May 10, 2013

Stop Saving the NHS: new book

Stop Saving the NHS cover (small).jpgWell I have done it. My book Stop Saving the NHS and Start Reinventing it has been published in Kindle and paperback. It's aimed at NHS leaders and managers, but will probably interest anyone who is interested in the shape of 21st century healthcare.

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June 22, 2012

Alan Turing Enigma

Picture of the user console of ACEIn the photographs, dressed in jacket and dark tie, he looks like the prefect at my grammar school who cowered against the corridor walls when other pupils approached him. The mathematician and visionary Alan Turing is the subject of a compact exhibition at the Science Museum in London.

During the Second World War Turing famously helped to crack the German Enigma code using one of the earliest electronic computers, the 'bombe'. The cracking of the cipher, which the Germans believed impossible, probably shortened the war by years, saving countless lives.

Dozens of wheels rotated in each bombe making a noise like 'a thousand knitting needles'. And a legion of bombes supported decryption on an industrial scale. So effective was it that on one occasion a message was decoded in less than 15 minutes.

When the war ended, Turing worked on the government Advanced Computing Engine (ACE) project. Before such machines were invented, large scale arithmetical calculations were carried out by teams of specially trained women.

Computers were then quickly applied to complex problems in chemistry and life sciences. At Manchester University, Turing researched the relationship between mathematics and cell growth, beginning a new field he named Morphogenesis. At Oxford, in 1957, Dorothy Hodgkin used Pilot ACE and X-ray crystallography (a technique also fundamental to the discovery of the structure of DNA) to help her to crack the structure of vitamin B12 and was awarded a Nobel Prize.

Turing was condemned for homosexuality in an era when it was illegal. Under constant surveillance as a security risk, he apparently took a bite from a cyanide-laced apple. His death was officially declared suicide, though the exact circumstances remain a mystery.

As a leader in computation--particularly in programming--he deserved better. However, in recent decades he has been recognised as one of the greatest thinkers of the 20th Century.

June 10, 2012

Twenty First Century Healthcare with IT

There was a good turnout of clinicians at the planning session with an NHS client the other evening. Main strategic work streams were quickly agreed, and we got onto enablers. I expected the usual suspects: more consultants, more nurses and more money. I was wrong. Almost all of the groups chose IT as a major enabler of change for the better.

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May 22, 2012


I make my offering at the altar, pay the priest and nod at the high priestess as I leave the temple of Apple on Regents Street. I still have ten minutes to make it.

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October 16, 2011

What's After the NHS IT Programme?


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September 13, 2011

EPR Models: checklists or constraints?

I was reminded of the good old six level Electronic Patient Record (EPR) model that originally appeared in Information for Health back in 1999 through a posting on the E-Health Insider group on LinkedIn. For those of you who haven't seen it or have maybe forgotten it, here it is...

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May 01, 2010

HC2010 Conference: sitting uneasily?

Doubling the quality of thinking on the podium of the opening plenary session of HC 2010, veteran Professor Heinz Wolff arrived late and stole the show.

After listening to the platitudes and threadbare academic definitions of the three previous speakers, octagenarian Professor Wolff hobbled across the stage on crutches, followed at a respectful distance by a cushion for his rear carried by the session chair, and applied his razor sharp mind.

The UK's aging population would ensure healthcare became unaffordable, so it would be split into acute and community care, he suggested. Acute care, treating and operating on disease, would be the job of the NHS. Community care, watching out for your neighbours and helping to care for them, the job of the local community. To fund your own community care, you would acquire credits throughout your life by good deeds and community service. Agree or not, at least it was insightful and stimulating.

Which is more than can be said of Dr. Ben Goldacre's after dinner speech that evening. Delivered at the rate of the 36 barrel Metal Storm gun, his speech was too clever, too factual and too long. After 15 minutes I watched Blackberry ® smartphones (yes, I did look up the plural) being unsheathed and eyelids drooping.

But any who did drop off were galvanised to wakefulness by the first chord of Helter Skelter's set, so potent it immediately drove guests at the tables nearest the stage to the exit with the rest of us soon following. 'Was the enterainment no good?' asked one of the cloakroom staff as I left for my hotel 40 minutes later. 'About 200 people left all at once.' The band was very tight, I assured him, but their music inappropriate and too loud.

Though it has been relocated, recovered with go faster stripes and refitted with stereo headphones, the comfortable old chair that was the HC conference stands unsteadily.

January 17, 2010

iPhone not the One

Use IT now to help the people of Haiti.

I dismissed suggestions that I would become one. One of the spiral-eyed ring wraiths from Morden (and everywhere else) who ride the London Underground white stoppers in their ears and 6 inch square screens before their eyes through which they experience reality while reality passes by.

I was excited. My telecoms provider had called me to tell me that I could renew my contract and become a proud user of iPhone. I called a friend who enthused about its apps and gave me the impression it was the coolest thing since a morning dip in the Ford of Bruinen.

Almost convinced, I was passing a retail outlet and couldn’t resist taking a peek. What a shocker: the touch screen text entry system is one of the worst I have experienced. Even after a bit of practice my typing speed would have fallen by 25 percent at least.

One ring to rule them all? I’ll stick to my Blackberry. When it comes to a method of entering text which is quick, portable and unobtrusive we are still bound in darkness.

"One Ring to rule them all,
One Ring to find them,
One Ring to bring them all and in the darkness bind them."

JRR Tolkien, Lord of the Rings.

December 18, 2009

Modelling Clinical Trials

London Euston station is a child waking up. Shutters raising. Bleary-eyed passengers staring at the information board. I am catching an early train, for which I’m early.

WH Smith bright and inviting. On the shelf the US edition of Wired. What's inside? Yes: The Body Synthetic. Something to enjoy on the journey.

In 1997 David Eddy applied a model he designed called Archimedes to predict the result of a clinical trial named Collaborative Atorvastatin Diabetes Study or CARDS.

Archimedes is like a Treasury Model of human physiology: knowledge from epidemiology, clinical trials and clinical interviews encoded into differential equations.

Using broad patient data, Eddy and his team constructed a comparable trial to CARDS in 2 months and issued the results. When the 7-year clinical trial reported, it turns out the findings of the model were remarkably close.

It is also remarkable to read the criticisms of the model: a self contained ant farm that has no bearing on reality, a black box. Interesting remarks, because the whole of medical practice is based on abstractions, assumptions about biological reality. Do we fully understand the complexity of human physiology? We do not.

Medicine is often quick to point to the mote in the eyes of others (black box, lack of evidence), while forgetting the beam in its own (black box, lack of evidence).

Nonetheless, it’s refreshing to read about people prepared to face criticism and innovate with IT. To open eyes. Like shutters raising in the morning.

August 11, 2008

Healthcare IT: no evidence

cane.jpgGeorge’s nightmare began with a succession of illnesses. At the beginning of the year he endured agonising head pain for a week after he was discharged from hospital. He was eventually readmitted, and medical staff discovered he had a bleeding capillary in his head. After some persuasion from my Mother--they are of a generation that prefers not to disturb doctors “unnecessarily”--he had called the out-of-hours GP service, but the doctor attending said he could do little because he did not have George’s medical record, thus lengthening the agony. But they say there is little evidence to support the use of ICT in healthcare.

Last week my Mother tried unsuccessfully to call George for several days. After calling his family and even sending an acquaintance round to his house she thought she had done all she could. After all, he was the customer of a care service that checked his well being with telephone calls and that would send someone around if there was no reply—except it didn’t.

He was found on Thursday lying paralysed and unable to speak on his bathroom floor having suffered a stroke on the previous Sunday evening. Of course, the technology to monitor remotely is available, but they say there is little evidence to support the use of ICT in healthcare.

I have been reading Max Pemberton’s Trust Me I’m a Junior Doctor in which he relates his experiences of the UK’s National Health Service. I worked in the NHS for 10 years and many of his anecdotes brought on a wry smile of recognition.

When I was studying for an MBA I remember learning about corporate culture (now an overused and devalued term) and how it might be described using myths, heroes, legends, stories, jargon, rites and ritual. An NHS manager on my course suggested the consultant’s ward round as an example of a ritual. In it the medical consultant and a retinue of junior doctors progress through a ward reviewing and discussing patients. An extreme example can be seen in the film Doctor in the House (1954) when the formidable Sir Lancelot Spratt humiliates his underlings.

Max Pemberton was also at the bottom of the pecking order, because he’s packed off to get the coffee and croissants for the round. That seems poor reward for the time he spent excavating X-ray films from behind radiators and tracking down missing pathology samples and results in preparation for the ritual. He even has to transpose manually drugs charts by interpreting the glyphs of senior medical staff. But they say there is little evidence to support the use of IT in healthcare.

A rigorous scientific approach to medicine is to be applauded; but using demands for “evidence” as a way to slow down IT adoption in the face of common sense is not.

June 28, 2008

Healthcare: plagiarism and expertise

Sir Isaac Newton said he saw further than others by "standing on ye shoulders of giants" thereby acknowledging his sources and influences. Celebrity psychiatrist Dr. Raj Persaud seems to have attempted an easier ascent by using ye copy and paste on the published work of others without such clear acknowledgment.

The UK General Medical Council found Dr. Persaud had behaved dishonestly and had undermined public confidence in the profession. Some examples of his plagiarism are at the bottom of this article.

But giving Dr. Persaud a kicking is not on my mind. I am more interested in the reaction to the GMC's decision.

The UK media are notorious for building up celebrities only to bring them crashing down. However, in this case the journalists seem to have wriggled uneasily in their ergonomic chairs. A web search will reveal the majority of the coverage is ambivalent, many journalists and others trying to deflect the debate by saying what a good chap Dr. Persaud is and that blatant plagiarism does not mean he is not a good doctor. Fair enough, but let's stay on topic, guys.

In the main, journalists earn expert status vicariously. It takes about 10 years of intensive work to be considered an expert in a field, and few journalists--particularly in healthcare IT--have that experience. Hence, we get the phenomemon of journalists interviewing other journalists, who are meant to be experts but in reality have a superficial understanding of their subject. It is no longer necessary to invest 10 years to be considered an expert. A few hours of web searching and mugging up can give that impression without the hard graft.

Comments allegedly made by Richard Madeley and Judy Finnigan encapsulate my area of concern. It was on their TV programme--which considers itself qualified to comment on life, the universe and everything--that Dr.Persaud first came to media prominence. They have stated they wish to continue working with Dr. Persaud. So it seems professional honesty comes second to presentation skill. Is the Internet taking us to a form of celebrity medicine where the ignorant are led by the superficially informed?

June 20, 2008

Mancunian Ways

Mountain ViewIf you think Windows Vista is slow you should have tried using Fortran IV. I studied at Manchester University where we were able to take advantage of the computing facilities—quite novel in those days. This entailed creating a stack of punched cards which I dutifully placed in a tray in the morning.

After lunch I returned keen to see if my program for calculating square roots had worked only to find the dreaded words “run time error” on the print out, usually after the first milliseconds of the programme’s run. I found my mistake, corrected it and put the cards back in the tray and thus it continued until I got my brainchild to work.

It’s the birthday of Baby the world’s first electronic computer created by Manchester University in 1948, the BBC reports today. Baby could complete calculations in hours that would have taken days by hand.

The UK NHS, also born in 1948, celebrates its 60th anniversary. Health Secretary Nye Bevan was ceremoniously handed the keys to the Park Hospital (now Trafford General ) in Manchester to mark the foundation of the Service.

As if that wasn’t enough coincidence, this year’s NHS Confederation Conference took place in Manchester this week. I was surprised to see how many NHS agencies had individual stands: NHS Improvement, NHS Pathways, NHS Connecting for Health, NHS Institute for Innovation and Improvement, NHS National Technology Adoption Centre.

They all do worthy work, I'm sure. But I was heavily influenced by the work of Enid Mumford who was a professor at Manchester Business School and her promotion of socio-technical systems, so I find it odd the NHS should have so many trays in which to stack what should be a unified blend of people, processes and technology. One day we will produce that blend, but only after this tendency to reductionism is addressed.

Listening to Joe Simpson (Touching the Void) tell the story at the Conference of his ascent and unconventional and agonising decent of the Siula Grande in the Peruvian Andes puts life into perspective. If we only have a fraction of his courage and dogged determination the NHS will become the socio-technical system it must and gain again the envy of the world.

June 11, 2008

NPfIT: full circle?

The departure of Fujitsu from the NHS National Programme for IT (NPfIT) dealt the Programme another body blow. Where does NPfIT go from here, if anywhere?

Perhaps the Southern Programme for IT should be handed to one of the remaining huskies . But this summary from the UK's Guardian newspaper leads to the conclusion that would not be easy because of the alleged poor reception of the Cerner Millennium system.

Yesterday I attended a talk at the Smart Healthcare 2008 conference in London. Last year a similar talk was packed to capacity. This year the same venue was barely half full.

Although the speakers were meant to address healthcare transformation, I heard little evidence of it. The speaker from NHS Choices came closest showing the NHS Choices website had the potential to increase the power of patients by providing them with real performance data on healthcare providers. But the CIO of the London Programme for IT gave a history lesson on NPfIT and implied that NHS organisations would play an even greater role in the choice and implementation of IT.

Now I have tried a few times to read James Joyce's Finnegans Wake. I have never succeeded fully, but I know, set in world between dream and reality, it begins and ends with the word "riverrun" having come full circle: "riverrun, past Eve and Adam's, from swerve of shore to bend of bay, brings us by a commodius vicus of recirculation back to Howth Castle and Environs". So it seems with healthcare IT.

For decades NHS organisations implemented their own choice of IT systems before the intervention of NPfIT. Is the dream ending and flowing back to a parallel reality having run full circle?

March 02, 2008

Peer Review and Innovation

Picture of woman reading.Lecturers told students on my wife's Physiotherapy course that journals using peer review--like the British Medical Journal--were the gold standard.

But in New Scientist 23 February 2008 Donald Braben argues that we are seriously deluded if we think peer review can lead to innovation. Peer review might work for the mainstream, he writes, but it excludes radical research. Now this chimes with an exchange between Checkland and Jackson I read when researching a Masters dissertation.

Checkland's Soft Systems Methodology is a way of finding solutions to problems that cannot easily be defined and might only be sensed as a vague feeling that all is not well. Predictably Checkland suggests defining the problem and then "identifying feasible and desirable changes". Part of this identification is for the interested parties to generate options and it was here, as I recall, that Michael A. Jackson argued group dynamics meant the methodology was normative, rather than radical. Groups tend to fall into heirarchical working, he suggested, often with one particular individual or group of individuals dominating this meant that radical solutions would often be rejected by those supporting the status quo.

The same limitation may apply to multi-disciplinary review. In a previous posting I wrote about a presentation by Prof Berg in which he argued computers should support standardised pathways of care which would be continually enhanced by review. On the face of it this sounds reasonable. Indeed the idea is not new. I was proposing it at least 15 years before Berg and I doubt I was the first.

But Berg argued that the review would generate innovation. I doubted it and what I have read and heard about the dynamics of multi-disciplinary working supports my scepticism.

Nor is that the end of the story. Peer review may be part of the future of medical practice, but only part. Wikipedia also quotes Drummond Rennie of the Journal of the American Medical Association:

"There seems to be no study too fragmented, no hypothesis too trivial, no literature too biased or too egotistical, no design too warped, no methodology too bungled, no presentation of results too inaccurate, too obscure, and too contradictory, no analysis too self-serving, no argument too circular, no conclusions too trifling or too unjustified, and no grammar and syntax too offensive for a paper to end up in print."

February 07, 2008

Health Informatics and Science

I've been reading Garrick Alder's Mind Bombs which is a collection of short articles designed to galvanise your thinking.

He reports Professor Richard Smith, editor of the British Medical Journal until 2004, said only about 5 percent of the entire planet's scientific papers came up to scratch. In most journals, Professor Smith said, it was less than 1 percent.

I have a comparable view of most of the Health Informatics publications I have read. They fall into two categories: the bean counting variety best kept by the bedside as a soporific and the other weak and subjective.

Health Informatics faces the same challenges as fields like sociology and psychology which also depend highly on the interpretation of human behaviour. At this stage in its evolution, the success or failure of healthcare IT is largely determined by how well users apply it. Therefore, IT must become fully integrated into healthcare, not seen as something separate. This goal is not best served by the creation of another specialty, Health Informatics, in a field already overflowing with them. That just gives practitioners an excuse to continue to pass the buck: "It's not my specialty, mate".

December 07, 2007

Got Them Healthcare Blooze: motivation the rock’n’roll way

Picture of leaping guitarist.It's been a while since Peter wrote for FHIT, but he's back. You can also read some of his previous entries. Let's rock!

‘I was looking for a job, then I found one. Heaven knows I’m miserable now’. How often have you heard these words for real in the workplace? Poor morale and motivation account for massive waste in effort, costs and profits in even the most successful organisations. So what can Morrissey, Minztberg, Meatloaf, Maslow, Motorhead, Madonna et al teach us about how to create a work climate and culture that rocks? In the book ‘Sex, Leadership and Rock’n’Roll’ I explore classic ideas about motivation through a rich mix of great academic thinking ‘tamed’ with the pithy wisdom of rock and pop culture. Let’s start with a look at the Blues.

Can’t buy me love?
Most Blues songs begin: ‘Woke up this morning’ and then move on to motivational problems such as ‘The landlord wants to repossess my home’ or ‘My woman left me’.

In the modern workplace, you cannot have a Blues that goes ‘Woke up this morning, the server was down’ or ‘Woke up this morning, I got a good HR manager who self actualises me!’

Quite surprisingly, this cheesy contrast makes a great deal of practical sense. Frederick Herzberg pointed out the difference between those factors that merely remove dissatisfaction at work, e.g. pay, administration, supervision (called dissatisfiers) and those factors that encourage job satisfaction e.g. responsibility, advancement etc. (called satisfiers). Just think about those ‘fly like an eagle’ motivational posters in some hospital corridors. Yes, they are cheap, but they do not create workplace satisfaction.

Many reward systems only focus on removing dissatisfaction - it’s no surprise that they fail to motivate – just try doubling someone’s salary and notice how long they work twice as many hours! As Prince said ‘Money don’t buy you happiness, but it sho’ ‘nuff pays for the research.’ i.e. inadequate pay dissatisfies, but no amount of pay will produce long term job satisfaction. This is especially true for Generation Y and beyond, who crave much greater things from work today. Companies such as First Direct, B&Q and Prêt à Manger have learned this point well and surpass others with people who bring their heads, hearts and souls to work. The NHS is well positioned to offer people some Herzberg satisfiers e.g. career development, intrinsic job satisfaction etc.

Key point:review Hertzberg’s model in the book and ask yourself ‘How does our motivational strategy line up with his findings?

River deep, mountain high
Coming back to our Blues examples, repossession of the home and losing one’s lover are located towards the lower levels of Abraham Maslow’s hierarchy of needs i.e. shelter and belonging. Maslow crucially pointed out that there was a hierarchy of needs from physiological through to ego and self actualisation. So we really cannot have a Blues that starts ‘Woke up this morning, I got a good manager, who sets meaningful performance goals and leverages my talent in ways that provide long term career development tailored to my talents’ unless the basics are also in sufficient supply. As an aside, the lyric does not scan well either!

Key point:HR needs therefore to be not only strategic and visionary but also tactical and detail conscious in the way it motivates staff.

I want it all and I want it now
In a culture of mass individualisation, employees expect to be treated as individuals, yet many HR systems tend to treat them as a collective in the interests of fairness, equity and conflict avoidance.

Key point:personalisation is the key to individual motivation. This requires motivational systems that are responsive both in speed and flexibility. Ask your HR people to tell you how the HR system achieves these ambitions.

We gotta get out of this place
Blues can take place in New York City, but not in Newark. Hard times in Minneapolis or Canterbury is probably just clinical depression. Chicago, St. Louis, and Kansas City are still the best places to have the Blues, not York, Bath or Slough. You can’t have no Blues in a shopping mall. The lighting is all wrong.

The physical and psychological environment are important components of motivation. Although working conditions are a Herzberg dissatisfier, poor working conditions really make for poor performance and, more importantly, these things are not so expensive to put right. Companies that recognise the contribution of the built environment on performance include Pfizer. However, as I pointed out earlier, décor is cheap but insufficient if people feel unable to do a good job. Furthermore, a pleasant work environment is no substitute for the least expensive and most effective motivator – behaviour that encourages others to give their all, which leads us to our last point…

I’d do anything for love, but I won’t do that
I did a gig with Lorraine Crosby, who sang on Meatloaf’s classic song, but failed to discover what ‘that’ is in the context of the song, so we’ll concentrate on the ‘love’ part… Praise is the least expensive but highest value motivator. It merely takes time and must come from the heart.

Key point: the built environment helps people to feel good about work, but how people behave is crucial to long term motivation. Find ways to spot people doing things well and let them know about it.

You can buy Peter Cook, MD, Human Dynamics's book: Sex, Leadership and Rock’n’Roll – Leadership Lessons from the Academy of Rock.

He is also speaking at a conference for the NHS Innovation Institute HR Network Scotland Conference on February 14 2008.

December 03, 2007

Where the Horlicks is Sweet

Picture of the sea.This weekend I went on a nostalgia trip back to the North East of England and sat for an hour in the Rendevous Cafe sipping coffee and contemplating the incoming North Sea. The feel of the Cafe is encapsulated in a poem by local poet Julia Darling, who died in 2005 after a fight against cancer and a photograph of her drinking coffee on her final visit hangs on the wall. Throughout her illness she promoted poetry for its healing properties, particularly in this collection of poems which I have.

"Poetry should be a part of every modern hospital, not just as something to keep patients amused. It's a powerful force, which can help us through the darkest times."

The rising tide of technology will wash away much that is commonplace in tackling illness, but the role of the human spirit will stand.

November 27, 2007

Two CDs and a Storm

Picture of CDs"Please check the coffee cup coasters on your desk just to make sure," quipped a colleague today. But it's no laughing matter. Who would have thought two mislaid CDs could brew such a storm?

And it's just beginning. In future, cyber criminals will target high-value information. Personal emails, grocery purchases and—dare I say—patient record information such as the results of genetic and HIV tests, will have value on the black market and could lead to anything from spam mail to blackmail.

Technical steps such as encryption and identity management take us only so far. I remember hearing an anonymous cyber thief on the radio saying he wouldn’t bother trying to hack computer security. It was easier to simply bribe unscrupulous employees to get information.

But most people working with sensitive data take their responsibilities very seriously, though, as HM Revenue and Custom's loss of CDs packed with confidential information shows, it only takes one mistake (and we are human) to rattle plans for large databases of shared records to the roots.

June 17, 2007

Thin Ice

Picture of a husky.Hindsight being a perfect science, I can see why Richard Granger, Director General of NHS IT, seemed more relaxed than I have seen him before at the presentation the other day. Times Online reports he is moving on by the end of this year.

Mr. Granger's most quoted comment likens the NPfIT's suppliers to huskies pulling a sled. The weaker dogs would be shot and fed to the rest to sustain them and as an example. Certainly, some well-known huskies are gone, Accenture and IDX being two. Lead dogs have also fallen to the back of the tugline. But will the remaining huskies survive the departure of the sled driver? And will they be challenged by new teams pulling different sleds? We'll see.

April 29, 2007

To Go and To Come?

In its editorial the Health Service Journal of the 19 April 2007 says Mr. Richard Granger, the Director General of NHS IT is "expected to leave soon". Now how many times have I heard that in the last 2-3 years? Nonetheless, the recent mostly critical report on NHS National Programme for IT by the House of Commons Public Accounts Committee (PDF 4.5Mb) cannot have strengthened his position.

The HSJ also refers to a report by Professor Sir Ara Darzi, the national advisor on surgery and one of the medical profession's rare technological innovators. In Saws and Scalpels to Lasers and Robots Professor Darzi suggests 80 percent of local surgery could be carried out in health centres and large GP practices.

It seems if anything is going to drive NHS modernisation it will be public expectation combined with the march of technology--with or without a centrally led IT programme.

March 25, 2007

Then We Will Fight in the Shade

Ancient Greek ruins touched by the rising sun.The Healthcare IT conferences in Harrogate may be an ember of their glory days, but one determined to continue glowing. Maybe in sensing that, I enjoyed HC 2007 more than its recent predecessors.

Given the UK release of the movie 300 about the battle of Thermopylae, it is topical for me to refer to a tale of ancient Greece.

The crowd jeers an old man looking for a seat at the Olympic Games until he reaches the Spartan section, when every Spartan younger than him, and some older, stand and offer him their seat. The crowd applauds and the old man turns to it and says: "Ah, all Greeks know what is right, but only the Spartans do it."

I attended a couple of notable presentations and I’ll write something about them next. After 20 years in healthcare IT maybe I have become jaded, but many of the presentations reminded me of that tale: many know what to do, few do it.

January 27, 2007

What is the Sound of One Wing Flapping?

butterfly.jpgListen, do you hear it? Has a balloon been pierced by a pin? Or is NHS Connecting for Health deflating? If so, how quickly and by how much?

Government agencies aren't the only ones to have felt a jab. The Guardian's Polly Toynbee in a jerkily argued article says underperforming GPs should be brought into the fold of the NHS (more interesting are the emotional arguments in the comments section that follows it). Also, in a recent TV program management trouble shooter Gerry Robinson turned his attention to Rotheram General Hospital where consultant medical staff apparently arrived late, left early and were never in theatres on Friday. Undoubtedly tensions between managers and clinicians are still with us.

Let's hope it's the sound of metamorphosis then. For with or without a national IT programme it is beyond debate that a 21st Century NHS must emerge as a system where humans and technology seamlessly interact. The real question is how that is to be created. Many of us who have worked in the NHS could have saved Gerry Robinson the walkabout by pointing out the problems. Maybe he could then have turned his talent to addressing them. That would have been interesting.

December 29, 2006

Melting the Darkness

Picture of dawn with a lighthouse.“Dark days before Christmas,” my Mother says. It may be those short days just after the winter solstice that are dulling my mood while I look back on my time in healthcare IT. How much has changed and how much have we learned? Not nearly enough.

Darkness hangs over the NHS National Programme for IT (NPfIT) as we end the year. Accenture has left and the future of software supplier Isoft is unclear. Progress on the core cross-organisational National Care Records Service—for me the Programme’s essence—is also well behind schedule.

But shafts of light pierce the dark. NPfIT’s PACS deployments have progressed well. Though an easy win, they are nonetheless an important one because they highlight the benefits of sharing electronic patient-based information. Also, Cinderella sections of the NHS like Community and Mental Health are benefiting from the deployment of new systems.

My mood has also been lightened by the number of young clinicians, especially doctors, excited by the possibilities of information technology. I have recently met several—some working with Professor Sir Ara Darzi’s unit in London, which looks at the integration of technology into medicine.

At this time of year the days lengthen slowly with the darkest hours just before dawn.

December 15, 2006

Admiring the Heights, Gazing into the Chasm?

Mountain ViewIn the last month or so I have attended a couple of conferences as a speaker and a chair. What caught my attention were the number of opportunities for using technology in healthcare--particularly in remote monitoring and diagnosis--and how this contrasts with the situation of UK healthcare ICT.

At the BCS eBrochan conference in Glasgow (brochan means porridge, apparently) Prof. Frances Mair, Professor of Primary Care Research, at the University of Glasgow, talked about the real application of telecare and telemedicine, stressing the importance of having clear aims and of adequate preparation and reorganisation. Too often such projects are tacked on to existing practice, which often means staff have to do their day job and manage the pilots.

I chaired the recent Mobilising the Clinician conference where talks ranged from making better use of the PDA to remote monitoring and diagnosis using wireless and GPRS. On the second day, Professor Istepanian of the Mobile Information and Network Technologies Research Centre (MINT) described an array of applications some using GSM or the faster GPRS for monitoring vital signs; for example, transmitting ECGs, blood oxygen saturation and blood sugar levels. Ultasound scans have even been taken remotely in Cyprus.

Dr Omar Aziz works in Professor Sir Ara Darzi's unit at Imperial College in London. He described the possible use of body sensor networks (BSN) in mobile health (m-Health). BSN could be applied widely in healthcare; for example, in monitoring vulnerable patients and post-operative recovery.

Lest we lost touch with reality at these rarified heights, Jon Holmes, Informing Healthcare Project Manager at Gwent Healthcare Trust in Wales, told us about the challenges of implementing wireless computing on wards, which allowed nurses to record Admissions, Discharges and Transfers in real time.

In the UK, 21st Century ICT must be implemented in a 20th Century healthcare system. Benedict Stanberry of Avienda suggested healthcare IT is on the brink of the chasm referred to in Geoffrey Moore's book Crossing the Chasm. The chasm is a void on a notional curve that spans the phases of technology adoption. Moore's chasm opens up between the phases of early adoption (comprising the enthusiasts) and early majority (the pragmatists), because expectations are distinctly different.

The illustrious Royal Society also suggests UK healthcare's adoption of ICT is dilatory. Its report Digital Healthcare covers familar ground for readers of FHIT. As well as looking at the view from the top, it suggests more can be made of existing systems and that even applications like mobile phone SMS messaging still offer unexploited footholds.

Hmmm. When it comes to integrating ICT into healthcare, scaling the peak will be an achievement and the views will be fantastic--but there's a lot of abseiling and climbing still to do.

October 29, 2006

Telemedicine and Self Care

Worker with a PC.jpgPhysician, heal thyself with the support of remote monitoring, suggested Dr. Paul Johnson, Director of the telemonitoring service Xenetec last week at the International Healthcare Innovation Congress in London.

He pointed to a pandemic in lifestyle-related diseases exacerbated by growing levels of obesity in Western countries (in the UK 23 percent of us are now classed as obese—the highest level in Europe). As a consequence, incidence of chronic diseases—like asthma, coronary heart disease and chronic obstructive pulmonary disease—is increasing. In the UK, chronic disease apparently accounts for 65 percent of the visits to Accident and Emergency departments.

With such a pandemic, it's fortunate advances in IT and communications make 24-hour health monitoring a reality. Vital signs like respiration and heart rate are useful indicators. A healthy heart rate has a high degree of variance, showing as a spikier trace than an unhealthy one. In addition, nocturnal breathing disorder is often a co-morbidity in asthma, COPD, hypertension and heart disease. Close monitoring of such signs could assist sufferers to manage their conditions and carers to pre-empt crises.

Dr. Johnson said that multi-centre trials in Europe show such monitoring is practicable. Patients in the trials had worn a cluster of electrodes on their chests stuck on with adhesive tape that reminded me of the spaghetti at the back of my aging HiFi system—yet compliance was high. This is a good sign. If patients can tolerate being wired up like that then compliance with newer, wearable equipment should be at least as high (see future posts).

Supported by monitoring centres, self-management of chronic illness is real option. As an example of its possibilities, Dr. Johnston referred to work by Dr Dean Ornish et al on the effect of diet, exercise and stress management on heart disease. Dr. Ornish's work assessed the power of a rigourous risk management regime to arrest—or reverse—the progression of atherosclerosis.

If it's practicable (inevitable maybe), where does remote monitoring figure in NHS plans, or indeed in the NHS National Programme for IT (NPfIT)? Do the operational vision for the NHS and the technology planned to support it need revision?

October 22, 2006

Healthcare Must Ride the Wireless Wave

Picture of surfer.I used this soapbox piece as a the basis for a short introduction to the session I chaired at last week's International Healthcare Innovation Congress in London. I will also be posting on a couple of talks that caught my interest--though all of the speakers were good.

Though information is its basic currency, healthcare has been remarkably slow to embrace Information and Communications Technology (ICT). It has mostly been applied piecemeal to automate existing practice rather than transform it. As a consequence, ICT implementation has rarely dramatically improved care or the patient's experience of it.

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September 30, 2006

RFID: mark of the beast?

Picture of Turkish angora kittenMad sorties across the sitting room on legs spinning like Tom's chasing Jerry in a Hanna-Barbera cartoon. Constantly supervising his hosts while giving them lots of affection: a Turkish Angora kitten has arrived at home. The breeder had him RFID tagged, which will identify him and may renunite him with us if he gets lost. It also helps the vet to maintain her records.

The thought of humans tagged in this way fills us with horror. Some allude darkly to the "mark of the beast" referred to in the Bible's book of Revelations. Others aren't concerned about eschatology and worry about tags on high street goods: could they be used to track us or our credit card use? Or could criminals target homes by scanning trash for the tags on the packaging of expensive new appliances, like TVs or mediacentres?

A previous post reported the ease with which encrypted data held on RFID tags on prototype passports had been accessed—so there is cause for concern. I recently chaired a seminar at Intellect, the UK IT industry's trade body. Delegates agreed that RFID tags should store only an ID number—which anyway is the original concept. Related patient-based data should be stored on more secure IT systems. This may give the anxious some comfort.

Mind you, some members of the Baja Beach Club in Barcelona are happy to be tagged with a subcutaneous Verichip for ease of entry and card and cash free payment. Cool for cats, maybe?

June 25, 2006

Smartpen: rewriting the record

smartpen.jpgFinding the right data device for clinicians resembles the search for the Holy Grail, as I have commented before.

I continue to like pen and paper-which provides me with the freedom to use a mélange of words, diagrams and runes. Perhaps that's why I was so taken by Datapulse's Smart Pen, when I came across it at a recent IT Directors event.

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June 18, 2006

Changing the System: NAO’s report on the NHS IT project

For weeks the UK’s media have been cleaning and oiling their guns preparing to lay a broadside on the NHS IT Project.

Last Friday, on the morning of the release of the National Audit Office’s report on the NHS National Programme for IT (NPfIT), even my favourite BBC Breakfast news presented by the elfin Sîan Williams and the grounded Bill Turnbull could not resist a ranging shot: the NAO report would “criticise” the NHS IT project.

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June 04, 2006

NHS: back to quill pens and ledgers?

Picture of quill pen.Lord Warner announced last week that NHS Connecting for Health’s National Programme for IT (NPfIT) was likely to cost closer to £20bn than the much-quoted £6.2bn. This has brought out the emotive in journalists and the hoped for response from some members of the Public.

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May 21, 2006

Blundering the NPfIT?

Last week, I attended a presentation by David Craig (a pseudonym) who wrote Plundering the Public Sector, which criticises the cost, justification and management of NHS Connecting for Health's National Programme for IT (NPfIT). Book and presentation contain nuggets of wisdom tarnished by uneveness and inaccuracy.

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May 09, 2006

Scientific Metamorphoses: robots resemble humans

woman.jpgIn a recent interview for an article, Honda Motor Europe’s William de Braekeleer told me: “The long term objective of our engineers is to create a robot able to help people in their daily lives. So that is why ASIMO has been designed to walk and move just like us.”

Others have in mind resemblances beyond movement. Android Science in May 2006’s Scientific American describes an honest-to-goddess android called Repliee Q1Expo that looks like a thirty-something woman. To create it, Hiroshi Ishiguro used silicon rubber and polyurethane to cover the metal armature and Japanese newscaster Ayako Fujii as his model.

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May 01, 2006

SmartPill® Tracks Your Tract

In 1995 I visited the exhibition in London's Tate Gallery of the (infamous) Turner Prize shortlist. Stepping into the darkness of Mona Hatoum's installation Corps Etranger I watched a video journey through her intestine and other bodily passages. Today she could avoid the discomfort of the endoscope in the interests of Art by using the multi-vitamin-pill sized Smartpill®.

When swallowed, SmartPill records its trip through the digestive tract using its battery of on board equipment and sensors, like a thermometer, pressure gauge and acidity meter.

Unlike the miniaturised submarine carrying Raquel Welch et al in the 1966 movie Fantastic Voyage, SmartPill is propelled by peristalsis. When excreted 24-48 hours later, a doctor downloads its data in less than 10 minutes and analyses them, a process which could transform the diagnosis of conditions like dyspepsia, constipation and irritable bowel syndrome.

For more see Roger Dobson's article in the UK's Daily Mail of 25 April 2006 or visit SmartPill Corp's website.

April 24, 2006

Winning Ways: transforming healthcare using IT

I am a big fan of Idries Shah’s tales of the Sufi wisdom of Mulla Nasrudin. Here is one of my favourites:

One night a neighbour found Nasrudin down on his knees looking for something under the street light: "What have you lost, Mulla?"

"My key," said Nasrudin.

After a few minutes of searching, the other man said: "Where did you drop it?"

"By my house."

"Then why, for heaven's sake, are you looking here?"

"There is more light here."

A veteran of a Hospital Process Redesign, I remain an advocate of transforming healthcare with IT. So, I enjoyed consultant vascular surgeon Simon Dodds’ book Three Wins, which recounts his experience at the Good Hope Hospital, Sutton Coldfield, UK of developing the Leg Ulcer Telemedicine (LUTM) Service.

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March 27, 2006

Views of a Hybrid: clinician and informatician

Picture of surgeonSimon Dodds is a Consultant Vascular Surgeon. He refers to the debate reported in this FHIT entry. I am posting this extract from an email he sent me with his permission.

With my clinical head on I rant about the informaticians that never actually come and see what frontline healthcare delivery entails, never experience for themselves what the problems are, or help tease out the information requirements from the rest of the process (i.e. write the information requirement specification), then offer simple, workable, quick, cheap options based on existing technology, then help choose the most viable options, then quickly design and build prototypes that are usable, then test options and find those that actually work better than what we were doing before, then implement the best seamlessly so we never really even notice it's there (until it goes away and we suddenly realise we can't do without it).

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March 14, 2006

Healthcare Input: mission impossible?

Image of paper records stacked up.I am perplexed. Will we ever find the right input device for clinicians? The ones we have are too big, too small, too slow, too unreliable, too nickable or may carry bugs.

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March 07, 2006

Evolving Medical Relationships

In January, delegates at a conference at the the Regenstrief Institute Inc. discussed Relationship Centred care and how important it is to success. The conference considered the interactions of the healthcare team, the patient and the patient’s relatives and friends. But a more virtual relationship is increasing in importance.

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February 26, 2006

Close Communities or Remote Monitoring?

I have just come back from visiting my Mother, who lives in the north of England. On the outbound train I found myself sitting next to a recently-qualified GP, and we talked about primary care. I explained to Helen (let’s call her that) I thought using IT for remote monitoring would be the key to healthcare in Britain’s aging population. She thought that closer communities and families were needed.

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February 19, 2006

Patient Choice: nightingale or nightmare?

Peter writes for FHIT as a guest author

I was working with a group that provide call centre services for the NHS Choose and Book system a few weeks back. Casually I enquired: “Do patients exercise choice when asking for health services?”

The person I asked appeared to swell a little and then launched into a bit of a rant:

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February 03, 2006

Forget Clinical Involvement

pacs.jpgAt a conference last week in London, UK “Successful Implementation of NPfIT 2006” engaging clinicians in the National Programme for IT was brought up time and again by speakers: let's engage them, let's involve them, let's get them on board—phrases that to me are meaningless shibboleths. I do not want to involve them at all.

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January 14, 2006

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?

December 12, 2005

RFID: healthcare waiting for the holy grail?

RFID-1.jpgIt seems the healthcare sector continues to adopt a wait and see approach to RFID (Radio Frequency Identification) whilst the private sector deploys it in ever more diverse applications--not just tracking goods and assets, but also people and processes.

RFID comprises a wide range of technologies operating at different radio frequencies, using different operating principles (location finding, active/passive) and with a variety of available functions (writing as well as reading data, sensing, security, range).

In the supply chain arena there has been fast progress in the development of a global standard for RFID in retail supply chains (EPC Global), however standards are often used as an excuse for complacency. Continuing development of the technology, its diversity and ongoing development of standards will always mean that the healthcare sector will never find the holy grail of one technology with one standard set of characteristics that will fit all possible applications.

The healthcare sector needs to get a grip and begin to trial and deploy RFID where it has proven itself in industrial applications ranging from asset management through process control to logistics and supply chains. In these applications RFID has demonstrated for more than two decades a cost benefit or improved performance that increases customer satisfaction. There are many parallels and lessons for healthcare.

Photo by kind permission of Zebra Technologies Europe Ltd.

December 05, 2005

Robots in healthcare

asimo-small.jpgI have loved robots since I was a child and saw Robbie in "Forbidden Planet" at the Saturday morning pictures. But my attempts to make one from old shoe boxes, torch bulbs and a couple of batteries ended in failure.

So, it was a great pleasure for me when I went eyeball to lens with the RP (remote presence) 6 robot being piloted at Imperial College Medical School at St. Mary's Hospital, Paddington, London. You can read more about my encounter with the RP6 in an article that I wrote Carebots in the Community.

The RP6 looks like a vacuum cleaner base carrying a flat screen monitor. A doctor consults a patient remotely, steering with a joystick and the help of an on board camera. It is also handy if a doctor in Birmingham needs a second opinion from a colleague in London, or in New York for that matter.

The advantage of remote presence robots like the RP6 over conventional telemedicine is that they can move to the patient, rather than the patient having to move to a telemedicine suite. In addition, they respect privacy, so there would be no need for a person at home to be subjected to 24 hour surveillance. Mind you, how would the RP6 make it upstairs unless it developed Dalek-like levitation skills?

Humanoid robots can climb stairs and will operate in our world. They will do the heavy work—like lifting patients, moving equipment and working gadgets like the washing machine and microwave—remember, many people give up living independently because of arthritis.

Here is a nice brochure about anthropomorphic robots from the University of Waseda in Japan. The University plans for its robots to use "multimedia such as speech, facial expression and body movement" (!) Robots like these could make carers' jobs less physically demanding and help the elderly and infirm to stay independent.

My wife says she wants one now (I say she already has one). Honda’s ASIMO (see pic) is an example of a bipedal humanoid robot, which unfortunately for my wife (and me) is still about ten years away from general deployment. Now where did I put those shoe boxes?

Picture of ASIMO by kind permission of Honda Motor (Europe) Ltd.