17 April 2016

The Future of Medicine

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

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

10 April 2016

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

Prof Rafael Bengoa

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

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

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

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

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

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

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

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

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

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

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

01 April 2016

Dooey Beach, Donegal - virtual reality

Here is another Virtual Reality file for Google Cardboard, this time of Dooey Beach, Co Donegal, Ireland. It's just like being there! Well, not quite, but it's still pretty epic.

  • DOWNLOAD HERE. You will get a file that ends in vr.img
  • You need an Android phone or device plus the GOOGLE CARDBOARD APP
  • You will need a Cardboard Viewer (link provided for info - there are many suppliers). These only cost about £3, so they are dirt cheap.
  • Place the vr.img file into the folder on your Android device called \DCIM\CardboardCamera - this really important! You can find this folder using the File Explorer app, or whatever you use to manage your files on your device.
  • Open up the Cardboard App and go to "Cardboard Camera"
  • Select the desired panorama, and view it.
This one contains sound, and real 3D, which is a feature that I like about Cardboard Camera. I'll post some more of these, and any time I'm anywhere interesting, I'll get a panorama. Such as when I'm cycling the Galilee. Please go and sponsor me!

31 March 2016

Cycling to raise money for Nazareth kids

Nazareth EMMS Hospital needs your help!
Back in 2009 I joined a group of 18 cyclists travelling from Madaba in Jordan down to the Dead Sea and up the Jordan Valley, eventually crossing into Israel and up to Nazareth, in order to raise money for the Nazareth Hospital.

Operating Room facilities in Nazareth
In 1993, as a young medical student, I spent my overseas elective period in Nazareth, learning about medicine and the local culture. Nazareth is home to the largest Palestinian Christian community in Israel, although the majority of people in the area are Muslim. There are also a lot of Jewish people, so it's a somewhat eclectic place, and given the history of the last few decades, you can imagine that it's not without its issues.

When I was there in '93 the facilities were, while not exactly primitive, hardly up to modern standards. There has been a massive amount of work put in to upgrading things, much of it funded from international fundraising activities, and Nazareth Hospital is now one of the best-performing hospitals in Israel. It is also a shining beacon of coexistence in a very troubled region - a model, perhaps, of how people can put aside their differences and work together for the benefit of all.

But this success is not assured, and has required constant attention. This year, 2016, the Nazareth Trust is holding a sponsored cycle around the Galilee to raise money for the much-needed refurbishment of the Paediatric Ward. Unlike many hospitals elsewhere in Israel, there are no wealthy American donor organisations willing to fund expansion - just hard working people in Israel/Palestine, Europe, USA and Australia, who are trying to make a difference.

You can make a difference too - you can sponsor me, OR you can sign up and do the cycle too!

VISIT SHANE'S SPONSORSHIP PAGE: https://my.give.net/shanemckee


30 March 2016

Virtual Donegal Banjo

This is an experiment. Please feel free to ignore, or collapse in amazement if it works...

(Or let me know if it doesn't...)

You can also try the Spherecast link.

23 March 2016

An Apple Watch a Day Keeps the Doctor Away

This morning I gave a talk to the Northern Ireland Connected Health Ecosystem at Belfast Metropolitan College. The theme of the meeting was digital health & social care, and my talk had the above title; I was keen to get the audience thinking about the new opportunities offered by tech to radically change our models of healthcare delivery.
My central thesis: over time we have let our ideas of "health care" grow quite massively; certain things now fall under the auspices of "health" that in years gone by we would have anticipated that other agencies, individuals and structures would have been able to fill. Care workers have taken the place of normal family interaction. Patients are disempowered to control even the smallest aspect of their daily lives without having to consult their doctor, nurse, carer etc. We have, perhaps, created a top-down hierarchy that has removed the initiative from the patient/service-user, and made them feel like a slave in their own skin, rather than the master or mistress of their personal vessel. Quite how much that issue is playing in the dramatically rising costs of healthcare, who knows? But I think it's likely to be significant, and if we are going to make things sustainable, we need to look at this. Some patients are making a big splash, like Molly Watt - have a look at the slides to see if there's anything that you may agree or disagree with...

13 March 2016

Digitising Healthcare - how hard can it be? #EHR4NI

Robert M. Wachter, MD
Professor and Interim Chairman, Dept. of Medicine
Chief, Division of Hospital Medicine
University of...

Pretty hard. And the rewards can take some time to arrive. Don't take my word for it - let Dr Bob Wachter explain.
[Click here for video]
[Click here for slides]
The Productivity Paradox is definitely something we need to be very aware of before we embark on this journey - but the journey itself is definitely worth taking if we keep our eyes open and our brains on.

A single health record for Northern Ireland? #EHR4NI

The Health Minister has unveiled the eHealth Strategy for Northern Ireland, and a key part of improving services for patients, and ensuring we can deliver high quality health care in an environment of continual improvement and patient engagement is an electronic health care record (EHCR) which brings together data from a multitude of sources and makes it available to inform what we do as health care professionals in many different environments. The plan also calls for patients to be able to interact with their own information - to view their doctors' letters, communicate with health professionals, arrange appointments, see their medications and access health promotional materials.
Dark Hedges, Co Antrim. Photo: Bob McCallion (Farm Life)
Unsurprisingly, this is a complex and potentially costly undertaking, and we're talking about doing it at a rather large scale. Not that our population of 1.8 million is particularly large, but the potential numbers of sectors involved means that there is a great deal of work to be done if we're working towards a single record.

One fairly significant problem is that a product that integrates all aspects of a patient/client's data (I'm going to try to avoid using the word "care" for reasons I've partly already outlined) doesn't actually exist - yet. The big integrated health platforms that are widely used in the US and elsewhere are marvels of software engineering, and do allow us to potentially do some very valuable things, but they are at best only part of the solution, not the full package. And I think this is an important point - when we are lookng at our strategy and where we are going, we are not looking at the product, but at what we are going to do. An EHCR project is not a procurement exercise for an IT solution, it is a redesign of how we (patients, doctors, nurses, allied health professionals, government etc) develop and support ways of working that make the most of what we have available.

A significant part of the challenge is linking together data from sources such as paper hospital records, GP systems, community systems, pharmacy, government etc, and making it actually work for us. This is not a trivial proposal, and there is no doubt that it's not all doable at once. The "change management" (or "service improvement" or whatever we end up calling it) presents enormous difficulties, and if you're mapping this across a health economy of tens of thousands of front-line staff and something like 500 different system installations, the potential for problems is very high. In many (perhaps most) cases where an "all-at-once" change was tried (the "Big Bang" approach), the experience was not at all straightforward.

It's clear that a skilled team is required to lead the change, and that team may need to be large. Where do we find these people? If we take them out of their front-line jobs (which we will have to - we need skilled and innovative doctors, nurses,AHPs who know their subject areas and their patients), how do we back-fill their positions with similarly skilled people to keep the services running? In Northern Ireland, being across the water from the rest of the UK, this may not be achievable.

To cut this long story short, I don't think we can do a "Big Bang" in Northern Ireland at the present time, even if a product was available off the shelf. One proposal which has been put forward is a bimodal approach - implement a version of a large EHCR for central hospital functions (including a patient portal), while in parallel working on an integration of specialist systems onto an open-standards data platform, such as one based on OpenEHR specifications (for example).

This has a number of potential advantages. We can stage the implementation over a longer period, allowing the system to adjust. We can continually review progress and change direction if required. We can foster innovation by providing an open standards platform that is accessible to smaller vendors and to health-delivery organisations themselves. We can avoid "lock-in" to a single vendor. We can support a more open and dynamic IT landscape. We can develop a cadre of healthcare professionals who are highly engaged with improvement. We can get patients and clients properly involved at a real decision-making level.

Some disadvantages may also be perceived - the whole process may take longer to bring benefit than a Big Bang. Standardisation may suffer if there is too much "innovation". Silos of data may re-emerge if not constrained in a single system.

My view is that the disadvantages of a bimodal approach are perhaps overstated, and in any case are not avoided by a monolithic Big Bang. We're on a journey here, and we have to accept that there will be a great deal of diversity in health systems even in the best case scenario of a Big Bang. We'll know we are on the road to success when we are moving towards a world where the data is secure and consistent, as well as independent of the system that is used to generate or display it. And far more importantly, where health decisions, whether made by patient or healthcare practitioner, are based on the very best and most up-to-date data.