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HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!

PAGE 1!

HC6 – Lessons from the First 10 Years of Large-‐Scale Implementa=on of Interoperable

Healthcare Systems in England

1

Dr Michael Bainbridge – Adjunct Professor, University Of Victoria, BC and Clinical Architect ASE Consul=ng UK – [email protected]

Disclaimer and Declara=on

•  This is a personal view •  I am not represen=ng:

– The NHS or NHS Connec=ng for Health – Any other government body UK or otherwise

•  I work as the Clinical Architect to ASE Consul=ng UK Ltd.

•  I have no commercial interests in any Health IT related company


PAGE 2!

BIG AND SMALL LESSONS FROM ALMOST A DECADE OF DEDICATED INPUT

DO YOUR BEST TO DETERMINE YOUR CURRENT HEALTH POLICY

Lesson 1


PAGE 3!

An English Project

Wales

Scotland X

X Northern Ireland X

Budget $120Bn Popula=on ~ 60M Health Spend = 9% GDP

Healthcare is never a stable environment Policy and medical prac=ce changes are a fact of life

Provide

Prescrip=o

ns

Service

Build Life

-‐long

Health Record

Service

Provide Bo

okings

Service

Pervasive na=onal electronic infrastructure (N3)

2002

1994

1998

IM&T Strategy for the NHS

Provide Prescrip=o

ns

Service

Provide Bo

okings Service

Build Life

-‐long Health

Re

cord Service

Pa=

ent C

hoice

Digital Imaging

NHS

Num

bers fo

r Babies

Second

ary Uses S

ervice

NHS

Email System

Transfer of records

betw

een GP

s

Quality Managem

ent

Analysis System

Bowel Cancer S

creening

Pervasive na=onal electronic infrastructure (N3)

Original Scope Addi=onal Scope Key:

Commissioning Payment by Results Plurality of provision


PAGE 4!

KNOW WHERE YOU ARE GOING AND TAKE YOUR FIRST STEPS WITH A PLAN WHICH ENABLES YOU TO TAKE SECOND ONES (UNLESS THERE IS A VERY GOOD STRATEGIC REASON TO DO SOMETHING ‘SHORT TERM’)

Lesson 2

PUBLISH YOUR SUCCESS AND MAKE IT UNDERSTOOD !

Lesson 3


PAGE 5!

Some highlights of the delivery

NHS network

Secure applica=on servers Encrypted

email

Na=onal indexes Data

standards

Technical standards

4 prime contractors

Hospitals GPs Community and Mental Health

PACs SUS

Later reduced to 3 then 2

Two solu=ons iSof Cerner

(replace IDX)

Choice from an approved list

New products developed

100% coverage – saved more than

forecast

Hub to standardise measurement

and transac=ons

Spine and SCR

Choose and Book

GP to GP transfer

Access Framework

DON’T JUST SOLVE THE PROBLEMS IMMEDIATELY IN FRONT OF YOU

Lesson 4


PAGE 6!

From Genetics to Ergonomics

Change is accelera=ng

ENSURE YOU HAVE A PLAN WHICH TRANSCENDS THE LIFETIME OF INDIVIDUAL CHAMPIONS

Lesson 5


PAGE 7!

TURNING REQUIREMENTS INTO FLEXIBLE AND EFFECTIVE “ENTERPRISE” SOLUTIONS IS A RARE SKILL IN HEALTH

Lesson 6

ANSWER _THE_ QUESTION Lesson 7


PAGE 8!

What is the examinaWon quesWon ?

•  How do you provide to me : –  Safe –  Effec=ve –  Reproducible –  State-‐of-‐the-‐art –  21st Century medicine – Wherever I am – Whatever the =me – Whatever is wrong with me

•  And beler s=ll: –  Prevent me gemng ill –  And don’t harm me in the process

15

But is this the right quesWon any more ?

How do we collaborate to deliver ? :

SO WITH THIS IN MIND


PAGE 9!

IT’S TIME FOR A RADICAL CHANGE TO THE HEALTH DELIVERY MODEL

Lesson 8

18

0

200

400

600

800

1000

1200

1600 1700 1800 1900 2000

Source: Harvard Medical School, 2001

Challenge – “Major” Medical Advances 1600 to 2000


PAGE 10!


PAGE 11!

Patient

Source: Dr Marc Probst Intermountain Healthcare

He bien! Messieurs, vous l’avez vu, cele opera=on qu’on disait impossible a parfaitement reussi… Mais, Monsieur, la malade est morte…. Qu’importe! Elle serait bien plus morte sans l’opera=on…

Medical Mindset ?

Source: Dr Charles Guleridge -‐ DHID


PAGE 12!

Years ago Today

This gap injures patients

Knowledge processing capacity

Knowledge processing requirement

“Current medical practice relies heavily on the unaided mind to recall a great amount of detailed knowledge – a process which, to the detriment of all stakeholders, has repeatedly been shown unreliable” Crane and Raymond The Permanente Journal Winter 2003 Volume 7 No.1 Kaiser Permanente Institute for Health Policy

Challenge – Clinical Knowledge-‐Processing Burden

Adverse Drug Events A study published in Bri=sh Medical Journal in 2004

concluded that: •  1 in 16 hospital admissions are the result of an

adverse drug reac=on – 76% avoidable. •  This equates to 4% of hospital bed capacity At any

one =me 7 x 800 bed hospitals are occupied by pa=ents admiled with ADRs

•  Cost = £466m annually -‐ £354m avoidable by pumng in place e-‐prescribing ?

[1] Pirmohamed, M. et al: Adverse drug reac=ons as a cause of admission to hospital: prospec=ve analysis of 18,820 pa=ents: BMJ 2004; 329: 15-‐19


PAGE 13!

IT’S TIME FOR A RADICAL CHANGE TO THE HEALTH DELIVERY MODEL (MESSAGE RECEIVED ?)

Lesson 9

26

The sky is falling.. Ageing Popula=on 2001 – over 60s > than under 18s 2050 – 4 =mes as many needing care At 4 =mes the current cost

Remember hidden costs

Source OPCS 2003


PAGE 14!

27

US Health Expenditure will soon exceed 20% of GDP

Source: Employee Benefit Research Institute estimates from Centers for Medicare and Medicaid Services and U.S. Department of Commerce. Last Updated: January 6, 2008

National Health Expenditures, Aggregate and Share of Gross Domestic Product (GDP), 1960-2017

All health economies are on the same trajectory

Eric Dishman – Intel Corp. Presenta=on to US Senate April 2010


PAGE 15!

Chronic disease is gaining increasing global alen=on....

29

30


PAGE 16!

Silver Tsunami is only the start of it .... A popula=on who do not believe there is a problem A profession, many of whom believe paternalism is s=ll appropriate Are _we_ ready to be ‘empowered’ ? A belief in get rich / fit / thin quick

32

Lifestyle diseases

Lifestyle diseases (also called diseases of longevity or diseases of civilizaFon) are diseases that appear to increase in frequency as countries become more industrialized and people live longer.

They include: Alzheimer's disease Atherosclerosis Asthma Cancer chronic liver disease cirrhosis Chronic ObstrucFve Pulmonary Disease (COPD) Type 2 diabetes, heart disease nephriFs or chronic renal failure osteoporosis acne stroke depression obesity.


PAGE 17!

2009 Con=nua Health Alliance Brigile Piniewski, MD 33

Lifestyle defines ‘Group Health’

–  58% Reduc=on in Diabetes with lifestyle modifica=on Tuomilehto, 2001 NEJM 344(18): 1343-‐50

–  60% Less Cancer De Lorgeril, Arch Int Med 1998;158:1181-‐87

–  83% less Heart Disease –  91% less Diabetes

Nurses Health Study, NEJM 2000;343:16-‐22, NEJM 2001;345:790-‐97

–  73% less CHD –  69% less Cancer

HALE Project. Knoops JAMA 2004;292:1433-‐1439

–  60% Fewer Cardiac Events Hambrecht Circula=on 2004;109:1371-‐78

–  44% Reduc=on in total mortality (NNT=16)

Lyon Heart Study, Circula=on 1999;99:779-‐85

–  45% Reduc=on in total mortality (NNT=2.4)

Indian Heart Study, BMJ 1992;304:1015-‐19

–  40% Mortality Reduc=on GISSI-‐Prevenzione, Med.Diet AHA11/01: Marchioli

–  67% Mortality Reduc=on Indo-‐Med Study, Lancet 2002;360:1455-‐61]

60 % - 80%

of Group Health issues may be preventable

2009 Con=nua Health Alliance Brigile Piniewski, MD 34 2008 34

0 25 65 Age

Illne

ss

Pre

-Illn

ess

Wel

lnes

s

Unpredictable Health

Predictable (Rules-based) Health

Death

60-80% Lifestyle

Modifiable Health


PAGE 18!

2009 Con=nua Health Alliance Brigile Piniewski, MD 35 2008 35

0 25 65 Age

Illne

ss

Pre

-Illn

ess

Wel

lnes

s

Death

Modifiable Health

Fun

No Fun £££

The Global Challenge......

[Jennings, Miller, Materna 1997] aVer Tom Ferguson -‐Healthcare Forum Journal Jan/Feb 1995 pp28-‐33

37


PAGE 19!

IT’S TIME FOR A RADICAL CHANGE TO THE HEALTH DELIVERY MODEL (DID I STATE THE CASE ?)

Lesson 10

$1 $10 $100 $1,000 $10,000 0%

100% Healthy, Independent Living

Chronic Disease Management

Doctor’s Office

Community Clinic

HOME CARE

Assisted Living

Skilled Nursing Facility

RESIDENTIAL CARE

Community Hospital

ICU

Specialty Clinic

ACUTE CARE

COST of CARE/DAY

QUALITY of LIFE

39

Focus Areas must change

Source: Intel Corp. 2006


PAGE 20!

YOU ARE NOT ALONE Lesson 12

Not just where I come from

•  Australia •  Egypt •  Singapore •  Hong Kong •  Sweden •  Denmark •  Canada •  Netherlands •  Brazil •  US •  EU

•  Industry – tradi=onal and ‘open’ •  Gates /Rockefeller / WHO/ UN

41


PAGE 21!

43


PAGE 22!

WE ARE ALL TRYING TO DEAL WITH INEQUALITIES

Lesson 13


PAGE 23!

KEEP UP TO DATE WITH NEW TRENDS

Lesson 16


PAGE 24!

Keeping up with new trends ?


PAGE 25!

THERE ARE TOO MANY THINGS TO TELL YOU ABOUT IN 40 MINUTES !

Lesson 19

THE NIKE FACTOR Lesson 20


PAGE 26!

Just do it !

•  Some things MUST be in place – Unique ID

•  Some things must be mandated – Terminology – Drug database –  Interoperability standards

•  BUT -‐ Get things in the right order. – Buying the boxes is NEVER the first step

‘Just do it’ according to and overall architecture and plan ISO 14639


PAGE 27!

Lesson 20a – Think Scalable You’ll always think of new things to do

NHS network

Secure applica=on servers Encrypted

email

Na=onal indexes Data

standards

Technical standards

Spine and SCR

Choose and Book

GP to GP transfer

Thousands of NHS medical records lost Daily Telegraph

Central Exper=se

RIGOROUS APPLICATION OF STANDARDS CREATES AN ENVIRONMENT OF USABILITY AND SAFETY

Lesson 21


PAGE 28!

•  Terminology: SNOMED CT hlp://www.ihtsdo.org/ •  Drug Database: dm+d hlp://www.dmd.nhs.uk/ •  hlps://www.uktcregistra=on.nss.c�.nhs.uk/trud/ •  Professional Record Keeping: hlp://www.rcplondon.ac.uk/clinical-‐standards/hiu/medical-‐records •  Professionalism: UKCHIP hlp:www.ukchip.org.uk •  Defini=ons: i.e. ‘Allergy’ and ‘Current Medica=on’ •  Messaging: HL7 v3 hlp://hl7.org •  Logical Architecture / Archetypes:

hlp://www.connec=ngforhealth.nhs.uk/systemsandservices/data/lra •  Knowledge and Knowledge Authorship: •  Device Interoperability: www.con=nuaalliance.org •  User interface design: www.cui.nhs.uk •  Open Health tools: www.openhealthtools.org How many Wmes do these need to be invented globally ? Adopt and enforce

Standards for interoperability “We will employ a ruthless approach to standards” – Sir John Pa=sson 2003

A simple example... •  What is the date tomorrow? •  It is the 1st of June 2011 •  UK 01/06/11 •  US 06/01/11 •  Sweden 11/06/01

•  So in health it is 1-‐Jun-‐2011 and that’s final !

•  By doing this I just reduced the number of errors it’s possible to make for 12 days a month.


PAGE 29!

21a Don’t show complexity to clinicians. Show them clinically

relevant deliverables

58

To deliver what a clinician wants...


PAGE 30!

SAFETY, SAFETY, SAFETY Lesson 24

Safety

•  Is not an aferthought •  In the UK we were the first to write some of this down

•  You don’t need to •  It took 8 years and is s=ll in progress •  Don’t try it alone •  Collabora=on is good


PAGE 31!

hlp://www.npsa.nhs.uk/nrls/improvingpa=entsafety/design/informa=on-‐design/

67


PAGE 32!

68


PAGE 33!

Design for pa=ent safety

CULTURE EATS STRATEGY FOR BREAKFAST

Lesson 25


PAGE 34!

Culture eats strategy for breakfast

•  Security and Privacy – Be VERY careful ! •  Educa=on

–  Professions –  Ci=zens –  Reduce the need for ‘in service’ training

•  From now on.. The future of your Health Service •  Move forwards not backwards or sideways •  Having a strong cons=tu=on and a sense of humour helps.

The final lesson....

Não confunda movimento e progresso. Um cavalo de balanço está sempre se movendo, mas não faz qualquer progresso.

Alfred A. Montapert

73


PAGE 35!

Why am I here ? •  We have all the pieces •  We have the knowhow to move medicine forward

•  We cannot do this alone •  You must not do this alone •  We do need to pool scant resource •  We need to pool ‘configura=on informa=on’ •  We do need to achieve step change •  None of what I have presented is achievable at scale without us all working together


PAGE 36!

“Strong reasons make strong ac=ons”

– King John Act 3 Scene 4 – Shakespeare

“It is unethical to carry on doing what we are currently doing”

Professor Sir Muir Gray 01-‐Oct-‐2004

77


PAGE 37!

HC6 – Lessons from the First 10 Years of Large-‐Scale Implementa=on of Interoperable

Healthcare Systems in England

78

Dr Michael Bainbridge – Adjunct Professor, University Of Victoria, BC and Clinical Architect ASE Consul=ng UK – [email protected]

himss middle east 2011 – conference · standards$ technical$ standards$ 4prime# ... icu$...

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