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HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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HC6 – Lessons from the First 10 Years of Large-‐Scale Implementa=on of Interoperable
Healthcare Systems in England
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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
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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BIG AND SMALL LESSONS FROM ALMOST A DECADE OF DEDICATED INPUT
DO YOUR BEST TO DETERMINE YOUR CURRENT HEALTH POLICY
Lesson 1
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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Some highlights of the delivery
NHS network
Secure applica=on servers Encrypted
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
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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From Genetics to Ergonomics
Change is accelera=ng
ENSURE YOU HAVE A PLAN WHICH TRANSCENDS THE LIFETIME OF INDIVIDUAL CHAMPIONS
Lesson 5
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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TURNING REQUIREMENTS INTO FLEXIBLE AND EFFECTIVE “ENTERPRISE” SOLUTIONS IS A RARE SKILL IN HEALTH
Lesson 6
ANSWER _THE_ QUESTION Lesson 7
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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
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But is this the right quesWon any more ?
How do we collaborate to deliver ? :
SO WITH THIS IN MIND
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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IT’S TIME FOR A RADICAL CHANGE TO THE HEALTH DELIVERY MODEL
Lesson 8
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0
200
400
600
800
1000
1200
1600 1700 1800 1900 2000
Source: Harvard Medical School, 2001
Challenge – “Major” Medical Advances 1600 to 2000
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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IT’S TIME FOR A RADICAL CHANGE TO THE HEALTH DELIVERY MODEL (MESSAGE RECEIVED ?)
Lesson 9
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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
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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Chronic disease is gaining increasing global alen=on....
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HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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
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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.
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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
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HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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
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Focus Areas must change
Source: Intel Corp. 2006
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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
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HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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WE ARE ALL TRYING TO DEAL WITH INEQUALITIES
Lesson 13
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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KEEP UP TO DATE WITH NEW TRENDS
Lesson 16
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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Keeping up with new trends ?
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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THERE ARE TOO MANY THINGS TO TELL YOU ABOUT IN 40 MINUTES !
Lesson 19
THE NIKE FACTOR Lesson 20
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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Lesson 20a – Think Scalable You’ll always think of new things to do
NHS network
Secure applica=on servers Encrypted
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
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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• 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.
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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21a Don’t show complexity to clinicians. Show them clinically
relevant deliverables
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To deliver what a clinician wants...
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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hlp://www.npsa.nhs.uk/nrls/improvingpa=entsafety/design/informa=on-‐design/
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HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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Design for pa=ent safety
CULTURE EATS STRATEGY FOR BREAKFAST
Lesson 25
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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
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HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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
HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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“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
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HIMSS MIDDLE EAST 2011 – CONFERENCE | 31 MAY 2011!HC6: Presentation by Michael Bainbridge!
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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]