19 June 2016

Digital doctoring for #EHR4NI

I'm currently reading Dr Bob Wachter's fantastic book "The Digital Doctor" - a hard-hitting and insightful analysis into the whole field of the computerisation of medicine. Medicine has undergone a profound transformation in the past decades, and computerisation was, in many circles, felt to be the Next Big Thing that would deliver better care at lower cost for a greater number of people. The impact of digital in other industries - and indeed in our social lives - was felt to be translatable across to the messy world of Medicine, and we'd swiftly be on our way to a new and safer healthcare world. Billions were spent on this promise, and the big IT contractors gleefully piled in to address the issue.

And of course the reality was that Healthcare is much more complex than they imagined. Rather than this being a *technical* challenge, that could be sorted by wheeling in the appropriate tech and software, we are faced with an *adaptive* challenge, where the problem lies in the people, processes and indeed culture of the healthcare world. If we want to use IT to help us build better healthcare, we have to start with what is going on at the coal face. It's not enough (indeed it's positively fatal) to engage the CEOs and Medical Directors of healthcare delivery organisations (e.g. Trusts in the UK), and expect adoption and improvement to automatically follow.

I'm still something of a newbie at this, despite blogging about various aspects of our Northern Ireland journey over the past few months (in between digressions into biking and virtual reality). However at a recent meeting to discuss our plans for a unified Electronic Health Record for Northern Ireland (#EHR4NI), I heard a senior decision-maker (not a clinician) actually state that the road to clinical engagement would be to speak to the Chief Executives and Medical Directors of the Trusts; this would be how we would deliver the necessary buy-in from the doctors, nurses, AHPs and others that would make the process a success.

Bob Wachter's findings would very much suggest otherwise.

The good news is that NI has appointed Chief Clinical Information Officers for each hospital Trust, to join established colleagues in the Public Health Agency, the Health and Social Care Board and the NI Ambulance Service. There are five HSC Trusts; Belfast is one, and I have the pleasure of being the CCIO there. However, I and my colleagues also have busy clinical jobs also, and this clearly limits what we can actually deliver.

So what do we need to deliver? The "Clinical Engagement Piece" is one element, but exactly what are we asking our clinical colleagues to engage with? One possibility is that NI will go to market to purchase an all-in-one monolithic computer system on the basis of uniting primary care, community services and hospital based care. I have written about this Standard Model before, and it's one that I have a number of deep concerns about. The principal concern is that if we presuppose that we're looking for a computer system, we'll turn this into an IT project rather than a programme to improve the quality of clinical care. This sort of thing has been done plenty of times worldwide, and the common element seems to be that it generally doesn't work - sometimes spectacularly. The systems are beset by problems, the re-design of processes becomes an exercise in fitting the clinical workflow to the software, rather than reimagining both to actually do a better job. [See this 2-part article from Heather Leslie for some excellent learning.]

Another model might be to continue to purchase multiple "Best of Breed" solutions - software written by subject experts, and tailored as best as possible to the clinical process that we're trying to improve. Whether many of the systems we use would qualify as even mediocre, never mind Best of Breed, is debatable. And we're locked into contracts that are difficult to escape from, while our patients' data remains fossilised in systems that are reluctant to give it up again, much less to interoperate across the silos they were engineered to sit atop. It's pretty clear that this way lies madness; patient care is not markedly improved, but we end up spending a whole lot of money anyway, and digging ourselves into an even deeper hole.

So let's see how we resolve this problem. It turns out that farming these important issues out to IT professionals and consultants (not the clinical type!) is a critical error because these people cannot understand the clinical world. How can they? They're not trained. Nor can we just hand over to clinicians, because without the necessary background in quality improvement, change management and multidisciplinary vision, we just end up consolidating irrational variation (based often on whim) and making decisions that end up reinforcing silos, and indeed multiplying them. We need to find ways to get all these people - clinical, IT, managerial, and (most crucially) the patients - collaborating.

I'm still working my way through Bob's book (reading and re-reading each chapter - it's worth it!), but it's reinforcing some thoughts that I and my CCIO colleagues seem to be rapidly coalescing around. One is that we need to get the Data Interoperability issue highlighted (Bob calls it "baked in") from the outset. I'm going to suggest that we very explicitly and at an early stage in the process - now's good - state that we are NOT going to go down the route of a single electronic system to replace all the systems and functions of a healthcare IT infrastructure. Instead, we must create an ecosystem where the patients' data forms the core resource, and multiple developers and vendors can work on refining the interfaces that serve the clinical, management and analytical needs of the health service.

In effect, this seems to imply (and I am continuing my research, so this represents my current view, which may change according to new evidence and arguments) that we address the data first, then progressively migrate the apps to the data, instead of the old ways of migrating the data to the apps. We need evolution, not revolution. Plenty of Positive Pops rather than Big Bang.

What will this allow us to do? Firstly, it should encourage standardisation around best clinical practice - since we will be collecting the same data, we can assess variation, and analyse processes to see how best we can remap them to the most solid evidence base. Secondly, it will encourage innovation - agile software development will make it easier to quickly adapt interfaces to new clinical developments, without the need to change an entire system. Thirdly (and as a result of these), it will allow frontline staff and patients to get much more involved in refinement of the apps and systems that are being used. Fourthly, since the apps will be using the same data according to agreed definitions, data can be reused across clinical scenarios, reducing duplication, waste and errors.

Now these are very logical benefits, but will they actually pan out in practice? That is the million dollar question (or in the case of the UK's largely-failed National Programme for IT, 16 BILLION dollar question). There is good reason for scepticism that all the advantages that come from magical thinking will actually appear in the short term. They call this the "Productivity Paradox" - computerisation should help, but it usually requires a long time before it actually delivers, if at all. Our budgetary decision-makers in NI need to be aware of this - if we are going to go digital, it will cost money up front that may take years to deliver a return.

But let me get back to the main point - our prime objective here is NOT to computerise Health & Social Care - it is to improve the care of our patients. If we keep that principle front and centre, and build in the absolute requirements for an open and interoperable data platform supporting multiple partners, then we can do something pretty special here.  One model that I am very keen on is #OpenEHR, and we are actively exploring what we can do with this approach (and I think we should be doing more).

Is Northern Ireland up for this challenge? Well, before we head too far up this loanen, (old Ulster Scots term - look it up), I suggest we need to invest a good deal more resource (still cheap!) in freeing up some more of the time of the young (or at least not too senior) doctors, nurses, AHPs etc who will explore these waters and energise their clinical teams. I feel we CCIOs need significantly more time in our job plans to be CCIOs (one day a week? seriously?!), and we need clinical colleagues funded within our organisations who will join clinical informatics groups. We also need the CCIO role beefed up in terms of where it sits in the organisational hierarchy. We need specific specialty and patient focus groups that are structured around actual delivery, rather than merely producing wordy documents. We need a workable governance framework for the data, and we need money to do the groundwork and to experiment with various implementation models. This has to involve links with academia and IT industrial partners. We need to take risks. We need to be prepared for multiple Plan/Do/Study/Act cycles, supported by rapid innovation and rigorous data analysis. And we need to be ready to put our backsides on the line.

We have already had remarkable success with the Northern Ireland Electronic Care Record (NIECR) - that rare beast of an IT system that clinicians love, and that has had a dramatic effect on the practical delivery of patient care. Most hospital doctors now use NIECR as their first port of call when trying to find clinical information (letters, lab reports, radiology, medications) on patients, and it makes a real difference. It has shown us what is possible, and now we have to take things to the next level.

It's going to be a lot of work, but by the time Bob writes the second edition of "The Digital Doctor" (or maybe by the third - let's be realistic!), I want Northern Ireland to be one of his shining examples of what is possible when a country gets things right. So let's make sure we do that, rather than ending up as yet another cautionary tale of what happens when you try to turn a quality improvement process into a large scale IT project.

07 June 2016

Slovenian cycling bliss - again in Virtual Reality

We went cycling in Slovenia. The event was the Single Speed European Championships - mountain bikes specifically modded to have only one gear setting. It's all the rage among the kids these days, and certainly imposes an interesting discipline on one's ride.

Anyway, Slovenia is utterly beautiful. And of course I took my phone and captured some fantastic immersive 360 degree virtual reality images of the scenery. You'll really like this one, from the heights of the idyllic Soca Valley near the fantastic little town of Kobarid.

Click here to download the vr.jpg file. Put it on your Android phone and view in the Google CardboardCamera app.

Oh, and in the race I came 4th. Along with about 300 other people. There is no 5th in this race. In the short video below you'll get a flavour of events, and you'll see my brother Rick, and friends Hugh and Davy - as well as a load of new friends. And stuff.

05 May 2016


A beautiful evening in Greenisland. This is a 3D panorama for @GoogleCardboard Virtual Reality, in the vr.jpg format. It has audio and a true 3D still image. You need an appropriate smartphone (I use a Galaxy S7) and a Google Cardboard viewer (£4 on Amazon - seriously). Get ready for an amazing immersive experience - it's just like being ME beside my BIKE! Beside a ROAD and a FIELD! You'll notice that the software compresses moving vehicles into rather strange abberations, but the immersive virtual reality effect is pretty darned good.

I'm getting quite besotted by Virtual Reality and @GoogleCardboard in general - I think it's potentially a fantastic educational tool. Plus, I want to make sure as many people as possible share in my Nazareth experience, so when I do that, I'll be posting plenty of VR pics too. So make sure you get your Cardboard before then... 

[NB. This photo works in Google Cardboard Camera app on Android smartphones. You need to place the image in the Device Storace \DCIM\CardboardCamera folder, and then view it via the app itself. Have fun!]

01 May 2016

Views over Belfast - in Virtual Reality.

Want to see the #VR view on my morning bike ride up Knockagh in Co Antrim? Well, with Google Cardboard, you can! Click here to download the immersive Virtual Reality file, and view it on your Android phone. (some more instructions here).

And don't forget to follow my Nazareth journey - I'll be taking lots more VR shots there, so you'll get a real taste for what it's like to bike around Israel/Palestine. If you sponsor me, I might even take more... go on - it's for the children of Nazareth :-)

30 April 2016

Nazareth bike ride - come along!

OK, so here's the deal. You EITHER have to sponsor me, or sign up to come along and raise your own sponsorship. It'll be epic, and the cause couldn't be better - refurbishment of the Paediatric Unit in Nazareth Hospital. You in?
Musical greeting on our arrival in Nazareth, 2009
CLICK HERE to learn more and (go on!) sign up...

If you're not able to come along, PLEASE SPONSOR ME! :-)

I'll be posting plenty of cool 3D panoramas that you can view on your smartphone using the amazing GoogleCardboard virtual reality setup (really, everyone should get one of these).

17 April 2016

The Future of Medicine

If we are to drive progress in medicine, perhaps we need to think about the distant(ish) future. If we make our projections too near-term, we allow ourselves to get shackled to the status quo, and dream too small. So, what will medicine look like in 2050? That's far enough away that we don't have to worry about how we get there, yet it's close enough that many of us will either still be practising, or may be the recipients of that healthcare.

So go ahead - in the comments below, DREAM BIG! Tell me some stories (science fiction perhaps) about what medicine in 2050 might hold. And you never know - we might even be able to deliver some of them much sooner than that...

10 April 2016

Electronic Health Record - #EHR4NI - a vehicle for Standardisation?

Prof Rafael Bengoa

As you might have gathered from earlier entries in this blog, we in Northern Ireland are embarking upon a journey which will (hopefully) lead to a unified health data structure across the whole region. There are a number of reasons why we want to get all our health (and social care) data into a structure that is operative across many sectors, that reduces duplication in data entry, that is up-to-date and accurate, and streamlines the whole process of health care. It Makes Sense.

The DHSSPSNI have recently given approval to a Strategic Outline Case (SOC) which proposes developing a detailed business case for procurement of what we're calling the #EHR4NI - Electronic Health Record for Northern Ireland. This is potentially momentous - if all goes according to plan (!), Northern Ireland will have a unified health record for all its citizens, incorporating such items as outpatient records, prescribing information, lab tests, radiology and much more. There is also the prospect of bringing Primary Care (GPs) and Community Services into the mix, but the precise scope and detail have yet to be worked out.

In many ways this work directly assists delivery on the Principles of the Bengoa Review. (This is a major review of Health & Social Care in Northern Ireland, mandated by the Minister Mr Simon Hamilton, and which is taking place at the moment.) I'll be blogging at some point on how the Principles align with the #EHR4NI project, but one element that has been prominent in discussions has been that of standardisation of medical care across NI.

I have to declare that I am a fan of standardisation, so long as we're delivering meaningful outcome measures that we can reflect on in an effort drive improvement. If we are all doing things (largely) the same way, we can analyse the outcomes for our patients, and react quickly if things are not going as well as we would like. That's all well and dandy, but if we're all doing the same stuff, can that limit innovation and hence prevent us discovering other ways of doing things even better? Can standardisation be the enemy of best care? If we end up valuing the cookie cutter more than the cookie, we run the risk of missing important insights, demoralising our inventive and innovative health practitioners, and stalling the progress that our patients rightly expect.

Here's my worry - in the rush for an EHR4NI, we may end up simply doing things the way a Big Vendor decides we should do things. We standardise our processes to the standards of the incoming system. The constraints of the IT solution translate into constraints that we have to apply across patient care, because we have no other option. If we go back to the suppliers to suggest a Different Way of Doing Things, we risk being met with stony gazes and the reply that the process is set in stone (near enough). Or if we go to our Department of Health, they respond with a massive governance ask (submitting things to committees and review bodies etc) that stifles the little shoot of innovation before it even deploys its first leaves.

Standardisation, in other words, can become the engine of conservatism, and prevent the very improvements we're trying to achieve with the EHR.

Now all that sounds very pessimistic. But here's another scenario - we simply don't get the required agreement across multiple Health & Social Care sectors to allow us to move to a unified system, people start fighting with each other, and the whole plan falls apart. That is quite clearly worse than standardisation itself - BUT it's an outcome that many other EHR implementations have experienced grief over. It's a likely scenario, not an unlikely one. That's scary, and we need to avoid that at all costs.

Let's re-state what we want: we want the best evidence-based patient care, we want the right information at the point of care, we want near-real-time analytics to let us know how we're doing and to spot problems early, we want systems to help us do our job, and to help our patients better manage their own healthcare. We also want the data to allow the big decisions about resource allocation to be made in an informed manner.

So how can we make standardisation a force for good, not evil? How can we make sure that innovation is rewarded, creativity is encouraged, and changes are properly evaluated? I think the way around this is to explicitly state that standardisation has to be something that emerges from the bottom-up, rather than being enforced from the top-down. The role of the health managers, civil servants, committees and so-forth must be to curate and cultivate the front-line activity, to facilitate sharing of process data and outcomes, and to assist rapid regional adoption of improvements, using the EHR as a key enabler. If we make sharing an explicit part of the process, we create an evolutionary system where continual improvement can be encouraged - possibly even become inevitable.

This may mean we need to look at the EHR differently. The EHR can't be a single monolithic computer system - although that's how many people think of it, it's not possible to achieve the aims of #EHR4NI using this model. Instead, perhaps a specific core system could carry out a large number of the administrative and core clinical informatics tasks, but other platforms and sandboxes could tap into the underlying data structure to allow new applications to be developed, and new ideas trialled. This can be done without having to subject everything to a slow conservative process where deviation from the Agreed Norm, while not exactly heresy, becomes so mired in procedure, that we can't move forward.

Maybe even these thoughts are themselves heresy. Surely the People At The Top know best? I wouldn't count on it. The history of major ICT projects is littered with tales of projects going belly-up because they were treated as ends in themselves, rather than as vehicles to bring real benefit to patients and staff. Let's make this project one that we can be proud of.