Tranquility Base we have a problem!

Just updated to let people now about an important meeting in Brisbane on Digital Disruption in Health 23 September 2015. Looking forward to hearing all the solutions! Click for details – HISA Qld – Digital disruption and the future of health

Arriving in 2030 and we have a problem!

No it’s not rising sea levels – which will of course be an astronomical challenge with new diseases and the spread of new hosts and vectors and drug resistant infections – sea_levels_rising-300x186 it is the complexity of our eHealth systems around the world. They are now so complex that they are stagnating and costing unimaginable amounts of money and expert resourcing to maintain. Even the experts are moving to more profitable development spaces and the turnover in the industry is impacting on knowledge retention and the ability to maintain legacy systems once integral to digital health facilities.


There is increasing concern at the steady incidence of adverse occurrences, medication mistakes, genetic splicing errors, privacy and security attacks and a continuing increase in complaints by consumers that their care has become ineffective. Chronic disease sufferers are struggling to understand their personal records and Coroners around the world are criticizing the software giants for decision systems that are out of date, have allowed poor decisions to be made and with rules that do not reflect current evidence for best practice. Governance costs are steadily growing at the expense of direct patient care. We have reached a terminal point. Decisions made, or more correctly not made, have taken us down pathways that are no longer comprehensible.

Previously immensely wealthy developers of health systems are locked in legal conflicts losing millions in settlements and contractual arguments as they find themselves unable to make their systems cope with rapidly emerging demands. Terminologies have become so complex that even small changes bind them into conflicts as decision systems fail abruptly and prevent the upgrading of decision systems. Failed interoperabilty between jurisdictions is causing dissatisfaction with vendors, consumers and regulatory bodies.

Fiction? Yes of course. No one would ever let such important systems get to that point, would they?


Putting the Health back into eHealth


There has been considerable growth and sophistication in the world of Safety and Quality in Australia and internationally. There are many well documented and specific elements to the safety and quality process such as auditing, standards, guidelines and education plus a steadily increasing commitment of resources and expenditure to ensure the achievement and maintenance of safety in health care. Still far from perfect, significant achievements have been put in place and are making a difference.

A number of hospitals are approaching ‘digital hospital’ status and there is an exponential growth in all manner of health care applications from mobility, advances in telehealth, home monitoring and complex messaging relating to interoperablity between facilities, specialists and primary care services.

It is my belief that eHealth will need an equal or larger commitment to clinical safety into the future. There are many aspects that will need long term management.

These include though not limited to:

  • The clinical safety of applications, system interactions and interfaces
  • The currency of reference terminologies and guidelines
  • Ongoing review and currency of evidence justification for digital clinical pathways, guidelines, rules and templates.
  • Ongoing governance of Clinical Decision Support system rules that are in place or being introduced. Deprecation of rules will also be essential.
  • Essential and innovative auditing processes will need developing to examine and improve the system outputs and inputs including medications, letters, summaries, results, reports etc.
  • Managing clinical aspects of coronial and external investigations of adverse events related to information systems
  • Reporting and KPI analysis for Safety Commissions and facility accreditation, plus inevitable political concerns
  • Ensuring that clinical risk aspects are identified, managed, documented and demonstrated to have been resolved or mitigated for the future.
  • As the Digital Hospital culture grows across the nation, ensuring that appropriate training curricula and updates are managed and in harmony, particularly as clinicians move between different facility based systems
  • Monitoring the safety, messaging content of integrated Point of Care and procedural device safety (e.g. robots, scanners and genomics)
  • Putting in place quality audits of the increased textual components in the various modules and overall professionalism of the clinical content
  • Reviews of the success or failures of the integration aspects in regard to semantic interoperability and data accuracy of the various systems, small and large, local and cloud, fixed and mobile.
  • Ensuring telehealth and remote systems are accurately recording event episodes and that the records are synchronized across aspects such as allergies, alerts, procedures, medication changes etc.
  • Determining and monitoring that the validity of third party (clinical data) is safely integrated and input (i.e. Primary Care, International, Private Sector).
  • In a similar structural way that the clinical Safety and Quality movement has dedicated teams, independent or preferably integrated, with existing structures, I believe this needs to occur within the clinical informatics domain. While both movements need to move in harmony, new sets of skills will be needed along with education, accreditation guides, auditors and a host of research activities. All these functions will need to be networked with a central functioning safety body to ensure consistency and integration as well as leadership, training and career development.

    Then we should all feel safer when the machine asks us how are you feeling today!

    E Health – the Hidden Expense.


    It was Leslie Lamport quoted as saying: A distributed system is one in which the failure of a computer you didn’t even know existed can render your own computer unusable.

    This truism has been highlighted over the last few years through often unforeseen incidents and consequences of failures in highly complex, loosely integrated systems, especially when running feeder systems through often distant, unrelated and often multiple applications. While the advantages of federated systems are substantial they are sadly often highly susceptible to failures in any one aspect of the network.

    To manage such chaos, highly resilient systems and redundancy are essential, as the loss of both intended and unintended connections between systems can have serious impacts on patient care, resource allocation, workforce, data quality and collection as well as the inevitable political and media stressors. Even external agents can create chaos, as Sony is now so clearly aware. Health is just as, if not more, susceptible to attacks.


    The solution is not simply good design and architecture (essential) but also expensive mirroring, security, cloud use, redundant storage systems and well planned paper backup solutions. Achieving 100%, 24×7 system availability should be the holy grail of ehealth systems but it is very, very expensive. Many non-clinical architects, analysts and developers downplay the need for such costs or support systems but as we find greater and greater integration into the day to day clinical management of patients these costs must be seriously considered and only rejected or watered down following thoughtful consideration of the tragic impacts that may follow.

    As massive gains to clinical safety, effectiveness and efficiency are achieved by ehealth, these marginal gains start to decrease relative to the growing insidious and potential harm of major system failures.

    Comedian Bill Murray said “Don’t think about your errors or failures; otherwise, you’ll never do a thing,” and while there is modicum of wisdom in his thoughts, it is critical that we understand and learn from our errors and failures when another’s health is at risk. Sadly if one looks at the last 20 years in ehealth we do learn but ever so slowly and only after the repetition of the same outcomes over and over – but fortunately we do learn!


    As we move rather rapidly down the integration pathway, we should keep asking our clinicians to consider the impacts of sudden or silent failure and ensure solid, well practiced back up processes with auditing are in place and not left to the rushed search for a notebook and pen when the inevitable happens.

    Isaac Asimov understood this when he said: “It is change, continuing change, inevitable change, that is the dominant factor in society today. No sensible decision can be made any longer without taking into account not only the world as it is, but the world as it will be.

    Our work continues!

    What are we learning in the Electronic Health Record World?

    Recently I sat through a Gartner talk on the EHR.

    While many of the points below are valid issues and relate to an major EHR implementation there was little focus on the underlying knowledge management issues, such as cross system integration, standards in data sets and interoperability.

    Issues around safe user interface design and new and innovative uses of telehealth and seamless patient movement around a nation have not been taken up. The USA model of the big vendor system (e.g. CERNER, EPIC, ISoft) misses the wonderful integration achieved by Australia in the last few years and while it is far from perfect in many ways it leaves the USA gasping in its wake.

    As long as you never move between hospitals things will be fine and well integrated for those patients but change providers, move between jurisdictions and your EHR rapidly becomes hidden and of diminishing value.

    The following points though are all valid and important but don’t for one minute think this is all you have to deal with.

    There clearly needs to be consideration of planning, project management, vendor selection, change management and execution.

    The following areas were highlighted as a main focus of complaints and concerns during and after implementations.

    • Lack of clear executive clinical leadership
    • Complex technical organizational regulatory, cultural challenges
    • Lack of dedicated resources
    • Poor project management
    • Weak governance
    • Poor change management
    • Weak benefits realization process
    • Poor communication
    • Vendor inability to deliver to specification
    • Clinical rejection of system

    Many lessons therefore should be considered constantly both before, during and after implementation.

    • Unrealistic timelines
    • Failure to review clinical workflows / processes
    • Failure to understand the technical requirements
    • No clear vision as to why we are doing this
    • Stakeholder conflict
    • Scope creep
    • Inadequate in-house support
    • Lack of clarity on interface requirements
    • Underestimating data conversion


    The following cycle of issues may be of value to follow and review n a very dynamic manner and particularly  as warning signs are developing.

    • Develop a communication plan
    • Review Total Cost Ownership
    • Review EMR Lessons
    • Review Procurement Model
    • Review Readiness Assessment
    • Review EMR Strategy
    • Identify stakeholder Engagement model
    • Review Governance
    • Plan for Change Management

    Other Factors to Consider

    • Standardisation of medical practice and reducing variability and variance between practices
    • Development of the CMIO role to assist in the redesign of clinical workflows
    • Develop and review your engagement strategy as issues and tension develops.Some of the long term demanding issues will be sustainability and optimisation over time.

      Gartner is pushing The Real Time Healthcare System

    Telehealth – A Time For Growth

    Telehealth has been alive and reasonably well in Australia for over a decade now. There are a multitude of services being provided across a wide range of specialties and professional groups.

    While some innovative apps, home monitoring and consultation styles are being developed or in some cases are well entrenched and in place, there seems to be a gap and  limited growth in the seamless electronic medical record with the non-virtual health world.

    This is about to change with integrated repositories of patient data, a national infrastructure of providers and access, web based user interfaces for viewing and studying repository material.

    Risks and Mistakes are Inevitable.

    As defined by the Britannica Concise Encyclopedia, safety defines activities that seek to minimize or to eliminate hazardous conditions that can cause bodily injury.

    There are innumerable risks to human safety and the management of those risk to ensure a safe environment is a task that is imposed on every human being from the earliest age as a genetic imperative around which cultural taboos, social norms and engineering, in all its aspects, cocoons society and its members.

    Risk Management is all about identifying safety risks and putting in place controls to minimise or eliminate those risks. Errors and mistakes are an inevitable part of human development be it as a child touching a hot surface, tripping over, ingesting inappropriate materials to their elders speeding, utilising infectious needles or simply loosing control with legal or illicit drugs.

    Mistakes can often be as good a teacher as success, (Welch, Jack) if you survive. If you don’t of course that meets the genetic imperative. The Darwin Awards make light of some of those issues. Unfortunately one person’s mistake, sometimes remote from the final outcome, can lead to the deaths of many whose loss to humanity should never be underestimated.

    Safety First!

    What makes a computer application used in the health care industry safe?

    Simple answer is we do!

    All tools – cars, aeroplanes, hammers and chisel are extremely safe until a human decides to use them. Mind you an unused tool is not really a tool at all and a computer application that is not used is of no intrinsic value to anyone. It is only when the button is pressed, the icon released or the message sent that those relying on the accuracy of the underlying systems and the human input provided are in receipt of a benefit or harm as a consequence.

    Many applications look fantastic, attractive and modern but are incredibly unsafe either in their own design, the systems they reside upon, the messages they send or the lack of skill of the human at the interface.

    This site hopes to look at all aspects of creating safe health information systems and the issues the applications development.