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Wow that was a bit of an introduction

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We we've had

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quite a bit of what and how and

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I thought I'd give the CIO's perspective

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bit of a confession first

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Before I started doing this crazy day job. I'm actually I suppose always will be a software engineer, so I'm actually obsessively

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Interested in the what and the how

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But you know as a CIO, it's not about the what and the how it's all about the why initially

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So I thought I'd just spend a little bit of time explaining the thought process we had to go through to set out our strategy

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Because if you can't make the case for this type of approach

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To integrate a digital care record you're never going to get into the what and the how

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And you know it'll be hopefully useful to other CIOs so Derriford hospital. I'm the CIO

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director IM&T here

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still I

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Think one of the largest single-site hospitals in Europe one massive block of concrete doesn't win any architectural awards at all

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But it is in a very very nice place and very functional because it's all in one place

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We're pretty much typical of an acute trust I think

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talking to colleagues, so we're about 900 to 1200 beds depending on what you can as a bed

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We've about 6,000 staff. We're a major trauma center, and we're a tertiary center, so we're pretty normal acute trust

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We've got pretty standard IT I believe

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We've had a Best of Breed Interface strategy

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we'd buy better preclinical products since 99 when I joined the trust and we interface them together with HR 7

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and standards

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We've replaced up housing 99

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We've got an open standard interface engine we use into systems ensemble for those indices with people in the crowd

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I've done your plug. I want to reduce license fee next year, please.

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We've got fully rolled out order comms.

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Pack summaries, I'll talk about a bit later on we've done three times

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And we've got something unique called Salus, which is home developed. It's a patient flow solution

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that becomes a bit more interesting later on where I'll talk about what we're using that for and how it will benefit others.

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And

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Thomas said we've got a 170

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departmental solutions, you've underplayed the problem. We've actually got a 190

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departmental clinical solutions, so these are wholly independent

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proprietary clinical applications

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by specialty, and they say I don't think we're unique. I think most people are nodding that's pretty sort of normal, I think.

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And this is the diagram that

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freaks me every time I see it. This is actually our interface architecture, and you can see at the top

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July 2017 so that's pretty current so the level of complexity

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to do just what we've done and actually we've still got 190 per spoke solutions, it's incredibly complicated

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So that's where we started from

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We've got a few issues other than complexity

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We're wholly locked in

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We can't change many of those solutions

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because we're wholly locked in and we find ourselves in a really strange place.

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I'm sure this will

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some of you will actually pick up on this one, I'm sure

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We buy licenses in perpetuity

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To make software read-only because we can't migrate their data when we buy a new one

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and we do that a lot if I'm honest

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That's a big big problem for us

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proprietary vendor locking because of the proprietary nature of the data

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Note to migration nightmare and it's there's no strategic fit at all if we're really really honest

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so

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we're starting from a place where we know we've got to move

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and where are we trying to get to?

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There's quite a few people here of my age, so you probably remember in old money we had

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EPR one to six, everybody's trying to get to EPR six

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Nowadays, it's HIMSS level 7

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In EMR adoption model we're all trying to get to 7. That's our aspiration

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You know we don't do this sequentially. We're probably around 2 at the moment

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We've pretty much done PACS three times, we've got e-notes. We've done observations,

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order coms, so we're starting to do this in pieces

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OPENeP I'm going to talk about in a minute

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So what we're starting to get towards that level 6, level 7 a bit at a time

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But there's one real kicker. There's one thing that we can never nail on our current strategy, and that's level 4

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Clinical decision support, proper, true clinical decision support, connecting those 190 solutions

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in a real way that makes absolute sense

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and enterprise-wide scheduling. So that's the type of thing that if a doctor on the ward

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requests a specific test and it comes back and says the patient's allergic to an antibiotic

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it goes off and tells pharmacy and pharmacy prescribes another one

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That's the level we're talking about real-time decision support.

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I don't know anybody worldwide. That's managed to achieve that with the architecture we've got

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and there's one fundamental reason that would be

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Unbelievably complicated if we try to do that in that architecture.

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Even as a software engineer, I don't believe that's possible and I've never ever said anything is impossible as a software engineer everything's possible

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But I don't believe we would ever get there

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And the fundamental reason, I believe, this is this is my take on this is that to achieve that you've got to have a truly

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integrated single digital care record. You've got to have that data in a single integrated form

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to achieve that level of interoperability for enterprise-wide scheduling and real-time clinical decision support

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Couple of ways you can achieve it

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You can buy your way into it

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So you can go down the "Big Box" solutions. You can do the EPIC's, the Cerner's, the Lorenzo's, the TrakCare's

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There's you know, as well as I do, the Allscripts has lots of them

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very, very proven, it's a very proven model

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you deploy it for the

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level of functionality it provides you, you pretty much get benefit out of the box when you start, so it works

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and and you've got a consistent user interface. It's one system for the functionality it provides, and you heard earlier

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it doesn't provide everything obviously. A couple of cons however,

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boy, are you locked in!

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You know EPIC for one, and I'm sure the others will tell you the same. They make a big play about the fact

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they've never lost a customer

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It is a good system

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but you know if you actually take all the effort to put in something like EPIC or Cerner or Lorenzo or whatever

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would you really want to migrate away?

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So true, but you know you are wholly locked in and you've got that same data migration nightmare

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and as we know it's incredibly expensive

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Mostly probably followed Gartner reports. I read a couple of weeks ago about the US actually that they've now cited

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implementations of Allscripts, Cerner and EPIC, I'm not singling any out here,

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as "eye-watering" the costs, the level of costs. Now ten years ago, they were citing these as a model of how to do it

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They've suddenly realized now billions and billions of dollars are spent on regional implementations

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That's probably not surprising to anybody, but here's the thing

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they're no closer now to having a truly integrated digital care record for the patient than they were twenty years ago

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Because none of them interoperate in the states

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21st century Cures Acts which you're probably familiar with it's probably going to

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make that change over the next few years at an interoperability level

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But if you're a patient, and you're at the center of a region where you've got an Allscripts

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and you've got an EPIC and you've got a Cerner you will have three patient held records

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You won't have one.

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And to me that's an absolute frightmare, if I'm really honest, and that's not where we want to go

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I know we're a little bit behind in terms of implementing big boxes, but I don't want to be there at all.

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So we wanted another approach

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So we thought okay if we can't buy our way in, can we build our way in?

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So if there was an open standard framework where we could

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set out an aspiration of true

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vendor neutrality at every level of the stack

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wouldn't that be something sensible to do?

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So that was kind of our vision. It fits with our strategic thinking

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we've always had that best-of-breed interface on standards approach, so it kind of fit.

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We could do it a bit at a time. We wouldn't have to try to make this case this huge thing and do it all at once and

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a key one for me is, we would start to reinvigorate

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that small to medium enterprises marketplace that the national program killed stone dead

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You know those of you that used to go to Harrogate like me saw the marketplace pre-national program

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And if you go to the NEC and see it now

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it's wholly different, and you know the national program did that so we want to really get that back.

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We want to reinvigorate the SME marketplace and really start to get this ecosystem built

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Once we've done it, we've got no vendor lock-in

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Because our data is completely abstracted

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We'll have no data migration issues. We can swap pieces of functionality in and out and

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everything will just carry on working as it did before and

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Incremental investment is both less, and you don't have to make these massive investment cases

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to an NHSI

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You know try taking an 80 million pound investment case to the NHSI... good luck on that one

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It's not something I particularly would like to do

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So it does give us the ability to incrementally invest year-on-year business cases year-by-year to do pieces of the puzzle

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So we've ruled that one out and we set our strategy on an open standard approach.

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This is interesting. How do you do one bleep on two strings?

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So bottom right in that diagram

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The bottom layer is the data layer

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The bottom right actually says PACs, hopefully

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We've changed PACs three times in the time I've been at the hospital

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we had Agfa for pre-national program

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the national program came along and asked us politely to change it, so we changed it to GE

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and then the national program kind of came to an abrupt stop

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as did the contract, so we had to do something else, and we've now got Insignia

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So we've had three completely separate pieces of software for clinicians to use and you know what?

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Wholly seamless. We trained clinicians to own a new product, and they just carried on as they did the day before simply because

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it's got a data standard DICOM been there like forever as far as I can remember

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So because the data was holding it in a data vendor neutral format

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we could simply swap out one solution with another solution, train our users

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and they just carried on as they did before and that was kind of the lightbulb moment for me

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that was the

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wow, what if we could do that on the left-hand end of that bottom stack which is the 190 solutions

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If we could get to a point that each one of those has

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unique functionality, fine, but had a

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non-proprietary

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open data model

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we could then compete supplier against supplier,

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swap software out and not have any lock-in at all. So that was my kind of lightbulb moment, all sat under our nice

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open architecture.

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For us, it's Ensemble, but it could be anything you like really as long as it's open standard based

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We've had standards there for years. We've had hl7, we've had ITK remember that?

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We've had IHE, now we've got FHIR and FHIR isn't

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a competitor for openEHR if you want my opinion, I know there's a lot going on about this

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They're totally and utterly complimentary to each other

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discuss

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Then we've got an application stack across the top, all delivered through Salus, which I showed you earlier

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That's our view. We want it all delivered through a common portal to any device

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So that's kind of our aspiration

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Then we had a bit of good luck

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We actually went out to procure an electronic prescribing solution. We went out to OJEU

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We got right through the end of it

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And we actually didn't shortlist anybody because we didn't find anybody actually that was capable of meeting the full requirement

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That's not a good luck. The good luck is

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CGI who we were working with at the time actually introduced us to MARAND and they've shown us their

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OPENeP product, and they've shown us their

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view of the world I guess their vision for how this should all hang together and

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they're really alike and honestly we did not

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rob either

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We certainly ever said to Thomas before we certainly didn't rob theirs, that's for sure. These were created totally in isolation

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But you can see a complete similarity and when we when we actually met with these guys we looked at the product

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we looked at their philosophy and the openEHR platform the Think!EHR

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that they developed and their ethos around open standards. There was a there was a unique fit there for us

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We then said okay, we'll take OPENeP as the first application on that application stack

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Based around an interoperable framework with the openEHR platform as the vendor neutral data layer

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That would be our first line strategy

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Where we are now? We started that

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January? April? It seems a long time ago now, so we've been doing this

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Yeah, you nodded, right about April time

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We're first of type for OPENeP in the UK

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It's open source

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held in the Aperta foundation

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Not-for-profit organisation which is fundamentally us, so we own the source

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All set up nicely for us by NHS Digital, thank you very much Peter.

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and

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it's based on

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the Think!EHR Platform on an openEHR repository, and it's going to be delivered through Salus, absolutely happy days

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We go live in June next year. We have the test environment in place at the moment, and it's looking really really good

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I've got to say

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So all things are starting to really start to pull together with it

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As I say the Aperta foundation is the means by which we're going to hang all the source together certainly

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for OPENeP to start with

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But other things that come which I'll talk about in a second, and there's a key thing for me

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I'm not standing here saying we're trying to do away with commerciality

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I think a lot of people see this as what's in it for the software supplier,

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what's in it for the commercial partner and I get asked it a lot I've got to be honest and

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what I try to say is

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We we need relationships with software innovators. We just need a different type of relationship

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What I don't want is

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Licensed software that's licensed by site, by named user or concurrent user

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specific to me for X amount of money

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What I want is something a little bit more fluid

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Something that we can create an innovation partnership around. For argument sake and this is just throwing it out there,

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why wouldn't we license on patient rather than named users, sites, services and concurrency?

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So that for me instead of having my remit stopped at the end of that concrete block

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My remit now will have to go into the whole of Devon because we've got to interoperate across the whole of Devon

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I want to deploy software out of the hospital into the community, into primary care, into other acute trusts

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It's all the same patients. Why should I why should we pay again?

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We need a slightly different model because when we've looked at our existing framework,

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even if that software was capable of doing the whole community piece

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you know, what we couldn't afford to deploy it based on our current license model

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And that's just madness

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So there's a whole lot of work that needs to be done

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to work with our commercial partners to actually set that up.

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Very early days, we don't have all the answers

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But the software

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certainly SMEs and some of the bigger players are working with

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very, very interested in having that discussion with us because they see the future and the future isn't "sell us a licence

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based on X number", that's not the future

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So this is Salus, just to give you a quick flavour of what we've what we've actually done

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This this is the piece we've written and you can see,

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we probably can't actually it's not particularly clear,

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there's a little tab at the top that says "meds" which was unique to this project. When they click on meds,

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in context, this piece down the bottom is actually OPENeP, the MARAND product, and

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my developers and the MARAND guys have been working joined-at-the-hip

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And they've actually seamlessly integrated these two; we're not talking interfacing now. We're talking absolutely bolted these things together

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at the, I guess, the doing level rather than the interface level.

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We're not passing messages, I think was one saying so there's no joins whatsoever with this

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It all appears to the user like it's Salus which is great for me because I get all the credit

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but behind the scenes

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MARAND have put in the OPENeP clinicality, that really safe clinical product

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So where from here?

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If you remember the application stack, we've done one, we've done OPENeP

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We want to do more now all based on that same stack

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We just want to roll applications out as quick as we can get our hands on them. We want order communications, we want electronic observations

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anything you like; whether it comes from MARAND,

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whether it comes from an open source community, whether it comes from other trusts that are involved in this game now

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We want as much as we can get and we want to deploy as soon as we can

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To start to build this this whole ecosystem up

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We're looking to make Salus which is the product we brought to the table

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open source through the Aperta foundation and NHS Digital so that for argument's sake our implementer is CGI

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it could be one of a number, but we're using CGI

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We want them to be able to come to another trust and for a fixed price deploy OPENeP

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And if the trust haven't got a portal they can deploy Salus as well

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And they can have all the benefits of bed management, patient flow and all that kind of stuff

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it should be as simple as that. There's a fixed price model for a

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commercial support partner to just come along and say you want that one, you want this one

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If they've got an existing portal deploy OPENeP and integrate it with that portal

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That's where we're trying to get that that framework set up

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And lastly, but for me probably the most important,

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we're all pioneers at the moment, you saw the nice diagram earlier. I wish I had that.

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We're very much at the forefront of this, a lot of people don't even understand this at the moment and one of the things

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we've got to do, I think one of our biggest challenges, is how we

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we get out there

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and we both evangelize it and we build this ecosystem; this thing that's going to take it from quite niche,

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which is where it is at the moment,

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to actually being fully mainstream such that it can challenge the EPIC, the Lorenzo, TrakCare and everything else

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And for me involves a whole blended approach really

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We need to invest locally in our own development teams and make them work differently because they're not going to be writing everything

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We need to certainly invigorate local SMEs

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and we need to be

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connecting with bigger partners, for us people like education

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when I was a kid in Plymouth

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the school gates used to open in June and the dockyard gates used to open and kids used to flock out from school straight into the dockyard.

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Now what we want to do is do that with with education. We want people graduates coming out of

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University in Plymouth and spending 18 months to two years working with us

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developing apps, building this ecosystem

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Giving themselves a CV.

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In two years they're going to go off to the industry they're gonna come up and work in London and make a fortune,

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but for that 18 months to two years we want to get that vibrancy locally

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with those those

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very skilled people that can write these apps for a pastime if you put a little bit of rigor around them,

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a little bit of structure

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and

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national global developments. Things like this, working with other trusts; we've got Salus you can have it for free

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You've got a business analyst tool, we can have it for free. Moscow have written this fantastic thing, they'll charge us I'm sure,

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but we'll come up with some deal

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That kind of arrangement and the reason we can do it is because it's all based on one

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open data record

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Thank you

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And II just as good as last time, thank you

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We have a tech. We are a little bit over. But not too bad

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thanks to all our speakers for keeping well to time and

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You know it was a pact a pact program any questions before we break to break for lunch

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We're hungry people

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Somebody ought to have a slot before lunch

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Yeah, we'll all be available to chat. Please go and enjoy lunch, and we're due to be back here