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

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 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 Succeed


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.. 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 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 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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