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January 30, 2006

Reposting for Eyeforhealthcare Delegates

This is a re-post of three entries about the increased mortality reported in “Pediatrics” after the implementation of a Computerised Physician Order Entry System (CPOE) for the convenience of delegates at the “Successful Implementation of NPfIT 2006” in London. These entries relate to discussions during the sessions I chaired on 30 January 2006.

First entry on the Pediatrics article.

Second entry on the article.

Third entry and link to post-publication peer review.

Links to other relevant blogs and websites are in the postings.

January 29, 2006

Sound teaching: updating the stethoscope

The stethoscope was invented by Rene Theophile Hyacinthe Laennec in 1816 and has become the letimotif of the doctor. It still provides the clinician with a concerto of medical information, about heart and lung conditions. To help medical students to tune their ears, Dr. Michael Barrett of Temple University, Philidelphia has used digital sound recordings.

This is what the London Times said about the stethoscope in 1834:

“That it will ever come into general use, notwithstanding its value, is extremely doubtful; because its beneficial application requires much time and gives a good bit of trouble both to the patient and the practitioner; because its hue and character are foreign and opposed to all our habits and associations.”

It is easy to see a parallel between this embarrassingly incorrect assessment and the criticism often aimed at the NHS National Programme for IT (NPfIT). Here is a quote from the Sunday Times about Choose and Book:

“The author of the memo concludes: “Clinicians will not take kindly to accepting changes that are detrimental to existing working processes unless there are significant or proven benefits.”

Plus ça change!

Time magazine in Updating the Stethoscope with an iPod reports that Dr. Mike Barrett produced a CD of sounds of six abnormal heart conditions and gave it to students who prompty ripped and loaded it onto their iPods. After about two hours the students were able to identify up to 80 percent of the sounds in a test.

January 26, 2006

Telemedicine: changing the way healthcare meets

telemedicine.jpeg I did not know it was so isolated. The nearest referral centres to the north, south and east are more that 2 hours drive away. To the west the nearest is across the Irish Sea in Dublin. But Bronglais General Hospital in Aberystwyth, Wales overcomes distance with telemedicine.

At a seminar in Slough, UK on Tuesday held by Multisense Communications Ltd. clinicians from Bronglais described (online, of course) how they manage cancer cases at the hospital using multi-disciplinary teams (MDT) and virtual consultation. Telemedicine combines live video with diagnostic data, images and even access to the Web.

Five south-east London NHS Trusts in the South East London Cancer Network also consult virtually with thoracic surgeons from Guy’s and St. Thomas’s Hospitals. The Network’s lung cancer MDT meets weekly to review 10 to 15 cases and shares diagnostic information. Dr. Stokes, Consultant in Thoracic Medicine at Queen Elizabeth Hospital, Woolwich says: “The system allows us to access the CT scan results directly from the scanner or PACS and transmit these live during the meeting.”

Here is technology embedded in healthcare helping patients by shortening waits, saving travelling time and giving access to the best possible treatment at centres of excellence and tertiary referral. All healthcare IT should aspire to this level of seamless integration and benefit.

January 24, 2006

Sex, Leadership and Rock 'n' Roll (and the NHS)

Part two of Peter Cook's entry as a guest author for FHIT.

Top Business Guru Tom Peters recently said of it: None would doubt that we live in a Rock 'n' Roll Age -- so what makes more sense than a brilliant, original, rockin' Rock 'n' Roll model of business management and leadership? Sex, Leadership and Rock 'n' Roll is a marvellous book, which closes the door on the tidy, hierarchical, know-your-place 'Orchestral Age' and ushers in a new, creative era of challenge and change. Hooray!

… and then there was jazz.

John Kao noted the connections between jazz and leadership in his book Jamming: The Art and Discipline of Business Creativity. Kao is a Harvard Business School professor, a jazz musician, has a PhD in psychiatry from Yale University and a successful career in Hollywood. He points out that creativity is fuelled by contradictions: between discipline and freedom; convention and experiment; old and new; familiar and strange; expert and naïve; power and desire. He points out that leaders should not try to resolve contradictions but work with them.

Kao’s vision is mostly about genius level creativity – he uses Charlie Parker amongst his examples of successful freeform jazz musicians who operates at the ‘edge of chaos.’ You have to be a brilliant player to be able to do this and this points to one difficulty with the jazz analogy; that much creativity at work is quite ordinary and does not always require or value genius level contributions – Have you ever tried to get different professional experts to work together? The jazz analogy is right in companies that operate at the ‘edge of chaos.’

Both the orchestra and the jazz analogies offer us complementary insights into leadership. The Rock’n’Roll analogy is both structured and improvised, is more accessible as a popular artform and relates better to the less certain post-industrial society which we play in. The musical analogies of leadership range from the highly formal and structured through to informal and more chaotic. Rock’n’Roll sits in the middle, which is where most organisations are--both tight and loose...

Peter's book “Sex, Leadership and Rock 'n' Roll” can be ordered on Amazon.

January 22, 2006

Bridging the Quality Chasm or Falling Into it?

I know I am at a stimulating talk when I feel my passion rising. So it was last Friday when I attended a talk given by Professor Marc Berg from Erasmus University Rotterdam at a NHS Faculty of Health Informatics Masterclass in London.

Professor Berg argues that quality improvement and health informatics must be combined if healthcare it to be improved and healthcare IT projects to succeed. At the core of his proposal is standardisation: of practice using Integrated Care Pathways (ICP), of semantics (using common health languages-like SNOMED CT) and of IT.

His approach is pragmatic, concentrating on changes that will make the biggest difference and on using the right expertise at the right stages of care. As you would expect in a method based on quality management, clinicians monitor outcomes and adjust processes as needed. So far, so good.

What Professor Berg did not adequately explain is how such changes are to be brought about. How are organisational politics and resistance to change to be prevented from bringing such major changes to a shuddering halt?

My scepticism comes from experience: I was part of a team implementing an almost identical system to Professor Berg's more than 9 years ago at a hospital in England (see my article “Making NP Fit” ).

Further, such quality management systems are excellent at normalising and standardising care-but what about innovation? Professor Berg argues routinely monitoring outcomes and changing processes where needed will bring about innovation.

I say resistance to change and the pressure to maintain business as usual will cause such feedback loops to normalise processes and thereby inhibit radical change. A similar argument to this is presented by Clayton M. Christensen in the “Innovator's Dilemma”.

Pleased as I am to see such ideas gain acceptance, hard experience has taught me their implementation often falters in the machinations of the real world. Focusing on technology (including IT) to the exclusion of human factors may lead to failure. But, the integration of technology into healthcare does bring about major change--consider, for example, the changes brought about by surgery, asepsis, anaesthetics, minimally invasive surgery.

So here the Professor and I differ. Changing attitudes, practice and IT simultaneously it just too difficult, no matter how attractive it seems in theory. A more pragmatic way to similar ends is to allow IT to be the focus and to encourage clinicians to exploit it to create better care.


January 19, 2006

Sex, Leadership and Rock ’n’ Roll (...and the NHS)

Peter Cook is just about to launch his book on leadership. Provocatively titled Sex, Leadership and Rock ’n’ Roll – Leadership Lessons from the Academy of Rock’ it explores Leadership through the metaphor of music. He writes for FHIT as a guest author.

Peter explains the Rock ’n’ Roll analogy and why it is an appropriate model for leadership in times of turbulence and complex change.

book.jpgIn the beginning there were orchestras……

For the last 200 years people have led organisations as though they were orchestras. Obsessed by the need for order and control in the way work should be organised, they created structures into which people were fitted. This meant that one person (the conductor) held the composer’s operating instructions (the score). The performer’s main role was to follow the score accurately and without deviation (improvisation). This analogy has remained attractive for the following reasons:

  • It gave leaders a feeling of absolute control and certainty about the future. This enabled leaders to make plans about long term futures based on extrapolating from the past. Essentially, a top-down planning approach to strategy.
  • It gave followers certainty about their role and required performance levels. Fixed job descriptions and performance management methods provide a rhythm and routine to daily life that lets people know that they are doing what is required of them. Over time, such systems become ‘unconscious structures’ or ‘scores’ that create conformity and level performance to acceptable rather than extraordinary levels.
The orchestra analogy assumes that the conductor (the leader) has the right sheet music, is supremely good at conducting and that the orchestra members are very good at following a pre-planned score. In other words, this analogy is most appropriate for stable bureaucracies. However, it is increasingly out of step with the way that work works, because:
  • The leader usually does not and cannot know everything required for establishing a top down strategy.
  • At best they only have some of the sheet music, or, even worse, might be using an outdated score.

These days you find staff who won’t follow the conductor’s directions. This is more likely if your current staff come from the so-called Generations ‘X’ (X = people born between 1964 and 1981) or ‘Y’, (Y= post 1982). These people are noticeably different from the ‘Baby Boomers’ (pre-1964).

They crave change, challenge, hedonism, speed, instant gratification, progression and freedom. They are individualistic and reject traditional forms of leadership based on the command and control model. In short, they will not be pushed around, even other people think it’s good for them. Moreover, they are very aware of their ‘market value’ and will walk if they think that they are not well catered for.

This is particularly noticeable in some parts of the NHS these days and manifests itself in the so-called ‘War for Talent’ and ‘Employer of Choice’ strategies adopted by many Trusts.

Part two of Peter's entry will be posted soon.

Peter's book “Sex, Leadership and Rock 'n' Roll” can be ordered on Amazon.

January 17, 2006

Documents and databases for the NPfIT record

paper-records.jpegWilliam Hooper is Senior Advisor, Healthcare, Xerox Global Services and writes as a guest author.

This blog has frequently looked at humans and computers in healthcare. Let us introduce another factor—types of information.

Historically, pretty much an entire acute note has been un-structured. Some forms have been used for transactions such as ordering tests or receiving results, and nurses, as ever, are organised. I have not yet found a fag-packet in notes, but you get the idea.

The National Programme attempts to take a structured approach. GPs have been working this way for years, and it has many advantages. Computers are good at validating entries, when supplied with sensible rules. The advantages in terms of activities such as prescriptions are obvious. They can also be programmed to make sensible suggestions on care given a set of patient conditions. To say that programming these care paths is complex and time consuming is an under-statement.

Databases (which are what underlie the clinical systems of CRS) are good at holding structured observations and measurements. But, it will be many years before they have comprehensively encoded the bulk of medical practice (if ever).

Meanwhile, clinicians today are still adding both free-text and documentary additions to GP and acute notes, to say nothing of psychiatric observations. Paper is being generated too, and a tiny proportion is now being scanned and added to the database note.

A database stores a blood-pressure reading effectively where the care-plan says one should be taken. Documents can store anything and everything from the patient’s mood this morning to a sketch of a planned intervention.

The technology is now available to integrate documentary with data notes. This is to be supplied in most NPfIT clusters. Rather than talking about heaps of paper as being a problem for records managers to sort out, should we not be concentrating on who needs what information to deliver care, and how best to make best use of this?

January 14, 2006

Robot wards

asimo-tray.jpgBefore Christmas I went for lunch in London with my wife and my father and mother in law. We were looking at some ideas for designs that will soon adorn this blog. As a consquence, my mother in law said that if she were having surgery she would prefer it to be carried out with robotic precision.

In a recent article published on the E-Health-Insider website I present a straw man that robots will be better than humans at caring:

“Humans compare unfavourably with robots, tiring easily, taking longer to train, needing special fuel, being expensive to maintain, becoming easily bored by repetitive tasks—and—you just can not get the spare parts for them.”
As Alasdair asked in a comment to a previous article: even if machines can care, should we let them? I think that machines will free clinicians and carers from the heavy, boring and repetitive tasks; but they can never give patients what we can--our humanity.

Read “Robot Revolution” on the E-Health-Insider site.

Image: Honda Motor Europe.

Healthcare IT will not fix broken health processes

operating.jpgThose of you who have been visiting regularly will know this topic is a hobby horse of mine. Often, healthcare finds an operational problem, and instead of addressing it by changing human activity (which is difficult) it decides to buy a computer (which is easy) hoping that it will sort everything out. Invariably the IT makes matters worse or creates a new set of problems.

For an example of IT in action, please read this account on HHN Most Wired of a man who took his son with meningitis to a US hospital: “A Patient's View of Health IT”.

Now, of course, there is no excuse for poor customer service. Healthcare in UK is different from that in the US, and, in the main, I have had few problems with it. Most of my irritation is caused by long waiting times and administrative processes that often seem to be for the benefit of staff rather than the patient.

However, I guess what I should be concerned about is outcome. After all, poor processes and old-fashioned buildings are much less important than a first-class outcome. The National Patient Safety Agency in the UK in “Right Patient, Right Care” (PDF) identified a 10 percent mismatch between required and delivered treatment for the UK's annual 8m inpatients.

Is that mismatch symptomatic of broken processes? And, if it is, will the deployment of the National Programme for IT's (NPfIT) information systems make them better or worse? I remember reading this on a poster in an office:

“We all make mistakes that's very true indeed,
But to really mess things up a computer's what you need.”

Shouldn't we address the real problem before implementing the IT?


January 11, 2006

Blogposium

Jack Mason has developed the idea of a "blogposium" of healthcare IT bloggers to address some common topics. Could be productive and fun. Find more here on the HealthNex site.

January 10, 2006

Human effect of RFID

rfid-tag.jpgThe recent debate on CPOE brings to mind some of the human and cultural issues surrounding the introduction of new technologies and RFID in particular. Although the focus of RFID applications has been on tracking and tracing of goods and assets, the side effect is that you often end up tracking the activities of people.

Some years ago an RFID enabled weighbridge system was installed at a waste plant in North London to which several local authorities subscribe. The system works by fitting long-range active tags in the cab window of the waste collection vehicle so that entry can be gained to a weighbridge on entry and exit.

Before the RFID system was introduced the whole procedure was manual and slow. The new system allows data on quantity of waste disposed of, time, vehicle, authority, to be collected automatically saving time through the site and automating the billing process. However, the system was introduced with little regard for the waste collection operatives on the vehicle who viewed it with suspicion and saw it as a spy in the cab.

For some the reaction to this intrusion on their normal working practices was to prise the RFID tag off the window and throw it away. It took a little while for it to dawn on the operatives that the consequences of the system were in fact beneficial for them; they could get through the site quicker on each return and finish their rounds earlier. Still, it would have been better to bring the staff into the project from the outset.

See this article on the innovative use of RFID in healthcare.

January 07, 2006

Healthcare IT: full integration in care

da-vinci-healthcare.jpgI am reading an excellent book: “Jacquard's Web” by James Essinger.

Joseph-Marie Jacquard was a master silk-weaver in Napoleonic France. Jacquard invented a loom that accelerated the rate at which master weavers could create their exquisite fabric by 25 times. The loom stored patterns and instructions for the beautiful designs on punched cards, which were in turn used by Charles Babbage to programme his Analytical Engine--the world's first computer.

The precursor of Jacquard's loom was the drawloom. Individual threads of the warp were lifted by it to create a path through which the shuttle was passed by a draw boy. The drawloom allowed patterns to be weaved at the unprecedented rate of two rows a minute (!)

This book is an excellent read and this caught my eye:

“The real problem was that the drawloom was not a machine at all. Instead, it was only a device for facilitating the manual weaving of patterns or images in the fabric...”

Facilitating the manual weaving. It seems to me that is what healthcare IT does: it's an aid to care rather than an integral part of care--still somewhere between the condition of an abacus and a calculator.

The picture is of the da Vinci operational robot which is used by surgeons to achieve unprecedented precision in minimally invasive surgery. It eliminates a surgeon's hand tremor, which is magnified by the lever effect of the long keyhole surgery instruments, and further improves visibility by the stereoscopic view of the site that its twin lenses provide.

Sure, it needs a surgeon to operate it remotely but how much longer before IT and tools are further integrated creating the medical equivalent of Jacquard's loom and freeing professionals to weave even better patterns of care?

Picture of the da VInci copyrighted property of Intuitive Surgical.

January 04, 2006

Health IT: making care better or worse? (cont)

The debate about the sharp increase in mortality reported in Pediatrics after the implementation of a computerised physician order entry system (CPOE) at the Children's Hospital in Pittsburgh. (See FHIT entry) rumbles on.

I spotted this reference to a post-publication peer review, which states:

“A more accurate summary of the findings is that there were significant problems with the implementation process for CPOE at this hospital and that the hospital simultaneously instituted other system changes that may have accounted for adverse effects.”

Compounding the criticism of the study by health IT experts and others, the hospital’s medical director and other hospital officials have also disagreed with the study's findings, according to the Wall Street Journal.

In the UK the original study was also picked up by the E-Health-Insider website. Please look at the comments after the article, which are instructive and tell us about the polarisation of opinions on healthcare IT in the UK.

Even after 15 years of implementing health care IT it never ceases to astonish me how quick people are to criticise it and how little healthcare has learned about its implementation.

Implementing information systems without first changing processes and medical practice to accommodate them and carefully monitoring the result is folly, not to say negligence. This applies doubly to processes that may already be poor.

How long will it take us to learn these lessons?

More on the on the eHealth Blog.

January 01, 2006

Health Informatics: a rant to begin the new year

I was woken by the sound of a text message arriving on my mobile phone. Ahh, I thought, a message from my old university chum who lives in Mauritius. Or, maybe my Mother has learned to text and is about to impress me with a New Year's greeting.

No such luck. A message from my accountant telling me that my VAT (UK sales tax) return is due. Brought down to earth with a bleep and a buzz. As Bono sings: "Nothing changes on New Year's day".

Suitably grumpy, I thought I would write about this field of Health Informatics that has been on my mind.

I took a partial sabbatical from health to work in other areas of the UK public sector, thinking to expand my experience and skills. During my time away from full-time engagement in healthcare IT, Health Informatics in the UK seems to have grown from an egg into an assertive fledgling.

I looked up a definition of it on Wikipedia:

“Health Informatics or sometimes Medical Informatics is the intersection of information science, medicine and health care. It deals with the resources, devices and methods required to optimize the acquisition, storage, retrieval and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems.”

Now, having worked for about 15 years in healthcare IT and led three major Electronic Patient Record Implementations I became used to walking the tightrope between the views of clinicians and NHS IT professionals. In general, over the years these two poles have learned to co-exist.

Into that polarization—for me rather uneasily—come the Health Informaticians. Are they clinicians, healthcare IT professionals or a new breed of academic? Why are there no fields called Finance Informatics or Supermarket Informatics..?

Wikipedia's entry did little to help me, giving the following as aspects of the field:

  • Architectures for electronic medical records and other health information systems used for billing, scheduling or research

  • decision support systems in healthcare

  • messaging standards for the exchange of information between health care information systems (e.g., through the use of the HL7 data exchange standard) - these specifically define the means to exchange data, not the content controlled medical vocabularies such as the Standardized Nomenclature of Medicine, Clinical Terms (SNOMED-CT), Logical Observation Identifiers Names and Codes (LOINC) or OpenGALEN Common Reference Model - used to allow a standard, accurate exchange of data content between systems and providers

  • use of hand-held or portable devices to assist providers with data entry/retrieval or medical decision-making

If this is a correct description (and it may not be, given the democratic nature of Wikipedia) it seems to sit firmly on the IT professional end of my conceptual tightrope.

Having read the Wikipedia description and having looked at a HI text book it seems to me that this field misses best half of our affair: the integration of IT into, and the transformation of, medical practice. To succeed it is essential that IT becomes fully integrated into care. Is Health Informatics the best way to bring that about?

Only joking about the grumpiness. In fact, it is a lovely day here in London and I enjoyed my run!

I wish you all a happy and successful 2006.

Health Informatics: a rant to begin the new year

I was woken by the sound of a text message arriving on my mobile phone. Ahh, I thought, a message from my old university chum who lives in Mauritius. Or, maybe my Mother has learned to text and is about to impress me with a New Year's greeting.

No such luck. A message from my accountant telling me that my VAT (UK sales tax) return is due. Brought down to earth with a bleep and a buzz. As Bono sings: “Nothing changes on New Year's day”.

Suitably grumpy, I thought I would write about this field of Health Informatics that has been on my mind.

I took a partial sabbatical from health to work in other areas of the UK public sector, thinking to expand my experience and skills. During my time away from full-time engagement in healthcare IT, Health Informatics in the UK seems to have grown from an egg into an assertive fledgling.

I looked up a definition of it on Wikipedia:

“Health Informatics or sometimes Medical Informatics is the intersection of information science, medicine and health care. It deals with the resources, devices and methods required to optimize the acquisition, storage, retrieval and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems.”

Now, having worked for about 15 years in healthcare IT and led three major Electronic Patient Record Implementations I became used to walking the tightrope between the views of clinicians and NHS IT professionals. In general, over the years these two poles have learned to co-exist.

Into that polarization—for me uneasily—come the Health Informaticians. Are they clinicians, healthcare IT professionals or a new breed of academic? Why are there no fields called Finance Informatics or Supermarket Informatics..?

Wikipedia's entry did little to help me, giving the following as aspects of the field:


  • architectures for electronic medical records and other health information systems used for billing, scheduling or research

  • decision support systems in healthcare

  • messaging standards for the exchange of information between health care information systems (e.g., through the use of the HL7 data exchange standard) - these specifically define the means to exchange data, not the content

  • controlled medical vocabularies such as the Standardized Nomenclature of Medicine, Clinical Terms (SNOMED-CT), Logical Observation Identifiers Names and Codes (LOINC) or OpenGALEN Common Reference Model - used to allow a standard, accurate exchange of data content between systems and providers

  • use of hand-held or portable devices to assist providers with data entry/retrieval or medical decision-making.

If this is a correct description (it is subject to the democratic nature of Wikipedia) it sits firmly on the IT professional stretch of my conceptual tightrope.

Having read the Wikipedia description and having looked at a HI text book it seems to me that this field misses “best half of our affair”: the integration of IT into, and the transformation of, medical practice.

To succeed, it is essential that healthcare IT become fully integrated into care. Is “Health Informatics” the best way to bring that about?

Only joking about the grumpiness. In fact, it is a lovely day here in London and I enjoyed my run!

I wish you all a happy and successful 2006.