Can the road to open platform run alongside closed systems?
- 22 November 2017
I have read with interest the recent blog post by Ewan Davies where he describes the meaning of open platform. Some people are viewing this now as EMR 2.0 and an implementation of the ideas from a recent article on this website, quoting Gartner as saying that there has been too much reliance on single vendor closed proprietary systems.
There are several reasons why this is important, and luckily it falls in line with a number of things that have been going on nationally at INTEROPen, and locally within University Hospital Southampton (UHS).
In case you did not know, UHS is an integrator model for EMR, and benefits from access to all, or most, of the data held in its systems. These are not necessarily implementations of the standards that Ewan talks about in his blog, but by using Integration Engine technology from Intersystems (there are others available as well), we are achieving success and hope to drive our vendors towards those standards.
We will also increasingly select vendors on the basis they can support open data and look to move away from those that cannot.
Data migration
So why do we want to do it?
Because if we continue to buy software from monolithic vendors who lock the data into proprietary and closed data models, we will be subject to whatever that vendor wishes to do or not to do.
At the end of the contract, data migration is such a complex task that it is, in fact, unachievable and the choices are very stark: either accept the vendor contract terms for renewal, or accept a very sub-optimal access to historic data should you move.
There are also some horrendous double running costs in the transition. None of this sits very well with the concept of lawful procurement and competition.
To be fair, until recently it would have been difficult to think of doing things in this open way as the database technology coupled with performance and information governance issues would make extremely challenging. These are the reasons why the previous advice from the likes of Gartner was that if you wanted to achieve HIMSS level 7, there is only one way to do it: buy big.
Make no mistake however, it continues to be in the commercial interests of software vendors to build it big and build it proprietary. We have to battle against these forces to some extent. This battle will not be won unless it actually becomes in the interests of suppliers to work in this way, so we need to reach a tipping point.
How do we do it?
There are, it seems, two approaches to open data, from my perspective at any rate. There is the OpenEHR model which structures the underlying data in a common standard way using archetypes of clinical data modelling. As Ewan says in his article, these are typically commercial offerings that are not open source, but they do in theory allow you to move your data between vendors.
For most of us however, we will have what you might call legacy platforms where the data sits in a proprietary structure and the applications that run on that data require it to be so. This is where Health Level Seven (HL7) and Fast Health Interoperability Records (FHIR) come in, because they allow a vendor to open up that data by supporting standard plug-ins, or APIs (application programme interfaces).
If they have a FHIR interface that allows a new app vendor to use that data, both in a read and write way, then we can achieve openness without needing to port all of the data.
Where’s the catch
In fact, the monolithic vendors are not against going the open FHIR route, since they can use it as a way to suck more data into their proprietary platform, making it even more “valuable”, and this is something we must guard against.
I am therefore in favour of sitting an open platform alongside the proprietary ones – to allow an exchange of data, and over time moving much more towards the open platform. It will be a challenge getting the EMR vendors to work like this.
Road to Nirvana
The lesson here is to not only support the standards, but have a clear vision of the architecture you want to support, and stick to that. If we don’t do this, we will be left with bigger and bigger monolithic systems from a smaller and smaller vendor pool. That cannot be a good thing.
The good news is there is a path, and that OpenEHR and FHIR are different but not incompatible.
This is going to take strength in contractual negotiation and a clear vision that must be maintained. We as CIOs need to get behind it if it is going to work, otherwise we will be picked off by a supplier market that does obviously have at least some self-interest, and interest of shareholders at heart.
We may succeed, we may not but I think it is worth trying. If we do not, well whatever, nevermind.
35 Comments
This is the way to go….I am fully supportive and its time to make it happen.
Fully support this move, and the need to start somewhere making steps in this direction. We are laying foundations for year to come. Great article and comment trail.
Bingo. Many great points and comments.
National Blueprints section 1. Paragraph 1:
[cut and paste the above]
This should be mandated as MO for all CIO’s and Trust strategies and procurement frameworks – Otherwise that horse will never drink the water. Time to drive the change. Well done Ade.
DigitalHealth,
Can we have more articles like this? Enjoyed the article and the replies. More on INTEROpen, standards (all those mentioned in the article), open source, etc
Thanks.
In my view, this is the strongest implementation of ‘data-centric’ architecture that I’ve see in Health.
Other industries have keenly adopted such approaches, and I view Health as the industry which would value most from this!
While the initial ‘sell’ of ‘everything in 1 box’ may seem to accelerate when starting afresh, many organisations have quickly learned of the later trade-off when trying to make iterative changes that become expensive or unexpected license costs.
Separation of concerns + openness = flexibility & sustainability !!
Fully agree with the article. The approach has a name – Postmodern EHR! Check out the blogs of wolandscat.net and marand.com
Thanks Tomaz, sorry hadn’t seen “Postmodern EHR” in those, nor elsewhere.
From Wikipedia:
“Postmodernism … an ambiguous overarching term for skeptical interpretations of culture, literature, art, philosophy, economics, architecture, fiction, and literary criticism.”
So may be true, but perhaps a term for socio-historical analysis?
This enterprise is more important, and more engineered, than that:
“Progressivism is the … advocacy of improvement of society by reform … based on the Idea of Progress, which asserts that advancements in science, technology, economic development, and social organisation are vital to the improvement of the human condition.”
The Naming of the Thing matters for its promotion to other domains such as the political. This great socio-technical enterprise should be in the Sunday papers.
here is a link: http://blog.marand.com/2017/01/30/postmodern-ehr-solving-the-feral-systems-dilemma/
Open can’t happen soon enough.
The problem is that most people in the NHS don’t see it as too much of a problem. Legacy software kind of “does the job” so they’re happy to continue using it. Things will only change if the pain of sticking with legacy software > pain of changing.
The pain of changing is immense. Even in my own GP surgery it was a nightmare when we switched a few years back. I can only imagine the how tough it must be to do this in a hospital setting.
The important thing to remember for creators of open technology is that no one (including clinicians) cares if your technology is open. Just like no one cared about the technology behind the internal combustion engine – consumers just want a reliable service that does the job.
Thank you Tomaz, so following this, your blogs and http://www.digitalhealth.net/2016/06/ewan-davis-texas-grass-fertiliser-and-the-postmodernehr/ … when Gartner’s 2015 report first suggested “post-modern” they used it to just mean “even more modern than modern.” So it’s out-of-place here as it is already used differently in discourses on culture and artistic criticism. And, risking even more pretentiousness, it lacks the hallmark self-referential irony!
To reach outside the IT bubble with the exciting issues raised by this alternative design of the health informatics industry, without re-purposing this term, suggest we need another name. “Progressive” works for me, in that we do know where we’re going; there are surely others – postcards please?
Yes Clive, everyone needs should be considered (the main gist behind DevOps). I missed off clinicians:
I like this Ripple page: http://ripple.foundation/pulsetile/ (The demo shows a very common design pattern). So
8. UI must support Clinical need (the ripple demo shows a very common pattern)
Technical Comment:
Doing the working together approach: The API (calls between Pulse and QEWD), is a very common pattern in health. Ripple isn’t using FHIR or openEHR for this API, but it’s like the numerous API’s that led to the FHIR standard. This is the area where FHIR excels. If you imagine this ripple API was FHIR, it shows how FHIR (API) would sit with openEHR (repository) and show they are not competing standards.
I don’t agree. I spent a lot of time going through the Gartner Postmodern concept and it is very aligned with my thinking and this article as well. The “post” in Postmodern they describe is about what comes next – after the megasuite – shinking the megasuite to a core and allowing for innovation with new applications around that core. Think Salesforce CRM augmenting the megasuite ERP installation. Or Workday, etc. Also plays well into their Bi-Modal IT theory.
Clive, have you been on the beers?
Sorry for the confusion, my reply was to Colin…
Clinicians want a career “pathway” and to make money, managers want a career “pathway” and to make money, and let’s not forget the “hands on” techies, who also want a career “pathway” and to make money. Hope that makes sense?
Sure, Tomaz, agree fully with these “Postmodern” concepts, the term first used by Gartner, promoted within IT by you – many thanks (for 2 years now, so this is too late.)
This is about terms to communicate it to non-IT people: this use of “post-modern” conflicts with common usage as per wikipedia definitions (for brevity). It sounds as if it should mean “new” or “next-generation” or “the latest” – but to others it doesn’t.
Just a suggestion for promotional communications …
Let’s be clear and honest, individuals and organisations need and want to make money. Nothing wrong with that is there ?
Economic models play a major role in this domain.
A lot like stock markets control trade data, HIEs and vendors form a commercial segment. Decentralization is a big issue as well as balancing business models to enterprise outcomes.
Progressivism = advancements in science, technology, economic development, and social organisation vital to the improvement of the human condition.
This addresses them all.
This is what #progressivehealthinformatics looks like.
thank you Ade
This is excellent. The best short yet smart summary on moving #healthIT forward I’ve seen for some time. thanks for your real CIO leadership (#DoRightThing) on this.
Your call to arms towards #openplatform in #healthcare is timely.
Count me in of course and please let me know how I/we can help
Tony
PS I should mention we ‘ve (Ripple Foundation) have done much thinking and work towards the approach outlined here.. this article might give a view as to how we can get “from here to there” with a staged approach..
http://ripple.foundation/2016/02/integrated-care-digital-records-maturity-model/
Hope its helpful
Tony
No contest as far as I can see.
But while open standards are essential, they are not sufficient. Serious resources still have to applied to using them to achieve the data interchange we need, although most of the work is one-off. As part of this we also need to devote serious resources to bringing together the different flavours of patient data generated by the different care sectors (secondary care, primary care, mental health, community health, hospices, patients and their carers). This is eminently achievable but not trivial, as the Discovery Project run by the Endeavour Foundation in East London, and other UK innovators, demonstrate.
Thank you Tony
For some this is obviously the only game in town
For others there is a lingering doubt that it can be achieved
Up to people like yourself to keep on going and prove the model. I think there are signs of success, and not all from vendors. We have used Ensemble and built FHIR APIs now into our order comms and document management systems. We are surfacing data into a mobile messaging app. Quite exciting really, when you realise what can be done.
The main challenge as always I think will be to build and retain skills to do this kind of work.
Indeed Ade,
Happy to be leading on it, though this is a team sport and we’re just part of a broader international movement towards an open platform in healthcare (see here too
for another angle http://digitalsquare.org/globalgoods/ )
What’s important from a NHS CIO/CCIO leadership perspective is to now “start a movement”, by “showing others how to follow”..
https://www.ted.com/talks/derek_sivers_how_to_start_a_movement/
Let’s chat soon on how to take this forward.
T
Combine this with Rachel Dunscombe’s message here: :https://www.horizonbusinessinnovation.com/cio-podcast-improving-public-sector-procurement-for-smes/
And you have a very real opportunity and mechanism for positive change
I agree. For an organisation to provide the best outcomes for patients, it has to innovate. And I believe that for an organisation to be innovative it has to operate in this way, allowing proven new technologies to be plugged in and replace (yes, I really mean turn things off!) or supplement what is already there.
In what other circumstances do we operate with a one supplier for all model? For example, we don’t buy everything for our house from one supplier or replace the whole house when we only want to renovate the bathroom…
I’m in and I think even for the GDE trusts that have invested in a mega-suite there is a compelling argument for the bi-modal approach where an open platform that allows rapid implementation of innovation is integrated with stable core EMR functionality.
Just to clarify my ‘fag packet’ comment. I was referring to principles which need to be clear, simple and not fall into TLDR.
So (delegating down to tech level), a starter for 10 would include:
1. Your vendor MUST support a (open) RESTful API
2. SHOULD support a HL7v2 Patient feed (unless REST API’s is enough)
3. MUST support OAuth2 security
4. MUST support Audits
5. MUST support 3rd party access
6. API and system must not be unnecessarily complicated (complexity can be added later)
7. Data should be available (and useful) to trust SQL Analytics staff.
Questions: Are all NHS employees staff and what about those who actually “build” the NHS IT S, or are they allways “vendors” ?
Exactly, but here is something even more poignant to ponder:
SELECT PATIENT, NHS_ORGANSIATION FROM INFO_TABLE WHERE PATHWAY.RTT.DURATION > 14 WEEKS
No, sorry that’s too vague, try this:
SELECT CHILD, PROVIDER_ORGANISATION FROM UK.INFO_TABLE WHERE
PATHWAY.RTT.DURATION > 3 WEEKS
If you work in health tech, then be honest, work together and yes, it’s good to get your hands dirty because someone has to do IT.
This is certainly the way forward.
Ade is right about the difficulties of migrating away from the 20th Century systems that run the NHS, But if we don’t make a start things will never change. Hence the call from Tony Shannon and I for 1% for open platforms.
I can’t identify a single new entrant to the NHS IT market in the last 25 years that has got to scale (i.e. ceased to be an SME) – This is clear market failure. It’s a result of lock-in and has starved us if innovation. If we look to other sectors the big names that have brought about transformation were unknown 10 let alone 25 years ago.
Disruptive innovation does not come from market incumbents. It was Amazon not Folyes, eBay not Exchange and Mart, Porn Hub not Paul Raymond.
This is not because the incumbents lack able, innovative people or the desire to innovate but because they are as locked-in to their legacy technology and business models as much as their customers are. Nature has solved this problem through aging and death – The sooner we put these companies out of their misery and redeploy the talent and resource locked in them the better.
A few detailed points.
For those who have not read Defining an Open Platform – openplatforms.apperta.org – I hope you will find there is lot more than “a fag packet” plan, both in DOP but more in the other work and example of this happening it points to.
Open platforms are agnostic to licensing models (open or closed source) but there are both open source and proprietary implementations of the open platform components and certainly viable open source implementations of openEHR alongside the excellent proprietary ones
Very clear.
It’s a ‘fag packet’ plan to success. CIO’s please list the key points, distribute and let it get implemented.
Another behind you..your.logic is clear.
Next steps ?
Agreed too – count us in
Agreed. Who’s with us?
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