All posts tagged Chief Information Officer

#CIO100 The 2019 edition…

Being part of the CIO100 has meant something to me every year that I have taken part, this year I didn’t make the event itself and it looks like it was a roaring success from the photos on social media and the WhatsApp commentary from so many of the CIOs that were there.

Being able to be part of a community of leaders every year that support each other, laughs at each other, finds ways to promote each other, shares stories and battle wounds with each other has been a great way to create a collegiate environment regardless of business area that the CIO works within. I think the key take away from the CIO100 celebration year on year is the similarities that the role brings ‘regardless’ of the business area that the CIO works within.

Its fascinating moving to a new organisation as a digital leader, no longer a CIO, but a member of the team with an interest and a remit in the key items of the CIO agenda I can see now how transferable the experiences of a CIO can be.

I remember reflecting on similar when I moved to Ireland, the way we described the issues faced by us every day delivering digital to healthcare in the UK were so similar to those described in Ireland and yet both sides of the Irish sea thought they were unique.

One piece of advice, if I am qualified to give advice, to all CIOs and aspiring CIOs, get out of the business bubble you may find yourself in, use events and groups like the CIO100 to learn about the challenges of other areas embarking on digital transformation and innovation in a business area. If you have an issue today, I will bet that either it has been solved at least once in a community like the 100 already or at the very least someone else in that group is going through the same issue.

The CIO100 is perhaps the greatest support group that a digital leader in the UK can be part of, a group I am proud to call ‘home’.

Well done to everyone in the list, looking forward to a year of connections, collaborations and having some fun.

… and perosnally from me, whilst I am no longer at Leeds teaching Hospitals Trust without the amazing team there my place would never be so in the CIO100, a huge thanks to all of the team for working with me for 12 months on the crazy journey we called #LeedsDigitalWay.

Super heroes each and everyone of you!

 

The Shades of Grey IT.

What is one of the most wicked problems in large organisations seriously adopting digital today? Many digital leaders would say it’s the challenge that Grey IT brings, and then some board members would turn to them and say what is Grey IT?

Digital functions the world over have adopted a multitude of phrases to describe a core issue that manifests in many ways and for many reasons. Grey IT is ultimately the organisation voting with its feet (or its projects) and buying and implementing technology without going through any digital function or digital governance. It’s a problem with its genesis in technology teams not meeting customer demands and the consumerisation of technology. There is an element of being careful what you wish for. In the 1990s technology leaders bemoaned their business functions for not being engaged in digital transformation, often the National Programme for IT and its perceived ‘failure’ within the NHS is accredited to the lack of business engagement; and now here we are a decade later complaining that the business is so engaged in digital solutions that they can deliver this stuff without digital teams getting involved.

The management training catch phrase of the 1980s, “Don’t bring my problems bring me solutions” needs to be turned on its head, when the business has an issue the ask now needs to be; “Come to me with your problem and lets together come to a solution for it.” This will be a first step to avoiding the Grey IT issue getting any worse, but once instigated the digital function now needs to be able to react to all the issues that are brought to the door, quickly, and in an agile manner that truly delivers on defined customer needs.

I propose that Grey IT is often so rife in large public-sector organisations because of two key reasons; a capacity to keep up with the now consumerised technology delivery that is possible and an often-backward view of innovation that comes from the business by digital professionals. The expectation that digital innovation can only come from those within technology rather than those at the cutting edge of business delivery has to be reconsidered by us, the digital leadership of any organisation! Sometimes the customer does truly know best!

We must combat these two root causes of this if we are to remove the negative outcomes of Grey IT’s existence. Technology outside of a decent governance capability is ultimately dangerous for business and healthcare delivery in particular. Grey IT does just that, delivers a layer of technology that does not have any governance to it. The real manifestation of Grey IT in the NHS today is often seen 12 months after the initial project go live, when the bill for the second year of the licence arrives or the need to upgrade becomes obvious and the technology professionals are called to assist. Worse still Grey IT becomes clear the day the system built, supported, procured and run outside of IT doesn’t work anymore, suddenly Grey IT falls back to its base colours, black and white, whose problem is it and who is going to fix it!

My organisation has been on the receiving end of one of the worst outcomes of Grey IT, many years ago we suffered a significant outage in the digital systems that were used in the Pathology Lab. Whilst the solution had been bought through a governed and appropriate manner it had not been taken into the technology team within the trust it had been developed, evolved and supported by keen and enthusiastic users, but a workforce that had moved on, had a higher priority (patient care) or simply had forgotten how to do stuff was left supporting a solution that was on legacy infrastructure. So when a server went pop, a disc array went AWOL and a back-up was missing disaster struck. This is all stuff the good book ITIL teaches digital professionals to avoid, but once the grey mist has descended upon it even the good book couldn’t help! All that the technology team could do in this case was take control of the recovery and work hard to ensure that the right lessons had been learnt and applied to the future.

I think we are looking at a plethora of different types of Grey IT that all need a different solution; Feral IT Guerrilla IT, Shadow IT and traditional Grey IT.

Feral IT for me starts as a digitally led project often a collaboration, an exciting chance for the digital team and the ‘business’ to work together to come up with a solution. It gains ground as it delivers benefit but slowly drifts away from good governance, often because the project is so successful. Over time though the project will grow and its delivery focus and the team will change, as that happens the digital governance of the organisation can break down and the project is then being delivered outside the parameters of good governance.

The key to making Feral IT work is to ensure that the governance of the project is grounded in the foundations of the digital agenda, organisations are often looking for agility and a start-up culture to enable innovation to happen, but innovation becomes scalable only when a rigour of governance is applied. As digital leaders we should try to encourage the agility that this type of project culture offers, but it is also our role to ensure that the foundations of decision making and corporate risk management are clearly understood. It is tricky in a new decade where digital is a consumerised product, building an understanding of why we the digital function of an organisation needs to be continually part of the decision making in this kind of project can only be achieved with the right style of engagement, one that at least can light a candle next to the consumer style digital capability now available to everyone.

Guerrilla  IT is a phrase that best describes the technology project that has been actively hidden from an organisations digital team, a project that has wilfully been created outside of governance for so many possible reasons. Guerrilla warfare was a phrase first coined in 1808 to describe the Spanish resistance to Napoleon, Guerrilla IT is an identified need that a team has understood and has been unable to get help with the delivery of, at this point the business function decides to go ‘rogue’ and deliver it anyway.

In the NHS today Guerrilla IT exists for many reasons but I would suggest the key reason is an inability to make the national solutions that have been delivered work in the way that locality needs them to. When we have Guerrilla IT projects we need to understand why they exist, much of the reason will often be traceable back to the nature of the solution being sought by the business to the problem and the digital functions inability to react in a way that achieves the desired outcome. The use of WhatsApp in the NHS is possibly the best example of a Guerrilla IT project, organisations have been saying for more than five years that this platform should not really be used inside a healthcare environment, and yet every day that I am in Leeds I see and hear of staff using it in ways we have actively said it shouldn’t be used. Why, because it achieves a need, it is easy to use and it’s a consumer product, and in reality, alternatives to its use are very new to the digital fabric of healthcare. The same could be said for ERS, there is a desperate need fro the NHS wide booking system to offer a ‘many to many’ booking capability, hospitals refer to hospitals! And yet it doesn’t and therefore department after department has its own growing digital solution to enable the digital transfer of information about patients moving from hospital to hospital, we have to fix this!

Shadow IT manifests often from the digital team, when disagreement exists in strategic direction, standards to be adopted or simply in the procurement of a system. Digital professionals can be a real pain, we all know best, we all know our subject matter and sometimes this can boil over into a Shadow IT project. A project that is delivered against the wishes of the governed decision and with an intention to compete with a decision made. Shadow IT will often be kicked off with good intentions; a project just in case the agreed and governed solution misses a deadline or as a risk mitigation to functionality delivery, but sometimes the project is started because it is a ‘pet project’ of a leader of the organisation, digital or otherwise. Shadow IT can be a useful mitigation to risk, but needs the same level of governance,  risk management and rigour applied, it needs to be managed as a project that has goal of being there just in case and should not be tolerated as a vanity project because someone with the digital function is unhappy with a technology decision that has been taken.

Grey IT becomes the collective term for these issues, all shades of grey, successful in some ways in delivering user defined need but with risks to the business that need to be quantified and mitigated against. Removing Grey IT has already become one of the wicked problems, maybe we should accept that we can’t remove Grey IT from what we do, but we should look to understand where it is, why it is and what the risks are to us. There is also an element now of learning from the collective Grey IT projects and understanding better how to avoid them starting up, and that I think is about understanding the investment decisions that are required to initiate a digital project and the engagement needed to enlighten everyone in decisions being taken.

Investment and the return it brings has to be part of the equation in the answer to the ever-present Grey IT problem. Investment in infrastructure for healthcare needs to have a digital element in the same way as the investment decision would call for electricity, heating and light. In 2015 KPMG Ireland called out the need for the fourth ‘utility’ for the building of the National Children’s hospital in Dublin to be digital, it wasn’t, and we now see a furore in the media as the whole digital backbone of a brand new hospital is going over budget because its digital element was expected by decision makers to be run as a Grey IT project. Misunderstanding or on purpose I am still not sure but I do know that the digital team across the project, the ‘centre’ and the department were clear that the hospital had to be a digital hospital and yet the return on that investment was not judged to be worthwhile capturing properly and openly, IT costs money, when will we learn!

We are asked to consider the Return on Investment (ROI) that digital makes when we build a case for spend, perhaps the key to removing the plight that is Grey IT from digital health care could be to start to consider a different set of terms more strongly, what if we considered the Value on Investment (VOI) instead? Let’s not pretend anymore that investment in digital in healthcare anywhere in the world will ever return money back to anyone’s budget, capacity and demand are so ‘topsey turvey’ right now that no amount of digital innovation will return investment, what it will do though is increase efficiency to bring us closer to the demand need, increase quality to bring us closer to the required need and bring a new interest back to the daily roles to deliver a new enthusiasm for what we do. If we all consider the VOI together then just maybe no one would want to set up their own little Grey IT project anymore because we would all be heading towards the same increased value curve.

So we move from ROI to VOI and start to build the case for change in a different way, we still are missing a piece of the colourful puzzle that will be laid over the top of Grey IT though. Return on Reputation (ROR) was a phrase I first heard uttered by Ted Rubin a digital marketing expert and social media evangelist, Ted suggests that the way to building reputation is by building the network of believers and doing this by being ‘nice’. Quite an American ‘thing’ to want to do I guess but there is something in this I think. Digital functions all over the NHS have not adopted any form of ‘Del Monte’ attitude, we are quick to say no, we are quick to say get in line we have a prioritisation process you know! When we do this without listening, we do two things, we set the preference for our customers to understand that its quicker to ‘go elsewhere’ and that we are not part of the team, we are ‘another’ corporate function, maybe even an overhead, with our own benefit blocking agenda. If we adopt Ted’s principles then we should be more open to listen, more transparent in what we will do once we have listened and allow the ‘business’ to work with us to decide what to do first, second and third. The return we would all then get from this is an improvement in the reputation we have.

Grey IT is here now and no matter how big your One IT (insert other corporate programme name here!) is that you are instigating to remove it you won’t without attitude and aptitude change in the digital functions of healthcare. Change is hard to make happen but we have to make it happen, as a journey we are on not as a demand dictated to the system we can become one transformation function for the NHS.

Bring out the problems, let’s work together to create new ideas to solve them and then lets seek the right way of describing the investment and the way we are all going to deliver this together, let’s create joint solutions to problems we consider to be joint as well.

Somehow let’s make digital first be a way of working together that is about innovating for the future not simply concentrating on tomorrow.

 

 

NB If you ever see Ted Rubin on an agenda at an event you are at, go and see him speak, one of the most inspiring speakers I have ever had the joy of seeing, he changed my outlook and I still quote him years later, ‘just be nice!’

Arch Collaborative

First published as a KLAS blog after Leeds teaching Hospitals NHS Trust received the analysis of the Arch Collaborative. If anyone wants access to the full Arch Collaborative results from Leeds then feel free to get in touch, happy to share.

The Arch Collaborative exists to ensure that we understand what the users of our systems really think of them!

The technology industry is one of only two industries[1] that describe their customers as users. Launching the Arch Collaborative locally ensures that each healthcare system that takes part can move further and further away from that ill-gotten term, user to a new paradigm where we have valued customers with opinions that matter, perceptions we should act upon, and innovations that we would be foolish not to consider.

The first time that my organisation, NHS Leeds Teaching Hospitals Trust (LTHT), considered the Arch Collaborative was in early 2018. We regularly share ideas and concepts with two NHS Trusts: The University Hospital Southampton and the Salford Royal Foundation. Those Trusts had taken part in the survey and were clear that it was a great way to really understand the clinical views of the Electronic Health Record (EHR) and the way it is implemented.

My organisation has risen to the EHR challenge in a different way than many. 15 years ago, our organisation decided to begin building its own EHR. We released new functionality in subsequent years until it became clear in 2017 that the organization had evolved the solution to the point where it was a clinically developed EHR.

Taking on the Arch Collaborative survey felt like the next step in understanding the direction we should head. It could be the basis for a strategic road map.

Standing up on such a public stage was a big decision for an organisation that has invested so personally in the creation of an EHR. For us, this wouldn’t be a comment on the vendor implementation or the partner development of the training materials; this would be a comment on what we had built, what we had prioritised and what we had invested our time in.

There were no gimmicks, backing tracks, or staged production; the Arch Collaborative just asked for an evaluation of our raw digital ability.

By the time we agreed to get involved in the Arch Collaborative, there had been a number of departmental changes in our organisation. We brought together individual teams and elements in the hope that we could form a super group.

We were so nervous about what would happen next that a colleague compared this process to an audition for the a cappella singing team at university, but we were resolute to know how our voice fit into the digital health mix.

The Arch Collaborative involves getting the broadest clinical input possible to a series of questions about the functionality and implementation of the EHR solution within the organisation. The survey is quite in-depth and requires time and energy to work through. We asked one of our Chief Clinical Information Officers (CCIO) to take on the project. The CCIO worked with our digital engagement team to ensure that the survey terminology was anglicized and then to widely promote the survey. In the first week, over 400 members of the hospital team had completed the survey; by the time we closed the survey, over 980 members of the workforce[2] had completed it.

We were so proud that so many clinicians had come to our gig. We were not playing to an empty stadium—they had come to join in and sing about the EHR they used every day.

Our organisation uses the EHR for point-of-care delivery; over 19,000 unique users accessed the system in September of 2018. In the same month, there were over 74 million interactions with the system. An average nurse is now collecting over 100,000 data items a year!

When we consider the size of the audience that the Arch Collaborative response will reach, the throughput of the system feels huge. That comparison to the a cappella sing-off is more like the national sing-offs at the Kennedy Centre in the film Pitch Perfect.

When organisations and senior staff members look at the success of EHR implementations in the NHS, it is easy to focus on the traditional project management triumvirate of cost, time, and quality. That is understandable—these are important aspects of a large-scale procurement project.

But a lesson hard learned and seemingly relearned many times over in digital healthcare is that an EHR project is not just a procurement project. The Arch Collaborative was the perfect way for us to test the pitch and tone of our EHR.

We believe we have an approach worthy of blueprinting for reuse but not a specific system, although that is possible. We are more keen to consider the approach we have taken—an approach that includes the following: open standards; the concept of the geography as a platform for care rather than separate healthcare systems trying to interact and integrate; and the clinical focus we have placed in the prioritization of developments.

Each of these methods has been a major part of how we developed the #LeedsDigitalWay, and we believe it is worthy of blueprinting and digital implementation in healthcare across the world.

Ultimately the Arch Collaborative at LTHT would be a comment on the concept of the #LeedsDigitalWay as much as it would be about the actual EHR.

In discussions with KLAS about the decision to take part in the Arch Collaborative, they stressed that our taking part showed humility, a strong word that meant a great deal to us. Around the same time, a tweet from Damian Hughes (@LiquidThinker) resonated particularly with our reaction to the Arch Collaborative results:

Ego is often a roadblock to your development. Humility is a key to a new pathway.

Taking the ego out of delivery means that we can adapt and learn more quickly and ensure that the silos that so easily spring up between clinicians and digital leaders can be avoided.

The results from the Arch Collaborative are not for the faint of heart. They deliver a complex, true, and statistically sound message that will shine a very powerful light on the weaknesses of the work that you have done and specifically highlight the areas that you can change to improve your “Net EMR Experience score” with minimal effort. Unlike a HIMSS score, the Arch Collaborative is based not on what is in the “box” but how the box is used and the success of its functionality.

The headline score for Leeds Teaching Hospitals Trust was a 41% Net EMR Experience score. This is the macro score that sits front and centre on the report. The score ranges from -100% to +100% and is built up from the entire survey. We were pleased with our score.

60% of our staff members described themselves as “pleased with the experience” that the EHR offers, while 19% are frustrated daily. The detail of the Arch Collaborative report allows you to investigate how to improve each evaluated area as well as the headline figures.

By offering just four hours of training every year to every staff member that uses the EHR (that’s over 19,000 people, remember), we could improve our Net EMR Experience score by a further 10%.

That final statistic makes a digital leader in the NHS pause for thought; the cost-to-impact revenue on that 10% Net EMR Experience change is not insignificant, and the debate about where the cost sits would be a long one to resolve. Is it the digital team’s job to continue to deliver business changes? If the digital solution has been embedded in everyday life, should it be a cost of ownership?

35% of our team members that use the EHR daily would describe themselves as proficient in the use of the solution. That seemed immediately positive. However, 8% of our staff members indicated that they struggle every day.

The Arch Collaborative shines a light on what you need to do and the evolution that you need to inspire. Being on the receiving end of a complex statistical readout of your digital agenda enables you as a digital leader to take a breath, look around you, and consider how you move to the next stage.

Computer Weekly refers to the CIO role and its responsibility for the transformation of a system for driving business outcomes. It suggests that the CIO role is the “third leg of the stool” of modern “business” evolution, the other legs being marketing and sales. In healthcare, we are also in a modern evolution, made clear in the following quadruple aims:

  • Purpose
  • Productivity
  • Efficiency
  • Better health and better care

The Arch Collaborative provides an opportunity to focus on the aims of the quadruple claims, but it doesn’t provide the means.

The Collaborative is grounded in the quadruple aims by accident rather than by design, but it does expose how necessary EHR capabilities needs to be implemented with the aims in mind. The Collaborative does not pass judgement on the EHR, though—it offers the statistical vision of how to improve.

If we consider the Virginia Mason Institute improvement method that was based on the Toyota Production System management methodology, we can understand how to innovate and improve using the Arch Collaborative as a baseline measure and the evolutionary plans as the rapid-improvement plans.

To ensure that what we deliver is received better, we need to find a way to offer 19,000 extremely busy people a way to not do what they do for four hours of the year! (I picked those words carefully.)

We can offer the opportunity to do the training and learning relatively easily. It is a great deal more challenging to find four spare hours for each professional who needs to use the EHR to devote to the digital agenda. It feels like a budget issue at first; who is going to pay for this? However, it soon becomes clear that it is an organisational culture issue.

The statistics from the Arch Collaborative allow you to dive into perceptions from different parts of the clinical team. The definitions need a little work to map with NHS language, but they work well at a rough-order view. For LTHT, the Collaborative highlighted a difference that we already knew, but the existence of the analysis reinforces where to focus. Clinical roles placed the LTHT EHR in different percentiles of approval, and they map as follows:

  • All clinicians – 72nd percentile
  • Physicians – 41st percentile
  • Nurses – 63rd percentile
  • Allied Health Professionals – 59th percentile

The results also include sophisticated symptom analysis to distil some key phrases for us to work with:

  • Enhance initial EHR training and follow-up education to focus on supporting efficient clinician/speciality-specific workflows using personalization tools.
  • EHR personalisation tools for shortcuts, filters, and report views have the highest impact on satisfaction. The use of these tools should be a focus in initial training and follow-up education.
  • Timely, helpful support for clinicians’ EHR requests will improve the clinicians’ trust in leadership and the wider digital agenda. Trust will be further built as clinicians are solicited for their input into workflow designs and personalisation tools and as those enhancements are delivered as communicated.
  • Engaging clinicians in ongoing enhancement of the EHR will support a culture of teamwork at Leeds that will ensure that the group coalesces around the digital agenda.

This kind of commentary was very powerful for LTHT for two key reasons: first, it wasn’t particular commentary on missing functionality—it concentrated on additional ways for system use; second, it refocused on the engagement piece as an area for improvement. We took these statements as suggestions for how we can do better.

The distance we have to travel on the journey of improvement is not to be underestimated. KLAS and the Arch Collaborative may have hit on something important. If the rest of the NHS spent the time to consider their suggestions, the wealth of comparison data that would become available could bring about the change in attitude and aptitude that digital healthcare needs so badly. Southampton has completed their Arch Collaborative research, too.

The CIO in Southampton, Adrian Byrne, commented, “I think it’s hard to come up with a set of measures to get a good evaluation report. We want to have some things we change and refine and some things we keep the same, so we can measure improvement. I like the Arch Collaborative’s ability to measure across peers. That is its main benefit. We can measure improvement ourselves, but it’s all arbitrary. KLAS has a great record in research and tends to provide real insight.”

That is the key. The Arch Collaborative today, in its full glory, enables LTHT to build its strategic direction for the continued evolution of the EHR. As more NHS organisations take part in the survey, more souls are bared, and more agreement is reached for sharing the report’s details, then we will build a platform that can inspire the next phase in the NHS digital revolution where the stars align. We will ensure that digital healthcare is about collaboration between CIOs and digital leaders who lean into the challenge together.

My last comment is from many years ago:

Forgetfulness is in the learners’ souls because they will not use their memories… they will be hearers of many things and will have learned nothing; they will appear to be omniscient and will generally know nothing; they will be tiresome company, having the show of wisdom without the reality.

Socrates (5th Century BC)

Let us prove the genius wrong. Let us learn from each other by remembering the past and noting the opportunities of the future with a humility that allows us to continuously learn and collaborate. As David Amerland says;

Collaboration is the new competition!

 

 

[1] The illegal drug trade has used the term since the 1960s and yet the technology industry has remained the only other business to maintain this reference.

[2] 530 clinicians, 147 Advance practice clinicians, 153 nurses, 154 allied health professionals

Partnerships and dancing…

Originally edited and published by www.digitalhealth.net reproduced here ahead of the Digital & Informatics Team at Leeds away day in July. Partnerships applies just as much to the team as it does to the age old ‘vendor’ relationship.

What do you need from the perfect dance partner? Someone with the same ear for a rhythm as you, someone that doesn’t tower over you, someone with strength and grace in awkward situations, someone who can stand up to a change in beat, or someone who will help when you miss a beat. All descriptions that a healthcare CIO needs to apply to building the perfect relationship with their commercial digital partners.

As an analogy does the search for the perfect ‘strictly’ partner help when picking the digital delivery partner, lets us look and see by considering the different ‘dances’ we have on offer:

Argentine Tango; is characterized by its hold embrace and complex leg and foot movements. It is an improvisational social dance that is truly a dance of leading and following.

Represented by a digital delivery partner that follows your every move no matter how complex the delivery is that you are trying to achieve. This type of partner, in the new agile environment of what is asked of digital in healthcare, needs to be able to improvise within a plan and deliver at a high speed, in a structured and planned manner. The risk with this kind of partner is that you as the digital leader either have to be leading the ‘dance’ at all times or if the partner wants to lead in this style of delivery they will be driving your organisation to their beat which comes with risk as your organisational goals and the digital benefits you are striving to achieve will have to be closely aligned to your partners throughout the relationship.

Ballroom Dancing; is a form of partnered dance that has pre-defined steps following strict tempo music, such as waltz, quickstep and foxtrot.

If your digital partner fits to this analogy then you have created a very structured but perhaps rigid partnership. Both you and your delivery partner know what is needed of you every step of the way; you are working closely on delivering against contractual elements that are clearly defined and well understood or at least a delivery plan that you have both worked hard on to ensure has wins for both parties included. The area of concern here would be the ability to react and work off plan together may take time. Creating the next steps in the new ways of working will not always meet the needs of a modern business change project, whilst that could be described as a failing the original plan will be delivered. This is ok if it is all that you need and therefore working in this way will be perfect for you both.

Contemporary dance; is not a specific dance form, but is a collection of methods and techniques developed from modern and post-modern dance

This style of partnership requires a true relationship to have been developed, one where a high level of trust has been put in place, after all you are about to embark on a journey that some will think is a little odd. Few digital delivery partnerships have been able to achieve the level of trust to work in this way, however if it can be put in place it will bring a surprising amount of success for both parties, a relationship that can be reaction driven and therefore drive an agile response to problems can be achieved through working in this way. The level of sceptism from the ‘audience’ though will be high for the success of the partnership and it is likely the partnership will be under constant observation from a governance point of view to test its validity as an ‘art form’. Conversations about delivery of digital in a post-modern world have been raised over the last couple of years a number of times, this way of working with partners perhaps is the way to see this come to a place where we, as digital leaders, can truly understand how this would work and indeed even what it means.

Jive; is a social dance that can be practiced to a broad range of popular music, making it highly versatile, which adds to its appeal. It is easy to learn and has simple footwork, making it accessible for beginners, but it is tricky to master.

Jive as an analogy for delivery partnership is perhaps best used for those quick partnerships that are only in place for the term of a single delivery focus. The partnership is easy enough to learn and create and is driven by the tempo of the delivery. No lasting commitment needs to be made to the partnership if all that is required is a successful and sharp delivery, but if this is to be maintained longer term and the pace of delivery kept up then a strict set of performance metrics need to be put in place to ensure the pace can be maintained longer term by both partners. A jive relationship will be tiring for all partners, a new level of contractual sustenance will need to be created to enable the relationship not to ‘flag’ as it gets tired of the pace.

Salsa; is in 4/4 time in two bar phrases with a pause on the 4th and 8th beats, which gives a quick-quick-slow rhythm. In classes a choreographed sequence is generally taught, but in practice it is an improvised dance.

Salsa can be described as a sales driven digital relationship. The initial excitement of the contract being signed and the new relationship created will give those early deliverables a focus; a shared impetus to deliver almost jive like, however without collective improvisation as the relationship matures the speed of delivery will slow down. This can be beneficial in creating quick wins and then moving to a more considered and managed relationship as long as the slowdown in delivery does not hit a stop. Improvisation of the relationship in after sales behaviour can ensure that this relationship continues to evolve and is successful.

Tap Dance; is an example of a non-partnered dance that is generally choreographed, with one or more participating dancers.

Going solo to deliver but in tandem with others is perhaps the best way to utilise this as a learning example. Maybe the Local Health and Care Record Exemplars (LHCRE) are a good example of five tap dances being performed around the country. Each of the cohorts will now be trying to create their own tap dance, the original choreography being provided by NHS England and the beat and shoes provided by NHS Digital and others. Each LHCRE cohort will be able to have an element of choice in the type of shoe and outfit they decide to wear but when the dance is the performance the music and choreography will have to be the same for the System of Systems approach to deliver across the country.

We need to be awake to the style of partner we are choosing for the dance, we need to be able to live with different ‘dance styles’ as part of our eco-system of partnerships as the same style will not work for each project nor each partner we choose. True success will come when we have picked the right partner for each type of dance we need to deliver and we know how to move seamlessly from style to style.

Grab your partners by the toe, let’s go do the Dozy Do, or as the legend that is Sir Bruce would say, Keep Dancing!

AI a shiny thing or the next loop in the evolution of digital healthcare.

In 2001 AI was ‘just’ a Steven Spielberg film; in May 2018 it is being described by many as a solution too so many ills within the NHS.

On the 21st of May the Prime Minister provided the NHS with her view on the way Artificial Intelligence could revolutionise the delivery of care for patients with Cancer, Dementia, Diabetes and Heart Disease and by 2030 save 50,000 lives. Grand claims and grand plans and a new direction for government. One that focuses on a digital art of the possible although certainly to leap from paper records in vast wire cages and trolleys as an “ok” solution through to AI as an opportunity for the delivery of care is no mean feat, but a goal we can try to play our part in.

The following day Satya Nadella the Chief Executive Officer of Microsoft gathered CEOs and CIOs from digital business from across the UK to discuss what the team at Microsoft described as “Transformative AI”. The CEO used a quote by Mark Wesiser the prominent scientist of Xerox and the father of the term ubiquitous computing to open his presentation,

The most profound technologies are those that disappear. They weave themselves into the fabric of everyday life until they are indistinguishable from it.

This is where we want our EHR to get to!

The conversation continued to try to deliver the fundamentals in AI. Data is what feeds and teaches AI, it provides the fuel to grow to learn the what and the how.

Collecting more data therefore will educate AI more quickly; the next horizon is to make the nine billion micro-processors that are shipped every year become SMART devices. The micro-processor in your toaster, your alarm clock, your motion sensor light can become part of the data collection capability that will be responsible for our education of AI. The sheer growing size of data is something well documented, the creation of data will have reached a new horizon by 2020 and will look something like the figures below:

  • A SMART City – 250 Petabytes a day
  • SMART Stadium – 1 Petabytes a day
  • SMART Office 150 Gigabytes a day
  • A SMART Car 5 Terabytes a day
  • Your Home 50 Gigabytes a day
  • You 1.5 Gigabytes a day

20 Billion SMART Devices will exist in the world

(8 bits to the byte, 1,024 bytes to the kilobyte, 1,024 kilobytes to the megabyte, 1,024 megabytes to the terabyte and 1,024 terabytes to the petabyte) The average mobile phone now has 128 gigabyte; the first man went to the moon on a computer that had less memory)

So much data to educate the AI of the world, the insights that could be gained are incredible.

The journey from what we know as an IT enabled world to a digital world sees the move from ubiquitous computing to Artificial Intelligence as a pervasive way of life and then on to a world where we live in a multi-sense and multi device experience.

The impact on the relationship between us and technology has evolved in how it is perceived; technology was ‘simply’ a tool, initially as AI evolved it worked for us as a subordinate and as AI evolves still further it will become more of a social peer in how we consider what it can offer us in healthcare. The most common Christmas present in the UK this year was one of the voice activated assistant, people all over the UK are now having chats with Alexa, Siri, Cortana or simply saying Hey Google to find out some fact that just alluded them or to ask for a simple task to be done.

The original concept of distributed computing (or cloud) gives us the ability to create the computer power and data storage that is needed to evolve AI capability. Distributed compute adds IT complexity, it is now our job to find ways to tame the complexity by ensuring consistency and a unification of experiences, this applies more to digital healthcare than any other ‘business’ as we try to utilise digital as a way to standardise the delivery of care as much as we possibly can.

The definition of Artificial Intelligence is said to have been first coined in 1956 in Dartmouth, the journey from this definition now includes the term Machine Learning first applied to algorithms that are trained with data to learn autonomously and more recently since 2010 the term deep learning, where systems are enabled to go off and simply learn beyond a set of specific parameters. The art of clinical practice, the need to have a human touch though is well understood in healthcare. This is why more and more AI in healthcare is referred to as an ability to augment the delivery of care, AI does not deliver a solution to offer less clinicians in the service, what it does is remove the need to have clinical time spent on anything other than patient care, AI offers the opportunity to increase the human touch. A further quote reinforces this in the book The Future Computed;

In a sense, artificial intelligence will be the ultimate tool because it will help us build all possible tools.

Eric Drexler author of Nanosystems: Molecular Machinery Manufacturing and Computation (1992)

The journey to AI in our world is getting quicker. The journey to AI being successful is best measured when the different components of it reach parity with us humans;

  • In 2016 AI became able to see to the power of us, and passed the RESNET vision test with 96% able to see 152 layers of complexity.
  • In 2017 AI became able to understand speech to the same degree we can the 5.1% switchboard speech recognition test.
  • In January 2018 AI was able to read and comprehend to the same degree as a human passing the SQuAD comprehension test with 88.5%.
  • In March 2018 AI became better than a human at translation, now able to translate in real time successfully to an MIT measure of 69.9%.

The road to an AI augmented world though is about amplifying human ingenuity; AI can help us with reasoning and allow us to learn and form conclusions from imperfect data. It can now help us with understanding; interpret meanings from data including text, voice and images. It can also now interact with us in seemingly natural ways learning how to offer emotionally intelligent responses. A Chat Bot launched in China now has millions of friends on across multiple social media channels, it has learnt to offer help to its ‘friends’ that are demonstrating symptoms of depression, phoning up friends to wish them good night and offering advice and guidance on sleep patterns but in a very human way.

Gartner have reported that the ‘business opportunity’ associated to AI in 2018 is now worth $1.2 trillion! Suddenly AI is the new Big Data which was the new Cloud Computing, which was the new mobile first. All of these terms have had hype but have all in reality brought a new digital pitch to our business strategies and our lives.

Great Ormond Street Hospital in partnership with UCL is leading the way in AI application into healthcare with several projects delivering startlingly real results.

Project Basecode: Transcribing speech in real time and utilising AI capability to add information to spoken word dictation capture.

Project Heartstone: A device for passing messages, verbal and video to patients of GOSH that may be too young to have their own Smart Phone, the device can be expanded to offer services to children who may be deaf or blind.

Project Fizzyo: Puts in place gamification to the delivery of breathing physiotherapy for children with Cystic Fibrosis and captures the information for the clinical record offering analysis as it goes.

Sensor Fusion: Creates perhaps the most immersive AI elements in healthcare today, recording events throughout the hospital, offering machine learning developed advice and data driven descriptions of events as they occur.

At Leeds Teaching Hospitals Trust we have created a platform in the form of our Electronic Health Record (EHR). With this platform we can now begin to consider how this clinical push for AI and the difference it can make to patients lives and the way we work can be achieved in a carful and considered way.

This digital revolution can make a real impact on Leeds; the patients, clinicians and staff enabling us to provide the care we want to provide following the Leeds Way principles with digital as a supportive backbone.

If you want to know more or have an idea as to how you could help in this area get in touch with us via @DITLeeds

Handover CIO

First published in CIO Magazine, November 2017.

In 1797 George Washington instigated the first handover period for the presidency of the USA, he handed his responsibilities to John Adams. Since the 1960s a 72 to 78 day handover period has featured in every transition of the presidential role, and yet in almost all other public sector and civil servant role changes a handover period simply doesn’t happen, in all the CIO roles I have had I have never had the opportunity to conduct a proper handover one that means you hit the ground running, rather than running to catch up.

In a few days time I will leave Ireland for Leeds after three years working in a country with a passion for what digital can do for healthcare. When I resigned from my post my boss, the director general of the health service here in Ireland could see that there was a need to have a careful, considered and informed handover process to maintain the pace of change that we have been working to. In a break from what would have been the easy decision it was decided to look outside of the Office of the CIO for an interim person to hold onto the digital healthcare business and to receive a handover. Appointing a progressive, digital business leader to the role of interim CIO eight weeks before my departure has meant we have been able to work through a handover of the business, we have been able to agree priorities for 2018 and at this time in the Irish political calendar we have needed to agree how the budget for next year should be spent.

CIOs need to get better at succession planning, I would suggest one of the reasons we have not been seen to be great at this so far is that we have very much an individual stamp on the businesses we run as CIOs. Our styles and how we work with the ‘business’ to achieve digital goals is one of our core values, handing that to another is always difficult.

With an interim CIO appointed we began to plan the handover, we broke the content down into areas that would make the most impact the quickest, what this did was highlight a prioritisation process for the work of the team and the office.

There were five themed areas that we agreed would be our area of focus:

1 – Delivery of Person Centred Care

2 – Trust and the Protection of the health systems assets

3 – Value add services – Patient focused innovation and proving the digital capability.

4 – Create Insight and Intelligence through data that is already collected.

5 – Connect the Care Delivery Network

The digital strategy has been in place since 2015 and the delivery plan for this was agreed in 2016. This means the interim CIO can move into the continued delivery of this, however what does need to be refreshed is a new operating model for the Digital team, an operating model that reflects changes in how service is delivered and how engagement can be brought from a digital responsibility to an organisational scalable way of working. This now becomes a priority for the new CIO, not always ideal, making changes in the early stages of taking on a new role but a necessity to continue to enable the evolution of the team.

Being able to instigate a proper handover has given the organisation the opportunity to really consider the way the team works as one function. In a recent Gartner presentation the idea of four digital accelerators was raised and how these are now being applied to the future of team working. These areas are; Digital Dexterity; Talent, Diversity, Skills and Goals; Network Effect Technologies and the Industrialised Digital Platform. The handover process with these as core values as to where and what is done next has helped hugely as we strive to put in place a robust way forward that continues to drive a new pace to digital in healthcare.

The handover process has included not just a new ownership of the digital agenda but a new face of the change being brought to healthcare through digital. Therefore involving the new interim CIO in all engagement events has been part of the process and one that has seen the new CIO move into the public eye. The handover has also been delivered in the public domain using social media as the platform to enable the team and our partners to see the process and to meet the new CIO in a virtual way. The #HandoverCIO has been used as a way for stakeholders to see the activities that are underway. The culmination of the handover process was a meeting of all partners to an open interview with me and the new interim CIO, the design of the session was to make it part of one of the quarterly Eco-System meetings but also to ensure that the partners could see that they were going to be able to continue to evolve the relationship they have from a traditional vendor relationship to one that continues to be described as a partnership.

The transition from Bill Clinton to George W. Bush in 2001 was a fraught process best epitomized by the Clinton prank of the removal of all of the ‘W’ keys from keyboards throughout the Whitehouse. The transition from CIO to CIO often does end up with a lack of knowledge of where ‘the bodies are buried’, a phrase used when I came to Ireland in 2015. A colleague offered his services on my first day to help me avoid digging up the bodies that had been carefully hid. By working on a handover process and a proper transition there can be no ‘buried bodies’, no surprises and no need to re-learn what has gone before.

Handover has been great, but now its time to let go as the quote suggests below…

Make yourself available for advice if they want it, but only if they ask for it – don’t stand in the shadows trying to hang on to something you’ve decided to stop doing. Professor Graham Moon

Giving up your ‘baby’ is hard to do but as a CIO in transition to a new role it has to be done smoothly and the new CIO empowered. As handover comes to an end please support a new CIO with advice and guidance, Jane Carolan is a digital leader that is now a CIO, she is excited to be in the role and can’t wait to engage with the wider CIO community, tweet Jane @janemcarolan

What is Pink Socks?

A simple pair of Pink Socks can change your world! Pair by pair pink socks have become the new paradigm in connectedness for healthcare IT professionals all over the world. To have a pair from Nick Adkins that you can gift on enables you to become the Network Effect Technology!

My first pair arrived from the Netherlands, from Ignar Rip, a simple gift of a few pairs to pass on, to create a little enclave of Pink Socks for an Irish health care conference, in this case the socks represented more than a new connection for technology people, they represented an awareness of improving Dementia care globally, they also created me a new friend who loves a variety of music and believes in the transformation of health care.

Being able to pass the socks on at the Future Health summit to such giants of the industry like Andy Kinnear and Rachel Dunscombe was a great pleasure, seeing the founders of One Health Tech Ireland in the socks as they began to formulate the plans for creating diversity in our industry was also a great thrill.

         In just three connections the socks were making more difference than Block Chain is yet to make on health care!

Next came the wonderful Roy Lilley and Shane Tickell at the first Irish HealthChat, live from sunny Dun Laoghaire, Pink Socks times three now made it on to live TV and still represented partnerships and friendships coming from working together. Over the last three years we have worked hard with team in Dun Laoghaire to try to ensure there are ways that an Irish company with an amazing idea can be supported by the Irish health care system that needs their amazing ideas. Pinks Socks in action for another reason!

Last but by no means least is the Pink Socks feature at Health Innovation week, a pair of the Pink Socks 2.0 gifted to every speaker at the main event ensured that they then featured in the whole week of events. It didn’t matter if you were the newest digital engagement expert from Samsung, the CEO of CHIME or the Minister for Health, in that week Pink Socks became the way to connect.

Nick finishes his recent TEDX in San Francisco by asking everyone in the audience to turn to someone they don’t know and with intent say, “I See You!” Three words that can make a connection.

   So for me Pinks Socks is…

…a new connection, a new way of seeing people, not roles, not prejudices, not functions, not end game goals, but real people, who, if we truly make the connection we will be able to have help in everything we do.

I want to be seen because I want to help.

Leaving Ireland…

The 31st of July was a very sad day for me, it was the day I had to sit down with the Director General and say those words, ‘I resign as CIO of the HSE.’ Nearly three years in Ireland has been amazing. In the following week one of the team asked me, ‘was it a hard decision?’ Yes it was, one of the hardest I have ever had to make, over the last three years I have met some of the most committed and talented people I have ever had the pleasure to work with, a team of people who truly, with the right support, can change the face of a country!

Some of you will have heard me tell this story before, so please forgive me; my second day in Ireland, I grabbed a taxi, the Dublin driver turned to me and did the usual, where are you from etc, and then asked what brings you here? I replied without hesitation, somewhat green to Ireland and the culture, that I was working for the health service. The taxi driver stopped in his tracks and said, “You have a lot to learn, you have joined the second most hated organisation in Ireland, after water Irish people hate the health service the second most!”

I assumed he was joking, but no he was kind of right. The health system of Ireland is not a loved system, its not cherished, its described as bloated, regularly someone has a ‘pop’ at it being top heavy, or spending money wrongly, or deploying resources in the wrong places. Yet, here we are with a health system that every day saves hundreds of lives, a system that has a workforce like I have never seen before, a committed one that knows how to deliver care with compassion and often against adversity.

Let me take my own crisis management experience in Ireland, Wannacry, as an illustration. On the Friday evening the team identified the global impacting issue was heading our way, without any consideration for the plans for the weekend the team mobilised, created a defence strategy and set about working all weekend, all hours of the weekend, to protect the systems that delivers care to the Irish citizen. Nobody was paid to do this, no one received any bonus, time off in lieu or really any kind of recognition other than a heartfelt thanks from the system. In fact some ‘friendly’ people on social media suggested that the strategy adopted was even wrong, and that the focus should never have been needed if the HSE had been more prepared. I was so proud when on the following Tuesday we returned all systems back to normal and were able to say we had protected Ireland when others across the world had not been able to achieve the same.    

Leaving this role, not being part of the team in the HSE leaves me with so much trepidation; the personal focus that so many people have put into the changes that we have made over the last three years is significant, I wonder if this ‘perfect storm’ of personalities will ever be created again. One of the first programmes of work I ever owned in healthcare was the delivery of a system called the Data Transfer Service (DTS). The solution was a new way for primary care and acute and administrative functions to share information securely and in a timely fashion and we had to deliver this in thirteen months, this was back in the late 1990s. I thought that was the best team I had ever worked with until I came to Ireland.

The team make-up is a happy accident that has evolved to be one that I will look to emulate elsewhere. The team is a mixture of evangelists, sceptics and pragmatists, after a couple of years in the role that mixture hit the right balance. The team has a group of people who believe in being open and a sub-set who understand the need to be closed. The creativity in some has been astounding and the sheer dogged focus to keep going in others has given us a drive that has seen us get to the finish line on so many projects.

What I have learnt is best described by a Yorkshire phrase; “It takes all sorts!”

Handing the team to a respected, committed and digitally enthused leader has given me a new reflection on what can be achieved. The team are gathering around my interim replacement ready to support her and help her continue the success, not just of the last 3 years but the building success that the team has been trying to achieve for the last decade. There are some new tools now; a ‘brand’ that is synonymous with success and openness is in place in the form of eHealth Ireland. The health identifier is a foundation for information stored digitally, enabling a leap forward in patient safety initiatives with a data flavour. Ireland and its health system has a renewed vigour for what can be achieved in healthcare through the foundations of a digital system. Its first examples of digital hospitals are live and are a success, the programme to sequence the genome of patients with suspected epilepsy is changing the lives of many people this year, people with a disease that is often not considered high enough up the agenda. The readiness to consider innovation, how to work with the new, the fresh, the different ideas is also now part of the way the Irish healthcare system is changing and delivering benefit. In the last 12 months alone there have been over 50 new digital solutions deployed into the health system, each of these implementations requires the unwavering commitment of a team to make the system live and support the system going forward.

Perhaps the biggest ‘thing’ that we have achieved though in the last three years is to place the possibility of digital in health on to the agenda. We have a minister who says that digital is no longer a nice to have, we have a HSE leadership team that has embraced the concepts of digital into the way it works and the way it considers reform. The representation of all of this is the passion of the team that deliver this though, as my goodbye reflection I want to pause here and call out, maybe even embarrass a few of them, “live” on this blog site, to be remembered here and learnt from in the future.

First and foremost, an often unsung hero of the team is Joyce Shaw, the driving force in how we have transformed as a team, a lady with a passion for the team, how It works and perhaps most importantly the reality of people working hard together. Joyce is the conscience of the team!

The most considered, calm and truly gentlemanly Fran Thompson would be next on my list of essential elements to any team of the future. Without Fran being there through thick, thin, muddy and clear so much of what has been achieved in the last three years would have got absolutely nowhere.   

When I consider the team that we were in December 2014 and think about the difference people have personally made I have to call out Michael Redmond as well. Michael is a true example of a leader building through engagement. Working with Michael and seeing him go from sceptic to optimist over a three year period of time has been one of my own personal highlights.  

The eHealth Ireland committee has been a joy to work with, and is a group of people I now call friends, Eibhlin Mulroe, Derick Mitchell, Andrew Griffiths and the ever committed Mark Ferguson have ensured that the path we have walked has been supported. The success of the eHealth brand can be put down to these people and others in the committee who work hard in the background ensuring that we can make a success of what we do.

I have been lucky in that I have worked for two ministers who have wanted to engage with the digital element of health in a different way, they have taken a personal interest in what we do as a team, supported us and been there for us. eHealth Ireland has been able to enjoy an open door to both ministers over the last three years an acceptance and realisation that the team here in health is a high performing team of committed and capable staff is a great by product of that engagement.

A wise old colleague of mine said to me once that those of us that want to evolve and change simply need a good manager, once that person is in place we will be able to achieve anything. It felt a little like a piece of Jedi advice at the time but working for the DG of the health service here in Ireland I now understand. The DG has empowered us to get on with it, insisted we stay calm in the most stressful of situations and supported all that we have tried to do in a way that ensures success, certainly without this support we would still be thinking through how to make some of what we have achieved happen.

There is space for just two more names on this list for fear of it turning into a gushing speech that no one will read.

Niamh Falconer is my conscience, where Joyce ensures the team has a voice in everything Niamh reminds me of my voice in everything, caring for me and reminding me that successful change needs time to happen and time can’t be magically created; although she has had a magic wand in her hand for the last two years doing Tinkerbell like tricks to make sure we can do what we need to do.

Last but not least is Maria O’Loughlin, when grey clouds appear Maria has blown them away for so many parts of the team. She has a unique ability to translate ideas into reality whilst adding a shiny creative style to them, if we adopt Pareto’s rule Maria is the way to achieve the last 20% in all that we do.

Calling out individuals is dangerous, I know that, the reality is that in every single case of every person I have worked with over the last three years they have touched what we have done and indeed who I have become in some way, I would love to simply list everyone here now but no one would find that an interesting final comment from me.

A vision of the future has to be my final comment, I came to Ireland in October 2014 to present at the HISI conference what my vision of the future would be, I think much of that vision is still valid! The purpose of eHealth in Ireland is to create digital as a platform for change, a platform for a health service that has every citizen’s health and wellbeing at the heart of what it does.

If I could have a final wish it would be;

… be nice to the system that is there, help it continue to evolve.

It needs to find a new way to celebrate what it is, the Health Service Executive is the life blood of this country, treat it as that, realise what is limiting its capability and focus on fixing that rather than damaging and attacking the resource that is at its disposal. The HSE is an organisation that is committed, it is an organisation that is caring and it is an organisation that is capable, treat it as that and it will deliver the best healthcare system for the population of this great country.  

Hospital in a box…

First published as a KLAS blog in June 2017.

Do you remember being a kid at Christmas time, toys came wrapped and in boxes and by Christmas evening so many of us had reverted to playing with the boxes that all the new toys had come in! Imagine your parent’s frustrations…

Imagine if the hospital EHR came in a box ready to deploy, would we be ‘playing’ with the box within the first week I wonder? Once upon a time we used to talk about a hospital without boundaries, in some areas that evolved to a liquid hospital, as we move to the next decade a new idea is starting to emerge, a new parallel, the digital hospital in a box.

No this isn’t a chapter in the SIMS game or an elaborate Minecraft playground, this is where clinicians, patients and managers want to be! The mobile experience has continued to evolve at such a pace that the expectation of what we can do with our devices puts eHealth into a new world, a world we want to go. A world that seems like it could be attainable with just a little different type of effort.

Twice in one week I have been shown patient applications on mobile devices that enable patients to take control of their care wherever and whenever they want to.

The digital Haemophilia support capability deployed in Ireland allows a patient to be in complete control of their care and the treatment plan they have, ‘live’ from their very own smartphone. Ordering new treatment to be delivered and allowing the health system to track this treatment brings a level of patient safety never before seen. The solution also takes the theories of ‘just-in-time’ efficiencies and applies them to healthcare. Just like the fast-moving consumer goods industries where ‘just-in-time’ was invented, this has brought remarkable cost savings and the removal of so much waste in the delivery of drugs to the patient.

The second app is a collaboration between a charity, an academic partner, a technology delivery group and the health system. The epilepsy patient application now delivered in Ireland brings a huge change to the delivery of care to people with this long-term condition. Communication with clinicians is important for any patient with any long-term condition, and the impact on patients with epilepsy has been particularly revolutionary. A patient can now record and communicate the frequency, type and severity of a seizure to their clinician who can use the app to securely communicate suggested changes to the drug and treatment regime.

For patients with a genomic sequence they can now see the geneticist’s opinion of their illness enabling the control of illness to be shared and the nature of the ‘expert patient’ to evolve considerably. In a remarkably short period of time, some patients have been able to come off the drugs they have been on for long periods due to near real-time evaluation of efficacy of the drugs regime they are on and the shared ownership of data about their illness.

When we consider the impact of digital advances on healthcare one of three things can happen; it can continue to evolve at a slow pace but a ‘safe’ pace; digital solutions can optimise what is delivered already, or truly digital could transform the way healthcare is delivered.

The question we are asking ourselves as digital leaders in healthcare is, are we trying to change the way healthcare is considered and delivered or are we ‘simply’ trying to improve it. A supercharged hospital in a box could be the answer we have all been looking for.

On a recent study trip to Barcelona I was lucky enough to meet the team from TicSalut. More than anywhere else I have seen, the Catalonian health system has ‘cracked’ the mobile application and data problem for health, and the way they have done this is by taking the concepts of a mobile engendered Eco-System and making it real in every possible way. Catalonia has built the first box for the hospital to be packaged in! How have they done it?

First and foremost, they have managed to maintain control of the market place by offering a type of accreditation which has significant value to the builders of mobile applications. Their brand is trusted, respected and brings value to patients, by offering a marketplace for accredited apps they have managed to ensure an agility to market without stifling the innovation capability of its growth.

TicSalut have gone a step further than merely a ‘kite mark’ for health apps though. As part of the accreditation process the organisation asks that, with patient consent, the data collected in the app is not only made available to the app supplier but also the healthcare system of Catalonia. A clinician can see the information a patient or carer has and from a clinical point of view decide if the information is a valid addition to the clinical record, accepting it into the EHR of the patient where appropriate. The patient then can see they clinical record and can make use of the information inside the apps they have decided to use themselves. All of this strikes me as a bit like a box with both sides pushed open, truly a system facilitating a new eco-system approach to the delivery of healthcare.

Innovations like these don’t come overnight, of course. TicSalut have been building towards this for 10 years, ensuring that a new paradigm in innovation and openness of data can be achieved for the patients they serve. The concept of the health and wealth of the ‘nation’ really being at the heart of what they are delivering. The links to innovation through universities and academic fellowships are now well established. The apps are always recommendations and not mandatory, also the patient still chooses the app that they want to use. Prescribing an app can take place but it still always comes back to a patient choice.

Throughout Catalonia where clinical apps are used they can also be rated and reviewed by clinician and patient, taking from the travel industry and sites like Trip Advisor the clinical solutions deployed via mobile are crowd source reviewed and the results of this adds weight to the kite mark applied to the app.

If we are to apply the successful digital lessons of other business areas then we need to ‘wow’ the customer. Healthcare has a difficulty in defining its customer which makes this goal complex but, in the case of the hospital in a box this becomes easier. We need the patient that is receiving care to want to be part of the journey and the clinician who is delivering the care to understand the benefits of the information they are receiving, the veracity of that information. Maybe the much used three V definition of Big Data (Volume, Veracity and Variety) can find better application in simple clinical information!

The new concepts of digital allows businesses to become services rather than costly (sometimes wasteful) capital expenditure items. Take for example the work Phillips has done at Schiphol Airport, by applying circular economy principles Schiphol Group and Philips have created a new way of working, a new partnership. Philips now has responsibility for delivering light to the airport, responsibility for the fixtures and fittings and ultimately the recycling of the fittings. By taking this responsibility Philips can offer their most innovative and cost effective lighting solutions as a service to the airport, making a capital free investment for Schiphol in lighting innovation. Now apply this to healthcare, and try to do it without creating perverse incentives.

An EHR service cost model in a public healthcare system, facing the budgetary challenges we all understand, cannot be charged for digital solutions per bed or per patient basis easily. Doing this will instead cause a different consideration; whether to put information into the EHR. Yet, the digital service model can still work. A hospital in a box, a digital solution deployed to the patient first can work in this way, we are seeing this with the consumer driven shift in primary care, Babylon Health, WebDoctor.ie and VideoDoc and others here in Ireland are all facilitating some service model type solutions to the delivery of primary care interaction. The patient becomes the payer for the service in a different way; but in a way that enables innovation to be fostered rather than kept to a decade long cycle of investment.

Service solutions or the new term ‘platform businesses’ are pivoting throughout the globe and becoming new innovations; Tesla becoming an alternative power company, charging home based batteries overnight on off peak electricity or Uber becoming a way of ordering the delivery of vaccinations direct to the citizen in need, and so many more.

The ability to deliver health as a service to patients seems today to be hooked to the mobile capabilities though and particularly to this idea of the healthcare system in a box. In the space of a single piece of writing then we have managed to move from a hospital in a box to the whole healthcare system!

Digital leaders in every jurisdiction of the globe are trying to consider where in the tipping point they are, “are we here to optimise the health system with digital? Or are we here to enable a transformation?” The “healthcare as a service” concept, facilitated by the healthcare system and being delivered in a digital box can transform the health systems of the world! We know that digital is ready but the human factors along with the business change elements, are the more difficult parts to resolve. That’s why I believe the concept of a healthcare system in a box is useful, it simplifies what we are trying to do. Samsung talks about the unboxing of the mobile phone for different reasons at the moment, but if we can deliver, and then unbox the digital healthcare system then maybe we have a route to achieve the business engagement and change that so many healthcare systems need.

The healthcare system in a box provides for our ability to be a multi-channel business, at last the engagement of our hard-to-define customer base can be done comparatively easily as we suddenly have many more digital routes to engage through. Engagement has to be done on the needs of the ‘customer’ rather than the organisation and therefore the idea of multiple channels means we can offer the ability to engage in the same way as so many businesses do who successfully put the customer at the heart of what they do, the box has so many routes into it!

One of the advantages of moving to a concept where the digital hospital is delivered through the proverbial box could well be the ability to lock the hospital in a box and use it to protect the data and the experience of the patient. Recent cyber threats and the escalation of the vulnerability of healthcare to cyber-attack gives us, the digital health professional, a new challenge to overcome. Placing the digital experience of the patient into their own hands provides healthcare with, at the very least, a new level of vigilance. We don’t ask one person to adhere to hygiene standards to enable infection control best practice to become standard, we ask everyone, maybe that is what can be achieved by ‘crowd sourcing’ the customer in the cyber threat battle.

We have had the cardboard box since 1817, and now whether it’s Calvin and Hobbes creating a time machine (or a ‘transmogrifier’) or the gag real on the computer game Metal Gear, the cardboard box is an accepted part of growing up; even the national museum of toys in the USA has a box in it, the only non-branded ‘toy’ it has as an exhibition. So, if the humble cardboard box can become a toy for all our children since the early 1800’s then I am sure as a concept for healthcare it can become the answer to the truly patient focused electronic health record!

The Liquid Hospital…

First published for KLAS research, republished here for completeness…

Liquid healthcare systems.

I was discussing a way to describe how eHealth can change the way in which hospitals deliver care recently with a learned colleague. He has come up with the phrase, the ‘Liquid Hospital’, which I have to say has grabbed my imagination completely. The concept of a Liquid Hospital is very much one not just supported by technology but actually made possible through technology and innovative ways of working. Its not that much of a stretch of the imagination to see it being possible but it will require a large amount of business managed change and can’t be made so ‘just’ through the implementation of technology. The thinking is starting to mature here and in November Ireland’s minister for health began to use the phrase a health system without boundaries, after all digital doesn’t recognise the ‘physical’ boundaries of a hospital or GP Practice.

Moving away from concepts of episode centric care will be a significant challenge for all considerations within any health care system worldwide. Let’s not forget even the concept of an Electronic Health Record (EHR) is based around recording the episodes of care that occur rather than around the patient. Breaking down the systemised walls for the provision of care will be key to the innovation that we describe here as the Liquid Hospital. Although as the concept evolves, we note a flaw in the name. The Liquid Hospital does not refer to one institution or hospital – the concept really is around the delivery of seamless care and wellbeing support to people (not just patients), however for the purposes of this article let’s stick with the name as a term.

Simple ideas

The idea is quite simple really; once the patient is in hospital the technology allows the episodes of care that the patient requires to come to them, rather than the patient being shipped around the hospital for different treatments and the risks that come with that. In other words, the system becomes clinical centric. I know from a stay in hospital in 2016 that being moved from ward to treatment room and back again is at the least uncomfortable and at worst darn right scary. The concept doesn’t just stop there though. It does also propose to achieve that panacea of eHealth – a truly paperless environment, as not only do treatments flow around the patient, so does information.

Imagine an outpatient visit to a liquid hospital. You arrive in reception and check in with a clinician who takes your identification and confirms back to you some details to allow you to confirm to them the reason for your visit. As a patient you have elected to collect information on your condition at home so you quickly synchronise the smart device you have with the hospital systems. This shares your medication record and real time recordings of how your condition makes you feel.

As your consultant comes to you they are fed this information to their tablet computer and are analysing the outputs in the lift as they come to meet you in your own personalised consultation room. As the consultant comes into your room your records are shared on the display on the wall for both you and the consultant to consider. You have also elected to share the consultation output with your primary care professional and therefore the actions the two of you now collectively take are recorded and made available to them digitally and directly into their system ready for next time you the patient are with them.

You elect to have a procedure related to your long term condition. Whilst with your consultant you choose when and where that procedure will take place and you are electronically introduced to the clinician who will be your key point of contact when you return for the procedure. Your consultant is then able to provide advice on what you need to do before coming in to hospital for the procedure and download this advice to your smart device for you to consider with your family when you are home.

You also consider a slight change to your medication. The consultant is able to provide you with advice and guidance from around the world and connect you to patients like you with a similar condition via a secure social media outlet. This allows you to consider the impact of a change in medication with a peer group over the coming weeks and access some key support.

Your clinician can provide you with a new prescription directly to the pharmacist of your choice and you can call there on the way home knowing your drugs will be ready for you. A copy of your prescription and your summary notes are also made available to you for your own health record as you have elected to keep this information in your own health vault solution in addition to the electronic record in the hospital.

A few days later your long-term condition takes a turn for the worse and you decide to drop into the primary care centre, which is in your village. You ring the centre and are asked to provide the information you have collected over the last few days via your smart device, which you can do whilst you are on the phone. The primary care centre advises you to up the dose of medication ever so slightly and alter the time you are taking your prescription and within one day your illness settles down and you don’t need to go in to the centre.

The time of your procedure and your short stay in hospital draws ever nearer. Rather than have to attend the hospital for a pre-op meeting you have decided to share your own collected data with your key contact in the week leading up to your visit and have a brief video conference with the clinician. All is looking well and the clinician does not need to see you face to face. Although you are a little anxious, the hospital has arranged for you to be part of a secure group on a social media site and you are able to communicate with patients from around the world who have been through a similar experience, and this goes some way to settling your fears.

On the day of your attendance at hospital you check in comfortably with very little fuss. You are provided with a secure tablet PC that is linked to the hospital’s WiFi, and all of your notes and updates will be on this device during your stay so that you have the comfort of seeing them as well as them always being with you during your stay. It’s your choice throughout your stay as to who you additionally share the information with, electronically. You elect to send all information to your own personal record and some of the key facts to your primary care centre. You also decide to email your nearest and dearest a summary of each day to help them feel less worried about your time in the hospital’s care.

After the procedure you are out of hospital very quickly. Your after care is already arranged and as you hand back the hospital tablet computer with your information on you can already see it has arrived both in your own personal record and at the primary care centre.

The social care provision you require in the first few days is arranged on line and again, as the patient, you have decided what information to share and with who. The social care clinician visiting you at home asks if they can view your record in more detail and you grant them access there and then. The information they are able to get from this satisfies any initial concerns they had and they are able to discharge you within three visits.

How much of a stretch of the imagination do you feel this is?

The technology is there to facilitate this. It has been available the last five years at least if not longer. The big change is perhaps twofold; investment in the aspects of technology to drive this (including training and development) and the change in how care is delivered at a business and service level. Healthcare provision and change related to it is often compared to changing the direction of a sea bound oil tanker, but, if the description of this kind of benefit can be brought to a wider audience (and bought into) by clinician and patient alike maybe this could be an innovation we can make reality, its certainly describes a system that puts the patient at the centre and yet is only just beyond our own reach. A tangible view, just over the horizon of eHealth in action.

Some countries across Europe are starting to put in place the building blocks to enable this change: in Scotland, a change to the commissioning model, facilitating health boards across all care delivery to allow the holistic delivery of care and here in Ireland, the HSE’s own integrated care programme and reform programmes beginning the concepts of change, the creation of the Individual Health Identifier and concepts like ‘money follows the patient’ will all start to enable this dream to become reality.

Technology and a business change programme truly can break down the physical walls of the care institutions of the country and allow care to flow around the patient in a manner as transparent as H2O.  Our 2020 vision sees health without walls made possible by digital.

 

 

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