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

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Posted by: Tony Shannon | November 10, 2014

EHILive 2014 Conference update

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

 

#1) Connecting – Leeds- Care Record update

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

 

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

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

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

 

Related videocast here;

 

Posted by: Tony Shannon | October 31, 2014

FAO Medical Leaders: Cynefin: A Leader’s Framework

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

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

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

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

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

The principles of complex systems..

A complex system is one that;

-is made up of many parts with

-has many interactions between its parts

-cannot be completely understood

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

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

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

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

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

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

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

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

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

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

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

Chaos-Complex-Complicated-Simple and the Cynefin Framework

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

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

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

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

Simple

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

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

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

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

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

Simple: Sense, Respond, Categorise (Best practice)

Complicated: Sense, Analyse, Respond (Good practice)

Complex: Probe, Sense, Respond (Emergent Practice)

Chaos: Act, Sense, Respond (Novel Practice)

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

Reference:

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

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

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

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

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

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

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

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

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

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

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

Posted by: Tony Shannon | August 30, 2014

Leeds Care Record: What’s that all about?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr Tony Shannon, Clinical Lead for the Leeds Care Record

Please see LeedsCareRecord.org for further details..

 

 

Posted by: Tony Shannon | July 31, 2014

Road Trip: EU: Summer 2014

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

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

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

shannonroadtrip2014map1_c

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

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

Posted by: Tony Shannon | June 30, 2014

21st Century Healthcare: the Open Platform that will Transform

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

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

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

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

Posted by: Tony Shannon | May 30, 2014

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

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

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

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

HealthcareChangePPIT_1slide_v3

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

A – A Myriad of Siloes

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

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

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

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

C-  Corporate/Conglomerate Choice

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

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

B- Best of Breed 1.0/2.0

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

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

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

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

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

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

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

Posted by: Tony Shannon | April 30, 2014

Healthcare: Generic Health Improvement Strategy

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

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

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

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

 

Mission & Vision

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

Lets accept that surge in growth for a moment.

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

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

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

HealthcareChangePPIT_1slide_v1

 

People:

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

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

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

 

Process

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

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

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

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

Information

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

 

Technology

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

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

 

Value:

 

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

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

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

 

##

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

So there’s your start.. more later..

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

Posted by: Tony Shannon | March 31, 2014

EHR// Hardship : Exception // Fix: Usability

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

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

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

 

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

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

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

 

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

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

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

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

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

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

 

Posted by: Tony Shannon | February 28, 2014

Shared Decision Making- a key to 21st Healthcare

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

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

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

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

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

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

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

 

 

 

 

 

 

 

Posted by: Tony Shannon | January 31, 2014

NHS Chief Clinical Information Officers: Vision & 12 Point Plan

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.

nhsvista_patientsbyagegraphv2

nhsvista_patientListv2
nhsvista_patientsvitalssignsngraph_v2

nhsvista_addallergyV2

NHSVistA_TabletViewv2

 

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.

Posted by: Tony Shannon | November 30, 2013

Leeds Lab Launch

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..

Posted by: Tony Shannon | October 31, 2013

Remote

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;

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.

Posted by: Tony Shannon | September 18, 2013

Transatlantic Thoughts.. A VistA .. to/from the NHS

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 2nd 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 21st 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.

Posted by: Tony Shannon | August 31, 2013

The frectal logo… a story of Design and Collaboration

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.

99DesignsLogoCompetionV2

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!

frectalLogo_wAltTypW

Posted by: Tony Shannon | July 31, 2013

Open Source in the NHS.. a landmark is reached

Open Source in the NHS.. a landmark is reached

The themes and interests that I explore in my writings cross a range of issues… the complexity of the world, of healthcare, of change, the challenge of change, which often involve a mix of people/process/information and technology..
Within that range you may note a few recurring themes and I return to one of them with this post.
That is that “open source”  is/will be key to the future of healthcare.

When I penned a view back in 2010 that “open source is part of the recipe” several years ago, it was a personal view that few others seemed to share… Over the last few years, its been interesting to see a slow but steady change within healthcare in that direction.
My sense is that in the fullness of time, several key related landmarks will be hailed at pivotal to the future of healthcare.

Back in 2011 the Veterans Health Administration in the US were the pioneers in the field, when leaders as they were and remain, they moved towards the establishment of an open source healthcare ecosystem, to both improve their own healthcare system and encourage others to get involved in new ways of working.

Now in 2013, in the month of July, another key landmark has been reached. Under the leadership of NHS England, the National Health Service in England, has for the first time, publicly declared the “potential benefit created by multiple NHS organisations collaborating ..[on] the ongoing development and improvement of these [open source] products.
Without wanting to overstate the significance of this “Safer Hospitals, Safer Wards” initiative, I believe this is brave, it is right and is a landmark move towards the future of healthcare.

Lest you get the impression that I’m suggesting that open source is some magical elixir that will cure healthcare on its own.. let me correct you. In fact let me point you to other writings on healthcare penned here… the key points of which are;

Healthcare Systems are examples of Complex Adaptive Systems, which are challenging to change.
Many of the complex healthcare systems around the world are on the “edge of chaos” and require fundamental change.
The common patterns of change that most agree are required in healthcare involve a mix of people, process, information and technology change.. towards a more patient oriented system.. that delivers better value for money.
The financial state of many western economies now mean that such change is no longer an option.. it will be essential.

Within the Information and Technology elements of healthcare, I have made the case elsewhere that the health IT industry could/should provide better solutions than currently exist .. to do so is not just about simply throwing money at the problem, but rather an understanding of the complexity of healthcare, an appreciation of its culture, of the common patterns of process that underpin the diversity of healthcare and a move towards IT tools that can survive and thrive in such an environment.

In earlier work, while involved in the NHS National Programme for IT, I was deeply involved in clinically led work, aimed at supporting key processes in healthcare, with an open, standards-based, architecturally solid approach.. yet hit a wall as I explained at the time. As the NHS moved on from the National Programme for IT, which was in some ways about purchasing  IT systems and rolling them out, the talk has moved  on towards “open standards” and “interoperability” between systems.. yet my experience in this field is that that alone is not enough… many of the current vendors in the market either can not or will not interoperate based on standards alone.  (Which should be read as a critique of the state of both the current Health IT market and current Health IT standards).

Which leads me to reaffirm the role that open source has in healthcare as part of the recipe.

To help explain , I’d like to draw your attention to an image.
Its actually a fractal pattern… (one of my other interests is fractals (hence frectal!).. known as the Sierpinski Triangle.

I use it to illustrate a relatively simple point..
.. that is there exists a hive of activity around the world involving health IT.
From the top of the international tree (eg WHO) down to the many many folk who are tackling change at the frontline in healthcare, many efforts are tackling the same challenges of how do you improve healthcare.. looking to IT to help

At this point in time there are far too few of those efforts joined up and far too much reinvention of the wheel,, over and over and over.

That is not to suggest that any top down imposition of any healthcare solutions (IT or otherwise) will work (we’ve tried that and it doesn’t).
Nor does it suggest that the disconnected Access/Excel health IT hacks that happen all over the world should continue indefinitely.

Rather it suggests that we can now start to connect..

Note:  You’ll also note that every triangle has 3 sides so let me reuse the number 3… 3 times..

What I would suggest is that if for just 3 reasons, I believe “open source” is key the the future of healthcare..

  • Unconstrained innovation – ideas and ambitions can be shared by folk who are oceans apart
    If any industry could/should be improved by folk who live miles apart its healthcare.
    I don’t know one doctor who wouldn’t want to share his/her good work with the rest of the medical world.
    The progress of medical science has been based on the spread of ideas..
  • Transparent credibility -allowing immediate detailed scrutiny immediately boosts credibility
    Again there is a fit with healthcare.. the “publish or perish” culture of modern medicine demands that healthcare advances are laid open for scrutiny by our peers
  • Decentralized control – amendments and improvement can come from the bottom up
    Yet again this fits with healthcare, a complex adaptive system, full of folk who locally innovate and do not/will not wait for top down approval to solve their local need

(I’ve taken these from elsewhere and have repeated them again here as I hope they are helpful)..

Last month I suggested that CCIOs across the NHS may want to make a stand on the important role of open source in the NHS.
Thankfully I didn’t have to try too hard and other CCIO leaders in this field are spreading the open source message.

For information, those 3 groups mentioned in the recent NHS Safer Wards, Safer Hospitals guidance as leading the open source movement in the NHS, Moorfields Eye Hospital, King’s College Hospital and Leeds Teaching Hospitals who began their own journeys at the bottom of the triangle of activity are now moving on to collaborate for the next phase of their work..

On reading this article, you now have at least 3 options with regards to this future!..

Deny it
Ignore it
Embrace it!

Posted by: Tony Shannon | June 30, 2013

Clinical Leadership: Time to Take a Stand

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

Posted by: Tony Shannon | March 30, 2013

Commissioners and Providers

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…

 

Posted by: Tony Shannon | February 28, 2013

Northern Lights – from the Economist.com

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”.

Posted by: Tony Shannon | January 31, 2013

Healthcare Design Challenge- Eyes on a Prize

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..

 

Posted by: Tony Shannon | December 31, 2012

Doing Less

As the year of 2012 closed it was time for some reflection in the rolling hills of SwaleDale..
.. one recent message stood out from the others, as worthy of attention for the year of 2013.

The Disciplined Pursuit of Less, was an article that I had come across towards the end of the year that struck a chord.

Many of us are busy folk who juggle work, play, family life etc. Most of us yearn for success and fulfilment in what we do, yet in the modern world, we recognise that no matter how hard we try our intray will never empty… there is always stuff to be done…so how do we ensure our time on this earth is spent well?

Having been very fortunate to have opportunities in my clinical, management and technology roles, at the present time I’m busy wearing 3 hats at work. As I said am grateful for the opportunities I’m having in life.

In the clinical domain of Emergency Medicine, understood as the front-line of the healthcare system, the ED In Tray is rarely empty.  While the intensity and mental stimulation of the work is as challenging as anything else you will ever find/anywhere, the lens of the ED highlights the unsustainable nature of modern medicine and the need for smarter solutions to improving healthcare..

In the domain of Healthcare Informatics, the challenging yet inevitable move towards “smarter” healthcare raises many people, process and technology challenges. People issues of cultural change and the need for leadership, processes that are siloed and slow to change, technology that is proprietary and difficult to flex and integrate.

In the domain of Information Technology, a buzz permeates the air with the Information Revolution around us, yet there remains a major gap in the tools I need at the ED front-line to make the best use of my time there..

As my working life unfolds, progress to see better smarter healthcare systems always seem slower than I would like. We know real change takes both patience and sustained effort.
One of the keys to explaining the difficulties of change involves exploring both success and failure..

The aforementioned article from Greg McKeown, he talks of 4 phases of personal and organisational success which explores this challenge.

Phase 1: When we really have clarity of purpose, it leads to success.

Phase 2: When we have success, it leads to more options and opportunities.

Phase 3: When we have increased options and opportunities, it leads to diffused efforts.

Phase 4: Diffused efforts undermine the very clarity that led to our success in the first place.

Curiously, and overstating the point in order to make it, success is a catalyst for failure.

McKeown suggests some approaches to get through..

First, Use more extreme criteria

Second, Ask what is essential and eliminate the rest, i.e Do Less..

That’s useful advise as we face into 2013, i.e. the challenge is where to focus our energies.. where best to focus efforts. More on that as 2013 unfolds..

Posted by: Tony Shannon | November 30, 2012

Better Care at Lower Cost

This month of November 2012 has seen a couple of significant events.

In the US we have seen the re-election of Barack Obama for a second term, though his first task post election is to face into a “fiscal cliff”.
In Europe we have seen ongoing economic challenges within the EU, with a recent EU budget summit ending in failure.

What relevance do these events have to any of us at a grassroots level?
Well several years after the global financial meltdown of 2007/2008, it demonstrates that the science of economics is still not agreed on a “spend or save” strategy, to get the Western world away from its history of excess..
The recurring theme for the West is how to work smarter…how to progress towards more efficient economies..?

In that context there has been a very clear report on the state of the healthcare sector that is worth a read. Its a report based on the US healthcare system, yet it makes a point that I believe applies to much of the developed worlds healthcare systems.

Named “Better Care at Lower Cost”, it highlights the shocking figure that up to $750 billion (yes billion) dollars are wasted every year within the US Healthcare System. That figure is worth a moments reflection… so too is the keyword waste..

Depending on your point of view that figure either represents a great big market opportunity or simply a big pile of waste. From a related commentary about these irresistible forces that will change the US HealthCare system, Brian Klepper makes the point that;

“Health care’s ever-increasing revenue growth has come at the expense of individuals and firms that pay its bills, directly through health plan premiums, and through taxes, often instead of buying other goods and services. It transfers wealth to health care from everyone else. Like the finance services industry, health care has become a disproportionate “taker” industry, sapping economic vitality from America’s communities.”

So its coming time for some hard discussions on how much economies spend on their healthcare system.

Now we know that the US is a outlier in terms of its % GDP spend on healthcare and the mismatch between its spend and its outcomes, which are not particularly good. However the US is not alone in this regard. Other economies are struggling to contain their healthcare costs.

The key lessons from the Better Care at Lower Cost are useful in any setting. The key points being..

Complexity of Clinical Care:
Physicians in private practice interact with as many as 229 other physicians in 117 different practices just for their Medicare patient population

Cost of Care
For 31 of the past 40 years, health care costs have increased at a greater rate than the economy as a whole

They commend 4 key Characteristics of a Learning Health Care System as a way forward.

Culture
-Leadership-instilled culture of learning, supportive system competencies

Patient-clinician partnerships
-Engaged, empowered patients

Science and informatics
-Real-time access to knowledge, digital capture of the care experience

Incentives
-Incentives aligned for value, full transparency

 

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You can learn more from this excellent report at iom.edu/bestcare

Posted by: Tony Shannon | October 31, 2012

Javascript & NoSQL: Some History and Some Future

Though I spend a significant part of my work in the Information Technology field, you wont have seen much in the way of real technical aka “techie” stuff on this blog to date.

For the most part, my work involves brokering discussions between those with no technical background (i.e. clinicians), those with some technical background (e.g. some management colleagues) and those with a deep technical background (the “techies” or the engineers of this world). Much of that brokerage involves trying to find common ground between those differing perspectives, so I find that I end up using words like change… discussing people, process and information issues…with a blend of technology.

In this post, I needed to bring your attention to some happening in the software/technical world that I think are worth sharing with a broader audience, so I need to use two technical phrases.. “Javascript” and “NoSQL”.

Java is an island, is also the name of a blend of coffee and for some of those reasons became the name of a software language which became popular in the 1990s. Script, or Scripting is a technical speak for quick and easy computer language..

Javascript was developed as a popular, quick and easy,  light weight, software language about the same time as Java, i.e. in the early days of the Internet.
Now Javascript is only 1 of many many software languages, though it is particularly interesting to me for 2 reasons.

1) It has recently become the most popular of all programming languages
2) It happens to be the same programming language that I used when developing a web based application back in 2000.

Furthermore though back at that time I was using Javascript in an unusual way (tech speak: as both the client side and server side language in an Active Server Pages environment), that approach has most recently become pretty popular. Thats not to say that I saw any of that coming, but quite simply it was the easiest and most software productive language I could find at the time, plus I only wanted to learn 1 software language and no more..
My sense is that part of the increasing appeal of Javascript is that is now starting to offer the power to do some amazing things with just 1 language, where in the past many software developers juggled several different languages to do the same thing.. which seemed inherently over complicated to me.

In brief Javascript (with tools such as Sencha/ExtJS, JQuery, Node.JS, the related rise of JSON etc) is becoming quite a force to be reckoned with and my instinct is that this is of real significance to the software industry, the web etc.

If you would just like to see one thing that Javascript can do, I have to commend these stunning views of the Periodic Table of Elements.

On a related note, I’ll now mention;

NoSQL – or No StructuredQueryLanguage

The term relates to “databases”, another key part of the software world, essentially where “data” gets stored.
Without delving into the deep history here, the engineering of databases has gone through several stages, as you might expect.

SQL StructuredQueryLanguage has become the basis of  most “standard” database approaches.. ie  it has for many years become the “norm” in databases and was the approach that I used back in 2000.
In very simple terms SQL databases are widely understood as “relational” databases, ie with several/many tables of data, with relationships between those tables,  more related reading on databases here..
It suffices to say that planning a SQL database can get/has become a complicated effort.. overcomplicated many might say.. so the limits of SQL databases seem to have been tested by some of the Big Data challenges that the web has started to throw at them.

Hence the more recent move toward NoSQL databases such as the very interesting (& JSON oriented) MongoDB, which have become increasingly popular of late…
Part of the promise of NoSQL databases, as I understand it, is that they allow for a much more flexible approach to database building and ongoing maintenance.
Looking back, the interesting thing was that though I was working with SQL databases back in 2000, I was made aware back then of a database that was meant to be very fast and flexible, so much that the US Veterans Administration were running their Health IT system on it… as it happens I know now that it happened to be a powerful NoSQL database.. by the unusual name of Mumps..an impressive but poorly understood technology, which may be best explained in this impressive paper on its role as a Universal NoSQL Engine.

Now to the link between these pieces of history.. it just so happens that a colleague who happens to know a great deal about both of these subjects has just begun blogging. His name is Rob Tweed and he has recently begun what I believe are a very important series of articles about these 2 technical elements, which share some history.

From what I have read he makes a very compelling case as to why these technologies have a very promising/important future… together. For some more history and more of that future, pop over to robtweed.wordpress.com

Posted by: Tony Shannon | September 30, 2012

Cell Counter; NHS+HackDay; openSource+openEHR

Last weekend the NHS HackDay movement came to Liverpool, where a group of “Geeks who love the NHS” came together for the second event of its type.

This bottom up movement for change in the NHS was started by a couple of smart junior medical doctors some months ago, with the first NHS HackDay in London in May. The Liverpool event attracted another very healthy number of clinicians and developers to work together.

The format of the two day events is very much in keeping with good practice in stimulating innovation within a complex adaptive system such as healthcare.
The days start with a round of 2-minute pitches by those with ideas- they may be clinicians with ideas looking for developers or indeed developers with ideas looking for clinicians.
Those 2-minute pitches are strictly enforced, so within an hour approximately 20 very different ideas have been shared.
Then the groups disperse to network and see who comes back working with who after coffee.
Its a simple approach that flushes out the “wheat from the chaff” and allows small agile teams to form and get working together fast.
Aside from that there is little structure or planning to the event, so the best teams take a user-centred and agile approach, working to complete their hacked app as best and fast as they can, aiming for close of play on the second day.

Then the results are judged by their peers and first/second/third place awarded, with small prizes on offer.
The related code is open sourced on public code repositories.

This time around the winner was a Cell Counter app by Wai Keong Wongs team. Wai Keong is a haematologist in the NHS and one of those behind the NHS HackDay movement.

The simple but important target of Cell Counter was to replace the physical cell counters used in Haematology labs around the UK for analysing Bone Marrow specimens, similar to the illustration below. The fact that such a tool is still in action in 21st healthcare illustrates just how far behind healthcare is behind the information age…

Worth mentioning at this point, when discussing healthcare apps – the opportunity of healthcare app development raises the related risk of siloed information system development that can not interoperate.
Thankfully in addition to a clinically driven, user centred and agile design taken by the Cell Counter team, one other very important related technique was used, that is they leveraged the “archetype” concept . With the help of Dr Ian McNicholl of the openEHR Foundation, the related cell count archetype was hacked as part of the process, aiming towards the interoperable use of the app in future.

All in all, a great lesson in the future of healthcare computing. Well done to all those involved!

Posted by: Tony Shannon | August 31, 2012

Open Source .. the story grows

Coming across a couple some new angles on the open source story in recent days.. thought it was worth a share.

 

Beyond the important case that can be made for open source software to transform healthcare with IT, there is a growing view that there is a case to be made that open source knowledge is also needed in healthcare.

It has been long established that as part of a medical career, one should “publish or perish” to rise the ranks.

Yet the truth is that with the growing number and volume of medical journals that has risen, it has become impossible to keep up with that deluge at the frontline.. hence the emerging gap between “bench and bedside” , i.e. delivering evidenced based medicine at the point of care.

Another concerning aspect of the medical publishing industry is the closed nature of many publications, ie despite the fact that much of the research is publicly funded, many of the journals are subscription only, so cannot be accessed at the point of care, esp in developing countries.

The issue is highlighted here in an important case for open access in medical knowledge sources.

 

From another angle, here is another nice article , this time making the case that open source is not limited to software.

It makes the case that 3 key advantages (which are making it a powerful force in other areas such as open source hardware.)

  • Unconstrained innovation – ideas and ambitions can be shared by folk who are oceans apart
  • Transparent credibility -allowing immediate detailed scrutiny immediately boosts credibility
  • Decentralized control – amendments and improvement can come from the bottom up

 

 

As followup to last weeks post on the NHS and its exploration of the role of VistA..
.. you may be interested in this recent project I’ve been involved in.

To illustrate the people, process and technology elements of healthcare IT development.. in a rapid and agile way.. I was involved in a small project which involved 1 clinician (myself) and 1 developer (Chris Casey) working together (though remotely) over 10days.

As the clinician I was involved in setting the “requirements” (a 1 pager) and the “design” of the application.
Chris was involved in the “build” and we both shared in the “test”.
Most of the 10days we corresponded by email/skype or phone to feedback on issues encountered…
..so an iterative and agile approach.

The result of our efforts are to be seen here and more project related material here at clinuip.wordpress.com
A summary 20 minute presentation for the VistA Community Meeting last month is available here.

Hopefully it illustrates the real benefits of user centred & agile development methods.. plus illustrates moves being made towards alignment with the Healthcare IT platform of VistA (an international leader in its field, which also happens to be open source).

Posted by: Tony Shannon | July 6, 2012

NHS & VistA; Exploring Challenges & Opportunities

The National Health Service in England has put much effort into improvements with Information Technology over the last 10years. While some successes were made, unfortunately important parts of the NHS (esp the acute hospital sector) did not particularly benefit from the massive investment, as recently explored in NPfIT Horrible Histories..

In that context the Nuffield Trust in London ran a workshop yesterday, exploring the potential for the open source VistA Electronic Health Record system in the NHS.
“Sharing international experience: Is implementing the VA’s electronic health record system an option for the NHS?”

The Veterans Administration are acknowledged international leaders in the fields of healthcare reform, process improvement and information technology in healthcare.

As I’m involved in promoting the role of open source in the NHS and been doing some work towards alignment with VistA, I was asked to speak on Practical Considerations for VistA in the NHS. 

The discussion was good and some important actions were agreed. The group involved will now begin working towards some of the recommendations of the NHS VistA campaign, in particular the prospect of a Gold Standard version of VistA for the NHS.

Posted by: Tony Shannon | June 30, 2012

International Conference on Emergency Medicine 2012

Having finished up at the International Conference on Emergency Medicine 2012 in Dublin , I’m uploading 3 related presentations, which may be of interest..

1) The Value of a Leadership & Decision Making Framework in Emergency Medicine – introducing the Cynefin Framework to addressing the Simple, Complicated, Complex and Chaotic challenges in Emergency Medicine, Management & Informatics.

2) Current Challenges with a Paperless ED, which examines some of those very challenges here and now..

3) Guideline Based Workflow Integrated Electronic Health Records– as the theme of the conference was Bridging the Gap: Between Evidence and Practice this explores the challenges in supporting real time support for this ideal..

Also of note, we had a second meeting of an international network of Emergency Physicians with an interest in Informatics.

Lastly the value of Twitter at conference times emerged, with an active stream of #icem2012 material helping to keep up…

(This post is adapted from an earlier article here
https://frectal.com/book/healthcare-an-introduction/
and is being posted in parallel on the Emergency Physicians International social network
in advance of ICEM 2012 meeting)

 

Aside from tackling patient care on an individual patient by patient basis, many of us are members of healthcare teams and departments making efforts to improve the organisation of the healthcare they provide.

As will be explored during the ICEM 2012 meeting in Dublin, there is an acknowledged gap between evidence based medicine and current practice, i.e. a real gap between “what we know and what we practice”.

Doing the Right Thing: Clinical Audit

One of the key approaches to tackling this gap can be termed “clinical audit”.

Clinical audit has grown in importance over the last few decades in the medical field. The common approach to clinical audit may be explained with the help of a cycle, the audit cycle. Within some healthcare systems the PDSA or PDCA cycle is the cornerstone of audit. PDSA meanings Plan, Do, Study, Act or PDCA meaning Plan, Do, Check, Act.

Lets examine these important elements in a little more detail.

What does the PDSA or PDCA stand for?

P is for Plan.. i.e. the clinician decides what they want or need to explore. For instance in the field of Emergency Medicine it may be the  management of asthma care in the Emergency Department (ED).

It may begin with an interest to explore this aspect of care in the department and compare this with the gold standard that may be recommended nationally or internationally.
With an eye on the “gold standard” knowledge base a number of parameters from a number of patient records need to be explored, i.e. in asthma care, perhaps the % of patients who had their Peak Flow Rate (PFR) measured on arrival to the department and/or the time within which they received their first treatment.
An analysis of a selection of patient records is needed, gathering the relevant patient related information in order to be able to compare current practice against the gold standard that the best evidence knowledge bases recommend.

That analysis usually highlights some common problems (e.g. the PFRs are not being routinely done).Then related solutions need to be formulated, such as standardise the process of initial assessment of asthma, perhaps with a proforma which mandates the recording of PFRs. This trial solution forms the basis of  the “Plan”

D is to Do..

The second step in this particular cycle is called Do. That simply means implement the changes recommended in the plan, at a small scale at first…

S -Study (or C for Check) is to then measure the effect of the changes that were developed in the Plan. It is hoped that improvements will have been seen as the cycle unfolds, but disimprovements are equally important to measure and inform further improvements and actions.

Act.. is in theory, the final phase acting on the further actions recommended in the Study phase.

It should be evident that as explained this is not a single cycle of change but at least two. One can also note that the formality of  the PDCA cycle is simply as a variant on the human problem solving cycle….albeit focussed on exploring the clinical issue in question.
One interesting thing to note is this clinical audit/process improvement cycle is one of many improvement activities that are to be cyclical in nature (i.e. you complete a loop and then reloop some time later). Most of the various methodologies behind quality and risk management are also cyclical in nature.  As are other approaches to quality management. Life is full of cycles..

Trawling through the notes.. Recurring audit theme: improve clinical documentation

Needless to say that much of the current activity of clinical audit involves trawling through patient records to see if things have been done well or not. Interestingly many of the key findings of clinical audit commonly highlight the poor information available and poor clinical documentation is very often an issues that is uncovered.
Without available, complete or legible clinical notes, much of the conclusion drawn in a typical audit are thereby limited by these constraints. Furthermore one of the most common conclusions from a clinical audit that I regularly see is to improve clinical documentation. ( e.g. suggest a template/proforma for specific documentation purposes)…

Ultimately the important and growing need for clinical audit as an integral part of medical practice clearly highlights that we need to get much slicker at information management in healthcare.
Indeed the clinical audit process ultimately needs to be made available as a by-product of routine care to enable real-time feedback of clinical care and continuous improvement. As this is challenging but important, currently audit has become a common driver to develop information systems around “secondary use” drivers such as audit, without serving the frontline particularly well, which has limited success.

So there is a related need for greater effort towards interoperability of health information systems, to ensure that benefits to primary users of clinical systems can also facilitate secondary use processes such as clinical audit.

 

The Right Thing to Do? Research

If clinical audit is aimed at ensuring clinicians are “doing things right” then healthcare research aims at searching for the “right thing to do”.

Academic Medicine has always been highly regarded within the medical profession and been instrumental in changing the lives of many many people. You may recall the story behind the research into the cholera outbreaks across districts of London by Dr John Snow in 1854. The secret of that breakthrough was by uncovering the right information that provided the “evidence” that there was a very strong link with a local water pump. This evidence helped break the cycle of cholera at the time and began the science of epidemiology.

Internationally, healthcare has of course developed at significant speed over the last decades. The rate of medical discovery is already outstripping our ability to keep up and provide Evidence Based Medicine at the point of care. In modern times, after much progress in medical research there now exists an important disconnect between medical research and information management at the frontline. This gap from “Bench to Bedside” is the target of Translational Medicine and Knowledge Translation attempts to “Bridge the Chasm”.
There also remains many unanswered healthcare questions that need to be tackled, particularly as we get into discussions about value for money in public services such as healthcare… we need to be increasingly certain that we are guiding clinicians based on the best available evidence, which will always raise related research questions

At the frontline, clinical care is paramount of course, it requires the support of Evidence Based Medicine in real time and given the right information and knowledge management systems, there could/should be increasing support for  important clinical research as a by-product of routine clinical care. Yet healthcare research is hard to do at the frontline, esp. in the midst of the complexity of an environment such as busy Emergency Departments.

The burden of parallel efforts = difficulty with research recruitment?

We have talked about clinical audit, which often begins with a retrospective look at clinical practice aiming to improve. The challenge of tackling prospective clinical research questions at the clinical coalface is an order of magnitude more complex again.. From my experience,  one of the key current challenges of supporting and participating in a clinical trial in an acute clinical setting comes down to the current paper based approach to both clinical documentation and research, usually in parallel rather than joined up. So when you are in the midst of a busy clinical shift in an ED, under pressure for time, you may find recruitment into a clinical research trials to be just a bit challenging.

So to better align the pressurised clinical frontline delivery agenda with the academic research agenda, we must forge a much better union between clinical frontline and the academic research information and knowledge systems. Indeed if healthcare information systems could better support clinicians at the frontline and harvest the information needed for a clinical trial as a by-product of that process, that would revolutionise the research burden.

In that way, I should be able to manage my patients care as needed and interwoven within the clinical encounter and with the patients consent, I may ask some additional research related questions, order an additional research related investigation without interrupting the clinical cycle of care the patient requires. In that way, in avoiding the current duplicative effort that is currently required (i.e. documenting clinical care of the patient in their record, then re-recording many of the same details in a parallel research proforma) we could align these efforts in a win-win for all

Integration between clinical frontline/audit/research systems required

So again the key conclusion from this look at Emergency Department systems and the Audit & Research agenda is that these are increasingly interdependent, so therefore require the greater integration and interoperability between Emergency Medicine frontline, audit and research information and knowledge management systems.

 

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Further reading

This article is based on a series of related articles on healthcare improvement at;

https://frectal.com/book/healthcare-an-introduction/

 

PS. For those of you who already have /think you may have an early interest in EM Informatics, please consider joining the EM Informatics Chapter here at Emergency Physicians International).

Posted by: Tony Shannon | April 27, 2012

Emergency Medicine: typical challenges at the frontline..

Emergency Medicine: typical challenges at the frontline..

(This post is adapted from an earlier article here
https://frectal.com/book/healthcare-an-introduction/
and is being posted in parallel on the Emergency Physicians International social network)

In the lead up to ICEM 2012 in June in Dublin, we began this series by looking at Emergency Departments as Complex Systems at the Edge of Chaos.

As most of us are well aware that that healthcare (and thereby Emergency Medicine) is under pressure across the world to change,  let us now look at a typical scenario  at the frontline, to identify some common challenges in the complexity of  Emergency Medicine and the “change challenge” ahead of us.. ..

Let us begin with a look at a single patient journey, a common case of a patient who has an acute episode of abdominal pain for instance…..

If the patients problem begins at home, they can (at least in some healthcare systems such as the NHS in England)  telephone a healthcare advice line and undergo a form of telephone assessment and get related advice…. e.g. please self-care/ go to your doctor/ go to the Emergency Dept/ an ambulance may be called.

If an ambulance is asked to attend, the paramedic will likely also perform another assessment, begin some preliminary investigations, commence some treatment before usually escorting the patient to the Emergency Department (ED).

At the Emergency Department the paramedic may hand over care of this patient to reception or nursing staff who will take over the care of the patient. Here they are usually seen by an ED nurse to reassess the patients condition, take a brief story from the patient and some vital signs (e.g. heart rate, blood pressure) , perhaps some more questions about the nature of their abdominal pain and then make a judgement their “acuity” (to triage), and assign them to a care “stream”.

Now  the doctor will review the patient and usually begin with what we call “history taking” ….this is a process that involves getting details on the patients most recent story (often a narrative of the patients problem) and more structured detail on past medical history, their medications, allergies, smoking, alcohol status etc.  Now while it is quite common for much of that information to be recorded somewhere else, the information required is often scattered around the rest of the healthcare system.
Without access to a shared patient-centred electronic health record, the Emergency Physician is often unable to get access and so reverts to safety first principles and reassesses the patient from scratch. (While there is absolutely merit in reassessing the patients condition at regular intervals along the patient journey, some of this is being done to cover for inefficiencies in the current system and highlights real room for improvement.)

After history taking, medical school teaches doctors to examine the patient and document related findings. There is a common structure to the approach required for this and this should be reflected in the patients notes..

Investigations are often performed and the results of previous investigations may also be needed at this point. Ordering tests and getting the reports of results is another extremely common healthcare process, one that is also information intensive and again an area ripe with room for improvement.

A “differential” diagnosis or problem list may now be in mind at this time after reviewing the “history” and examination. (e.g. is this appendicitis? a urinary tract infection? constipation? inflammatory bowel disease?)
This may be drawn from the doctors memory and innate knowledge base, or they may need to go to the books/online to check up on their knowledge.
There is an acknowledged gap in the “bench to bedside” cycle of medical discovery and its implementation in clinical practice, which can mean a gap of years changing “what we know to what we practice”
This is another point where information and knowledge management is critical in helping with the decision making process and thereby patient care. Their is no doubt much room for improvement in the current approach to this, with many doctors currently relying on their tacit knowledge base at the frontline which, while mostly effective, is subject to human error.

Once the differential diagnosis or problem list is drawn up, then a related treatment plan should be formulated, and treatments in the form of procedures and/or prescriptions for medications may be required.

The medical notes that are made to document the patients journey are collated during the patient clinician encounter. These are critical in several aspects- aiding the decision making process, helping to share information with the next person involved in the care of this patient (e.g. inpatient team), as a medico legal record (increasingly important) and as a record of care that can form part of a wider audit of clinical practice (as per the clinical audit/and or research process).

The patient may then be admitted to an inpatient team or discharged to a clinic or to the care of that patients General Practitioner and so the cycle of care continues….

Of note, in looking at this single patient encounter, it should be evident that the majority of the patient provider care processes in Emergency Medicine are very information intensive
Naturally any inefficiencies in the physician patient encounter of history-taking , examination, investigations, results, treatments are often replicated during successive encounters the patient will have with the healthcare system.
You can see that the current approach builds in much repetition as a safety measure though there remains considerable room for reducing both wastage and risk.

If we in Emergency Medicine are to be involved in a more patient-centred, cross- organisational approach to healthcare delivery/care pathways etc, you can see that changes needed in Emergency Medicine Information Systems will be vital to the future.

In the next article we will look at some common challenges at a Emergency Departmental level.

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Further reading

This article is based on a series of related articles on healthcare improvement at;

https://frectal.com/book/healthcare-an-introduction/

PS. For those of you who already have /think you may have an early interest in EM Informatics, please consider joining the EM Informatics Chapter here at Emergency Physicians International).

Emergency Departments; Tackling Complex systems on the Edge of Chaos

Emergency Departments have a well earned reputation for being pretty busy places to work.
For some Emergency Physicians, the conditions worked in provide a constant challenge, for others where there have been significant improvements in recent years, patient attendances continue to increase. A reflection that Emergency Departments offer the only 24/7 front door to  many healthcare systems, where pressure continues to mount..

EM Challenges: Simple/Complicated/Complex/Chaos

While the environment we work in occasionally presents simple challenges, Emergency Departments are very familiar with complicated clinical cases, indeed juggling several such patients at the same time makes it the complex environment we take for granted. We will also be familiar with shifts that quickly change, testing the whole team, when Emergency Departments move to the “edge of chaos”. While the range and variety of challenges that present themselves to us in EDs and the perpetual novelty can be part of the reason we enjoy working in Emergency Medicine, this complexity is not always enjoyable and at times our brains must struggle to cope.

So how can we make sense of the Emergency Departments we work in, knowing the same place can go from a quiet tranquil shift on a weekday morning, to a pretty crazy place within a couple of hours? As part of the education I’ve been fortunate to have gained in Emergency Medicine, I’ve learned that looking for patterns amidst complex systems is key to making sense of our challenges… so let’s look at some of the common patterns that come to mind and see whether this resonates..

 

Patterns in Emergency Medicine

If looking for key patterns with the complex adaptive systems that are Emergency Departments, what are the key patterns you see and the key elements for a good shift? If we can explore some of those common patterns & elements, we may be better placed to lead our teams, improve our care and support our patients better.

As I look I see 3 key patterns amidst our environment, related to People, Process and Technology.

Most all of us have significant People challenges in Emergency Medicine; How to recruit the best staff? Best means to train them to be excellent Emergency Physicians and Healthcare Leaders? How to support staff when things (inevitably) go wrong.  Importantly how to retain staff amidst the pressure and challenge of EM.

From a Process perspective, most of us would admit there is significant room for improvement at the clinical frontline, no matter where we work, there is and will be always ways to do things better. As a result many Emergency Departments actively engage in process improvement efforts, via clinical audit, lean thinking and or other approaches. Once started such efforts offer a never ending cyclical need for refinement and further improvement

Thirdly the information we gather and/or record about our patients is often a time-consuming and inefficient element of the patient-physician encounter. The Technology we rely on often does not fit well with our complex process and so can become part of the problem, rather than the solution. Equally the related knowledge base that informs our practice (i.e. the evidence behind what works and what doesn’t) in many important clinical areas can be difficult to keep on top of/ access when we need it, so these “tools” also need to be improved.

 

Working Smarter>Harder

As much of the pressure within Emergency Medicine lies on the shoulders of Emergency Physicians…. the pressure of increased attendances, search for greater efficiency, safety and effectiveness within Emergency Departments continues to mount and take its toll.

Yet as Emergency Medicine moves forward, the likelihood of increasing frontline pressure in the future should not simply involve asking the EM workforce to “work harder”.  We must increasingly look for ways to “work smarter” rather than harder-  to improve Emergency Medicine, to support our staff and improve our processes of care. From my perspective working between Emergency Medicine and Informatics for the last 10 years, I have no doubt that further improvements in information management and technology will be key and critical to success to the future of Emergency Medicine.

Over the next couple of months leading up to the ICEM 2012 meeting in Dublin I’ll be looking in more detail at the current state of information management in Emergency Medicine, looking at areas where we are strong and others areas where major change is needed.

 

Take for instance the typical patient journey in the Emergency Department, have you considered it can be considered “information intensive”? Do you see room for improvement as you talk to your patients/ examine them/ establish their differential diagnosis and related management plan? Are you/how are you able to keep on top of the EM literature and ensure all your care is evidence based? Are your patients happy with their care? Do you measure it?

Then think about the last clinical audit that you did. Can you recall any of the top recommendations? Did improvements in documentation, clinical data capture etc feature anywhere there?
If you manage an Emergency Department, do you find a tension and challenge in measuring and monitoring the timeliness, quality and safety of care in your department, aware that such efforts might be adding to the burden at the frontline?

Perhaps you have an academic interest? You may be involved in a clinical research area. Have you been struggled to recruit patients into a frontline research study and/or found research study documentation just a little bit more hassle than you needed on that late shift?

 

One Key to the Future

Over the course of several related articles, I’m hoping to show that while EDs are sometimes on the edge of chaos, that understanding and embracing the complexity of our environment is key to success within Emergency Medicine and indeed across the breadth of healthcare.
With a look at some of those common core processes that underpin our work I’ll be making a case that better information technology is key to the future of Emergency Medicine. While such an assertion is not news to our specialty, I’ll be exploring and explaining why related developments have not kept pace with the world around us and why some of us need to be more actively involved and look to collaborate to make things better.

 

More on these subjects soon..
For now… comments welcome please…

 

(NB. For those of you who already have /think you may have an early interest in EM Informatics, please consider joining the EM Informatics Chapter at Emergency Physicians International).

 

 

Posted by: Tony Shannon | February 29, 2012

Starting to fix Medicine.. with a Checklist

Just in time for the end of the months post and there’s a useful story on TED.com to mention.

If you haven’t come across TED.com before, please take a look. Its a powerful force for sharing ideas across the globe.

Yesterdays addition to TED was from Atul Gawande, a physician trying to improve healthcare.

The transcript of the session is worth a read. It highlights some key points;

  • The incredible cost of healthcare.
  • The quick move from hospitals as places for rest, offering shelter, food and attention to places that can offer 1000’s of drugs and procedures, in just a few generations.
  • Interesting data ” In 1970, the number of doctors a patient at a hospital saw, on average, was 2. By the end of the 20th century, it was 15.”
  • Too many specialists rather than generalists.
  • The risks of modern healthcare, from basic stuff e.g. lack of proper hand hygiene.
  • Amazing clinicians with amazing technologies, that rarely come together.
  • Wide gap between best results and worst results
  • Outcomes don’t match costs
  • “When your a specialist you cant see the whole story.. you need to be incredibly interested in data..”
and some simple solutions to the complexity, esp a simple information tool, the checklist for which he has become famous.

 

 

 

 

Posted by: Tony Shannon | January 31, 2012

Early Years in eHealth

With the passing of the Kodak into bankruptcy in recent weeks, its a reminder that “this too, will pass“.

The Leeds Photographic Society, established 1852, is the oldest of its type in the world. At a recent meeting of the photographic club, where I’m a member, I came across a small interesting exhibition of books on the history of photography. They made for interesting reading, a reminder of the early years of photography where the science of optics slowly met the science of chemistry. While we may associate many fields with momentous discoveries, the history of photography illustrates that it was many small advances that paved the way for this field we now take for granted that is photography.

So it is with the field of healthcare improvement today. Healthcare, a long established profession is meeting the worlds of management science and the worlds of information science and software engineering, that highlight that the many changes we are seeing in this field reflect the immaturity of the field as a whole.

What is interesting to note in recent months is the slow but steady recognition that healthcare needs disruptive innovation change with a new eHealth platform(s). Let me point you to several related developments that should help affirm that point, some of which I’ve mentioned before, some of which I have not.

Clinical Information Modelling Initiative (CIMI)

Collaborative Health Consortium

openEHR

OpenSourceEHRA

OpenHealthTools

SMART platforms

Take a look at this interesting visual which highlights where we are in 2012 and where we want to be. It highlights the current proprietary nature of healthcare systems which disconnects people and process, with the slow move towards “walled gardens” on the road to a vibrant open ehealth ecosystem that healthcare requires.

You may be very early in your knowledge of the intersection between medicine, business and IT, but I hope might be able to see a pattern emerging here amongst these efforts.

In time to come folk will look back at this year of 2012 as an early, though I hope important, year in eHealth.

Posted by: Tony Shannon | December 29, 2011

Big or Small – A Few Bright Minds

As the year of 2011 comes to a close, I’ve been considering some of the stories I’ve come across that have left me thinking.

  • 2011 was a tumultous year across Europe, with no clear end to the financial drama in sight.
  • The loss of Steve Jobs will likely be remembered in history for a long time to come.
  •  “Big and Clever: Why large firms are often more inventive than small ones” was particularly thought provoking.

The common thread that crosses these stories?    Conceptual Integrity

“Conceptual integrity in turn dictates that the design must proceed from one mind, or from a very small number of agreeing resonant minds” (Fred Brooks of the Mythical Man Month)

 

If you’ve looked across my Book of Thoughts, you’ll have seen mention of the chaotic/ complex/ complicated and simple parts of our work, as a means to understand the world.
The ongoing Euro mess is clearly a complex system on the edge of chaos. I’ve made the point that there is a lack of effective leadership on the worlds economic stage, from any angle (EU, UK, US, Asian or other). My view is that most/all those political leaders involved can’t/don’t understand the complexity of the mess on their hands and really struggle to develop solutions.
The most recent EU meeting and plan for a treaty within a treaty struck me a over-complicated approach to the complexities involved, which will be difficult, nigh impossible to implement. I hope I’m wrong.
The key issue here is that at the top of the tree there seem so few folk who understand the common patterns, across continents and history. Most political leaders lack the “conceptual integrity” to develop solutions that work.  So their plans struggle can be difficult/impossible to implement.
The only voice I’ve come across that makes regularly sense of the current mess is a lone voice, an Irish journalist named David McWilliams. His commentary usually explores the current financial crisis from an Irish perspective, but he has a big world view. For some time now he has forecast a breakup of the Eurozone now and championed the value in  controlling ones own currency.  Time will tell if his world view is correct but the conceptual integrity in his logic seems hard to beat from what I have read.

At the other side of the Atlantic, Steve Jobs passing was a major loss.
His personal story, told in an authorised biography, clearly demonstrates the “conceptual integrity” in his work.
It was his passion and vision for changing the world for the better that meant he focussed on changing the complex computing, movie,  music ,  phone and publishing industries.  Most of the breakthroughs he drove seem to have been driven by himself/very small team.. he was not a management by committee type..he was a champion of his own ideas.

 

Which brings me to the third story/article. In “Big and Clever: Why large firms are often more inventive than small ones“, the recent interest in fostering innovation and industrial growth via Small to Medium Enterprises is challenged in an unusual way. The argument is that the biggest companies can afford to be the most inventive (Apple, Google etc).  Its an interesting point.
Yet again the theme of leadership and conceptual integrity returns here.. most of the big inventive companies seem to begin with a leaders(s) with vision and passion (Microsoft- Bill Gates & Paul Allen, Apple- Steve Jobs & Steve Wozniak, Google- Sergey Brin &Larry Page, Facebook- Mark Zuckerberg). These individuals seem to have shared a vision that allowed for disruptive innovation in their chosen fields.
Many of these same companies now work to foster independent thinking from within their ranks and channel champions and their ideas into the greater organisation, by moving away from pure hierarchies and towards ecosystems of competing and collaborating units..

 

So whatever 2012 brings, the best solutions will come from a few bright minds..

 

Posted by: Tony Shannon | November 30, 2011

Better Information, Better Health

Dr Foster is an interesting development over the last 10 years within the UK.  Its tagline is “Better Information, Better Health” and to quote from its own sources…

“Dr Foster was founded on an idea – the idea that collecting and publishing healthcare information would save lives. We believe that better information has made the NHS a safer, more efficient and more transparent service, and will continue to do so in the future.”

“Dr Foster exists to make healthcare data better and help healthcare organisations improve the quality of care. ”

They offer a hospital guide and each year they now publish a Hospital Guide report which highlights key messages distilled from the mass of data that the NHS generates each year. In this years Hospital Guide 2011 report, published this week some very interesting key patterns observed are included;

Excerpts taken from “10 things we have learned this year:”  (Page 5)

1. There are many ways to measure mortality rates but, however you measure it, some
hospitals appear to have consistently high and low mortality rates.

2. Being admitted to hospital at weekends is risky. Patients are less likely to get treated
promptly and more likely to die. The chances of survival are better in hospitals that
have more senior doctors on site.

3. Delivering safe care 24/7 does not require more resources. Local A&E departments
need to identify the services they can provide safely and link with others to provide
the services they can’t.

4. London has now achieved the lowest mortality rate following a stroke in England by
cutting the number of A&E departments treating stroke from 31 to eight, but making
sure those eight provide the highest standards of care.

5. Do not have an abdominal aneurysm repaired in one of the 39 hospitals that perform
the operation infrequently. Patients are much more likely to die.

6. Private hospitals providing services to NHS patients get good outcomes and positive
patient ratings. Of course they have a much easier task, dealing only with relatively fit
patients. Nonetheless, if you are one of those patients, these organisations can offer
a high-quality service.

7. Better care saves money. Hospitals that implement best practice in helping patients
recover quickly from surgery achieve better outcomes for less money.

8. Some aspects of patient safety are improving but harm to patients still happens
far too often. Unfortunately, we still do not record what happens to patients with
sufficient accuracy to properly gauge how best to tackle the problem. Improvements
to the data are the first essential step to addressing the problem.

9. Take note of what other patients say on the web about their care. It provides a
valuable insight. In some cases, more than three-quarters of patients commenting
say they would not recommend their hospital. In others, over 90 per cent would.

10. Staff behaviour is crucial to patient experience. Our analysis of patient comments
on the internet shows that disrespect and not being kept informed are the two main
reasons why patients would not recommend their hospital.

While these insights may be familiar to those of us at the frontline, by exposing these to the wider public, this approach could/should be positively disruptive. Naturally none of us like to be involved in the practice of sub optimal care, though due to the complexity of the system many factors can make high quality, safe, timely care a challenge. By “sunshining” and opening up this data, to highlight areas for improvement, it feels (overall) like a force for good.

Posted by: Tony Shannon | October 21, 2011

Leeds takes a Lead

Leeds, England is the home of both the NHS National Programme for IT and Leeds Teaching Hospitals NHS Trust.

Leeds Teaching Hospitals is one of the largest trusts in England, with over 14,000 staff over 4 sites and is where I practice as an Emergency Physician.  I’ve been pleased to have a role as Clinical Lead for Informatics here in the last 2 years, where we have a clinically led Informatics Strategy.

At the heart of  that strategy we have agreed a clinical portal and integration approach building a care record in a move away from data siloes and centred around the patient. Interestingly we began to tackle our clinical portal requirement as a joint open source effort between ourselves at Leeds TH and a commercial partner (Restart Consulting).

I’m pleased that we have had a useful first phase of the project, having now been tested in a live environment it has proven clinically useful. In the spirit of “release early, release often” we have now put the code into the open.

So I’d like to acknowledge my NHS colleagues who have helped progress this effort to this point, the technical team behind it and hope it proves useful to others outside Leeds. Which is why we have also agreed to collaborate with the University of Leeds in supporting the early NHS based  eHealthOpenSource.org.

Am attaching a set of open portal related slides (inc. screenshots) here fyi..

BTW In case you might think this looks like an unusual open source approach to clinical information systems development, integration of legacy and moves towards an open, modular, standards based, service oriented architecture have a look back at last months story from the VA/DOD in the US.. If you look under the hood you will see much overlap in thinking behind these moves..

////

Note Added:  Nov 2014

As an update to this post, the Leeds Clinical Portal has continued to progress and thrive. Now aligned with another key system grown in Leeds (Patient Pathway Manager aka PPM) , the latest version of the platform is called Leeds PPM+ platform and powers both the Leeds TH EPR and the Leeds Care Record. An updated presentation on these is available here.

Posted by: Tony Shannon | October 21, 2011

Leader and Legend

While I’m not an Apple person, it would be impossible to look at the events of the this month without highlighting the loss of Steve Jobs.

As it has been said many times since his early death, he alone seems to have revolutionized several industries in own lifetime, i.e. computing (Mac and iPad), telephone (iPhone), cinema (Pixar), and  media distribution (iTunes).

He seems to have had a reputation for singlemindedness, did not tolerate fools and led from the front. In that sense while his leadership style was his distinctive own, it had amazing results. His legacy illustrates the potential of one individual to impact on the rest of the worlds population to dramatic effect.

What remains to be seen is how Apple will fair without his leadership at the stern. No doubt it will do very well for a long time, yet one has to feel it cannot be the same without Jobs. Its business model to control the user experience by controlling both hardware and software has delivered amazing results but is not the only successful model around, as the Google Android platform has highlighted against the Apple iPhone for instance.

None the less, whatever happens next, its right to acknowledge the very rare leader that Jobs was… a legend in his own time..

Posted by: Tony Shannon | September 30, 2011

An End and a Beginning

The month of September saw two interesting developments in the worlds of healthcare, change and IT.

Firstly and not all together surprisingly the UK Goverment called time on the end of the NHS National Programme for IT,  with the Department of Health moving to accelerate the dismantling of the programme.

As I spent 5 years within the programme, this came as no surprise in the end, indeed it was interesting that it took so long for the recent change in government adminstration to come to this conclusion.

While some of the successes  of the programme have been recognised (N3 broadband network for the NH, PACS Picture Archiving and Communication System for radiology in the NHS), the very slow progress made within the acute hospital sector was one of the reasons that the programme came to this formal end.

Of note, the change in approach emphasised is worth highlighting …”we need to move on from a top down approach and instead provide information systems driven by local decision-making.  This is the only way to make sure we get value for money and that the modern NHS meets the needs of patients.”

What is less clear is what will change within the significant NHS IT contracts still agreed, yet the move towards local change and innovation is welcome. There has been an implicit move from connect all to replace all for some time now in NHS IT circles, yet this is predicated on the availability of usable health IT standards for interoperability such as the NHS Interoperability ToolKit.
Yet is been my experience that detailed standards are not enough on their own, so open source is a necessary part of the recipe.

On that theme, the beginnings of the new approach to Health IT developments by the US Veterans Adminstration and Department of Defenc took more shape during the same week in September. In this new joint effort they are taking a commendable user centred design approach to their next joint record.. the iEHR.

While they have just released an Request For Information, the related documentation gives a nice overview of their thinking on their future, including thinking on portal, a common user interface to their EHR, integration of legacy systems, an enterprise service bus and a common information model.. I’ve placed a copy of this paper here and related architecture slide here.

Posted by: Tony Shannon | August 1, 2011

Shared Challenges: Sharing Solutions

Dr John Halamka, my US colleague with a shared interest in change, emergency medicine and informatics, has built a reputation as an international leader in healthcare informatics.

His blog “Life as a Healthcare CIO” is regularly good value and a testament to Johns work ethic, his passion to make a difference in the world and his mastery of many diverse fields.

In a recent posting he shares his advice on the Japanese Healthcare system as it recovers from its recent crises.

His paper “Addressing Japan’s Healthcare Challenges with Information Technology: Recommendations from the U.S. Experience” is brief but holds much salient advice for any healthcare jurisdiction.

I’ll pick out 3 key points from the advice he shares that are worth a mention;

  • “Do not “rip and replace” existing successful systems; instead focus on achieving broad
    functionality for as many caregivers in a local area as possible. Experience in countries like the
    United Kingdom has illustrated that it is often better to move forward rapidly with what is
    possible at the local level rather than attempt to provide a single centralized set of applications.”
  • “Encourage personal health records for patients who want to use them”.
  • “Create a national emergency care database from existing data sources and add new data sources
    in a federated fashion as they become available.”

You’ll note from his analysis that two diverse healthcare systems (US and Japan)  share challenges and potential solutions…

As ever John thanks for sharing your good work ..

 

 

Posted by: Tony Shannon | August 1, 2011

World Economics; Out of Balance

As the world economic order continues to shudder and lurch from one drama to another, there appears a clear pattern emerging.

There are spenders and savers and so as the West mounts up a large debt, China is increasingly serving that debt… to encourage the West to spend money on Chinese products.
(In many ways, who can blame the Chinese for serving the Wests needs and wants.)

Yet this international trade deficit is moving further out of balance, as David McWilliams intelligently explores in his recent blog article, An Unbalanced Economic World which is well worth a read.

David points out that the current complex system of trade imports and exports is perpetuating regular crises..ie. chaos. As ever to move away from chaos and to bring order to a complex world, leadership is needed and neither Europe, the US or China are providing that effectively at the moment.

Posted by: Tony Shannon | July 31, 2011

The Code; Mathematics in the Natural World

If any of you have easy access to the BBC or BBC iPlayer, you may be interested in this 3 part documentary on the BBC, called The Code.

The first episode explored common numerical patterns in the natural world, such as prime numbers, the fibonacci sequence etc.

The next will look at shapes where fibonacci and fractals will surely feature…

Again these shows emphasise that amidst the complexity of the world, patterns are all around us.

 

 

 

 

Posted by: Tony Shannon | June 29, 2011

Software Development; Simple+Complicated+Complex+Chaotic

In a nice article on the Cynefin guest blog by Joseph Pelrine  (and in more detail in a longer paper here) he explores the varying  perspectives of the software world, from those who understand it as all complex (e.g. Agile) to those who see it as a production line (e.g. Lean).

His useful survey of over 300 people involved in software development helps to illustrate that these differing views are not mutually exclusive.

Many software projects will have simple elements, other complicated elements, they often become complex (particularly when trying to scale up or maintain a solution in my experience) and can verge on the chaotic at times.

The Cynefin framework of Simple, Complicated, Complex and Chaos can be very helpful to understand this range better, as we have explored in an article on Cynefin & Information Technology previously.

I hope Joseph wont mind if I directly quote a particularly useful paragraph about software development;

“The activities tend to be weighted more to the complicated and complex domains, with activities related to the coding aspect of software development landing in the complicated (or sometimes simple) domain, and activities associated with project management landing in the complex (sometimes chaotic) domain. Tasks dealing with interaction with a computer tended to be in the ordered domains, tasks dealing with interaction with other humans tended to be in the un-ordered, i.e., complex and chaotic, domains.”

Thanks Joseph, it is good to see a growing move towards this perspective…

Posted by: Tony Shannon | May 31, 2011

Adapting – tackling Toasters to Terrorists

“You could easily spend your life making a toaster” is the interesting opening line from Tim Harfords book.

Adapt- Why Success Always Starts with Failure” is an effective introduction to the world of the complicated and complex systems of the world.

By explaining that the humble toaster has over 400 components and sub-components he illustrates how complicated many things are in the modern world.

He then goes on to make the case that many more elements of the modern world are much more than complicated , they are complex.

The principles of Variation, Selection, Decoupling and Adapting that he examines are all taken from the world of complex systems and are usefully laid out.

His case for change by challenging top-down organisational control, encouraging diversity, encouraging local experimentation and decentralised decision making…. all helpfully acknowledge the ecosystem like nature of change in most/all complex organisations.

His final pages include a classic Samuel Beckett quote;
“Ever tried. Ever failed. No matter. Try again. Fail again. Fail better”

Posted by: Tony Shannon | April 28, 2011

Fail..to Succeed

Failure…

You will have heard the term “Failure is not an option” and mention of developing “Fail-Safe” systems.
In the modern world there is a real stigma with getting things wrong, as if failure was a sign of weakness.

However “To Err Is Human“, which interestingly is the title of an Institute of Medicine report from 1999 that outlined the huge scale of errors in healthcare and the related costs..

Achieving high quality, safe systems is a balancing act often set against time and cost pressures, aiming to get the best balance of value from a system.

There is much to be gained by understanding  systems such as healthcare via a greater understanding of;

-the nature of complex systems, which are inherently unpredictable..

-key elements in many complex systems include people, process & technology

-to err is human, so solutions lie in supporting people with processes and technology that are safe to fail..

-failure is inevitable on occasion in any complex system.. it should not be stigmatized.. the key is to learn from it and make things better..

Therefore an iterative and evolutionary approach to change involves some failure..

..to Succeed.

Fail to Succeed” is the cover feature in the latest edition of Wired Magazine with features on Alan Sugar and Jimmy Wales..

Posted by: Tony Shannon | March 31, 2011

Less Waste, More Reuse, More Agile

For the second time in just over a year, the UK Cabinet Office has released an ICT strategy. That can be easily explained by the change in political administration that took place in the UK May 2010.
What is interesting to see is the overlap in the approach recommended in each.

Last years strategy from the Labour administration in January 2010 was entitled “Smarter, Cheaper, Greener” and contained an “Open Source, Open Standards and Reuse Strategy”.
The latest strategy, dated March 2011, from the current Coalition administration also makes some firm and related statements..

Some key excerpts;

“Government information and communications technology (ICT) has a really bad name. ..The Coalition Government is determined to do things better.

Government ICT is vital for the delivery of efficient, cost-effective public services which are responsive to the needs of citizens and businesses. We want government ICT to be open: open to the people and organisations that use our services; and open to any provider – regardless of size.

We have identified the following challenges, many of which are interconnected:

  • projects tend to be too big, leading to greater risk and complexity, and limiting the range of suppliers who can compete
  • Departments, agencies and public bodies too rarely reuse and adapt systems which are available ‘off the shelf’ or have already been commissioned by another part of government, leading to wasteful duplication
  • systems are too rarely interoperable
  • procurement timescales are far too long and costly, squeezing out all but the biggest, usually multinational, suppliers

To address these challenges, we have done – or will do – the following:

  • .
  • create a level playing field for open source software
  • impose compulsory open standards, starting with interoperability and security
  • create a cross-public sector Applications Store”
The strategy in full is available here
You may be interested to note its push for reducing waste, sharing and reusing solutions, greater agility in projects and a firm move towards more open standards and open source in the UK public sector use of IT.
Posted by: Tony Shannon | February 28, 2011

From Legacy to Leadership, steps towards an eHealth ecosystem

If one is looking for an evidenced based story of healthcare change enabled with information technology, then a look at the Veterans Administration (VA) in the US is well worth it.

Over the course of a 10 year period the holistic health service provided by the VA has transformed the quality of care it provides to its patients and they have the evidence to prove it.

Key to those improvements was the Veterans Health Information Systems and Technology Architecture (VistA) system, a health IT solution that has evolved over many years, largely led by joint efforts between their clinicians and IT teams.

Interestingly they have had great success with relatively “dated” technology ie MUMPS programming language, but their choice has something to it. Another of the largest EHR providers in the US, Epic also uses MUMPS and related Cache technologies.

Over time it is acknowledged that the architecture of the VA Vista systems has become cumbersome to scale and maintain, so it needs a technical refresh, a “modernization” as the 2010  Vista Modernization Report: Legacy to Leadership report from the US American Council for Technology/Industry Advisory Council outlines. Central to that reports recommendations are that the VA should move to open sourcing its development effort towards the generation of an eHealth ecosystem.

In recent weeks the VA has now moved these recommendations with a Request for Information, towards developing that open source ecosystem, towards “an openly architected, modular, and standards-based platform”.

This is a very welcome development in healthcare, as an international leader in the field of healthcare improvement has now acknowledged… that its own future lies in greater collaboration with an open source eHealth ecosystem, which could and should provide a win win for all..

While this change will not happen overnight, the VA are to be applauded for their leading moves in the right direction..

 

 

 

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