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..

 

 

 

Posted by: Tony Shannon | January 14, 2011

An Information Revolution … for the NHS?

The National Health Service in England has been in existence for over 60 years now and is generally well regarded by the population that it serves.

My experience of the difficult transformation of emergency care in the NHS suggests that it delivers a very good service all free at the point of care. As the NHS has developed in recent years the importance of process improvement and information technology has been increasingly recognised .

Read More…

Posted by: Tony Shannon | December 17, 2010

Economic Splits and Steady States

This year has seen further change across the world.

As the decade closes, the unfolding 2007-2010 global financial crisis continues to highlight that economics is not just complicated, it is a complex science, verging on the chaotic at times.

During this year some economies have continued to grow, others have contracted.
As the Economist recently reports there now seems emerging across the globe, with splits in progress between European, US and Emerging Economies.
In my homeland of Ireland, aftering the soaring heights of the Celtic Tiger years, unfortunately things have not gone well lately and the increasing gap between national income and expenditure has recently required outside assistance to support the economy.

Is there an inevitable cycle in that all economies aim to boom, to then be followed by busts? Perhaps inequality is simply an inevitable by-product of “the market”?

You may be interested in this great view of the progress of 200 countries over the most recent 200 years (in just over 4 minutes! from the “Joy of Stats” on the BBC).  It is inspiring to see that amid the booms and busts the real progress that mankind has made in that time.  There is a reassuring conclusion that all countries can end up “healthy and wealthy”.

Within this exploration is a finding that inequalities are common within countries as much as between them.
The Spirit Level: Why Equality is Better for Everyone is an interesting book. It claims that for each of eleven different health and social problems: physical health, mental health, drug abuse, education, imprisonment,obesity, social mobility, trust and community life, violence, teenage pregnancies, and child well-being, outcomes are substantially worse in more unequal rich countries.

The Spirit Level promotes a concept named steady state economics, which is taken further in another interesting report, named “Enough is Enough : Ideas for a Sustainable Economy in a World of Finite Resource“. This report asks the deep question of any society, “How much is enough?”.
While some of the recommendations may be somewhat controversial, others raise interesting challenges .. limit resource use and waste, change the way we measure progress, improve global cooperation.

It is that concept of improving global cooperation that strikes a chord. As so many health systems are working under pressure and need to work smarter, lets hope that the most recent financial pressures encourages greater international collaboration between those involved in the challenges of health system improvement.

Posted by: Tony Shannon | November 15, 2010

Sweden’s noble e-Health strategy

Having recently been able to travel to Sweden to look at their eHealth strategy, it seemed important to highlight their noble ambitions.

Sweden is a country that has a lot to admire.
It seems to have a better balance than most of a effective government sector with a competitive private sector.
It achieves a good international ranking for its healthcare system.
Some of the healthcare success  seems related to its leadership in eHealth

The current Swedish eHealth strategy is worth highlighting as leading the way internationally in my view for 2 key reasons.

1) The Swedish eHealth Strategy makes a very clear commitment that it explicitly aims to support clinical processes. Few strategies make this clear enough, fewer still understand the importance of supporting generic clinical processes as the Swedes do.

2) The Swedish eHealth Strategy aims towards a virtuous circle of clinical documentation support, decision support and quality registers support. This is a very noble ambition and strikes me as a very good means of supporting healthcare professionals to do the right thing as well as doing things right..i.e. aiming at delivering better value for money for all.

Their ambitions are far seeing and internationally leading, albeit with much work to do.

You may be interested in the technical underpinnings of their approach, which rely on the openEHR archetype amongst other elements.  The collection of presentations from their recent Swedish eHealth event is available, whereby they bravely invited scrutiny from outside of Sweden.

Well done to Sweden… on taking a lead in the right direction.

Posted by: Tony Shannon | October 22, 2010

The father of fractals

Having just recently shared some thoughts online about complexity and the importance of patterns, I have to mark the passing of Benoit Mandelbrot, known as the “father of fractals“..

You will have seen fractal patterns in many places, in nature, in art, on your PC and not necessarily known their name.

You may not have known that a French mathematician names Benoit Mandelbrot had formulated the term fractal and the related science known as fractal geometry, which though mathematical in focus has links from cauliflowers to coastlines to economics..

You might be interested in some beautiful images of fractals alongside some of his story here at TIME.

For more information on Mandelbrot’s life (1924-2010) and work, the Economist has an obituary while the updated wikipedia entry on Mandelbrot provides a nice summary.

If you haven’t heard of it before his famous  paper on “How Long is the Coast of Britain” is also available..

Posted by: Tony Shannon | October 1, 2010

Time to share a book of thoughts..

Having set up this wordpress.com site some months ago, I’ve been using it to collate some of those thoughts, ideas and experience that I’ve gained over recent years.

This site has been very useful place to collect these, though I have had to go offline over the last few weeks to flesh them out, structure, restructure and now I feel its time to share back here.

The resultant book of pages with 5 key themes with 5 articles each covers material from my background in healthcare, into complexity, onto patterns amidst change, the join between process improvement and IT, then back again to healthcare.

This book of thoughts is not perfect, the pages are works in progress, but in the spirit of iteration, I thought it was a reasonable time to share them now. Feedback very welcome of course. The material covers a broad range of issues, so diverse perspectives would be useful…

Over time, I’d like to refine these pages, so thanks in advance for any honest views and opinions that might help.
I hope some of this work may be of use to you..

Tony Shannon, October 2010

Posted by: Tony Shannon | May 12, 2010

This is a pretty interesting and challenging time

In this year of 2010 I’d say this is a pretty interesting time to be alive.

Within very recent times we have seen enormous change on this planet and the likelihood is the pace of change will keep accelerating.
Within our world there are now populations that survive between the extremes of subsistence living and those living “lifestyles of the rich and famous”.

An Inconvenient Truth,  a controversial film designed to provoke thought, offered some challenges to us all..
As the world grows in population and complexity,  the earth we live on offers physical resources that are clearly finite, so there is no doubt we have to get smarter to look after the planet for future generations…

Within healthcare, we have seen significant progress in the practice of medicine in the last 100 years.
We are at a point that we can offer major technical solutions to a host of clinical conditions, yet are equally frustrated by other big killers (e.g. malaria, cancer). So there remains large inequalities across the world….  Even within the western world, many governments are struggling to balance the needs of the many with the needs of the few.

As we look forward, we hope that with our ingenuity in exploring ways of living smarter, we may be able to tackle these issues..

To do that….

We need both leadership and we need the crowd involved.
We need to do more with less.
We need to share our efforts together which offers a win-win for all, via joined up global efforts.

To understand how just a bit of this challenge might be tackled, I hope this blog should explore a few useful themes..

We need to explore complexity of the world,  what change is made up of; looking in particular at healthcare as an important field and how it needs to be improved ..

Posted by: Tony Shannon | March 8, 2010

What is frectal

Over the last few years I have been learning a lot and wanted to start put some of it in writing.

The world we live in is a fascinating place and this is a fascinating time to be alive, to see so much happening in the world around us. My interests are reasonably varied, from healthcare to information technology to management and across those fields I have noted that as complex as they are and as complex as the world is,  that simple patterns are all around.

With that in mind I feel there are a number of interesting thoughts worth recording, sharing.

The picture on the top of the page is of a fossil, a spiral shape, known as an ammonite fossil.  To me it symbolises quite a few things.

Firstly as its a very old thing, it reminds me that we are only on this planet for a very very tiny length of time in the grand scheme of things. The world has changed in unfathomable ways since it began. Change has been, is now and forever will be, all around is.

Secondly, the shell symbolises (for me at least) the spiral of change, at many speeds- from the Theory of Evolution  that Darwin explained in his ”Origin of the Species”, to the more modern field of Rapid Application Development and the spiral model of software engineering.

Thirdly although the fossil is a complex structure in its own right, its made up from a very simple pattern.
As this spiral shell structure with its simple rules make up a complex structure, so it can be understood as a ”fractal“.  A “fractal” can be a very beautiful thing and are seen all over the place, like the spiral fossil above, a fern or a  snowflake and are all made from very simple and recurring patterns.
Of interest, the familiar recursive design of this kind of ammonite shell above is based on is linked to the fibonacci sequence of numbers (0,1,2,3,5…) that appear in many places around us.
Another dimension to fractals is that they exhibit similar characteristics, even if viewed at differing levels of scale.. a well quoted example of which is the coastline challenge, as in the 1967 “How Long is the Coast of Britain” paper ?

Fractals are closely linked with the science of Complex Systems which is a very useful multidisciplinary body of knowledge that I believe will grow in importance in many disciplines, from Healthcare, to Information Technology to Management fields and beyond.

Mix the name fractal with the word freckle and I came to frectal, hence “what is frectal”.

I hope to share some further thoughts on these issues and themes in further posts…

Posted by: Tony Shannon | January 5, 2010

Starting at frectal

I’ve started this frectal at WordPress.com. I’ve been looking for a content management system/blogging tool to start writing with.

The aim is to find a platform for writing some articles in a book and chapter style, or with a series of posts, aiming to update the pages as I go, while I learn.

This looks like a good platform. I appreciate its open source background. Given the fact that it is a free hosted solution, lots of good features and options mean it has to be commended. Only constraint so far are the themes, not found a perfect one yet. Anyway…. the initial focus is on the material, the ideas..

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