “information intensive” discipline yet the science of information systems and software engineering yield yet another discordant vocabulary that clinicians also struggle to comprehend.
If Medicine is an age-old profession and management a relatively new discipline, then information systems and software engineering are in their very early formative days. Of course it is clear from the world around us that these technical fields are in the midst of dramatic change, with transformative potential, yet this speed of innovation yields a rapidly evolving culture and language that seems a world apart from the medical domain.
As health IT projects require clinicians, managers and technologists to work together… yet each bring their own vocabulary to the table, so a related “lost in translation” challenge is commonly seen. The good news is that in the midst these complex technologies .. common patterns can be found and if team members work together they can be harnessed effectively…
Effective Health IT projects need teams that harness these key patterns…combining informed clinical leadership, agile project management and process improvement methodologies along with technical competencies towards a clear vision.
Ineffective Health IT projects mishandle these key patterns at play. They may involve well meaning clinical engagement, but often demonstrate a mismatch between process improvement efforts and naive technical choices .. without a clear vision in sight chaos can quickly result.
The root cause here isn’t simply underpowered computers, but a broader and deeper issue. Deep down, the lack of a common language/framework to harness those key patterns at play between clinicians/management/technologists contributes to the problematic health IT implementations that are all too commonplace and globally speaking a health IT market that awaits positive disruption.

The way forward; towards a common framework for progressing 21st Century Healthcare
How then, can the grand challenge of 21st Century Healthcare be delivered if these disparate medical, management and technical disciplines must work together, yet their education, culture and vocabulary all remain in isolation? To lead healthcare forward in the 21st Century, someone needs to lead that change. Those of us who understand the value of leadership & management as central to the future know and understand this, but how are we to engage every clinician, every manager, every technologist in common conversations?
Surely if we are to really lead the future of healthcare we must believe that our own generic problem solving skills, grounded in the scientific method but tempered in the art of medicine are key to the future. The contention therefore is that if /when medical leaders are to lead the way forward in this century towards the transformation and improvement of healthcare across the globe then we must work between us towards a simple yet clear vocabulary that we can share with our clinical, management and technical colleagues around at every meeting and every report. Does such a framework exists? Are common patterns to be found across our challenges? I believe the answer is yes.
The key to understanding 21st Century Healthcare is that this is not just a complicated challenge, but a complex systems challenge. Complex adaptive systems sit on the edge of chaos and coexist with both complicated and simple systems, an outlook which can help understanding medicine, management and technology fields and aligning efforts. For now that is just a taste … we will look in more detail at the key to this understanding (aka Cynefin) in a later blog..
So there is light ahead… if/when we move forward to enlighten the sciences and arts of Medicine/Management/Technology around a common framework with a common purpose ….we will be much better equipped to deliver 21st Century Healthcare.

Posted by: Tony Shannon | August 30, 2014

Leeds Care Record: What’s that all about?

This months post was featured earlier in the Leeds Care Record blog.

You may have seen material here before about the leading work that the NHS in Leeds is pioneering…
Leeds takes a Lead
Leeds Lab Launch

This “Leeds Care Record: Whats that all about?” article aims to explain the related story behind the the Leeds Care Record.
The team who have helped get this up and running have recently launched a very nice site with further reading material and related resources..
LeedsCareRecord.org

To share the story more widely I’ll reproduce the article here..
Please see LeedsCareRecord.org for further details..

This month marks a key point in the story of the Leeds Care Record. The Leeds Care Record you may ask …… what’s that all about?

Those of us who work in this field know that health and social care has become very complicated, complex you might say, delivered by a range of “providers”,  some large, some small, some generalists, some specialists, some healthcare, some social care… an amazing mix of people when one thinks about it.  Of course the aim of this whole effort is about the patient, that person is the middle of it all, who has a health or social care need and just wants to get better.

For patients trying to navigate the health and social care system we know that these worlds can be just too hard to navigate at times, not truly citizen or patient centred and simply more effort than it should be.  One of the underpinning reasons for all that hassle is that as time has progressed health and social care has evolved  from being delivered by single handed individuals to a large and diverse range of health and social care professional teams.  As that has happened (and it has happened over a period of many decades) siloes of information have resulted, (by accident rather than design) meaning a citizens/patients medical information ends up split or scattered. That information is often between the computer in your GP practice, the paper in your local hospital and across other paper and computer based records in community care, social care and mental health settings.

These information siloes have been holding us back from creating patient centred health services for some time now and simply put is the reason you have been asked the same questions all too many times. Despite pushes from on high in the NHS to move to electronic records, imposing such a solution from the top down has proved near impossible to do across a country the size of England, so in recent years more local efforts have begun to take shape.

So it is for the Leeds Care Record, a locally driven, Leeds city based initiative, supported by the patient representative groups in Leeds, funded by those who represent health and social care staff in Leeds and powered by the Leeds Teaching Hospitals PPM+ system.

Having built the foundations of this approach over the last year, the Leeds Care Record now brings information together, centred around the citizen and patient, from both GP and the hospital information systems, with community care, social care and mental health information to follow over the next year.

The lead up to this point has required health and social care teams to come together to explore new ways of working and we have already engaged with patient groups to make sure they are engaged and involved in this rollout.

With that early ground work done, the work to roll this out across the city began in earnest three months ago. By the end of August up to 400,000 patients (half the city population) may be able to benefit from this system. By the end of this year the vast majority of the population (800,000+) should be able to benefit.

As an emergency physician, and with every shift I do I’m conscious that better information could and should improve our patients’ care.  With the arrival of the Leeds Care Record valuable information such as patient’s medications, allergies and vaccinations will now be more easily available in an emergency than in the past.

We believe that this change will begin to make for a more patient centred health and social care system in Leeds, with greater efficiency, better quality care and improved safety.

We hope that the patients, health and social care providers of Leeds see this benefit before their eyes and we hope they notice that difference. We believe this is only the start of a journey, we thank those who have made it possible to get to this point and we welcome those who want to get involved on this journey with us.

Dr Tony Shannon, Clinical Lead for the Leeds Care Record

Please see LeedsCareRecord.org for further details..

 

 

Posted by: Tony Shannon | July 31, 2014

Road Trip: EU: Summer 2014

This months post is being filed after the event.. a vacation en famille around Europe with a Kia.

Will keep it short and sweet.
We set off and covered 4000+ km over late July into August with the help of ;
(1) Road Atlas of Europe (2014),
(2) an old GPS device (10years out of date) but still very very useful and
(3) a set of Google Map directions on a Nexus 7 to keep us right…
..so 3 points of reference..

This Google Map gives a sense of the trip… a great adventure.

shannonroadtrip2014map1_c

Thankfully travelling since the advent of the Internet, ATMs, the EU, the Euro, modern motorways, Google, GPS/SatNav etc has made it much easier than ever before in the past.
Europe remains perhaps the most fortunate continent on earth.. rich in history, art, architecture, good food and wine… yet diverse enough to always stimulate with differing landscapes, language, culture and road signage along the way..

Got a sense in the summer of 2014 of how fortunate we are …
20 years ago this would have been a much greater ordeal..
100 years ago it would have been unthinkable.

Posted by: Tony Shannon | June 30, 2014

21st Century Healthcare: the Open Platform that will Transform

The case for an open platform in 21st Century Healthcare:

As we begin, we restate the widely held view that 21st Century healthcare is under pressure, in a state of near-crisis in many places where the burden of disease and the limitations of current healthcare systems are becoming ever more apparent.  We acknowledge that at the clinical frontline that staff are already working under immense pressure , in unsustainable ways and that we must find ways to “work smarter, not harder”.  So too we must find ways to improve the quality, safety, timeliness and cost effectiveness of modern medicine. We must become more effective at efforts to improve through clinical audit and ensure our clinical research efforts are more enlightening than ever before..

After recent articles on the generic principles that should underpin any healthcare improvement strategy and a related healthcare information technology strategy, we now examine an issue that I believe will be key to the positive disruption of healthcare in the years and decades ahead.

In exploring change in healthcare we have looked at the key elements involved, an agile combination of people (esp. leadership), process (i.e. improvement), information (many industries are information intensive) and technology, to deliver better value (a balance of quality/risk/time and cost). We have looked at the high level options for improvement in Information Technology in healthcare.  We have examined related options A (A Myriad of Siloes), B (Best of Breed) and C (Corporate/Conglomerate Choice). In concluding that piece I stated that option B 2.0 was the way forward for healthcare IT and mentioned the prospect of an open platform in healthcare. Here and now I will elaborate that, to make what I consider now a case for what is needed to transform 21st Century Healthcare, an “Open Platform”. Read More…

Posted by: Tony Shannon | May 30, 2014

Healthcare: Generic Healthcare IT strategy: Options A/B/C

Following my earlier article on a generic healthcare improvement strategy, I’m going to drill down to the next level and look at a related health IT strategy.

We have discussed already that this needs to be seen in the wider context of healthcare reform and improvement, which requires an understanding of the complex adaptive nature of healthcare systems and the common patterns within. Those patterns include key themes such as people, process, information, technology, value .. so it should be assumed that strong leadership (esp clinical leadership) and an understanding of the healthcare process is a prerequisite to success with any technology strategy.

The complexity of healthcare can be understood by looking at another key common pattern seen when looking across of the current healthcare information technology market, which I’ll simply label as A, B and C with a related graphic.

HealthcareChangePPIT_1slide_v3

Current State of the Health IT Market – A/B/C Graphic

A – A Myriad of Siloes

On one side of the analysis, at least in simple terms, we have the most common state of healthcare economies , state A ( A Myriad of Siloes),  a landscape of dozens/hundreds/thousands/tens of thousands of siloed systems.. depending on how broad you take a look at this. Each siloed system represents a different clinical team and their own unique processes as well as the technology they depend on, each and every one slightly different to the other , none able to easily share data with the other.

This represents the current state of the industry from many vantage points and has come about by accident rather than by design, but the diversity represented here reflects the diversity of the complex adaptive system that is healthcare. In a typical hospital in the UK/EU/US it is not uncommon to have 100+ existing systems of this type.

[Explanatory aside: Not part of the strategic options but hopefully some interesting background information]

How have we arrived at that current state you might ask?
Consider this.. the history of the medical profession and our training at medical school encourages medical doctors to be both independently thinkers and clinical independent.
The science/art of business is not a regular part of the curriculum and certainly the language of business process analysis is an alien tongue.
Therefore when clinicians consider their options without training in this field and/or get involved in the healthcare process analysis/ improvement efforts which triggers related information/technology requirements gathering… you wont be surprised that they routinely come up with what looks like an infinite variety of processes and requirements.
This misses the deeper truth that there are deep recurring patterns in healthcare process that are generic and widely shared, but regardless, the current mindset 
begats the current health IT software industry -made up of thousands of disparate systems , that are all somewhat unique and do not interoperate.
[End of Explanatory aside]

C-  Corporate/Conglomerate Choice

On the other side of the analysis we have state C, (Corporation/Conglomerate Choice) which related to the number of large enterprise wide systems (eg Epic, Cerner, VistA etc) on the market. In simplistic terms these represent efforts (several successful and some otherwise) to move an entire healthcare organisations and their processes to align with an “enterprise architecture” from one vendor. While these are usually marketed as a single coherent solution, in several cases these are conglomerates of technical architectures that have been acquired and marketed under one banner by one vendor. Some of these C options are certainly more coherent architecturally, though as their approaches are often “closed” they are difficult to scrutinise, a point we will come back to.

In change terms a move to state C is a big ask, as it effectively means that the people  and process elements of the healthcare organisation need to be moved and then firmly tied to the approach of that single vendor.
Indeed to move from a point A to a point C is a huge cultural and organisational effort, a big bang and generally high risk, which is where the acute hospital care side of the NHS National Programme for IT got stuck and failed at scale.

B- Best of Breed 1.0/2.0

In the middle ground is what has historically been known as the “Best of Breed” approach, where a core number of organisational processes are supported by a related core number of supplier systems, eg Patient Administration, Order Communications /CPOE, ePrescribing, Clinical Document Management etc. For this to work, there are usually 2 other components in the mix here, an overarching common front-end (or “Portal”) and an integration engine ( or “Enterprise Service Bus”) which is the approach to integrating care around the patient taken in Leeds in recent years.
In terms of organisational change a move from A to B is certainly easier than A to C, particularly if the integration of legacy data is built into the plans, which helps to ease the path of migration.
This approach has proven to be a popular alternative to an outright move to option C and remains popular in many healthcare settings.

The challenges of integrating disparate systems is not trivial of course and remains a real challenge. While there may be initial people and process advantages to move a healthcare organisation from A to B, in the medium to long term the question of how and when to move to C often remains, particularly as one aims towards deeper integration between the moving parts.

Equally we are seeing that when healthcare organisations who have already made the jump to C want/need to then merge their existing Health IT efforts (eg VA & DOD) they are faced with the challenge of aligning two very different instances of the state C and so are also pulled towards an integration approach in the direction of C to B.

(Lets hope the A, B and Cs with the graphic are making this discussion easy enough to follow. Any comments/suggestions please feel free to post below)

As these limitations and advantages of integrating “best of breed” solutions via state B have become apparent in healthcare, a better understanding informed by lessons from elsewhere in the software industry is also emerging. One might label that “Best of Breed 2.0”  or it is now more widely known as Service Oriented Architecture, i.e. a move to align the core services of the organisation with a related modular architecture , towards a more “plug and play” approach. In this regard we’re also seeing a general shift in industry towards “Software as a Service”, where suppliers compete on the service they provide, not the technology they lock you into.

Healthcare as an industry is still in the early stages of moves between states A,  B and C, though my sense of the patterns emerging is a general move over time towards B 2.0 .. which brings us to look towards the future, ie the promise of a related healthcare “platform”.  More on the subject of platforms, particularly the prospect of an open platform for healthcare next time..

P.S.  21st Century Healthcare: the Open Platform that will Transform – article now posted

Posted by: Tony Shannon | April 30, 2014

Healthcare: Generic Health Improvement Strategy

While the issues in my Book of Thoughts cover a set of 5 key themes that I explore at many levels, I haven’t distilled them down into a single post for some time.

So towards that end, I wanted to use this post for an brief article (there may be related articles to come)  on improving healthcare.

One of the key points made in the Book of Thoughts is that life is full of patterns, so this article will simply explore some of those key patterns that I see across every healthcare strategy piece I see.

Hopefully by using this simple structure, this will make for a reasonably easy read, but may also form the basis of a template that you can reuse if you find it useful.

 

Mission & Vision

Every Strategy usually starts with a bit of mission and vision.
This one is about healthcare (though the principles are actually so generic as to be reusable across other industries).
So if we look to healthcare, we see a large and growing industry, so large that it is according to some commentators on the way to becoming the biggest industry on earth?

Lets accept that surge in growth for a moment.

Yet wait….  if healthcare is growing at such a rate what about other industries such as education, food, housing, technology?
After all health is of course important, yet it should not take over other important human activities.
So we need to contain the cost and growth of the healthcare industry. That much is already evident when we see the steadily increasing sense of crisis across the healthcare industry in the west.. it is widely agreed that healthcare needs to be reformed.. it needs to change.

So it we now look at the need for Healthcare change.. any strategy is simply about moving from the current state (real) to a preferred future state (ideal) and outlining the way forward.

Lets look at the key patterns observed across healthcare improvement strategies.
For now we will simply outline the key elements, to allow us time to explore these in more detail later on, but these are the key…
If your in a hurry lets cut to the chase with a related graphic..

HealthcareChangePPIT_1slide_v1

 

People:

Every change starts with somebody.. a person.. you/me/a.n.other..
So as is increasingly understood leadership is key to change.
In the industry of healthcare, where like every other “culture eats strategy for breakfast”, one has to understand the culture to get things done.
The most influential culture in healthcare may be the medical culture, its hard to deny it.
So who needs to lead the change.. that would be clinicians.. hence the need for clinical leadership..

Moving up from individuals, we’ll mention teams. So “clinically led” teams are the next important unit of influence.
A typical healthcare organisation is often made up of many diverse teams. Hopefully if well led by competent clinicians then they will work well … together with their management colleagues. There is an emerging saying from the NHS.. “clinically led- managerially supported”.. the point being that there needs to be a close union of effort between what have been distinct and somewhat dysfunctional camps who have not got on very well. We need to get over that and move on and work well as teams.

Organisations of multiple teams are just that, groups of groups. Diversity is to be expected in healthcare and to be fostered, but within that diversity to succeed as a group we must look for common ground.

 

Process

Process, i.e. perhaps can be very simply explained as what people do, is an area where the diversity of healthcare can appear a real problem but where there is common ground for all to share.

Some say that hospitals are now amongst the most complex organisations on earth.
Certainly one can look at a hospital and be overwhelmed by the complexity of the process within..
However if we look for common patterns in process, generic processes can be seen all around.

These core “processes” of healthcare are fundamental to the core healthcare “services” required by patients (i.e. Assessment, Investigations, Procedures) which is where folk can collaborate and cooperate to build a more patient centred approach.
We will return to this point shortly to see how this service orientation can help elsewhere.

The approach to process change should be a combination of Lean and Agile, cutting out the waste with small steady incremental improvements..

Information

Healthcare can be understood as an information intensive industry.
The key drivers of healthcare improvement…. Quality, Safety , Time, Cost are all information dependent.
You can’t deliver high quality and safe patient care without good information.
You can’t run a healthcare service or service improvement programme without good information.
You cant make breakthroughs in healthcare research without good information.
So healthcare needs information .

 

Technology

In technical terms , which I’ll come back to in more detail in a later post, one has generally 3 options for health IT.
The naming convention I use is pretty straight forward.
A- stand-alone healthcare applications that are crafted for a niche clinical specialty need (eg Renal Disease). There are hundreds and thousands of these across healthcare.
B –  integrated healthcare applications that are aimed towards a more generic clinical need (eg Ordering Tests, Managing Medication). These are very challenging to integrate, but that’s the point, so it become known as an approach called “best of breed”.
C – enterprise wide applications are aimed at supporting an entire healthcare organisation, though drawing a line around the boundary is nigh on impossible.

My view is that the industry is moving slowly towards a more enlightened approach to B.. towards what’s known as a Services Oriented Architecture (SOA).. with an increasing interest in open standards and open source.
If done right there should be a good fit between the key core processes of the organisation and this approach.

 

Value:

 

So then if done properly these elements of change should deliver better value.

While Value is a hard concept to define , one will find that again it is generally measured on a mix of the 4 factors mentioned earlier.. Quality, Safety, Cost, Time.

So we aim for ;
Quality Improvements
Safety Improvements (Risk Reduction)
Time Improvements
Cost Improvements

 

##

That’s all that’s needed for now.
If you look hard enough at any health strategy you come across, you”ll find these patterns at every turn..
If you need to devise a healthcare strategy, those patterns are impossible to avoid.

So there’s your start.. more later..

PS: Related/followup articles have since been posted
Healthcare: Generic Healthcare IT strategy: Options A/B/C
21st Century Healthcare: the Open Platform that will Transform

Posted by: Tony Shannon | March 31, 2014

EHR// Hardship : Exception // Fix: Usability

Sometime after the NHS in England wound down its multi-billion pound National Programme for IT (2005-2013), the US Healthcare system is now in the midst of a similar national effort to roll out Healthcare IT.

The US Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009 committed up to $25 Billion to promote and expand the adoption of Healthcare IT and bring the US Healthcare system into the 21st Century. One of the interesting aspects of the programme is that it involves a series of incentives for the Meaningful Use of such technology, which includes payments to healthcare providers of up to $44,000 per eligible professionals (e.g. physicians).

Yet despite such an effort and despite such unique incentives to adopt technology … Electronic Health Record (EHR) satisfaction ratings remain generally poor.. eg 70% of physicians in a recent survey saying that “their EHR investment (was) not worth the effort, resources, .. costs”, with significant concerns raised by physicians about key issues such as the usability of EHRs at the frontline.. more here. In a recent development, the efforts to achieve the “Meaningful Use” of EHRs are proving so challenging that some eligible professionals (ie physicians) are now entitled to apply for a “Hardship Exception” as their EHRs are simply not up to the mark.

 

What does this tale of financial incentives and hardship exceptions tell us about the state of the Health IT market… in one of the best funded programmes of its type  in the world..?

Or put another way, can you imagine any other industry where such an IT “Hardship Exception” process could be/would be invoked?

The bottom line is that the state of the Health IT market is not a good, with real issues such as the poor usability of EHRs systems a key concern to the professionals they are supposed to support. How can clinicians lead healthcare change and improvement efforts with technology so difficult to champion… if it essentially makes life harder at the frontline?

 

How then can the health IT industry get out of such a mess?

In my humble opinion, the future is clear… Clinically Led, User Centred Design and Agile Development will be key to getting us out of this mess… so should usability factors and human computer interaction principles be paramount to our work towards the broader Open Source Platform that healthcare requires. .

From the UK check out the good work of the NHS Common User Interface programme and some related work by members of the same team now leading Space Around People..

From the US check out the very interesting results of the US Healthcare Design Challenge..

For some small examples of the way forward .. see some related Transatlantic examples here:
1 Clinician, 1 Developer, 10 days- User Centred & Agile Development
and here;
2 Clinicians: 2 Developers: 20 Days: Agile Development towards NHS VistA

The bottom line is there has to be a better way….

 

Posted by: Tony Shannon | February 28, 2014

Shared Decision Making- a key to 21st Healthcare

As an Emergency Physician, one of the key routes to survival at the coal face is, in my humble opinion, seeking to harness the patterns one sees in ones practice.
I’ve explained elsewhere that Emergency Medicine is a classical example of Complex Adaptive System, with some simple elements, some more complicated, sometimes on the edge of chaos, but often complex..

So some of the patterns that I see and talk about in Emergency Medicine include;
.. a walk into the resuscitation room first thing on a shift.. anyone in trouble.. if so use the ABC pattern.. is their Airway OK/ how about their Breathing?/then their Circulation.
.. then who is waiting longest in the Emergency Department? what are they waiting for? a decision? some advice?
.. does that patient need to be admitted? are they safe to go home?
.. are they happy with the plan? do they have any questions? do they have a safety net in place?
These patterns I see every shift I’ve done and they help to navigate through..

Of these one that I think may be most important ;” is the patient happy with the plan”.
That is I have a general rule of thumb not to send a patient home unless they are happy to go home.
That is not to say that I will have had as much time to spend with them as I would like, I may not have ordered every test they wanted, I may not have offered a diagnosis or been able to cure their ills… but I hope they’ll understand I’ve tried.

As the West faces a growing mountain of healthcare needs with an aging population, reduced tax base etc  we will have to work smarter rather than harder. I’m pretty sure that will involve a significant shift in the patient/provider relationship.
Physicians will have to move from a paternalistic I’ll tell you what you need to do approach, towards a brokering approach, where information is key to the discussion between patient and physician.
By explaining the process of history taking , examination, available investigations and treatments we should open up our approach to clinical problem solving and decision making. Rather than keep information to ourselves /order an expensive test to cover all possibilities/suggest a diagnosis when we don’t have one/ offer a token treatment that is unproven, we are better to admit that sometimes we face dilemmas and conundrums and are not sure what to do with our patients.

I find myself explaining that medicine is as much art as science, that its key that patients understand the dilemmas I have in their care, that I’m not sure what the right thing to do is and that I’d like us to agree between us what to do next.
In many cases that will result in a patient who seems glad they’ve been consulted, understands why we aren’t doing that expensive test today, willing to see what course their illness takes rather than take too much medication.
I offer one more pattern that usually help as we close the consultation.. (A) If things get worse you can come back to the Emergency Department (B ) If things dont get better you are likely to need another review by a doctor in x days .. (C) I hope you get better, you probably will as nature takes it course and if it does then great.

Though its been a part of my practice for several years now, its only recently that I’ve realised a name has been coined for the approach. Its being called Shared Decision Making and its now been promoted across the NHS and further afield.

My sense is that Shared Decision Making will be key to the future of 21st Century Healthcare..

 

 

 

 

 

 

 

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