Supporting New Models of Care


“I’m pretty certain that the health informatics community know how to create the open digital ecosystem we need to support the emerging new models of care, but I have concerns that a lack of knowledge and experience amongst policy makers, vested interests in the care, informatics and vendor communities and a naive belief in the Tooth Fairy. Might mean we don’t achieve what’s possible.”

There are two things it is certain that we need to do to help address challenges that an ageing population creates for health and care. Firstly, we have to get much closer integration of health and care and move care nearer to the patient. Secondly, we have to leverage digital technology to support this change using both big data and small data to deliver more appropriate care more effectively.

I’m pretty certain that the health informatics community know how to create the open digital ecosystem we need to support the emerging new models of care and that there are examples of successful approaches that we can draw from. However, I have a number of concerns, that:

  • Policy makers don’t have sufficient knowledge of the available options or the technical understanding of Informatics and digital health and care to make informed decisions.
  • Informaticians and technologist from outside of the domain don’t have sufficient understanding of health and care to provide good quality advice to policy makers and worse believe that they have.
  • Organisations on the ground also lack sufficient knowledge and technical understanding which means they are not able to critically appraise proposed solutions from vendors and may be tempted to implement solutions that appear to address immediate priorities but which are not scalable or sustainable and which create vendor lock-in.
  • That many in the NHS, vendor and digital health communities have existing positions and conflicts of interest which disincline them from taking the radical steps necessary to work towards the creation of the open digital ecosystem we need.

The imperatives outlined in my introduction are recognised by policy makers and are the thrust of the approach outlined in NHS England Five Year Forward View Central to policy is the creation of new models for the delivery of health and care and policy makers are, rightly in my opinion, facilitating and encouraging various approaches to create new organisation and structures to deliver care. At the heart of all of these is the creation of some form of accountable care organisation (ACOs) with total responsibility for the health care of a given population. ACOs could emerge from various directions including General Practice, NHS Trust, Local Authorities ,the private and third sector. Yesterday NHS England announced 29 Vanguard sItes   to implement 3 approaches These are: multispecialty community providers (or MCPs), primary and acute care systems (or PACS), and enhanced health in care homes. We also already have work around the Integrated Care Pioneers  with the initial 14 now expanded to 25 and work under the Prime Minister Challenge Fund to improve access to GPs also has relevance and finally we have the ambitious plans announced for Manchester, which are likely to be replicated elsewhere.

All of these initiatives have massive implications for new and existing digital technologies, both to mobilise data and to enable the digital delivery of services to citizens. It will be necessary to create interoperability between existing systems across health and care and changes to make it easier to implement and integrate new digital services and apps. This integration requires interoperability both of data and workflows to allow the sharing of both information and tasks across multiple actors in care communities and needs to liberate information in open and computable formats to facilitate big data analytics to help us understand needs, what we are achieving and how we might do it better.

All of this has to happen in an environment where privacy, information sharing and governance issues are addressed but while this is in many ways the biggest challenge, it’s something that I’ll leave for a future blog.

There are many companies developing new and existing products to meet these challenges and while many of these have a more open approach than has traditionally been the case most are still based on solutions tied to particular vendor or technology. My view is that such approaches which give a small number vendors a dominant position are unlikely to have long term sustainability and even where they do create a degree of vendor lock in that is against the public interest. As far as possible we need to create solutions based on open standards independent, of particular technologies which allow multiple vendors to play allow the easy replacement of any single proprietary component to avoid vendor lock-in.

If we are to achieve progress policy makers need to recognise their lack of knowledge and be aware that those advising them both public sector IT specialists and vendors may a have vested interests which mean their advice must be critically appraised. This can only be achieved by a more open, collaborative and transparent process. All of us have our own agenda seeking some mixture of money, power, sex and glory with concerns about how we pay the bills. No individual or organisation can offer informed and impartial advice and it’s only if we are all honest about our motivations and concerns and debate the options openly that we can make progress – I’m in it mainly for the glory, have paid off the mortgage but could still use a bit more cash and a gentlemen never tells.

I outlined one approach I think has great promise in my previous blog

For more about ACOs see:

Kings Fund http://www.kingsfund.org.uk/publications/accountable-care-organisations-united-states-and-england

 

Moscow eHealth a Model for the UK


The approach that Moscow City Council has adopted to create an open platform to support health and social care services in Moscow which uses some of the same technology as the Code4Health platform would seem to have relevance to the UK and in particular is a good fit for the needs of emerging new approaches to the integration of health and social care like that recently announced for Manchester.

Many of you will know about HANDI-HOPD the HANDI Open Platform Demonstrator  that we have been working on for the last few months, this has now morphed into the NHS Code4Health Platform launched by NHS England during eHealth Week in London this week (5th March 2015).  However, what you probably won’t know is that one of the key pieces of technology available on the platform is the same as that which is currently powering the whole of the eHealth system in Slovenia and even more impressively Moscow.

Moscow

The Platform deployed in these two places brings together OpenEHR www.openehr.org and IHE XDS  in a very impressive way. And I believe provides a model for what we might do in the UK and even more interestingly aligns with the thinking in a number of UK city regions who are already looking at IHE XDS and/or OpenEHR and who in a number of cases have already implemented one or the other. However, the UK initiatives appear to know little of what’s been done in Slovenia and Moscow and in particular how XDS has been successfully integrated with OpenEHR, which I believe takes the capabilities of the platform to a new level – This blog aims to put this right.

One of our key partners in the Code4Health Programme who have provided the core of platform and open source components for the OPENeP Project www.openep.org are Marand,  and they are also the company who provided the platform for both Slovenia and Moscow and it is from their charismatic CEO Tomaž Gornik that I draw much of my inspiration and information.

Before turning to some of the technical details I’d like to describe a little of what I understand of the somewhat different approaches in Slovenia and Moscow and the motivations behind them, as while both use what is fundamentally the same technical platform they came to the solution from different directions in ways which graphically illustrate the flexibility of the underlying technology.

Moscow City Council is responsible for pretty much all of the health and social services serving Moscow’s 11 million citizens covering broadly what we call primary, community and social care and outpatient clinics. Moscow is a complex environment and has large number of siloed legacy systems, which made interoperability difficult and created significant vendor lock-in of data and systems. Moscow wanted to separate data from applications and store its data in a vendor and technology neutral format and chose OpenEHR to do this. They piloted this approach using the Marand Think!EHR OpenEHR implementation (which is one of the components on the Code4Health Platform) and IHE XDS components from  www.forcare.com. The same basic technology as Marand had already successfully implemented in Slovenia where the IHE componets were supplied by www.tiani-spirit.com . The pilot was successfully and the platform is now rolling out across the City.

While both Slovenia and Moscow have ended up with broadly similar solutions they reached this point from opposite directions. Slovenia started simply wanting to implement IHE XDS to allow sharing at a document level, but came to realise that this did not support their need for fine-grained structured data to support big data analytics. They solved this problem with the integration of  OpenEHR. Moscow on the other hand started with a view they just needed OpenEHR, but were persuaded of the quick wins IHE XDS could bring with document level sharing and in particular its ability to mobilise documents already produced by legacy systems that would take some time to be replaced or upgraded to take full advantage of the power of OpenEHR.

In both Moscow and Slovenia the same proprietary components have been used to implement both XDS and OpenEHR.  However, both have the comfort that because the data is stored in an open format, these components can easily be replaced if alternatives emerge which appear to offer better performance or value. Indeed this portability of data is something that HANDI have already proven in the creation of the Code4Health platform which required the data to be moved between two competing OpenEHR implementations.

Requirements and technology will evolve, but for me for now and the foreseeable future the approach taken in Moscow seems like the best bet for the integration of systems and information in the complex environment of health and social care across a city region. It brings the long-term benefits of OpenEHR, which has the capacity to put data into an open, fine grained, structured format that is technology and vendor neutral, with the tools to easily engage frontline clinicians and other Health and Care Professionals in its curation while delivering the quick wins with XDS that can ensure the right document is available in the right place at the right time to support safe, efficient care.