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!’
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
What does a soap factory, a hotel laundry, a cheese processing plant and a builder’s merchant have in common? They were all places that I learnt my ‘trade’, and somehow I became a CIO in the health service!
Yesterday was a great day for the digital team in Leeds, for the second year running the team interviewed for student placements for the summer. Six bright young things part way through their education in all things digital science came to meet the team and to work with us to decide if the digital team in Leeds is the right place to come and trial the skills they have been learning all year.
So over the next couple of weeks we will welcome; Daniel, Daniel, George, George, Alice and Reece to the team. A gang of Computer Sciences students who have a passion to do something good with their newly developed knowledge, to quench their thirst to try what they know in the ‘real world’! The exceptional thing that made me jump for joy though is that these 25ish year olds all wanted to be in Leeds for one key reason; they wanted to do good with the knowledge they have learned, they wanted to give back, the wanted to deliver return on the reputation that Leeds Teaching Hospitals Trust has built.
So much is written about the lack of faith that our future stars will have in the organisations they choose to work for and yet here I was faced with six stars of the future, all six of them looked ready to burst with enthusiasm. We delivered a presentation to them first, a bit of who we are and what we do, then another super star, Gareth Edwards one of our informatics nurses showed them what working here was going to be like. One of those age defining moments happened though as our amazing Informatics Nurse used a screen image of a computer game form the 80s and a computer game from now to show the difference in expectation that digital consumers have now. One of our candidates exclaimed; ‘My Dad used to play that game’, the sadness with a wry grin that swept over all of us in the room had to be seen to be believed as we realised just how fresh and ready for the challenge these new guys were going to be! But poor Gareth.
Much has been made of the Leeds Way, Davina Mcall has even explained it to Phil and Holly! When you see the Leeds Way ‘infecting’ new people into the organisation though is when you realise how well as a trust we have built this culture. After three hours with the team, in an assessment type scenario these guys were smiling, laughing and most importantly of all making amazing suggestions that we simply had not thought of. The assessment was a paper based affair, ‘think through how you would build the patient consent for surgery form?’ Remove the paper from the equation.
Now, lets just jump back a moment these are six students with no healthcare experience, the ideas they came up with, the references they were able to make to how people use technology, the way they really were appreciating the difference between digital transformation and IT really, truly blew my mind.
Thinking about colours, size of font, language, sensitivity about information recording, data protection, data ownership, access controls, the physicality of kit, the nature of the form; and most importantly the human nature of what was being considered. All came up in a 30 minute paired task!
So, we now have six new inductees into what we are and what we do; my promise is that their ‘summer job’ will not be like mine was; I won’t simply leave them to do the rubbish jobs, I will try to inspire them, I will try to send them back to their next year with a story to tell and if I can help influence a tiny little bit of the next generation of people who do what we do then crikey I am going to love this summer!
The #LeedsDigitalWay just started to create its next generation.
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
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!
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.
What can digital health learn from the biggest trend in Hollywood block busters, the Re-Boot.
In the last 15 years Spiderman has been through three ‘re-boots’, Tobey Maguire, Andrew Garfield and now Tom Holland. Batman has managed even more changes that have brought various degrees of success (personally I thought Michael Keaton did a great job!). Digital health can learn from this trend, a re-boot or two of how digital health is ‘sold’ to the public, the tax payer and the media is perhaps a little overdue.
The cynic amongst us though would be worried of the PR agency spin at this point, but I would disagree. Earlier this week I was being taken on a high-speed car chase through the streets of Leeds, otherwise known as a taxi ride from the train station to St. James. The usual conversation, what do you do and where do you come from ensued (does anyone else feel they are on a game show sometimes when they are in a taxi?) What was surprising was how much the taxi driver knew about the digital reform of the UK health system, but here is the issue; “Was that the disastrous IT project that failed”, says the taxi driver. No matter where you go the National Programme for IT (NPfIT) is almost universally hailed as a failure, and yet the programme put in place foundations for digital health to rival any country in the world, it put in the ground work to engage the customer whether that’s the clinician or the patient. I guess much as Michael Keaton put in the ground work for the plethora of super hero movies that have become de ’rigour as the summer hit movies!
Ireland still has its own NPfIT. PPARS is still described by the Irish media as a ‘comedy of errors’, and just as NPfIT it has its failings, PPARS today is a success that can be built on! To go back to the superhero movie analogy, PPARS and NPfIT are best linked to the Daredevil and Elektra movies, Ben Affleck and Jennifer Garner vehicles of 2003, fans know these were ‘great’ films, the critics were convinced they were rotten tomatoes, but, they now have influenced some of the best Netflix superhero fodder ever to be made!
The culture and leadership of the digital team is significant in a judgement of success.
Building a team is a trick that every digital leader should accept as their number one priority. Without the team the priorities, the governance, the customer at the centre, any of the benefits of digital will not be delivered! Across the world the delivery of healthcare is under financial pressure and this in turn means that the immortal words, ‘do more for less’ are likely to be uttered to you as a digital leader.
When you then look at what you can do less of there is a risk that the things that ‘could’ be seen as not digital’s responsibility are the first to go. If your mind lands on this as a decision please, please think again!
All over the world organisations are being told digital fails without business change resource, and yet as fast as this is becoming a key message for many business areas health systems are trying to cut the business change element from the budget of digital. In Ireland, we have spent the last three years trying to reinforce the message that the projects we have set as priority projects will fail without proper business change elements. The success Ireland made of the first digital maternity hospitals was a success of the business change functions and the clinical leadership. The need to have 9,500 hours training in one of the hospitals is described in some of the Irish media as a failure, what a shame that is. Business change perhaps shouldn’t be labelled as training, I guess that’s where we went wrong in Ireland, the ‘brand’ of business change resources within the team needs to be clearer, they are the engineers of success!
In my move to Leeds I was recently asked what sort of a CIO I am? One that focuses on technology or one that focuses on information? I think I confused the person asking the question when I said I am a CIO that focuses on the people. The need to create a team that cares most about the business change we are trying to achieve; I hope is part of the legacy I leave in Ireland as I begin the handover of what I do to the next digital leader for healthcare, a team that has moved from one that delivers digital to one that helps create business change through digital innovation.
Resourcing any organisation to be able to achieve a business change is difficult, trying to ‘re-boot’ the view of the team at the same time really does require an engaged and enthused leadership team.
How will we find the right people for the right job at the right time is a tricky question for any digital leader trying to create a cultural change. It’s a challenge that we have worked hard on in Ireland. In November 2015 the department of health gave us permission to recruit 49 new members of staff to the team. An exciting time being able to consider how we could now truly begin to move the ‘dial’ on the ratio of staff available to the business and how we really could begin to focus on the delivery of business change. The trick though was what sort of staff did we need. We were pleased with permission to recruit 49, we had asked for 150 new staff which meant a prioritisation exercise and a structural alignment that matched the resource we were now allocated, a re-boot with a limited budget. Not all of the re-boots require the superstar actors and huge budgets though, think of the collection of superhero TV series now gracing the screens of Netflix, nowhere near the super budgets of Batman Vs Superman, nor do they have the big name actors and yet they are probably making a bigger dent in the film buff psyche than the most recent Batman film ever will, sorry Ben Affleck!
How do we professionalise the digital health function though, how do we become recognised as the go to function to achieve change in healthcare. First and foremost, the logic of success building on success is key. Pick the projects that can be successful, not the easy projects or the quick wins, but the projects that will make a difference and that you know can be achieved. Professionalising the digital role in health is influenced from the outside in to some degree, the clinical engagement in the success of digital will build an organisational ally to help in the consideration of what a professional digital workforce can bring.
The re-boot of digital health needs some tools as well as the new actors. The SAMR ladder has worked well for us in understanding where our focus needs to be. Are we Substituting, Augmenting, Modifying or Redefining the delivery of healthcare. Are the terms mutually exclusive or are they an innovation journey that digital healthcare is on?
Dr. Ruben Puentedura’s model gives any digital leader an opportunity not to just re boot the organisation but a model to re boot projects as well.
Lets look at PPARS in Ireland, its original premise using SAMR was to simply Substitute what was currently in use with a digital platform, what went wrong according to the general consensus is that a simple substitution wasn’t enough. The human process was exactly that, not a logical process that digital could be a substitute for but an emotional and geographically different process that actually needed a redefining re boot. The success of eReferral in the last 18 months is because the process has been augmented, and the project team set about the re boot of the process knowing that was the case.
As we move to the EHR programme here in Ireland we know that the whole programme of work has to be about redefining, that is why the business change resource is so important and its why Ireland’s EHR business case insists on the budget and resource allocation for the business change elements,
Einstein’s definition of insanity is perhaps over used, but it fits so neatly here; ‘doing the same things over and over but expecting different results’ is his tried and tested definition. Without a re boot digital health is not going to succeed and we need it to be the next Avengers re boot not the best forgotten Nicholas Cage classic, Ghost Rider.
Consider the re boot theme, build the business change resource and lets get this movie started!
Today is the Future Health Summit 2017, last years event felt like the firing gun for a change in the way eHealth Ireland delivered, not just the slightly loud theme we adopted on the day but also the openness we tried to drive, the collaboration we announced we would enable and the key dates and targets we set out to be judged against. I have a team in place who want to be judged by the actions they take, meeting targets we announce seems to be the best way to enable this.
So much has happened in 12 months for what we are trying to achieve, the success of the Epilepsy Lighthouse project, the maternity deployments, the delivery of a national digital function, the move to cloud computing, the delivery of the health identifiers infrastructure, all leaps forward in a single 12 month period.
We do wish we had done more, we wanted the EHR business case to be further along, we wanted the IHI to be live and in as many connecting places as possible, both of which will happen in the next quarter but not in time for a 12 month celebration.
Two amazing digital health CIOs take on the role of running the eHealth Festival today; Rachel Dunscombe and Andy Kinnear; when I think of these two I consider how far we have to go on our journey, I have known both of them for a long time now, the work they have delivered has grown and grown and grown to the point where I think of them as leaders on a global stage, but the right sort of leaders, understated, assured and friends!
I get a quick run on the stage today at their festival. We are going to talk about story-telling and a new paradigm in digital health leadership. We have said for some time, no idea is unique, eHealth Ireland has become good at translating ideas, joining ideas up and making them Irish. (Said the man with the Barnsley accent!) So a big thanks to Social Kinetic who set us off on the journey for todays take away elements.
Our proposal is there are three new types of role in digital health that ensure the function can truly begin to tell stories to engage.
The first new role is the ‘Hacker in Chief’ a merge of the knowledge that the Chief Clinical Information Officer brings and the digital authority that the Chief Information Officer brings. Can we together hack old ideas into a position where they can deliver for digital health in Ireland? Is it really a new idea though, to talk to the customer? I was told a story recently, a story about Heathrow Terminal five when it opened its doors. T5 had a few digital problems in its first few days, one not made in the media too much is the story of the queues in the gents toilets! Bare with me a moment whilst I explain. A week in to T5 opening there were significant reports of concern, there were not enough men’s toilets in the terminal, there were queues! The digital team were on the response for all issues due to the large amount of them being resolved by digital reform, so, the digital team went to investigate. They went to ask the gents queuing why they were queueing. This innovation, talking to the customers, proved to be a huge saving for T5, because the only reason there were queues for the gents was that the tannoy outside in the terminal was not loud enough and gents from all over the UK were heading to the toilet queue to hear the gate of their flight! I guess the morale of the story though is digital people have learnt the hard way that talking to the customer is the only way to really deliver what is needed and the ‘Hacker in Chief’ is here to make sure this is part of what we do in Ireland.
The next new arrival at the digital health top table is the ‘Collaborative Sense Maker’. What we are trying to do is complex, and comes with a real risk of not making the most of the resource we have. Health anywhere is always a big organisation, its why when we ask why digital is so slow to come to health we have an answer, the sheer size and complexity of change. The ‘Collaborative Sense Maker’ has a role to help ensure that business change happens. We have tried to say, ‘No more IT projects,’ but that can’t be true, after all we are leading a team of digital professionals. I think the new meaning to this is let’s not have projects that exist just to deliver technology, lets collaborate to make sense of what is needed to deliver integrated care in health. At the recent EU wide integrated care conference here in Dublin a number of patients and carers in the audience explained that they had become known as the ‘difficult mum’, they were wearing this badge as a badge of honour. They provided care for a loved one with a complex and rare disease, as a mum or a carer they had become the person responsible for creating collaboration around care and indeed for making sense of the care delivered.
This new function can be responsible for working with ‘difficult mum’ to bring about a change supported by digital solutions that will ensure that every step of the way integrated care is the key and maybe not such a reliance on being difficult!
Finally, legitimately borrowed as a term from the Microsoft halls in Seattle is the role of ‘Chief Story Teller’, we all need to become this. The only way to engage on some of these concepts is to tell stories, telling a story is key to building engagement, trust and belief in an outcome. Creating an analogy to describe a complex journey is not new, in digital health I think it could well be essential if we are to get the engagement and buy in we need. Understanding the starting point, the end in mind and the story required to get there, classic story telling, we just need a hero (Andy) and a heroine (Rachel) to lead us there!
None of these roles need the titles in their positions, certainly we have enough chiefs kicking around the system but imagine the functions coming together to make the changes the descriptions promise. David Holzmer talks about,
‘We are witnessing the collapse of expertise and the rise of collaborative sense-making.’
I think this is the answer to so many of our needs is here in these descriptions of new roles, how to make these happen is down to anyone who works in health today, these are not digital roles, they are roles that will see health in any country set up to be patient centred and able to deliver care in a contextualised manner, a manner that citizens deserve.
Seven predictions of trends in eHealth in Ireland in 2017
At the end of 2016 Boston Children’s Hospital in the USA published a blog describing the seven predictions for digital health in 2017. A focus of eHealth in Ireland in 2017 will be digital solutions to support the care of children, be that preparation for an EHR for the National Childrens Hospital or the continued implementation of the Maternity and New-born system. Ireland has, in 2016, delivered on so much of the promise it made, with this in mind we wanted to consider the predictions by one of the world’s leading children’s hospitals and apply them to what we think can be achieved in Ireland in 2017. eHealth Ireland has set its sights on being able to apply these trends to what it delivers in 2017, fully supporting the ‘building a better health service’ agenda of the HSE with digital solutions.
1 – Telehealth adoption by patients
We have seen the adoption of telehealth in other jurisdictions begin to make a difference to how care can be delivered, colleagues in Scotland have been making a success of telehealth in outreach regions for the last five years or more. Whether it is driven by the health system, special interest vehicles or the patient themselves it doesn’t matter in Ireland. The creation and adoption of design principles relating to telehealth and the digital identification of patients and clinicians will aid adoption. Three examples of success in 2016 that can be built on spring to mind. The wonderful work of the Heartbeat Trust in the connectivity of GPs for consultations prior to and after heart surgery has begun to change the model of care on offer and all at a price that is affordable from a technology point of view. The delivery of patient portals is something that will be at the forefront of care in 2017 with the go live of a patient portal for epilepsy and the initial go live of a patient portal for the viewing of a persons own elements of a summary care record will enable Ireland to understand better the impact of this information on the delivery of care away from the more traditional care centres. The final example is an Irish company called Web Doctor, a company that has gone from status as a start-up to truly delivering a platform for primary care that is centred around the patient and is built with the patient in mind.
2 – Increased engagement with patients for telehealth solutions
Boston Children’s describes the second trend for 2017 as increased engagement, in the UK Roy Lilley wrote a blog at the turn of the year asking the NHS to ban the word engagement, suggesting that it is a word that should only be used to describe the meshing of gears or the sound you hear when a phone line is busy! Taking his principles and applying it to this trend though, in Ireland we will see the interest from patients in accessing leap forward through digital solutions. The ‘dawn’ of the wearable and quantified self has occurred already and yet only as we move to 2017 will patients really be able to start to use telehealth that they define themselves, that they are in control of themselves and that the benefit is targeted for them.
3 – Innovative visualisation devices hit the clinic
The adage that health in Ireland has a great deal of data, not so much information and struggles to gain timely insights from the what it collects has been pointed out a great many times over the last two years. At the innovation showcase in November a number of amazing new solutions that enable visualisation were demonstrated, no matter whether it was a holographic anatomy or virtual reality anxiety training this type of technology can and will be adopted where appropriate in 2017. The idea of training clinicians through the use of virtual and augmented reality has become something that the RCSI is pushing ahead with, it is an exciting prospect. The eHealth Ireland team is now in the process of implementing Microsoft Surface Hubs into a number of maternity hospitals, a piece of hardware built to enable visualisation and interaction of data in a whole different way.
4 – Clinical experience software
The piece from Boston’s Childrens describes how the interoperability of information, a move away from data messaging and a move to information integration will change the way in which the clinical experience is delivered. Certainly when Ireland considers the change in the experience now possible in Cork University Maternity Hospital, Ireland’s first digital hospital, I would have to agree. The ability to have information live with the clinical team regarding the care of the patient in front of them, the ability to collect critical information and apply it to the clinical record as it happens clearly makes a difference to the care experience. When lab test results can also be automatically added to the record and algorithms can flag issues to clinical staff that can be linked to information collected in real time then at last digital will be making a difference to the delivery of patient care.
5 – Maturing market for digital health start-ups
The IrishCentral.com site published a review of digital start-ups in Dublin in late December 2016. According to the site there are 775 Irish digital start-ups that have decided to locate in Dublin, funding in 2016 to these start-ups was in the region of 734 million euro! Out of the top ten funded companies six were digital health start-ups, those top six attracted 164.54 million euro of funding in the last year alone. The eHealth Ireland eco-system and the initiatives put in place by the team to support innovation being adopted into the health care system will, in 2017, continue to grow this market, concentrating first and foremost on the health of the nation but allowing eHealth Ireland to meet is secondary challenge, to be a catalyst for the wealth of the nation too.
6 – Expanded offerings from insurers and pharma
The difference in healthcare systems between Boston and Ireland is significant. The relationship between big pharma and public health care systems globally is not always a comfortable one and yet at the same time as the issues of drug costs need to be resolved we are now seeing the role of pharma in digital health changing. For example the work that Pfizer has done with eHealth Ireland in 2016 to create a digital solution to support the medicines reconciliation process from acute to primary care has been extremely successful, so much so that eHealth Ireland will look to implement the solution country wide in 2017. The insurance companies in Ireland have led the way in providing access to telehealth solutions, offering solutions like Web Doctor mentioned above and the ubiquitous Babylon Health solutions to customers, changing the access model for customers to one that is less demanding on the health care system itself.
7 – Personalised care through voice enabled devices
Homes are now asking Siri, Cortana and Alexa for help, search YouTube to the video of all three in a perpetual loop seeking assistance from each other for a feel for how the battle of the virtual assistance is going to take off, one of the funniest things I have seen all year. We really can imagine these services coming to health quickly, voice recognition and dictation is already a key part of any radiologists ways of working for example. When an EHR for Ireland is specified there will need to be an ability not just for the capture of text and images but also voice recordings, a giant leap into new unchartered territory that will need to be managed carefully from a security and governance point of view.
Its great to consider the trends of the future, there is a whole career out there now as a futurist for many commentators on eHealth and where it is going. The difference for eHealth Ireland in 2017 is that because of the foundations created in 2016 each of these seven trends feels that bit more achievable.
It was 2:45am when I was woken to go on deck for the hardest watch of the day: 3am-6am. That brief moment between waking and dressing was important to know what gear to wear. Quiet, easy motion indicated warm clothes and wooly hat. The violent lurches of the boat and a loud rush of water overhead meant I’d be clambering into all the protective gear I could find: drysuit, harness, lifejacket and sea boots.
This was near the Grand Banks, an area of shallow water off Newfoundland that were rich fishing grounds but dangerous in a storm. It was during the last part of a transatlantic sailing race in September 2000. We had crossed the chilly Labrador current and were closing in on Boston having started in Southampton a couple of weeks earlier.
When had been tracking the weather forecasts showing a storm would pass as we planned to cross the Grand Banks. We evaluated the options and decided sailing South to remain in deeper waters was safest. We prepared the boat and ourselves for a difficult 24 hours and raced on. We were all tense, but we were ready.
These days the challenges I face are in the world of health IT. As I work in the Acute Delivery function of the Office of the CIO, I spend my time with managers and leaders in health figuring out how to travel the journey to more effective, efficient and safe services. These decisions are rarely straightforward, involve incomplete information, unforeseen consequences and significant uncertainties; much like the challenges I faced with my crew-mates crossing the Atlantic.
The Project Management Institute publication “Navigating Complexity” describes what constitutes a complex project:
These characteristics are present in many of the projects I’m involved in, day-in, day-out. Introducing technology to support patients and health professionals is usually broadly welcomed. But when the simplicity of pen and paper is replaced by the complications of structured data capture and formal workflows there are many challenges to overcome. Dr. Tony Shannon, a health informatics leader with Ripple, has shared many insights from complexity theory and how they help understand health systems.
As I work with hospitals and hospital groups to plan their IT investments into the future, there are many additional characteristics of complexity in play. Decision-making with imperfect information, ambiguity, and developments in the policy environment is decision-making under pressure. Nonetheless, decisions must be made.
The process we follow uses these approaches:
Nationally, a lot of effort has gone into developing a clear, coherent and costed view of an Irish Health system enabled by the Electronic Health Record. Part of being clear about where a hospital group intends to use IT, is to be clear how the EHR will enable their part of the health system.
Equally important is knowing the current infrastructure, systems and capacity of the hospital group. It’s more than just technology. It’s about understanding how the people involved in health IT can further contribute to health transformation.
The third part of the approach is to chart a course towards the desired future, identifying intermediate waypoints and milestones along the way. This involves making difficult choices about how to apply precious resources and skills to start and complete projects that will bring the organisation towards the vision. Small gains build to big wins for our health professionals, for our service users and for our communities.
The PMI guidance is valuable and describes the competencies required to manage complexity.
There is no one formula that assures success. Choices have to be made with incomplete information, with an uncertain landscape and unknown risks. Establishing the way forward requires collaboration between health IT experts, clinician leaders and service management.
When we skirted the Grand Banks in September 2000 we were making the best decisions possible with imperfect information. There was a storm we couldn’t avoid, but we planned ahead and we were ready for it; we battened down the hatches, we ate early, we shortened sail, we kept each other safe and we adapted to the conditions that came. With a mixture of exhaustion and relief we emerged out of that storm unscathed.
Thankfully there are few days in the office as dramatic as a storm on the Grand Banks. But the challenges we deal with on ordinary days are just as important. They require skill, perseverance, and good judgement. Patience, teamwork and communication are essential. And always with an eye on the forecast and horizon…