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.

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."

June 25, 2007

Evolution and Revolution

Picture of cogsWhile in a secondhand bookshop at the weekend I picked up John Gall 's book Systemantics. In it he describes the seductive nature of systems, which promise to do a hard job faster and more easily, but once set up take on their own life, growing and encroaching and eventually even opposing their own function.

Technological and demographic forces mean heathcare systems like the NHS cannot avoid major disruption. But, in another small book, Bodil Jonsson says: "All disruptive changes have at least one effect: they upset people."

Perhaps with that in mind both the Secretary of State for Health, Patricia Hewitt, and the Leader of the Opposition, David Cameron, speaking at last week's NHS Confederation Conference in London tried to soften the blow. Mr. Cameron promised "evolution not revolution". Though the phrase has a nice rhetorical ring, it means more change. Bodil Jonsson also says: "The most effective way of changing the future is to create a new system of thought." Perhaps that's what healthcare needs.

June 14, 2006

Real Innovation in Healthcare Delivery is Driven by Clinicians?

I took part in a light-hearted debate at the UK's Healthcare IT 2006 conference in March, which I reported in a previous posting.

The British Journal of Healthcare Computing transcribed the debate PDF (96K).

April 09, 2006

Connecting for Health: awaiting the winds of change

Connecting for Health faces the winds of change.Political and technological winds of change whistle through NHS Connecting for Health's National Programme for IT (NPfIT). They may erode the notion of a single, comprehensive, monolithic system serving GPs and acute, community and mental health care settings and deposit the spores of innovation, clinical inspiration and supplier diversification.

Continue reading "Connecting for Health: awaiting the winds of change" »

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).

Continue reading "Views of a Hybrid: clinician and informatician" »

March 24, 2006

Clinicians Thrash Informaticians

On 21 March 2006 the BCS London and South East Health Informatics Group sponsored a lively and light-hearted debate at the HC 2006 conference:

“This house believes that real innovation using ICT in healthcare delivery is driven by clinicians rather than informaticians.”

Simon Dodds and Mark Outhwaite proposed the motion and Ian Herbert and I opposed with Keith Clough in the chair.

I argued that healthcare in the UK was facing illness because of a shortage of cash and qualified staff and an aging population that is likely to lead to an increase in chronic disease. Never has healthcare needed ICT innovation more—but who will provide it?

I tacitly accepted that clinicians and informaticians must work as a MDT, but I was speaking against the motion. I had three main arguments:

  • Clinicians are experts in patient care, informaticians in ICT;

  • Informaticians have a broader view of healthcare than clinicians; and

  • Innovation is not about ideas, it’s about the implementation of ideas.

Cyber means “art of steering” in ancient Greek. Informaticians would be the cyberanauts building the pathways and finding the passages that led to a coherent, patient-centred healthcare system.

All to no avail, I'm afraid! After contributions from the audience—one of whom said he thought clinicians should be leading ICT innovation, and asked why then they didn't get on with it—the motion was carried by 18 votes to 9.

Rod from Informaticopia also wrote an official blog entry on the debate. In addition, Simon Dodds, a Consultant Vascular Surgeon and Innovator, is allowing me to use some comments that he emailed me in an entry to follow.

Reposted by FHIT on 29 March 2006 adding the hyperlink to Simon Dodds' entry.

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:

Continue reading "Patient Choice: nightingale or nightmare?" »

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.

Continue reading "Forget Clinical Involvement" »

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.

Continue reading "Sex, Leadership and Rock 'n' Roll (and the NHS)" »

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.

Continue reading "Bridging the Quality Chasm or Falling Into it?" »

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.