Many hospitals will have two systems at the core of their IT through nothing other than pure legacy. The first is a Patient Administration System (PAS) that largely came about to collect the NHS data model that arose out of the work of Edith Körner in the 1980s.
They will also have a pathology system that arose out of the fact that labs had analysers that were connectable and a naturally technically able workforce who wanted to join it up.
Both of these systems have in fact outgrown themselves for similar reasons. When people are doing things they look in the toolbox and see what they have. There’s a well known saying on this: if your tool is a hammer then every problem is a nail.
Thus, PAS has adapted to coding of the data for clinical and finance purposes, to run reporting solutions for analysis, and sometimes to take in departmental systems such as the Emergency Department (ED).
Pathology clearly had a need to do more than just report the level of serum rhubarb in a bottle of blood and their systems adapted to include a patient index so they could do delta checking and clinical reporting, that would otherwise be done in clinical hospital systems if we were designing the process today.
Along with these design flaws, the problem is exacerbated by another factor: we never renew anything. Therefore, the default position becomes to keep bolting things on in a most inappropriate way. This has the net effect of illogical system models completely killing the market, and we wonder why when you come out to buy something not much has been developed in the last ten years. Well, if you took out a system contract for 5+2 years and you’re still using it 20 years later, there is your answer.
Time for new systems?
So what would these things be if they were designed today?
A PAS is fundamentally a scheduler. I think we would go for a good scheduler from the market (there must be a market for such things). Nothing in this functionality would specifically need to be about health.
We would schedule everything from staff, buildings and equipment through clinics and patients. We would put the data into a warehouse for reporting and we would add the coding to that to have a rich platform for business intelligence, adding in other data for clinical decision support.
This would all mean we would not be encumbered by very niche and specific program add-ons for the NHS, making these systems difficult to replace. We would also not make this system look after the patient index part, another thing it has tended to become lumbered with.
Pathology would be a system whereby it would be able to manage a lab full of equipment dealing with a high throughput but essentially would not need to know anything about the patients. To look at range checking and other patient factors, the clinicians should be looking in hospital clinical systems (EPRs) for that, even the clinicians that are working in the lab, such as haematologists. If this were the model, the lab system would not even need to know a patient number. Much easier then to implement the seemingly favoured [Carter Report] model of factory style centralised labs. These things are now so steeped in tradition that they are probably difficult to shift until we can migrate to open platforms.
I should also add that of course there are large EPR systems that have been built from the ground up, but these are also getting long in the tooth and whatever your view on those, you should always have some kind of exit strategy.
I have been considering how to go about this and along with our Global Digital Exemplar programme manager who came up with the term, and we are thinking about deconstruction as a way to get from A to B. It is going to be interesting to see if anyone in the market is up for this. Scheduling was after all a part of the clinical 5. Does anyone think they actually met that criteria?
So how do we sort the market, this problem where we hang on to old systems and old models for too long?
I think the answer lies in the trend to turn all software into a revenue service. It has been too easy for people to make perpetual savings once a capital product has fully depreciated. It still works, so why invest in replacing it.
We need to keep the level of investment constant, and ensure that the platform is open so that we can change from one service to another at the end of the contract, or run multiple pieces of the jigsaw as separate services on the platform.
This will require a new approach from finance from top to bottom. We can see a looming problem with Microsoft around 2020 when our licences for MS Office terminate. . The same problem must also be addressed for all clinical and administrative software. The market must also balance to allow for the fact that the revenue is more assured; in other words, suppliers should not just receive a windfall on this.
Centrally, there continues to be a tendency to provide Public Dividend Capital (PDC) for initiatives where apart from the initial project costs, the overall “asset” is an ongoing revenue spend and service. This is also getting more difficult.
So there you go, I have thought about the directions to Tipperary and decided that I wouldn’t start from here. However, we do have to start from here, and we need a bit of imagination on how to get there.