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”.
While naturally the change that healthcare needs will require leadership and changes in the way staff work at the clinical coalface, one question that may have come to your mind is around the role of technology and specifically information technology in 21st Healthcare. In this year of 2014, healthcare commentators are, for the most part, all agreed that Information Technology is a key, while many are also aware that its great potential remains untapped. The gap between the aspiration and the reality of the promise of Health IT was one of the key frustrations during my time at NHS Connecting for Health. After 5 years there I left as I was clear that the health IT market was not as good as it could be, lacking leadership, with vendor lock in a real issue/problem and with a mixed bag of technologies on offer.
As a result it is still too hard;
-for clinicians to keep up to date with the latest evidenced based medicine,
-to share clinical templates, decision support tools and clinical intelligence reports between teams and across systems.
-to share patient information between providers and across boundaries
-to flex patient pathways in a way that combines Lean thinking with a flexible information system
-to support clinical audit and research which for the most part is done via parallel burdens that duplicate effort with additional cumbersome back room processes.
Indeed it was and remains my view that the current state of the health IT market is holding us all back from the advances that 21st Century healthcare demands.
So what is the alternative. IMHO there is now a strong/compelling case to say that healthcare needs/requires/demands an “open platform” for healthcare computing and will be key to international healthcare reform and transformation in this century. Tom Beale’s excellent article on “what is an open platform” is highly recommended reading on this subject.
In my humble opinion (imho) that ideal “open platform” is not yet available in the market today, yet slowly the market is moving in the right direction.
21st Century Healthcare: Open Platform Requirements
In highlighting key requirements of this platform, I will stick to my usual approach of focusing on the top 3/5 issues involved here. I will start by considering them from the clinical frontend back to the depth of the technical backend required.
# 1 Usability
Let me begin by stating that the healthcare platform we all require/await needs to have great usability as a key feature. After all technology of any sort, is just that, a tool, a tool to help we humans do things better. And so it is in healthcare, that we need great tools at the clinical frontline, easy to use, with clean, effective design. Therefore clinically-led, user-centred design is going to be essential to success of the open platform we require.
Needless to say this platform needs to be able to deliver to the web and mobile devices natively. While that may seem to an outsider like a given, not even worth a mention, bearing in mind where healthcare IT is coming from, lets agree that in 2014 that shouldn’t even require discussion.
While some very good work has been done on this in the UK (NHS Common User Interface) and the US (Health Design Challenge) these remain isolated and are not yet a key part of any leading edge platform.
Clinically Led, User Centred Design are key aspects of the approach that I’ve been promoting in our open source portal work in Leeds, with some key clinical UI patterns shared via ClinUiP and related NHS VistA efforts etc , yet the ideal open platform that looks and feels good is still awaited.. i.e. there remains a gap in the market..
Integration is the next given, simply because we have for too long been developing healthcare IT applications in isolation, to the point now that there are hundreds/thousands/hundreds of thousands of isolated clinical applications across the planet. To move forward I am not advocating a big bang switch overnight, but rather an approach that gracefully allows us to move off our legacy systems towards a better, improved approach and related stack.
This links into a move in the healthcare industry towards opening up Application Programming Interfaces (APIs) which though common in the software world are still relatively uncommon in the healthcare IT industry (or let’s just say that most of the incumbent vendors have not been pushing this). Historically the main way to get information between 2 systems in healthcare has been to agree a standard set of messages between those 2 systems, which is where the work of the standards body Health Level 7 came in, towards their standardisation. Yet that generally still required system A to “push” a message to system B, rather than the more recent advances in web services and related technologies which allow for a means to “pull” the data required on demand. As we are slowly seeing moves towards the greater sharing of healthcare information between healthcare organisations, this move towards a more open approach to integration with openAPIs will be key.
(Note: The efforts on SMART platforms and HL7 recent work on FHIR as at the leading edge of this movement internationally and I sense will be an influential part of the eventual solution. Also worth a mention here is the VA pushing VistA towards openAPI via MDWS, VSA and more recently the VistA Evolution programme. To their credit NHS England has recently taken a lead on a related openAPI policy. We have already done some related work in Leeds on a set of openAPIs as part of a Leeds Lab effort, leveraging the power of openEHR, which has fed into the recent progress by the HANDIhealth movement via HANDI HOPD… MedVision360s MedRecord and Marands impressive EHRscape are closely related. )
#3 Clinical Kernel:
Number 3 here describes the need to standardise the platform components and architecture itself. As mentioned previously the history of healthcare IT standards has been largely influenced by efforts to standardise the messages between systems rather than the core of the healthcare IT architecture itself. In my writings elsewhere I have made a case that this is not enough to transform healthcare. Rather if we are to truly transform healthcare, which will involve a combination of people + process + technology factors, we need to aim for a seamless fit between important process improvement efforts (eg Lean) and an agile technology platform. In that case, we need to ensure a very good fit between the core processes of healthcare and a related Services Oriented Architecture, particularly its clinical core/kernel.
On the face of it, that may seem a tall order, especially if you consider healthcare to be a terribly complicated field. Yet if one looks above that , one begins to understand healthcare as a complex adaptive system with deep patterns that pervade it. Within the diversity of healthcare a small number of (fractal) patterns are seen, which can guide the specification of the platform architecture required. The key place to start looking for these patterns is around a single patient, their encounter with 1/many clinical professionals along their patient journey through the health system.. you will see recurring patterns that help to engineer this clinical kernel – around the patient, not the organisation or medical specialty.
Having spent some time on this analysis during the NHS National Programme for IT, I came to the view which I still hold, that the best candidate architecture for this purpose is the openEHR architecture specification, which is openly published and slowly but steadily gaining in adoption around the world. Without spending the rest of this article on that subject, I believe it’s safe to say that its approach is centred around the patient, while the two level modelling in openEHR is key to addressing and supporting the diversity of healthcare, via the “archetype” (aka lego brick) concept at its clinical core. Certainly if one has any aspirations towards the informatics holy grail of Cross- Organisational/Guideline-Based/ Workflow-Integrated/Electronic Health Records or the like, then a firm basis like archetypes is essential. Hence why archetypes underpin the architectural vision of the Leeds Care Record and our related openEHR efforts there..
It’s always interesting to see how parallel research and development can reach similar conclusions. So it has been very interesting to see the leading edge work from Stan Huff of Intermountain Healthcare in Utah on Clinical Element Models, and the related efforts of the Clinical Information Modelling Initiative (also led by Stan Huff) reach similar conclusions about the potential of archetypes (ADL 1.5 etc).
(Note: This clinical kernel/core is something I always look for in any clinical application I’m asked to look at. While most market leading EHR solutions won’t let you anywhere near that detailed view of their architecture, in truth many/most struggle to get this right, the noble but imperfect efforts by openMRS and VistA may be educational cases in point).
#4 Code & Community
Here I will reaffirm that a measure of open source code is needed as part of this open platform for 21st Century Healthcare. This is not a new argument from my perspective; it’s one that I’ve been making for some time. Neither am I suggesting that the whole/entire platform stack needs to be open source …. yet. While I expect that over time, the majority of the open healthcare platform will become open source, I do not think that is required yet. Rather I think some key components are needed, particularly in my opinion the “clinical” frontend (i.e. the User Interface framework) and the “clinical” backend, i.e. the clinical kernel and models that reside within the database involved.
What are the advantages of open source? I sometimes cite a brief article I came across that explains it in 3 ways, which I believe resonate with the natural of healthcare, the medical profession and innovation;
#1) Unconstrained innovation – ideas and ambitions can be shared by folk who are oceans apart.
#2) Transparent credibility -allowing immediate detailed scrutiny immediately boosts credibility.
#3) Decentralized control – amendments and improvement can come from the bottom up
However this is an aspect that many vendors remain wary of, as they remain unclear what business model will work in the challenging environment of healthcare. So too the e-health standards bodies have generally been slow to embrace the advantages of open source and few national e-health bodies have been able to appreciate the potential of the approach. OSEHRA in the US and NHS England in the UK are the stand out leaders in this field and deserve commendation for their pioneering work in this regard.
The embodiment of the open source health IT movement at the moment can be seen in leading efforts such as VistA and openMRS which are making good efforts to develop related communities. Both have limited UI appeal and imho both lack the architectural semantics to support an international platform for healthcare computing and so are not the ideal platform solutions we await.
So while I do promote open source in healthcare, I equally promote open architectural principles, such as the archetype and I’m sure that a mix of open source and open standards is the key to this..
#5 Governance & Leadership
Last but not least I will mention governance, a non-technical notion you might say, but worth a mention here I think. The governance and steer of this effort is much more likely to come from the bottom up than the top down in healthcare. One of the drivers for setting my own company (Frectal Ltd) was the view that why shouldn’t this innovation come from the smallest and most agile players in this field? Why should we wait for some big brother in the sky to hand this down to us? No, rather some of us should just stand up and get this stuff done. It is happening. In the last 3-4 years I have noted a steady shift in the landscape, at times moving faster than I expected, but never quite as a fast as I would like. Thankfully there are very helpful efforts by the VA & OSEHRA in the US and NHS England in the UK to “do the right thing” and foster this move towards an open platform. So too we should mention the work of Stan Huff and the HSPC group moving towards an open platform in industry. Only a few years ago that may have been unthinkable, yet in the last 12 months, in that not insignificant market of the US Health IT industry another leading light is being shone. Yet again led by Stan Huff of Intermountain, the Healthcare Services Platform Consortium (with players such as the VA, Cerner, Harris etc) is acknowledging that there are too many small players in the market, too much fragmentation and too much difficulty interoperating, so they are starting to promote the concept of an open platform in healthcare. On this side of the water Ocean Informatics and Marand are two other leaders in the field, offering a leading mix of open source and openEHR to the wider world.
Yet all these guys (and gals) need help.
Yes that means our help, you and I to grow the movement, grow the market, grow the community.
Healthcare IT market : Futures?
For now I would contend that no one has yet has offered the ideal Open Platform for Healthcare with the 5 key elements I’ve set out
-usability – based on clean, effective design principles.
-integration- that caters for legacy data and can handle integration at the enterprise level
-clinical kernel – modular design– based on the archetype concept
-open source- to enable unconstrained innovation/transparent credibility/decentralised control
-governance- led by an innovative company while engaging the wider international community
Tomorrow, next week.. who knows.. the market has a gap and it’s waiting to be filled..
Healthcare’s Open Platform; The benefits ahead…
As this journey unfolds I expect the benefits of this platforms arrival to be considerable.
We can look forward to the day when healthcare professionals;
-can care for their patients effectively and safely based on this world class “open platform” for healthcare
-can work to evidence based standards, thoughtfully supported by this platform
-can share clinical templates, decision support tools, clinical intelligence reports across and between providers, across specialities, across borders.
-can share information more easily between healthcare organisations, so that the patient is at the centre of the process, rather than the organisation which is the current state
-can more easily and flexibly improve their ways of working with the flexible information system that this open platform should provide
-can more easily engage in research and audit without the burden of information management that it is today.
-can therefore move their efforts and skills away from navigating and negotiating the difficult, burdensome information management landscape that exists today, to have more time to spend with patients, understanding their presentation, explaining/discussing options and sharing in their decision making.
So this open platform is coming… its not a question of if, just when.
Will it cure all ills? No.
Will it transform healthcare? Absolutely.