Do you remember that school report moment, that evaluation and review of the academic year, the fear of what your teachers would say, or not say when your parents went to meet them? A year of hard work distilled to a 45 minute meeting with a bunch of teachers who, in some cases, were probably trying to provide feedback to maybe as many as 100 kids who had various degrees of motivation and ambition. It must have been a hard task for them and it was often a nerve wrecking experience for the pupil!
Key phrases from my school reports: ‘creative writing doesn’t always mean making it up as you go along!’; ‘Please follow the rules of emergency air supply on an aeroplane, secure your own work before turning to help others’; ‘Less communicating and more concentrating will bring more academic rewards, but will make the class a dull class’; ‘Richard’s passion for campanology outweighs any I have ever seen in any teenager’. The last one holds a dear memory for me as a retort from my Dad, who exclaimed he knew I liked camping but thought I wasn’t the only one in school in scouts!
So, a year into the role in sunny Leeds, a year in to concentrating in a new way on what a digital fabric can do for health and care across Leeds and I thought it would be good to try to put together my own school report. A progressive ‘school’ like Leeds would allow the pupils to put together their own review as long as it could be challenged in a fair and productive manner by teachers and peers, so here goes.
First subject to be graded has to be Delivery. I think the #LeedsDigitalWay deserves a B- for delivery in the last 12 months.
Delivery Grade – B-
The first 100 days saw a sea change in the way the team worked. The objectives of what we wanted to do were made clear and the team began to evolve. The ‘simple’ action of getting board approval to invest in the PPM+ solution as the Electronic Health Record (EHR) for Leeds until at least 2022 has seen a new concentration on the process for delivery. Leeds has delivered against an agile methodology for over five years but now delivers on a monthly release schedule; new functionality defined by the clinical team lands into live each month. A new focus on the release function and now the way that test, development and integration work together has brought about some immediately noticeable changes, largely the enthusiasm and engagement that the clinical team has for the solution has improved significantly.
Deliverables such as the A&E dashboard, flu reporting, tasks and jobs inside the EHR, the implementation of Forward, the delivery of the eRespect form, Nursing eObervations, single sign-on for all and even simple changes like the opening of the internet to ‘real’ use has seen a continuation of the acceptance that digital is a hugely important part of what a hospital needs in place every single day.
Scan for Safety and the mobile EHR solution are fast becoming a way of life in Leeds. Not new gizmos but a way to enable the understanding of patient flow and a way of capturing information without fingers being needed on a keyboard. Scan for Safety also is an illustration of LTHT-wide partnership working and what can be achieved when a delivery is led not by IT but by clinicians and key impacted departments.
The delivery of new infrastructure for PACS, Digital Pathology and the new Genomics service all considered to be that unfortunate term, ‘back office’ deliverables, but all crucial to the acceptable running of the digital fabric of the trust are well underway with a limited resource to make them happen.
A slow but steady reform of the way service management is delivered has started to take shape as has a new way of thinking for Information and Intelligence (I&I). The organisational change elements are now in place to enable a function within the I&I capability to focus ‘just’ on data within PPM+, something LTHT has been trying to make happen for some time.
Why the dropped marks in this area? Expectations have been set really very high and whilst the resource to deliver has been changed in its structure it hasn’t changed in its capacity in any dramatic manner. A phrase I think should be avoided has been used too often: ‘do more for less’. Outages have occurred on three occasions, all managed well with no patient impact but in all three cases these outages could have been avoided. On the positive side, key lessons have been learnt and business continuity lessons and disaster recovery plans are now well honed.
When in Ireland I was once challenged by a senior member of the team to spend a few months in the garden shed away from the team and the email. The meaning behind the comment was I was pushing at a speed that the team needed a rest from. I think I drop marks for not learning that lesson as well as I could have. We are going at a pace in LTHT that will tire the team out if I am not super careful in 2019 and therefore I do need to look around and be sure that the delivery ambition we have is met by the resource we can apply.
Culture Grade – B
Building the team I want to work in is always important to me in any leadership role that I have had. Putting in place weekly updates (Can you give me two minutes) and hitting these for 52 weeks in a row has been an important way to show the width of the team how we can act as one. The creation of the #LeedsDigitalWay and the associated goals, vision statement and key strategic plans have not been created in isolation by the senior management team but, following the ethos of the Leeds Way, these have been done through crowd sourcing and via the wonderful ‘Very Clear Ideas’ process.
I feel the team is engaged, not entirely, but better than many would be in the ideals of what we are here to deliver. That is largely because the LTHT culture, the Leeds Way, gives me a jump off point that I can simply add to, but this has to be seen as a great benefit.
The whole team has had the opportunity to come together four times in 2017/18 as a digital team of leaders in the digital health environment. The meeting is not mandated (nor will it ever be) and has seen a steady increase in numbers for each gathering. One of the best moments of the year was the morning after the third All Staff Meeting being stopped by another early riser member of staff to be told they had put the next meeting in the diary already and would be telling all their colleagues how important the meeting was for working in the team – superb, immediate and honest feedback.
It is often joked that only those ‘great places to work’ organisations get IT and Communications right all the time. We have tried to get the level of communications right but in a recent staff survey the team wished for more, so now we move to consider all the different styles of communications we have and how they impact upon the culture.
To me the Leeds Way is our culture and our values with a digital ‘sheen’ applied to it. We have come some way in 12 months but I can see the gaps that we need to improve on.
The reason for some of the ‘dropped marks’? We are going through organisational change and are desperately trying to get that right at every juncture, but we haven’t always been as successfully as I would like us to be. As soon as we create an open culture which we have done then we have to have the capacity to listen and act on opinions that are made clear to us, we are trying to get that right but we are not quite there yet, could do better may be the school report language best used here.
I think we have been able to pick up extra marks though for team development opportunities. In 2018, we were able to be part of content delivered by HIMSS, KLAS, HSJ, CHIME, Digital Health and BCS. We have opened opportunities for staff to apply for the Digital Academy, a hugely important leap for us, and had 10 interns join the team, many of whom have stayed on in some way. Exciting learning prospects for all of us continue to be available across the team and will remain a high priority for us in 2019.
Engagement Grade – B+
The awareness of the LTHT digital journey at a national and international level has doubled in the last 12 months. We have been successful in ensuring that when somebody wants to understand how to deliver an EHR in the NHS then Leeds is one of the top five places they think of. Being able to take part in the Arch Collaborative and achieve the Net Experience score that we did showed the engagement the large proportion of our clinical staff feel for the systems we have deployed.
Leeds’ success has been represented on three continents this year and is synonymous with clinical engagement, an open attitude to delivery, an inclusive ability to resourcing and a willingness to share. If I were to write my own obituary these would be words I would want to see and therefor I think the B+ is justified.
We have been able to bring leaders from across the health and social care system to Leeds to show them how the front line of digital health is really working and I would like to think that has impacted on policy in some small way.
The reason for the dropped marks is, despite the geographic location working for us (Leeds is after all the home of over 20% of the health informatics staff of the NHS), we have yet to truly make the most of Leeds the place. With so many organisations in Leeds that focus on digital health, our own position in that eco-system still needs to be eked out.
Innovation & Technology Grade – C-
Next year I have to focus more on this. We have so many ideas and so many amazing offers of help to make those ideas come to life but time and resource has run away with us too many times. We have been able to get the infrastructure for Single Sign On in place and the migration has largely gone well. Piloting the linking of devices to this infrastructure, not just the software side, is a remarkable feat I think.
I would have loved us to have our first implementation of cloud in place in 2018 but we are still a little way away from that. We have well formed plans for AI access to some specific solutions which I believe will be transformational, but again they will be early next year.
The speed of the systems we have and the reliability of the solutions they are hosted on has improved ten-fold, but user expectation outstrips our current capability to keep up. The work done to make the regional integration capability ‘bomb proof’ is outstanding but took us longer than we thought.
We know how we want to innovate and even who with, but in some cases we have come unstuck as we try to find ways to create relationships. For us, the way we have worked with Forward in 2018 has been a real test of how an NHS organisation can create a true partnership with a new innovative company and really build benefit. Being able to ‘gift’ the content of the Axe the Fax toolkit to Silver Buck for them to industrialise and make available to the wider NHS is another great example of an innovative approach with a new partner.
If ever there was a category with the immortal school report words, ‘must try harder’, it would be this area. I need to consider how to deploy more resource here to give us more chance at being truly ground breaking in this arena in 2019.
Collaboration Grade – C+
Achieving the Local Health and Care record Exemplar (LHCRE) status was clearly done only by collaboration across Yorkshire and Humber and was a big moment in 2018 for all of the team. Collaboration across the city area on the Leeds Care Record remains a highlight of the job and being able to represent Leeds as the platform with my fellow Proclaimer is something that enthuses me every time we get the opportunity to do it.
The dropped marks though here are because I know we have not played the part we should play in the West Yorkshire collaborative to the same degree. Something that next year I will prioritise is ensuring that the blueprinting work we do can be shared first and as a priority with colleagues across West Yorkshire. I know that we have the basis for a great relationship and one that will enable a better platform for patient care if we can find the right projects to collaborate on.
In the school report it was those summary words that always cut to the chase the most, the form teacher comment on the future challenges for the student and the head of year views on focus for the coming year.
I think if these words were being written about me after this year they would go something like this:
A successful start to the new school. Needs to keep a closer eye on the detail and avoid getting distracted by some of the wider picture, even though it is important to still see this and bring it back to the ‘school’ – we need to have all of our own foundations in place before truly looking to help so many others on the journey. The class (the Digital and Informatics Team) needs the focus to be slightly more on them than it has been on some occasions in the year. The key challenge for the next year is to keep moving at the current pace but with the whole class on the same journey. This will be difficult to achieve with the expectations that have been set but is entirely doable with the skills available.
… and if that was the summary I would sleep well at night.
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 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 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:
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:
The results also include sophisticated symptom analysis to distil some key phrases for us to work with:
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!
 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.
 530 clinicians, 147 Advance practice clinicians, 153 nurses, 154 allied health professionals
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!
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:
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;
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
First published on www.digitalhealth.net
When you are on holiday do you play that ‘why?’ and ‘what if…’ game? For example in the USA on a recent holiday we were chatting about why foods are called different things in different countries. A quick poolside thumb poll had the list below as differences between the UK and USA, and we are sure there are more:
The only excuse we could come up with for why this happened was timing. These food stuffs were perhaps discovered at around the same time across the world and therefore no name was ever right or wrong, just more timely and geographically rich. The experience of being in a different country and seeing these new words for the same things adds a little nature of the exotic, particularly when the country speaks the same language (kind of).
But these differences speak to the single largest challenge that faces our digital health menu today: the challenge of interoperability and integration. When we talk about the delivery of a new healthcare paradigm we speak of the delivery of integrated care, a care delivery experience that places the patient at the centre and has no boundaries. But to achieve this requires information to mean the same thing to all those involved in its delivery. Where this isn’t possible we put in place a perpetually repeating health system; one where learning the parameters of a situation, of an illness, of a prescribed cure are repeated at each gateway to a different healthcare system. We don’t want an exotic patient experience we want an efficient and safe experience.
The journalist Geoffrey Williams once said, “You can’t understand one language until you understand at least two.” Goethe went even further claiming, “He who does not know foreign languages does not know anything about his own.” Moving healthcare delivery to a system-wide approach is the goal of over 50 (locally driven) digital initiatives in the NHS alone. The goal of an integrated health and care record is to provide access to, and translation of, multiple care languages. The pressure facing healthcare systems across the world today will only be resolved through integrated approaches that enable health and social care to work together to manage the front and back door to every major acute hospital in the system. A busy Accident and Emergency Department is no longer the problem that the acute hospital can resolve on its own, it is a system-wide issue that the geography has to resolve together. Access to information will unlock this resolution, but first we need to enable the way we refer to the healthcare to be shared.
For the last two decades sharing information between care settings has been a digital goal. In the late 1990s Hampshire became ‘famous’ for the delivery of an exemplar record sharing environment, linking access to information recorded in the ‘Exeter System’ to information in GP systems, to aid the delivery of healthcare regardless of the setting. The largest issue that stunted growth of this early pilot though was the quality of the data and the ability to index the information. The need for a common identifier across health systems was raised and the NHS Number mandated by a target date. It’s a shame that this would not be the last time the NHS number was mandated by a target date…
Jumping forward to 2017, the Irish health system delivered a unique EU-wide identifier for the delivery of healthcare to its citizens. Huge effort was put into delivering this in an agile manner at a limited cost, and today the number exists and is available but its actual implementation in healthcare delivery itself remains very patchy. We can also look at an example in Leeds today too. Having spoken to other healthcare jurisdictions, the Leeds Care Record has become well known throughout Europe as an example of local systems working together to achieve something quite remarkable. The Leeds Care Record is a platform that enables integration at a level beyond almost anywhere else in the NHS. Over 35 systems are able to share information in a controlled, secure and legitimate fashion. 111 GPs also benefit from having access to what is recorded about their patients’ hospital visit. They also share key elements of the GP record with the healthcare delivery system throughout the geography. And that word is where the Leeds Care Record does fail; it works for the geography of Leeds and so this isn’t integration, this is interoperability. In Leeds, information is shared through the same platform but the reference points for the delivery of care remain in the same ‘language’ of the originating care setting. The reliance is on the interpreter and their own understanding of the information.
Culture plays a huge part in how we create an interoperable health care system which digital supports. In his book Culture, Terry Eagleton tries to define what culture means to organisations. He has four areas that he believes are most relevant to creating the right culture: values, customs, beliefs and symbolic practices. None of these particularly speaks to a standardised way of operating and therefore, if we believe in culture being how we make things happen in an organisation, then interoperability will always be an area we strive to achieve.
In the same book Eagleton, who is from Ireland, notes that the postbox, an original integration tool, donates civilisation. However the fact that Ireland has painted its mailboxes the famous Ireland green denotes a culture, a difference to others. In Leeds we have many gold postboxes, a legacy of the London Olympics, when gold medal winners had the postbox closest to their home town painted gold as an honour. Again, culture flouting a standard.
As quickly as we can, we need to begin to agree nationally (and why not even globally) if we are to achieve integrated or interoperable healthcare systems. The standards to do this exist in so many ways already. Digital health doesn’t need changes to be made at the mega-vendor level, the systems need to adopt the standards and then innovate to exist in a ‘system of systems’ approach.
Maybe we need to use Eagleton’s four cultural reference points as starting points to creating a joint understanding of where we need to get to.
Values: The value of having integrated care has been made clear for decades. Digital leaders are still at the begging bowl though, seeking funding to deliver the necessary platforms that are required to enable information sharing. Information is now becoming more complex, faster in the way it changes and more encompassing of the healthcare experience and value needs to be placed on the innovation needed to achieve a truly interoperable healthcare system.
Customs: Local customs need to be protected but somehow we need to move from the clinical system paradigm. You know the one, where the clinician you have engaged loves the idea of a single system across the hospital, they feel it’s a great idea, but their additional one special system still needs to be protected as well. This has become known as the ‘one plus one’ clinical system and in a hospital it means we have one system, plus one for every adventurous clinician in the hospital.
Beliefs: We need the healthcare system to stand up for the belief it has in the delivery of integrated care. That belief will drive the ultimate understanding of what a system of systems digital solution can provide.
Symbolic practices: Perhaps in the NHS this is about to happen with the launch of the Local Health and Care Record Exemplars funding and a platform to enable lessons to be learned, standards to be tested at local levels (of five million population) and a real drive from the centre and from the ‘spokes’ to truly achieve this.
There has to be a hook to the original Bevan statement about the creation of the NHS, “Healthcare free at the point of contact”, so now we need data ‘free’ at the point of contact and this can only be achieved if we all have the same reference points.
Now, can I get some fries, I mean chips, I mean crisps, I mean home fries…
Originally published by DigitalHealth.net
Since the publication of Robert Wachter’s book in the spring of 2015, the idea of clinical engagement in all that is digital health has been pervasive. But before ‘the’ book and over the last decade at least, I have seen a plethora of different styles adopted for the role of what we now call Chief Clinical Information Officer (CCIO).
The styles that can be adopted by CCIOs clearly work in different ways to match the culture and needs of the organisation alongside the benefits these digital projects are trying to achieve. The organisation in which I am now working, Leeds Teaching Hospitals Trust, has some amazingly talented clinicians with significant interests in many aspects of digital. As a Trust we are about to embark on the expansion of the CCIO role, creating a clinical leadership team of three, with individual responsibilities for:
The three CCIO roles will now be supported by nominated and clearly identified staff throughout the clinical service units (CSUs). The clinicians across the CSUs will act as the focal point for engagement in each of the CSUs throughout the trust. Also the creation of the office of the CCIO across Leeds Teaching Hospitals Trust will ensure promotion of the CCIO role in a way that facilitates a real width of clinical engagement, not just at the trust itself, but across what is becoming more and more referred to as the ‘place’.
Clinical engagement in digital is like pasta. There are so many different ‘flavours’ and ‘types’ and picking the right one is dependent on the digital ‘dish’ you are creating around your system. Many pasta types have regional variations and some have different names in different languages, for example ‘rotelle’ is called a ‘ruote’ in Italy and ‘wagon wheels’ in the USA. Let’s take three types of pasta and see if we can make this analogy work for the CCIO role:
In the last few years the model for clinical engagement in the digital agenda has transformed hugely. I remember discussing how to ensure that the initial delivery of the National Programme for IT’s Summary Care Record needed to be clinically led and this was way back in 2006. The amazingly driven Dr. Gillian Braunold pushed every part of the technology team so hard, often to the point of distraction as the need for clinical engagement was so new to us. But more than a decade later her style and her ideas for how clinical engagement can be achieved are really coming to the forefront as examples of the best ways of working. The concept of complete clinical ownership from an early stage of any digital project was something she championed way back in the early 00s.
The clinical engagement in place for the Summary Care Record was not seen as a CCIO role, more the twine that held the whole programme together. Certainly as the first sites went live the programme would have failed in its initial goals if it weren’t for the clinical engagement that had taken place. Clinical engagement in this case had to focus not on the benefit to the clinician impacted, the GP, but on the patient benefit and the longevity of the record of care, beyond system verticals. Dr. Braunold, even as far back as 2006, was talking about the fabric of information needed to offer the best care for patients, regardless of clinical setting, which is perhaps our earliest example of a digital fabric being raised.
This type of clinical engagement is epitomised, I think, by Spaghetti, due to the long twines of connectivity. In many ways the way spaghetti also has popularised the ‘dish’ also draws comparisons to what Dr. Braunold did in those early days.
To deliver business change in healthcare we need to engage our customers and they need to co-define the art of the digitally possible. At a recent presentation one of my CCIOs in Leeds put a statement up on a slide that I fell in love with:
“Dear clinical teams, please come to us with problems not solutions, then we can help fix your problem together!”
Clinical engagement in an acute hospital can often fall into the 1+1 story. The engaged clinician completely agrees that a single source of truth for clinical information is necessary throughout the organisation as long as their specialist and favourite application is also to be accommodated. That’s why in 2014, in Ireland, the health system had over 3,000 applications and in Leeds today I have over 300.
This influences my next example, which to this day I think is a brilliant illustration of not just engagement but full scale leadership. In 2014, the Cork region of Ireland decided to push forward with digital referrals from GP to hospitals. This project not only needed clinical engagement but clinical leadership of a kind, to that point, not seen in Ireland when it came to digital.
Joyce Healey, a physiotherapist, volunteered to lead the project and took it from the germ of an idea to a fully functioning solution, initially embedded in GP systems and then on to the possibility of integration into hospital systems across the whole country. The strength of the clinical leadership though is what is important here. Joyce not only took on ownership of the clinical engagement but the leadership of the project itself. It was agreed not to have a national project manager in its earliest days as the lead clinician suggested that the best way to truly ensure the project remained clinically focused was to actually be at the ‘coal face’ of the project.
The work here then calls back to the pasta analogy in that the sheer pervasive nature of the CCIO work in this project made sure that clinical engagement drove success. Lasagne delivers the meat filling with a layered approach to holding the dish together, maybe this is the best example we can use here, holding a superb dish together through a structure that worked well and ensured that the core elements of the ‘dish’ arrived where they needed to.
The development of the CCIO function in Ireland followed a similar path to the eReferral project. A council of clinicians was created under Joyce and then added to with successive and successful CCIOs. The initial style of ensuring that clinical leadership was apparent in everything the team did and this became a key part of the way of working for digital across the whole country. By the end of 2017, there were over 300 CCIOs in Ireland. This number has been criticised in some quarters as the vast majority of them did not have ring fenced time to act in this role, but, the nature of the way they were appointed into the roles has seen them enabled in being local clinical leaders for all things digital and they have become powerful and enabled as an influential voice for the digital health transformation across the country. The large group now created, and the way in which they line up to offer their expertise and advice, also works well with the Rigatoni pasta analogy, the sheer volume needed to create the dish!
I wonder who is the most influential CCIO in the business today? Who is the most famous pasta dish? For me it has to be the person described as ‘THE’ digital nurse: Anne Cooper. I worked with Anne for a while in the National Programme for IT and saw her vision for what clinical leadership should be, her vision of ‘card carrying’ NHS professionals ensuring that large digital programmes were successful, flows way back to the early 2000s. What Anne embodies different to so many CCIOs though, is her ability to not just represent the clinical need for digital inspired change but also her ability to translate from digital to clinical to citizen and patient speak. The Cavatelli pasta dish is known by 27 names throughout the world, let’s face it digital health and care programmes have so many different names for the same benefits that we are trying to deliver that perhaps Anne’s style is easily analogous to this type of pasta.
There are so many clinicians in the digital leadership business today and so many CIOs that truly now believe in the CCIO role; not as a nice to have but as an intrinsic element to achieving success. Professor Joe McDonald in his role as chair of the national CCIO leaders’ network in the NHS posted to social media in the run up to Christmas;
“A CIO isn’t just for Christmas, also without a CCIO a CIO is like one hand clapping.”
This new way of thinking reflects the views of almost every CIO I have spoken to in health and care recently. We are asked to collaborate as digital leaders but without a CCIO we will struggle and probably fail. The new ways of working that CCIOs bring to the digital agenda ensure that we are no longer moving to the digital bleeding edge without at least a clinician on hand to patch us up!
The NHS Digital Academy that Rachel Dunscombe is leading the creation of fits to this analogy too. What Rachel and the team are doing is setting up the Master Chef and cooking school for CIOs and CCIOs throughout the NHS. It feels like at last the opportunity is there for us all to learn from every Gennaro Contaldo there is and begin to truly build little Jamie’s Italians throughout the NHS!
All power and ragu to the CIO CCIO relationship!
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
Biden Vs Faulkner, whose data is it any way.
Having a common enemy, a common ‘bad guy’ will always help a cause. A figurehead to rally against is one of the best motivators for the creation of a movement. Maybe in the last few weeks the Biden vs Faulkner showdown will be the catalyst for a new lease of life for the patient data movement. If the reports are true the Chief Executive of Epic; the Digital Health multinational may have ignited a new enthusiasm for patient data openness, by challenging Joe Bidden as to why on earth a patient would want access to their own data.
The conversation is said to have gone like this; Faulkner was amongst a group of healthcare executives gathered together to discuss with Biden the Cancer Moon-shot. The internet based magazine Politico reported that Faulkner raised questions about the utility of patients being given access to their own health records in a digital format.
“Why do you want your medical records? They’re a thousand pages of which you will understand 10,” she allegedly told Biden.
“None of your business why, I, the patient want access to my information,” Biden is said to have responded. “If I need to, I’ll find someone to explain them to me and, by the way, I will understand a whole lot more than you think I do!”
The culture of digital health organisations in the UK and Ireland has changed over the last decade so substantially that Faulkner’s comments sent many of us into shock. I distinctly remember arriving in Ireland and in 2014 and being asked to take part in a patient advocacy roundtable. At this event the gentleman who represented the Parkinson’s patients of Ireland towered over me and demanded that I, “… stop pussy footing around and get my data shared if it means that a cure can be found for this god-awful disease!” His premise was that if I didn’t he would and he wanted his information now, on a memory stick so that he could give it to an academic.
In the US we are told that the way the patient portal payment structure was created for meaningful use means that vendors were paid on a ‘log in attempt’ basis, this meant it was in the vendors interest to lodge a member of staff in waiting rooms and ‘help’ patients log in to their records, just the once. Pretty much taking the meaning of the phrase meaningful use and throwing it away.
We can also think back to the National Programme for IT in the UK and its version of patient access, HealthSpace, I can place a clear reason why that didn’t take off too, it was so very very hard to authenticate yourself before you could use the service. It required to visit a library with three forms of ID, to receive a letter with a PIN and then set up a significant password structure, the drop off rate before people got to view their records was huge, and understandably so. And yet here we are in 2017 with a new start up bank, N26, who have the technology to allow you to authenticate who you are with a camera on a mobile phone, from the safety of your own bedroom you can have a bank account up and running in eight minutes! Technology moves quickly and really does allow us to implement the digital health dreams we have.
So there are a few technology examples of Faulkner being right, well at least the technology not facilitating her being wrong! But, now glance over to Finland and Catalonia two regions that have proven the ideals that Biden has described for patient access to information to not just be the art of the possible but be actually here now, information in the hands of the patient and making a difference to the care being delivered.
The first time I heard the solution that Finland has created to this issue I was in awe; the work is a partnership with Microsoft and shows the innovation and ingenuity of the possible through partnership, clever thinking and a will to put the patient at the centre of what can be done. In Finland the national electronic health record is effectively a set of data that is mirrored to two windows. The first is the clinical EHR, the first place the clinician sees information about their patient, the second window is the patient version of the same, the key difference is the patient can add information to the record via their ‘window’. The patient can add free text or wearable gathered data or home held diagnostic information, the clinician can see this information and decide to add it to the clinical side of the record. The clinical governance of the information is still held with the clinician but the ability is now presented to the clinician for them to value the patient input to the record and move it over to their ‘window’ on the information, thus giving it the clinical validity it deserves.
Suddenly the comment made by Faulkner become even more ludicrous; the patient information is not only about them and owned by them but now has real clinically valid input into the care being prescribed and practiced, let’s not forget that this is the person Faulkner is worried won’t understand the information, they are now an author of some of the information.
The next success story here must be the amazing work that Tic-Salut have done across Catalonia in this area. They have created an eco-system throughout the region that has driven a new type of credibility to the delivery of patient access to information. The proliferation of health apps is huge; in Catalonia the market place for these apps to be released into has been created by the health system itself. An accredited app store for the healthcare system built to allow patients and clinicians to use health apps with confidence. Unique though to Catalonia is the arrangements put in place around the data that these apps can use. If you have an accredited health app one of the conditions is where the data is made available, not just within the app but in a secure, audited and protected way the data can be used within the health care systems own information systems. What Tic-Salut have done here is ensure that the lines between clinical data created by clinicians can be blurred with the data created or collected by the citizen and patient without overloading the clinical team with data, after all data is only useful when it becomes information.
Then we come to our own projects; in Ireland we have a decade long history of under investment in digital health to first get over to allow patients digital access to information, but, in Epilepsy we are seeing an almost immediate patient impact by having access to information. The patient portal trialled in the delivery of care for patients with Epilepsy has been a huge success for many reasons. First and foremost the portal and its functions have been co-designed by the patients and families themselves, the elements you can do with the portal are exactly what the patient wanted to be able to do. So viewing the clinical note is there as a function that has been seen as being useful but also the new ability to record a seizure, its severity and frequency and type has enabled a new paradigm in the delivery of care.
The ability for a patient to be significantly involved in reviews of medication efficacy through the capture of data has seen around 100 patients come off anti-epilepsy drugs since the portal has been introduced. I have championed digital solutions for the care of epilepsy since coming to Ireland in 2014, largely because of the passion that clinicians and patients, the careers and the special interest groups have shown for what can be done here. I hope that this light house on the art of the possible in Ireland can continue in to 2018.
In Ireland we have a plethora of digital health start-ups and new organisations. The Jinga Life team for me are delivering a solution that is a ‘light at the end of the tunnel’ for what can be done in Ireland. A design unlike any I have seen in healthcare, truly a delight to use and see. The concepts of Jinga Life is to concentrate on the key member of the family who is ‘tasked’ with the care organisation of the family. In their research over 90% of care is managed and organised by the female in the family. The Jinga Life portal allows the family member a tool to organise that care and to provide new data that can become clinical information to the clinician. Part of the success on the build of Jinga Life is its clinical and patient focus, definitely one to watch and one that I hope will show Faulkner yet again how wrong she is.
In the same week that Ireland launches its Open Data portal this data debate rages on, whose data is it anyway? Much can be discussed here but one thing we do know, its not the data of the digital vendors that are out there, and we need to seize back the ability to get at that data. A patient engaged, involved and aware of the information that is used for their care is a patient that can be part of the clinical delivery process, a patient empowered to help themselves.
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!
Ahead of the Dublin Tech Summit (#DTS) in mid-February where we will be considering the links between what was Sci:Fi and what can now be described as Med Tech.
The leap from Science fiction to a reality gets less and less and less. Amazon Echo, Microsoft Cortana and Apple Siri, are coming so quickly from an odd idea to an accepted part of the daily life. How long before these technologies bring a new information style to healthcare. The digital persona that the Echo and the lovely Alexa are creating for Amazon are said to be worth over $200,000 per person. In some jurisdictions amazon can now value the lifetime revenue from a cohort of customers that have signed up for their Prime service to such a degree that they can actually trade against the expected profits they will make.
Would we want similar technology to come to healthcare, many today wouldn’t but what will the time line and generation gap be before we are happy for this to be the case I wonder? As many people unwrapped the Amazon Echo for Christmas this year the reaction on social media was very mixed, from why would you want the ‘stool pigeon’ in the room to I want one! And by keeping the cost of what in reality is quite an impressive piece of kit low we can see Amazon and others begin to make huge strides in tying up this market place.
Digital personas are starting to exist in many businesses lines; imagine the Amazon digital persona of a Prime user with an Echo and its uses in the consumer arena applied to the delivery of healthcare. The data based prediction of buying patterns and the commercial power this now drives has huge potential. As Amazon step into the pharmaceutical and FCGs market places this is going to grow and grow on its impact on healthcare, the fast followers of this technology are going to be able to make a big splash in healthcare quickly.
The digital twin is a concept now used by Rolls Royce and GE in the management of aircraft engines. Imagine a healthcare system that makes a digital twin and then offers to run ‘you’ in the same way as Rolls Royce run the aircraft engine, spotting the issue before it happens. Genomic sequencing could begin to offer us that opportunity, especially if we linked the data to a service akin to the Echo, where not just the scientific sequences were information the situational analysis of health but also the context of the person, we after all have been talking about the advent of contextualised healthcare for over a decade.
Again many will object and won’t want that information to exist or be willing to take the information risk of the information being misplaced, but some, perhaps a next generation will see the benefit of this. The blur-ing of the lines between next generation digital and Sci-Fi is becoming easier and easier, what is interesting though is the impact of digital on healthcare, the disruptive impact of technology on commerce and wider business verticals has been huge and yet in healthcare its still in its infancy, a bit like Sci-Fi of the 1970s I guess!
The beauty of slow adoption though is that untried and tested technology can be avoided and lessons can be learnt from other business areas more easily. Also, the ability to gain engagement from the user base, the clinical teams wanting to use technology has become much much easier. The consumerisation of technology has reached such a peak that more often than not the new Sci-Fi like advancement has often been tested in the home before it lands in the clinic. Take Microsoft hello, no longer will a clinician need to touch the keyboard to authenticate, hugely powerful in the application of electronic health information at the point of care. Mobile computing more generally opens up the place where care can be delivered. AI allows questions to be asked of learning made more quickly than ever before.
In the last two years Ireland has enjoyed its fair share of global recognition for its involvement in the most important Sci-Fi brand ever, Star Wars and the filming of those crucial scenes in episode seven. In the last two years Ireland has also leapt forward in its application of digital to healthcare, truly looking at how to make use of the next digital disruption enthusiastically.