Wow that was a bit of an introduction

We we've had

quite a bit of what and how and

I thought I'd give the CIO's perspective

bit of a confession first

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

Interested in the what and the how

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

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

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

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

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

director IM&T here

still I

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

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

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

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

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

We've got pretty standard IT I believe

We've had a Best of Breed Interface strategy

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

and standards

We've replaced up housing 99

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

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

We've got fully rolled out order comms.

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

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

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.

And

Thomas said we've got a 170

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

departmental clinical solutions, so these are wholly independent

proprietary clinical applications

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.

And this is the diagram that

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

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

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

So that's where we started from

We've got a few issues other than complexity

We're wholly locked in

We can't change many of those solutions

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

I'm sure this will

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

We buy licenses in perpetuity

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

and we do that a lot if I'm honest

That's a big big problem for us

proprietary vendor locking because of the proprietary nature of the data

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

so

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

and where are we trying to get to?

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

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

Nowadays, it's HIMSS level 7

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

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

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

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

OPENeP I'm going to talk about in a minute

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

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

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

in a real way that makes absolute sense

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

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

it goes off and tells pharmacy and pharmacy prescribes another one

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

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

and there's one fundamental reason that would be

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

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

But I don't believe we would ever get there

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

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

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

Couple of ways you can achieve it

You can buy your way into it

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

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

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

you deploy it for the

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

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

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

boy, are you locked in!

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

they've never lost a customer

It is a good system

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

would you really want to migrate away?

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

and as we know it's incredibly expensive

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

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

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

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

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

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

Because none of them interoperate in the states

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

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

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

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

You won't have one.

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

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

So we wanted another approach

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

So if there was an open standard framework where we could

set out an aspiration of true

vendor neutrality at every level of the stack

wouldn't that be something sensible to do?

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

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

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

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

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

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

And if you go to the NEC and see it now

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

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

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

Because our data is completely abstracted

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

everything will just carry on working as it did before and

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

to an NHSI

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

It's not something I particularly would like to do

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

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

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

So bottom right in that diagram

The bottom layer is the data layer

The bottom right actually says PACs, hopefully

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

we had Agfa for pre-national program

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

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

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

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

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

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

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

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

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

that was the

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

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

unique functionality, fine, but had a

non-proprietary

open data model

we could then compete supplier against supplier,

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

open architecture.

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

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

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

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

They're totally and utterly complimentary to each other

discuss

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

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

So that's kind of our aspiration

Then we had a bit of good luck

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

We got right through the end of it

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

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

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

OPENeP product, and they've shown us their

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

they're really alike and honestly we did not

rob either

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

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

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

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

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

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

That would be our first line strategy

Where we are now? We started that

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

Yeah, you nodded, right about April time

We're first of type for OPENeP in the UK

It's open source

held in the Aperta foundation

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

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

and

it's based on

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

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

I've got to say

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

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

for OPENeP to start with

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

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

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

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

what I try to say is

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

What I don't want is

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

specific to me for X amount of money

What I want is something a little bit more fluid

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

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

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

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

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

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

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

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

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

And that's just madness

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

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

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

But the software

certainly SMEs and some of the bigger players are working with

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

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

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

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

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

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

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

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

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

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

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

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

but behind the scenes

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

So where from here?

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

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

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

anything you like; whether it comes from MARAND,

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

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

To start to build this this whole ecosystem up

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

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

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

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

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

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

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

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

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

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

And lastly, but for me probably the most important,

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

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

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

we get out there

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

which is where it is at the moment,

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

And for me involves a whole blended approach really

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

We need to certainly invigorate local SMEs

and we need to be

connecting with bigger partners, for us people like education

when I was a kid in Plymouth

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.

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

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

developing apps, building this ecosystem

Giving themselves a CV.

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,

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

with those those

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

a little bit of structure

and

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

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,

but we'll come up with some deal

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

open data record

Thank you

And II just as good as last time, thank you

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

thanks to all our speakers for keeping well to time and

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

We're hungry people

Somebody ought to have a slot before lunch

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