The Wizards of Oz!

Over the years I’ve met a number of Australian health informatics specialists while working in the UK and I’ve always been impressed by their apparent ability to cope with any challenge! But I’ve never had first hand exposure to the Australian health system and the state of informatics – I had the opportunity to change this last October when we visited eastern seaboard to meet up with some companies and individuals.

Happily I also registered for the Health Data Analytics conference in Brisbane. My hope was that it would give me insight into the Australian health informatics scene and current projects. It did that and more!

As I’d hoped a broad range of analytics projects were presented but in addition I noted some really excellent sessions – highlights for me were:

  • the sessions on Precision Medicine with an excellent key note by Eric Dishman, Director of the Precision Medicine Initiative Cohort Program (USA), on the US initiative and, elsewhere on the program, a fascinating talk on moving the IT underpinning genomics services into the “cloud”;
  • a masterclass and sessions on FHIR which moved my understanding on in leaps – I’d come across it as a new technology for interoperability but not had the opportunity to understand it in detail. It was great to have Grahame Grieve, the inventor of FHIR, in the audience to contribute;
  • an inspiring masterclass and sessions from the team at Princess Alexandra Hospital, Brisbane, on their Cerner deployment and approach to using data to support quality healthcare and research. Their enthusiasm and determination to achieve their vision was inspiring.

Although the australian health system is smaller than the UK’s, spending slightly more as a %age GDP (9.4 vs 9.1%, WHO 2014) on a GDP that is about 60% the size, there is a lot of innovative thought and good science being done. I look forward to tracking progress over the next couple of years and I can strongly recommend the conference and our australian colleagues in the HISA.


The puzzle of why excess weekend deaths are difficult to research?

It has been observed across many healthcare systems that there are excess deaths in hospitals for patients admitted at weekends. In the United Kingdom, BBC Radio 4 ran “The Report: 7-Day NHS” last Thursday looking at recent research into “excess deaths” at the weekend and the link being made by Government Ministers to “avoidable deaths” and consultant and junior doctors weekend cover arrangements.  That any link is hypothetical and not proven seems clear … and then it becomes political theatre.

The interesting and significant question, unless you are a politician, is why it’s so hard to identify common causes for the excess deaths ?

Freemantle et al have shown convincingly that excess deaths are occurring, it is a significant effect, and that they cannot be explained away through differences in emergency vs. elective mix. They used nationally collected data for the analysis. It looks like a real effect and the search is on to find the cause.

The HiSLAC (High-Intensity Specialist-Led Acute Care) study has been funded to:
evaluate a key component of NHS England’s policy drive for 7-day services: the intensity of specialist-led care of emergency medical admissions, with a particular focus on weekend provision. This research is important for patients and for NHS strategy because it offers a unique opportunity to evaluate the impact of the transition to seven-day working, and to understand factors likely to impede or enhance the effectiveness of this change in practice.

It is important research and should enable future policy to be more evidence-based than is currently the case. Interestingly their website says that the initial research is being carried out by reviewing paper case notes from a number of case study hospitals.If their approach is going to be similar to that of the Global Trigger Tool, developed by IHI to detect adverse events, then it is very labour intensive process and applies practical limits to the size of research population that can be studied.

The downside of applying 19th Century technologies in the 21st Century!

The limitations of having to work with paper case notes means working with small samples (100s or 1000s rather than millions) and makes it that more difficult to identify any common causes unless the association is very strong – and the arguments over possible causes suggest that this isn’t the case. This is a stark contrast to the situation in other industries and the consumer sector where “big data” means that such questions are much more easily answered using purely digital data.

Increasingly there are hospital digital data sets being captured that should be relevant to this question. A lot of hospitals have used money from the nursing technology fund to implement systems to collect patient’s vital signs and record NEWS scores and other assessments for VTE, Sepsis etc. There are a number of hospitals with electronic patient record systems with clinical notes on their patients. The data from these systems could be analysed more quickly than paper case notes and covers the full patient population. Most of these systems are being used for clinical management and secondary use, for research for example, is not a priority in the typical hard pressed NHS trust.

There would be great value in establishing standards for the collection of clinical data and an “open data” policy which would enable important policy questions to be addressed through “big data”.

Planning for the future
We shouldn’t be making policy based upon opinion, rather than evidence, in the 21st Century. We should apply the data-driven approaches and supporting technologies being used successfully in many policy areas to inform decision making in healthcare.




Happy New Year

happy-new-year-1198595We wish all our readers a Very Happy 2016.

We leave the 2015 calendar year behind but not the financial year. The 2015/16 financial year is proving top be a very challenging one for the NHS with the majority of the provider sector in deficit. With a quarter to go, and lots of pressure on both revenue and capital budgets, the focus is on getting back on financial track.

It will be interesting to see this year’s out-turn, who is in financial balance and who isn’t, and the impact this has on next year’s plans.

But for now ………… we will focus over this next quarter on helping our client’s succeed this year, both financially and in terms of improving the quality of their services, and also build a sound foundation for future success through sound investment.


The myth that will not die?

I’ve seen Don Berwick speak many times, at the Kings Fund and IHI conferences, and it is always a pleasure to hear his well constructed, intelligent presentations delivered with that uniquely american “folksy” charm he shares with other great communicators from across the Atlantic.

His keynote address (link here) questioned why people (particularly politicians) still believe that it is possible to deliver high quality through “inspection” performed by regulators. It is the stock reaction to every failure in the public sector or any sector that has an impact on the public; how often have you heard “this must never happen again – the regulator has failed and we must” either i) “do a ‘root and branch’ review” or ii) “abolish it and setup a better one”?

Don Berwick argues against reliance regulators on the grounds that they generate fear, control of information and a lack of transparency amongst the regulated. Worse, the over reliance on external control stunts the internal development of quality improvement and innovation.

I would add another reason – because external quality control doesn’t work because of weaknesses intrinsic to every regulator and the organisations they regulate. In “The Challenger Launch Decision” by Diane Vaughan, the author describes the failure of safety regulation which was one of the causes of the Challenger launch decision and subsequent tragedy. The culture within NASA and its subcontractors was open, professional and not one of fear. She suggests that the regulatory system still failed for two reasons :

  • autonomy of the regulator, while giving objectivity, meant that the regulator had limited access to information and often lacked the specialist skills to interpret it.
  • this reinforces interdependence of the regulator and regulated organisations, where there are shared goals and sharing of specialist resources. This led to the regulators becoming a part of the regulated organisations culture resulting in negotiation and management of safety issues rather than discovery and sanctions.

When we look at recent NHS “never again” healthcare disasters (for example Mid-Staffordshire NHS Foundation Trust) we see the same issues in play.

So we must ask, if the definition of insanity is doing the same thing over and over again and expecting different results, why the knee jerk reaction to poor quality of service, or worse, is to setup “better” regulators? It doesn’t work, never has and never will!


Choosing Wisely – in whose interest?

In a recent article in the NEJM, by Nancy Morden and  others, titled  “Choosing Wisely — The Politics and Economics of Labeling Low-Value Services” the authors have reviewed the outputs of the Choosing Wisely campaign. The campaign engages professional medical societies (nine) in listing tests and treatments that should be discussed with patients because they are of “low value” – there may be better treatment choices, with lower risks and lower costs.Continue reading

Poor quality NHS hospitals cross-subsidised by the best – will this change with the new NHSLA approach?

UK News:

According to the Sunday Telegraph  nine of the 14 hospital trusts investigated as “outliers” in terms of high mortality have cost the NHS Litigation Authority £291m over the last 5 years while only paying £203m into the scheme. While the top 10 performing trusts paid in £500m into the scheme and cost £311m in settlements.

The NHS Litigation Authority (NHSLA) scheme is essentially a pooled funds insurance scheme where participating NHS trusts pay an annual “premium” related to their size, complexity and “risk”. A key principle of a pooled funds approach (such as car insurance) is that it smooths out over time the lumpy arrival of claims – not that the prudent and careful pay for the claims of the risk junkies! Premiums are typically based on a mixture of risk factors (e.g. age) and track record (no claims discounts).

The NHSLA scheme assesses risk factors by looking at the size of the organisation and the potential exposure to claims of the services it offers (maternity is a high exposure due to the size of claims). Until this year “risk” was evaluated by assessing the compliance of the trust with risk management standards. This approach is now being abandoned to be replaced with an “outcomes focused” approach based on helping trusts to learn from safety failures. The rational is that having risk management processes in place does not necessarily equate to a safe operation and compliance can be a crippling overhead – the NHSLA should be congratulated on belatedly resisting the lobbying of the safety industry and for anticipating the recommendations of the Berwick and Keogh reports.

It is not clear how NHSLA “premiums” will be calculated from here on – presumably increasingly related to track record over time rather than the (now discontinued) risk assessment regime? But let us hope that in future trusts providing high quality care are no longer subsidising the settlements incurred by trusts that are outliers providing poor quality care.



double helix

The unintended consequences on healthcare systems of a Brave New World?

The Royal Society of Medicine’s Medical Innovation Summit 2011 was held on the 25th June and presented an eclectic mix of topics (videos are available here) ranging from the use of genetically engineered sterile mosquitos to control dengue fever to the use of “Plumpy’Nut” as a food to treat acute malnutrition in the community; via pluripotent stem cells to treat cancer and skin cell sprays as a better option than grafts for treating skin burns. It was a stimulating way to spend a Saturday and a powerful illustration, as one of the speakers said, of the innovation that can come from combining knowledge and specialists from different fields of science.

But as I was marvelling at the amazing potential of combining the fields of genetics, cell biology, immunology, materials science and engineering I began to wonder what the effect of all this would be on the delivery of healthcare. What would be the impact on today’s healthcare system of introducing these technologies? There would be obvious benefits for patients from regenerative and reconstructive technologies but would there be unintended consequences on the delivery system?Continue reading

Reducing readmissions – lessons for England from Kaiser Permanante

In June 2010 Andrew Lansley announced in a major speech “..we’re going to ensure that hospitals are responsible for patients not just during their treatment but also for the 30 days after they’ve been discharged.” The NHS Operating Framework for 2011/12 states that hospitals will not be reimbursed for emergency readmissions within 30 days of discharge following an elective admission, and all other readmissions within 30 days of discharge will be subject to locally agreed thresholds, set to deliver a 25% reduction, where possible.

At the IHI conference in December 2010 Kaiser Permanente reported on their research into the causes of readmissions of all types within 30 days of an admission. They put in place an improvement programme that reduced readmissions across the board from 16% to 9% in 6 months.

What lessons can the NHS in England learn from this experience?Continue reading