Frectally speaking

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.

####

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 20^th 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.org. He 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

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…

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.

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

[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 21^st 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 21^st 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.

“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…

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.

#####

pdf

~~~~~

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

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

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

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

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

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

~~~~~~~~

Read More…

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…

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

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..

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..

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.

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..

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.

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

## 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.

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.

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

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

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;

 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 21^st 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.

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..

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.

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.

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

As we begin, we restate the widely held view that 21^st 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…

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.

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

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..

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

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….

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..

Since the demise of the NHS National Programme for IT, there has been a significant shift in the approach to change in the NHS in England. 

While it is increasingly understood that healthcare improvement is intertwined with information and related technologies…. in this new era of Clinically Led, Managerially Supported change… moves to facilitate related innovation and change from the bottom up are being fostered. Supported by eHealthInsider, the UKs leading eHealth news channel an enlightened campaign began just a couple of years ago to promote the role of Chief Clinical Information Officers (CCIOs) in the NHS. Over a short period of time a small but steady number of NHS CCIOs have already been appointed.

Within that rank, a chairman emerged, Dr Joe McDonald, Consultant Psychiatrist and Veteran of NHS NPfIT. With a combination of good humour and savvy politics, with the support of the rank and file he has helped to craft a NHS CCIO 12point plan.. .. so that this grass roots movement can advance a common cause..

Some of the key points from the 12 point NHS CCIO plan that has just recently been published;

• The appointment of a senior responsible clinician for information should be seen as one way of an organisation demonstrating its commitment to information quality
• NICE should produce a cross-cutting quality standard on clinical information, establishing core standards and metrics for the collection and use of information
• NHS England should integrate these standards into the Standard Contract for NHS services. The Standard Contract should make clear that all clinical information supplied by providers should be overseen by a lead clinician with responsibility for information quality
• NHS England’s work on the future of primary care and urgent care services should make clear the importance of clinical leadership on information, establishing core common standards across both sectors
• Health Education England should establish clinical information as part of the curricula for all clinicians

A key excerpt from Joes Introduction to the Plan is worth a special mention;

“This is why the development of a cadre of professional CCIOs is so important. We must make it our task to ensure
that the NHS gets the systems it needs to deliver the information required to drive quality of care. In doing so,
there are certain truths we hold to be self evident:
• If a clinical information system is to serve patients well it must first serve clinicians well.
• Clinical information systems must involve users in their design and continuous improvement.
• The NHS needs a vibrant, open market in EPR systems which is transparent from the point of view of usability, functionality and crucially, cost.
• The use of standards to promote open and interoperable systems, enabling the sharing of patient data is essential. This commitment to openness must extend to collaboration and exchange of best practice. For many CCIOs the collaborative nature of open source software development is particularly attractive, being analagous to medical practice.
• Implementation of clinical information systems will not be successful if they make clinicians’ lives harder

Already this plan has attracted the support of UK Ministers at the Department of Health.

So herein is a great example of ;

Clinically Led..
effort to support healthcare change..
..with effective Information Technology

Growing from these early roots, no doubt this plan will raise the profile of CCIOs and their important stake in 21st Century Healthcare Change.

Great job Joe.

A few posts back in my earlier article on “Transatlantic Thoughts.. on VistA .. in the NHS“,  I was commending some joint working between OS pioneers in both the UK and the US to move our learning forward on both sides of the Atlantic.

One of the recommendations in my presentation to the recent 2nd OSEHRA conference, in the Transatlantic blog article and at a recent related EHI presentation was to pursue an agile demonstrator of some key NHS standards (i.e. the NHS Common User Interface , Royal College of Physicians HIU Record Heading Standards) in the VistA stack.

Building on an earlier, though related “1 Clinician: 1 Developer: 10 Days Agile Development” project I had done with the UK based Rob Tweed and Chris Casey, they were keen to help..

On the “US side” and to their credit Medsphere and GDIT also picked up this recommendation.. so this has formed the basis of the first cut NHS VistA collaborative work described in this “First cut of VistA for NHS developed” article by Rebecca Todd from eHealth Insider.

The NHS VistA “first cut” work involved a week of my (Frectal Ltd) time, plus 3 weeks of Chris Caseys time, plus some of Dr. Edmund Billings (Medsphere) time, plus approx 1 other developer in the US.
(I should clarify that my input into this team effort was on my own behalf, i.e. not on behalf of either LeedsTH/LeedsNHS or the wider NHS..).
So a team of between 2-4 people working over a 3 week period… i.e. user-centred, agile and focussed.

The results were very interesting.. an open source, web-based, demonstrator of NHS VistA,
-inc basic NHS Common User Interface Patient Banner,
–core Royal College of Physicians Headings etc
… which can be used on a PC, tablet (eg iPad) or smartphone.

See screenshots below to give a taste and the related OS code here.

Thanks to Chris Casey for his very helpful video on this demonstrator.

Where this small first step goes from here is now to be considered….(e.g  we are planning to meet with the Royal College of Physicians to offer this as an open source showcase of their important standards).
I hope its been a helpful exercise and another demonstration of the art of the possible, with clinically led, agile, collaborative development using open source.

If folk do want to know more/see more of the work done, please do feel free to get in touch.

After a move from working with the NHS NPfIT some years ago, I made a move into a CCIO role at Leeds TH a few years ago. The initial focus of that work has been an informatics strategy, and a clinically facing, open source Leeds Clinical Portal which I wrote about some time ago..

Beyond that hospital oriented solution, related efforts have been made in the last year to establish a Leeds Care Record for the city. The city of Leeds is well positioned to tackle the changes that face the NHS, with a medium size, a single large multi-hospital group, one community trust, one mental health trust, one social care service and one city council all working together. Under the leadership of the city’s Health & Social Care Transformation Board, a city wide Leeds Informatics Board is setting strategy and overseeing key developments such as the Leeds Care Record across the city.

As the Leeds Care Record is aimed at offering a joined up patient/citizen centred record for the people of Leeds, we have had to plan it carefully.  Working initially with a diverse group that represent the NHS & Social Care in Leeds, we’ve now laid the foundations of this record with an internationally leading EHR standard (openEHR) to ensure this is being built based on an open, flexible yet secure and robust architecture. Some of the key lessons that this city has learnt from its place in hosting the NHS National Programme for IT (NHS Connecting for Health) are the need for clinical leadership, to align healthcare change with technical innovation, the importance of openness and standards and fostering improvements from the bottom up (vs imposed from the top down)… Most all of these principles underpin the approach to the Leeds Care Record (LCR)..

While the LCR developments are in their early formative stages, needing to engage busy staff, patients etc.. the city of Leeds also hosts important agencies such as NHS England, the Health & Social Care Information Centre, Leeds & Partners… all of whom are keen to see Leeds thrive as city with an internationally leading edge in Health Informatics. As a result of this interesting mix Leeds attracts interest from a wide range of eHealth folk who want to know more about Leeds, explore working and investing in the city etc.

A series of city wide discussions recently led to the establishment of a Leeds Innovation Health  Hub group to foster this interest in Leeds. In order to channel that positive energy of innovation, while progressing critical projects that are needed at the frontline.. the idea of a Leeds Health Innovation Lab came to be. 

So earlier this month we launched the Leeds Innovation Health Lab..
The aim was relatively straight forward.. to bring together a diverse group .. who are interested in the challenges that healthcare presents.. who want to tackle real life challenges and exploring how a combination of people, process and technology solutions might be brought to bear to deliver value and results. We can foresee that “live” challenges might initially result in a solution in the lab setting, while the lab may also foster ideas and solutions that are worth bringing into a live environment.

How this Lab will work out remains to be seen. In many ways these are very early days in the history of eHealth, yet formative important ones, so I’d suggest we explore this initiative with a curious mind.

For now I’ll conclude this post with links to;

– My slides on the Leeds Lab Launch event

– Leeds Health Innovation Lab website

–Leeds Innovation Lab Platform – technical details of the underpinning openEHR based platform

– Leeds Health Innovation Lab LinkedIn Group.

Feel free to explore..

Change usually involves a mix of people, process, information and technology.

So it is with remote working, a new way of work that is gathering pace around the globe.
In their new book “Remote: Office Not Required” , the founders of 37 Signals discuss this phenomenon that is changing how we work in important ways.
Some of the key points to take from the book are;

Remote is already happening and there is no point denying the deep change it heralds, the challenge is to positively embrace it.

Remote means that your colleagues may not need to be in the room/building with you… they may be down the street, down the city or down the other side of the world. One of the key principles is that if folk live and work where they want to be…. they end up with a better work-life balance and can be a more productive member of a team. To achieve that may involve less managerial control, less meetings face-to-face but should involve more trust and more real work done. In recruiting such a team one naturally needs to hire well, keep an open mind for international talent and skills, look for good communicators (i.e. people who can write well) and who want to be judged by the timeliness and quality of their work, not whether they can stretch their work from 9-5.

Remote is already happening in many ways already. Most of our delegate some banking, legal and other affairs to others who work outside our organisation. We can make contact with them as and when needed but we understand that they don’t need to be in the same building as ourselves to get that work done. There is now good evidence of a move towards remote working across a variety of industries, including the Government, Consulting, Design and Software industries.. amongst others. The book commends at least some joint overlap in the working day between remote colleagues (e.g. at 4 hour time lap in some part of the day) but otherwise it suggests few constraints. It makes a sensible case that a few regular meetups are required to brainstorm, team build, problem solve at key junctures, but between times there is often work to do that micromanaging and manymeetings can hamper and/or can just be wasteful. It also commends occasional team sprints to deliver on a deadline, project etc etc which can also be done remotely.

Remote is made possible by some key information and technology elements.
From an information point of view, the book makes a good case that any/all related information should be easily available for team members and  that roadblocks to getting at information mostly get in the way and make us less productive.
From a technology point of view, key developments over the last 10-15years have now accumulated to the point that has made Remote working possible. They are tools such as;

• Your laptop
• The internet
• Your mobile phone
• Instant Messaging (SMS etc)
• Email
• Google Docs
• Skype
• Basecamp (Online Project Management)
• Campfire (Online Water Cooler and Team Chat Room)
• GitHub (Software Repository)
• WebEx/ GoToMeeting/JoinMe (Conferencing and Screencasting)

So there are many now examples of successful remote working available. The authors of the book have played important parts in the open source software movement and their very popular Ruby on Rails framework has had over 3000 contributors from hundreds of cities around the world, most of whom have never met one another..

I’ve had positive experiences of Remote working myself with examples such as a “10 Days :1 Clinician: 1 Developer” piece of agile development with Chris Casey. We delivered that project over the web/skype/phone and the work was done before we ever met.

So I’ve progressed to more Remote working this year and can recommend both the book and the benefits.

As a keen supporter of the move to improve healthcare with better information technology and open source in particular, I’ve recently returned from Washington DC where I attended the 2^nd OSEHRA (Open Source Electronic Health Record Agent) conference. As I’ve recently been involved in OS EHR developments in the NHS, I was honoured to be invited to speak from an NHS perspective of the moves in the NHS towards Open Source in Health IT & plans for “NHS VistA” in particular. The time spent at OSEHRA was well spent, where it was great to meet others involved in leading the charge of healthcare improvement.

The OSEHRA Foundation is working to foster the development of an open source Electronic Health Record – something I believe will be key to the many improvements that are needed in healthcare in the 21^st Century. The OSEHRA Foundation has been born from the foresight and vision of the US Veterans Administration who have gifted their leading VistA EHR to the world, for both the betterment of the VA Healthcare system and indeed the greater good.  They made this move towards establishing an open source ecosystem, as a deliberate next step forward for their much heralded VistA EHR, which is acknowledged as a leading EHR that underpinned the VHA transformation in the 1990’s.

The OSEHRA/NHS/VistA presentation I was able to deliver gave me a chance to explain my own time in Informatics from when I began back in 2000 in Washington DC, through my time in the NHS National Programme for IT, working with the international openEHR Foundation and back more recently as in CMIO/CCIO role in the NHS in Leeds.  Over that time I’ve been observing developments in Health IT on both sides of the Atlantic and its plain to see that there is now much common ground between these two camps.

Thanks to the leading efforts of the VA and OSEHRA and since the demise of the NHS National Programme for IT,  there has most recently been an enlightened shift towards the greater role of open source to positively disrupt healthcare by the leadership of the NHS in England, so it is fair to say that the intersection of these leading edges of OSEHRA and NHS England is of real signficance to the world of healthcare.

While I’ll shortly explain the areas of difference between the OS communities in both the UK and the NHS there are as you might expect some common themes that span the Atlantic including

• Clinical Leadership is understood as key (OSEHRA is chaired by Dr James Peake, MD  and NHS England is moving to support the NHS CCIO movement).
• Healthcare is best understood as an ecosystem that needs evolutionary change
• Recognition of the key value of open source as a postively disruptive force to enable this change.

Open Source in Healthcare.. The challenge of bridging the transatlantic gap.

Through the efforts of the VHA,  the US has advantages in terms of open source Health IT in terms of VistA as the premier OS EHR in the planet.  While the NHS also has early movers in OS, there has been relatively little effort in terms of learning from VistA to date.
The UK has the advantage as being quite advanced in its effectively computerised primary care which has advanced their thinking wrt semantic interoperability, the GP2GP efforts being a case in point, while early innovators within the NHS OS community are moving towards adopting the openEHR industry “standard”.
I’m most interested in the intersection of these open source and open standards areas,  as per my own work within the Leeds NHS where we have 3 key projects that address this intersection (Leeds Clinical Portal/Leeds Care Record/Leeds Innovation Lab).

Certainly there appears to be fertile ground to build on success of  VistA, while aligning with related EHR progress that has been made in the UK, Europe and elsewhere.  To grossly simplify the roadmap of VistA development while exploring where this fertile ground may lie, I might explain a view of the current VistA community effort at 3 levels.

1)      Vista Refresh –Modernisation of the current stack (eg the work towards US Meaningful Use standards as part of the leading work of Oroville Hospital.)

2)      VistA Refactoring – this is a more indepth and medium term piece  of work, aligning the varying VistA codebases towards a common OSEHRA VistA version, again with the same current stack (CPRS, FileMan, M etc)

3)      VistA ReEngineering- work towards a modern web UI, amove towards web services and a service oriented architecture, plus some deep thinking on the way forward for Mumps the language/database.

To migrate VistA into the NHS will of course require more of this work, so one might imagine that the starting point for NHS VistA would be at least begin with the refactored OSEHRA VistA effort.  My sense is that given the current state of the open source community in the NHS, the interest and potential of an NHS VistA platform lies in exploring and collaborating with the deeper VistA reengineering effort. This has been challenging territory for the VA & DOD with their recent iEHR effort hitting difficult ground. Yet it is this challenging area where I believe that OSEHRA/NHS community collaboration may be most fruitful for all parties..

Ways forward for VistA in the NHS

Following the Campaign for NHS VistA, the NHS England Safer Hospital, Safer Wards initiative now highlights that there is clear interest in exploring the potential of VistA in the NHS. Certainly the strength of the VistA community in the US suggests that those experienced in VistA can help to make this work in an NHS Trust..with the right clinical leadership, healthcare improvement culture and the right technical team it could be done.

However if these VistA deployments are done as yet more standalone enterprise deployments in isolation from the already active NHS efforts towards open source and open interoperability standards, it will be an opportunity lost. So herein lies the real challenge for NHS VistA, not to make a success of 1 or more deployments, but rather to help underpin the bottom up grass root movement that has begun in the NHS towards an open source platform for the transformation of healthcare. This long-awaited platform needs to engage frontline clinicians, the SME market and the wide range of healthcare organisations across the NHS alike. Accepting this presents a significant opportunity for both the NHS and OSEHRA, lets now look at 3 related challenges.

3 Key Challenges

Challenge # 1: Community & Code
Challenge # 1 is to engage both the open minded clinical and developer community from the NHS in this NHS VistA effort.  So the work should look to leverage the energy and effort of the NHS CCIO movement, existing NHS OS pioneers, plus the NHS HackDay and HANDIHealth movements etc.

Having explored under the hood of VistA, I am now clear that there is definite value in the underpinning technology, ie Mumps. However that is not the orthodox view in the UK where it is perceived as an old, dated technology. In my opinion this relates to the poor way in which the Mumps community has communicated and explained the value of the technology.
To better explain the past and future of Mumps in Healthcare,  I would draw your attention to the writings of the UK based Rob Tweed who works on the leading edge of VistA. Based on his deep analysis of Mumps and its community he has made a compelling case and some great tools available for the way forward; 1) Mumps the language *can* be replaced by a.n.other language (NB As it happens Javascript may be a very good fit)  while 2) Mumps the Database has an excellent fit with healthcare data which has been very poorly communicated to date. His excellent paper on a “Universal NOSQL Engine” should be required reading for anyone trying to understand the technology that underpins VistA.

Challenge # 2: Integration & Interoperability
It will be easily understood that the NHS is not a greenfield site for health IT… the NHS has plenty of existing (and inoperable systems), with a rich history of (primary) healthcare computing.  In essence a rip and replace approach to the adoption of an enterprise system was at the heart of the difficulties of NHS NPfIT . VistA in its current form may be best understood as a large enterprise wide system, which has advantages of course, but such systems always have boundaries … so lets hope the push for NHS VistA is not just about large but isolated deployments, but rather part of an active push for advancing interoperability across the NHS.

Challenge #3- Usability & the Move to the Web
The existing NHS OS community is a savvy one, keen to showcase developments at the leading edge of agile software development (e.g. openEyes & Wardware).  As many of the these efforts use web based technology (with all the benefits that now brings), the limitations of the Delphi and “Roll and Scroll” UI elements of VistA become apparent and may lessen its appeal.  Equally as NHS OS community seeks an effective underpinning platform, so the move to ready VistA for the web and mobile devices (via EWDLite, HMP etc) should be made now as part of the NHS VistA effort.

3 Key Opportunities

From these challenges arise related opportunities, which I hope would interest both those promoting VistA in the NHS, as well as those already active in the OS community in the NHS.  If any of this work is to emulate the historical roots of VistA towards a NHSVistA Gold Version, it should be done along clinically led, user centred, agile development lines, so I might suggest the following areas of focus..

Suggestion #1 Common Interest at the UI layer
To engage clinicians in EHR work, the most effective way to do so in my experience is at the UI level. So engaging NHS clinicians in an effort to refine the VistA UI for the NHS world should be good place to start.  It is acknowledged that while the CPRS UI of VistA is liked and very effective , it is fair to say that it is ripe for improvement esp wrt bringing it into the web and mobile age. (eg the work on Janus, HealthBoard) The NHS already has work done on a NHS Common User Interface, the  OS movement in England has already embraced the web world (ref Leeds Clinical Portal, WardWare, openEyes), so exploration in that common space appears an important challenge that should be tackled fast. My own experience of a 10 day User Centred/Agile Development project with Rob Tweeds EWD (inc  M) framework highlighted the productive nature of this VistA ready stack.

Suggestion # 2 Common Interest at the Service Layer:
At a layer below the UI there is common ground across the NHS & VistA community towards the development of an open service oriented architecture across healthcare. Some related items: Within England the leading work by the RCP HIU has indicated a clinically led way forward for the structure of the health record in England. These are currently a set of standards that have yet to be showcased in any open source EHR and so the NHS Vista development is a prime opportunity to do so. The clinical overlap between the RCP Core Clinical Headings and VHA Virtual Patient Record work has the potential to be a useful steer to the evolution of related technical services.. which are currently spread across VA MDWS/ VA VSA/openMDWS/VistA Expertise Network Web Services/WorldVistA SMART .. all of which overlap with a real interest in the NHS on a set of openNHS APIs..

Suggestion # 3 Common Interest in the Challenge of Data Models & Persistence
To the uninitiated it is difficult to spot the generic patterns that underpin the VistA codebase, especially in terms of clinical content. My impression is that across the M language/database there are deep patterns that underpin the flexibility of the VistA platform.  The difficulty of their current state that as of now these are nowhere near as easy for clinicians to visualise, comprehend, review and improve as internationally leading approaches such as openEHR archetypes (which are gaining ground in the NHS  in Leeds Care Record, WardWare, UCL Moorfields openEyes etc(Explore the International openEHR CKM for a flavour) . My instinct is that the pioneering work on VistA FMQL may be well placed to help spot these patterns and work well with the openEHR archetype methodology to address the challenge of clinical data models.
At a deeper technical level, the value of Mumps as the ideal database for healthcare needs to be better communicated across the NHS, esp to those now exploring the optimal means of healthcare data persistence – with changes in the database landscape emerging in the form of new NoSQL technology (e.g. MongoDB) in the age of Big Data.

Conclusion
As the NHS starts to explore VistA , that journey may begin with some NHS Trusts looking to deploy VistA  on an NHS patch, but if this is done in isolation from the rest of the NHS OS community it would be an opportunity lost. More importantly, both OSEHRA from the US and the NHS in England now acknowledge the need for clinically led,  agile development of an OS EHR platform to transform healthcare in the 21st Century.
Lets hope that the OS EHR community of both sides of the divide can now look to better understand each other, collaborate and stimulate a wave of transatlantic innovation.

PS: The forthcoming VistA Expo conference in Seattle (Oct 22-25) should be a great place to learn more from the VistA Community for anyone fortunate to be able to attend.

As I mentioned as this year began, this year of 2013 is one of changes for me.
One of those changes is the move to focus on some key challenges via frectal Ltd. This is a company I set up some time ago and have recently moved to Dublin, Ireland.

Most companies have a logo that says something about themselves and so earlier this year I ran a design competition to design the logo for frectal.
When exploring how to get help with a logo I naturally hit the net to uncover great design skills. Assuming I’d use a local design shop I was quickly surprised and interested to find options in virtual design shops online, such as 99Designs, DesignCrowd and CrowdSpring. I wasn’t expecting them.
Yet these sites offer the option to run design competitions for logos, business cards, websites, etc etc from wherever you are, working with folk all over the world, wherever they are. The approach was intriguing enough that it had to be tried. So for little/no risk I began the process with 99Designs.

As an advocate of User Centred Design, I had some clear ideas of what I was after and was keen to lead the design process myself.

The Design Brief was indeed brief, i.e.

“I am keen to incorporate 2 elements in this logo design
No 1 is the Golden Spiral shape
http://en.wikipedia.org/wiki/Golden_spiral
No 2 is a clean/simple font for the brandname,
(perhaps something like an old typewriter font)
http://www.identifont.com/similar?BOQ

To construct the golden spiral shape
I’m looking for the letters from the word frectal
f r e c t a l
..using the clean font..
..to be arranged so that they make up the golden spiral shape
and the same font to be used to have the word frectal underneath the logo

So the logo would consist of
1. spiral shape on top , using the letters from the name frectal
2. brandname frectal underneath”

The rationale for this design was related to the
–frectal is a play on the word fractal,
–fractals are patterns seen all over the complex world around us.
-perhaps the most famous fractal relates to the famous “fibonacci sequence” and its “Golden Spiral“

Thereafter the competition began and lasted for one week.

In that time I was fortunate enough to have 123 entries from 19 Designers.

Key to this agile development process was regular, ongoing communication between myself and the designers, ie 157 comments over and back over the course of the week.
As the design evolved the number of designers that stayed in the competition dropped off, so in the end I was working collaboratively with a small number of my preferred designers.

This whole collaborative process of refining and refining the design I wanted was the essence of agile and iterative development and felt very productive from my perspective.
In the end of the process, the effort and help I received was so useful that I was very happy to award both a first and second prize.

So here now is the frectal logo, a story of design and collaboration!

Further to some recent posts on the challenges in healthcare, thought it may be useful to outline some steps that I’m personally involved in towards tackling some of those very challenges.

Since finishing my training in Emergency Medicine and Informatics, in one form or another I’ve ended up in positions of Clinical Leadership.

What does “Clinical Leadership” mean to me? Its a term that has gained increasing traction in recent years…
Simply put I believe its applying the principles of leadership to improving the healthcare systems of this world, by those who I believe should be leading that change… the clinicians.

In writings elsewhere I explore the complexity of the healthcare system and the simple rules that need to be applied.
Clinicians need to lead the change in healthcare. (People)
Improving the process of healthcare should be an important focus of our efforts. (Process)
Information is key to understanding and improving healthcare. (Information)
Technology, in the sense of 21st Century Information Technology is therefore an essential part of the change. (Technology)

Thankfully the NHS in recent years has matured in its understanding of the value of Clinical Leadership in general and the role of Clinical Leadership in Information Technology in particular.

The role of Chief Clinical Information Officer (CCIO) has recently been understood as a useful role in leading healthcare change.

In recent years as part of my role as CCIO in Leeds (aka Clinical Lead for Informatics/Chief Clinical Information Officer), I’ve ended up taking a stand on several aspects of healthcare IT that I believe need it, esp the role of open standards and open source in healthcare. The key aspects of our strategy here, via the active Leeds Clinical Portal and emerging Leeds Care Record work incorporate those important  elements for the future of healthcare.

Over the next week important landmarks for NHS CCIOs and NHS & Open Source are expected.
I’m looking forward to attending a workshop later this week to meet other fellow CCIOs for an inaugural CCIO summer school.
Within the week further announcements on the role of  open source in the NHS are also likely.

Will these two agendas will come together..?
Who will lead this change…?
I believe that clinicians need to be leading fundamental change across the healthcare sector, including the health IT market which underpins its reform.
Certainly it feels like the time has come to take that stand.

After what has been a particularly cold winter and spring here in England, we have also endured on the more difficult winters in the Emergency Departments of the NHS.

Aside from blaming the cold, there are a couple of other lessons to be learnt here.

The National Health Service in England, which has provided “free at the point of care” healthcare to its citizens for over 60 years is a noble institution of which folk are rightly proud.

In the last 10years I have been a witness to the tremendous and impressive changes within its Emergency Departments, with the advent of the 4 hour target/standard, which has transformed the approach to delivering care in EDs, with a focus of timely emergency care that only a time based measure could provide.

While it has been an honour to have witnessed and been part of that change, what has also become apparent has been, that despite/in spite/because of that standard and ambition to improve emergency care, that the population has voted with their feet and there has been a massive 50% increase in ED attendances since the advent of the standard.

One could argue that such an increase in business is a real vote of approval and confidence in the NHS EDs, though unfortunately aligned with the pressure to process patients from arrival to discharge in under 4 hours in 95% of the that time.. it has led to huge pressures within the departments and as a consequence a  real difficulty recruiting and retaining staff.

Other related have been raised in what is now been acknowledged as a current crisis in NHS Emergency Care..
-including the wisdom of providing entirely free healthcare, which some argue removes individual responsibility for managing ones own health
-and the challenge of the demographic timebomb in the western world, where limited resources are trying to fund the care of an increasingly aged population, which has led some to declare that the NHS simply cannot continue to the endless needs of an ageing population, i.e. it cannot continue to promise to offer to solve all the ills of all men.

Deep down, there is a more profound lesson to be learnt here, that if in the United Kingdom which has one of the most mature healthcare systems in the world, has despite targeted effort to radically improve its emergency services over the last 10 years, is back in a position of crisis.. what does that tell the rest of the world?

Surely, at least to my mind, it keeps coming back to the fact that the future lies in working smarter not harder. Throwing endless resource at the problem, current solutions and the current mindframes that have got the system where it is, simply will not work in future.

Radical, brave and far reaching change is needed, across the western world, in terms of what we promise and what we aim to deliver in healthcare.

.

.

Thankfully this month has also seen the publication of a related report which helps shine a light on a way forward..

“Affordable Excellence: The Singapore Healthcare Story: How to Create and Manage Sustainable Healthcare Systems” by William Haseltine is a great exposition of a carefully considered and developed Healthcare system.

One of the key opening lines tell us a lot ..
“Today Singapore ranks sixth in the world in healthcare outcomes well ahead of many developed countries, including the United States. The results are all the more significant as Singapore spends less on healthcare than any other high-income country, both as measured by fraction of the Gross Domestic Product spent on health and by costs per person.”

In brief, the story outlines some of the key features of the Singaporean model of government that has lent itself to fostering such as a healthcare system. Those include objectives laid out in a governmental plan such as :

º Become a healthy nation by promoting good health
º Promote individual responsibility for one’s own health and avoid overreliance on state welfare or third-party medical insurance
º Ensure good and affordable basic medical services for all Singaporeans
º Engage competition and market forces to improve service and raise efficiency
º Intervene directly in the healthcare sector when necessary, where the market fails to keep healthcare costs down

The Singapore System offers 3 key approaches:

MediSave- which is a mandatory healthcare savings account, from where accumulated savings may be used to pay for healthcare expenses under established guidelines

MediShield – offers an insurance to protect patients in the case of catastrophic illness or injury

Medifund- which is another system safety net, designed to help the needy with their healthcare bills.

The Singapore system promotes high quality, safe, and cost effective care via a national approach to guidelines for care, while recognising the importance of information to underpin such a system, through their recognised leadership in Electronic Patient Records.

Several of these lessons strike a chord particularly – the coordinated approach that recognises the need for both public and private players/ encouraging individual responsibility while offering a safety net where needed/ fostering good quality, safe care and the power of information.

The rest of the healthcare world has much to learn from the lessons from this small but smart leader in the field…I can commend it to you.

(BTW On the subject of small, smart, leadership and making a difference in the healthcare world, more on a career move of my own coming soon..)

Tony

For a change this month, I thought I would try a video. Based on some of my writing and a presentation I did at last years ICEM.. I’ve decided to try a brief related screencast.

These 7 slides start to explore the Simple, Complicated, Complex and Chaotic elements of work in Emergency Medicine.

If the video isnt displaying above, try this link to the original on vimeo

It also starts to explain the related Cynefin framework that brings these elements of Emergency Medicine work together.

The examples I use include;

• Simple- Measuring a persons Vitals signs – some say simple tasks take about 10 hours to learn
• Complicated- Managing a patient with Cardiac Arrythmia e.g. Atrial Fibrillation- some say complicated skills take 1000 hours to acquire
• Complex- Managing 1/many patients in your resus room in a state of shock (?hypovolemic ?septic ?cardiogenic) takes 10,000 hours of experience.. to spot and harness the patterns
• Chaos- Managing chaotic situations – requires instinct, leadership and action , e.g. patient in Ventricular Fibrillation needing defibrillation.

The Cynefin framework can be applied to Emergency Medicine, by pulling these elements of our work together to help make  sense of our daily challenges and suggests related solutions.

I hope you find these slides of some interest/value.

Tony

Within the next few days one of the most significant changes to the National Health Service comes to England.

From the 1st April, the NHS Commissioning Board (based in Leeds, England) formally takes over the running of the NHS. While it has been up in shadow format for some time now, this move is a landmark in the history of the NHS.

While it can be very difficult to comprehend all the changes in detail and while it is the subject of much debate within the NHS, what it key is the *split between the commissioning and the provision of healthcare*.

The NHS is a publicly funded healthcare system, i.e. paid by taxes. Over previous decades there have been previous efforts to develop an internal market within the NHS to promote competition has taken several forms (eg GP Fund Holding).

This latest initiative aims to promote, within the public sector, 2 separate sets of skills ..
..one around the commissioning of services (the analysis and buying power)
..another of the provision of services (the production of services and their related sales ).

There are similarities in this model and that of the social/healthcare insurance models that are seen elsewhere in the world..
..where the insurance companies generally act in that buying role ,
..while healthcare providers provide..
..and patients shop for the care they need/want.

My understanding is that there is a subtle but important difference seems to be part of the commissioning/provider split…
.. that commissioning should be done in advance to help project the value and cost of care by local area/clinical condition etc.
So there is a prospective planning aspect to the idea. Which should in theory help foster a different ecosystem than others..

It is assumed that the move should promote the funding of evidenced based care and hope to avoid unnecessary healthcare activity which does not improve clinical outcomes yet adds costs to the healthcare system.

Looking beyond the current changes, if one looks at other business sectors, my instinct is that this split is here to stay, whatever model of healthcare funding you use.
It is clear that as Walmart , Amazon , Tesco etc have shown how the retail trade has been shaken up entirely within the last century, so too will such changes come to healthcare.. most likely to the provision of healthcare in some shape or form as we are already seeing in many countries.
If “HealthMart” the global healthcare provider comes to be any time soon..then what will also be needed will be skills and expertise to oversee and govern such providers of healthcare.
Healthcare cant easily be purchased by the layman without some independent guidance and advice on how ones money should be spent.

So my sense is the role of commissioners in healthcare, in some shape or form is  here to stay…

Amidst yet a turbulent month in European economics – with the downgrading of the British economy from its valued AAA status and elections in Italy throwing the Eurozone back into angst and concern – came a very helpful special report from the Economist on the Nordic Countries.

Though small in number and population, 4 Northern European countries Sweden, Denmark, Norway and Finland have been quietly building very successful economies (and by many measures successful societies) over the last decades.

Having suffered a financial crisis within (back in Sweden in the 1990s) they have explored a middle way between capitalism and socialism that seems to be very clearly delivering results.

Those include high rankings of the Nordic Countries ;

• Global competitiveness
• Human Development
• Ease of Doing Business
• Global Innovation (think Skype & Spotify)
• Prosperity

Most manage to provide for the good of society (e.g. free healthcare and education) while embracing market economics (e.g. school vouchers offer parents access to a choice of private schools)

While the report admits there remains too much bloat within the Nordic systems (i.e. welfare states that cant be afforded indefinitely) it does confirm that these countries seem to balance a pro-business agenda with improving equality within.

There is much of interest within the report. As it says “The world will be studying the Nordic model for years to come”.

You’ve read much of the challenges facing healthcare.

Despite all the promise of change, you’ve likely read much of the challenges of healthcare innovation with technology.
“When you think how technology has reshaped everything from the way we shop to how we communicate with friends, the lack of progress made by the NHS is astonishing.”  The NHS’s troubled relationship with technology, BBC News, Jan 16th 2013

So here is a good news story, an example of innovation in healthcare you don’t often see…

Billed as the Healthcare Design Challenge, run by the US Challenge.gov agency who kicked off a contest with a prize back in October 2012.

The brief was pretty simple.. “We challenged designers across the country to reimagine the patient health record.”

1. Improve the visual layout and style of the information from the medical record
2. Create a human-centered design that makes it easier for patient to manage their health
3. Enable health professionals to more effectively understand and use patients’ health information
4. Help family members and friends care for their loved ones

The competition was run over 3 months, attracted over 200 submissions, competing for a prize of $50,ooo USD.
Yes.
Just 3 months (October 2012-Jan 2013),
Over 200 submissions (230+),
Sharing a prize of $50,000 USD ( a tiny tiny tiny % of US Healthcare spend)

The results they got were fantastic.
You can have a look at the successful outputs of the Healthcare Design Challenge here.

A good news story and a pointer to one important way forward to healthcare improvement..