The article below was published on the Local Digital website on 23 September 2015

The article below was published by DigitalHealth.net on 18 September 2015.

We want to encourage debate and discussion about Open Source and will repost and attribute articles whenever we can.  We would also like to encourage guest bloggers and commentators.   The article below has been co written by Source Code Control Limited and Protecode.

Our thanks go to Martin Callinan for bringing it to our attention.

 


From relieving people of repetitive tasks, to building everything around us that shapes our lifestyle, and on to transformation of volumes of data into new insights and perspectives, software has become the new feedstock for the human evolution. All facets of life are touched by software, and healthcarei s no exemption.

The Complex Web of Health Industry

The health and social care industry is a highly fragmented and complex industry with medical practitioners, nurses, health professionals, hospitals, clinics, government and non-government agencies all providing health services.
The spectrum of health care providers range from individual clinicians such as General Practitioners (also known as GP or doctor) to large monolithic entities such as the National Health Service in the UK which is the third largest employer in the world today.

Health and social care providers offer a complex and diverse range of facilities and services. By the nature of these services the healthcare industry is driven by large and varied amounts of data which in turn require varied and complex IT systems to manage this data. Generally, these systems come under the umbrella term of eHealth. While there is no consensus on the exact definition of eHealth two example definitions are:

“…the cost-effective and secure use of information and communication technologies in support of the health and health-related fields including healthcare, health surveillance and health education, knowledge and research.” The World Health Organization (WHO)

“…the use of modern information and communication technologies to meet needs of citizens, patients,
healthcare professionals, healthcare providers, as well as policy makers.” The European Commission

Whatever way people choose to define eHealth it generally encompasses:

 

  • Electronic Health Records (EHR)
  • Electronic Medical Records (EMR)
  • Telehealth and telemedicine
  • Health IT systems
  • Consumer health IT data
  • Virtual healthcare
  • Mobile Health (mHealth)
  • Big data systems used in digital health

eHealth Software Complexity

Software complexity is increasing with no end in sight as today’s code becomes the foundation for tomorrow’s more complex functionality. Historically, healthcare organisations have created platforms to manage these solutions fairly autonomously, both within individual organisations and industry wide. Quite often these systems were procured at significant expense from software vendors who lock them into solutions that restrict innovation, stifle diversity and have little ability to be re-used.

In the past, developing all software internally was a point of pride for many organizations. Today, the complexity of modern software, coupled with the pressures to release applications and products on tight deadlines, has made delivering projects that rely exclusively on internal code development almost impossible. Increasingly, organizations are turning to commercial third party code, code brought in from outsourcers and contractors, and open source software (OSS) to accelerate development and reduce costs.

If this approach is compared to other industries such as the automotive industry where in the early days of car manufacturing car models were largely custom made. In more recent times, automotive manufacturers have developed “platforms”, commonly re-used across companies and continents. This gives them the ability to re-use existing components and enables greater flexibility – a new model is no longer a completely new design and as a result costs are significantly reduced.

The same approach is now being applied to eHealth systems and with the emergence of Open Source Software there is a shift to adopt Open Systems, Open Platforms and Open Data. These solutions are developed efficiently without licence restriction where the code can be shared and re-used across the public and private healthcare industry.

Code4Health

A great example of this repurposing is an initiative launched recently by NHS England called Code4Health.

Code4Health is a resource used by healthcare professionals and providers of services to deliver better patient outcomes. It provides a platform for clinicians to come together with IT suppliers to identify and experiment with the systems in their Trusts and develop new functionality and products or solutions that they can potentially deploy.

“Our ambition for Code4Health is to educate clinical and administrative staff to develop their interest in digital technology and stimulate a desire to engage more closely in the design, development and delivery of systems and apps”.

Code4Health are currently piloting ‘App In a Day’ where individual clinicians are being trained and encouraged to play an active role in the development of apps or even develop their own apps using LiveCode.

Over time, the goal of the NHS is to:

  • Create a market of viable Open Source solutions
  • Provide evidence of the value of Open Source software to the wider Health and Social Care Community
  • Ensure by default all code created in the NHS is shared as part of a library of assets for re-use
  • Ensure a level playing field for Open Source commodity and infrastructure services
  • Achieve a self-sustaining eco-system of communities

Managing Open Source and Other Third Party Content

Clearly there are huge benefits to be gained from this approach but it is not without its risks. Along with the advantages realized by using third party code, there are a few challenges that can arise. Governing the quality, security, licensing and intellectual property (IP) ownership attributes are imperative in avoiding risks and potential downstream costs of using third party software. Last year Community Health Systems Inc. lost data related to 5.4 million patients which could end up costing the health system between $75 and $150 million. This data breach leveraged the bug Heartbleed to access VPH log-in credentials.

The process of managing third party content in a code base can be time-consuming and resource intensive, and an understanding of the effort associated with this exercise is the first step in optimizing the process and mitigating the costs. This highlights a need for a governance program to underpin Open Source initiatives. Indeed the NHS have created a custodian model for Code4Health and will have “code custodians” to manage the risks of OSS and make the adoption of OSS based solutions easier for less technically proficient trusts.

A study of common practices deployed at software organizations, concerning adoption of open source and other third party software components, has revealed a pattern consisting of a number of necessary as well as some discretionary steps. Originally coined as Open Source Software Adoption Process (OSSAP), this process is equally applicable to any third party software that is deployed and used in a project within any organization. Eight steps are identified in a structured open source adoption process.

  1. Establishing a software policy, identifying acceptable attributes of a third party software, and highlighting remedial actions that should be taken in case of a violation of the policy. Typically, an “open source committee” consisting of legal, technology, security and business stakeholders are responsible for establishing and communicating the policy.
  2. An optional software package pre-approval workflow process that allows technology teams to request open source and other external packages to be approved for use on a certain project under certain use-case scenarios. The package-preapproval process would allow the “software clearing house” in an organization to open and assess the requests and grant or deny permission depending on how well the requested package aligns with the policies established in step 1.
  3. Establishing a baseline, or taking stock of the existing code in the organization. This is a necessary step in all but the simplest cases and is performed using automated tools creating a detailed view of the code that is already present in the software organization. This will produce a resulting map of proprietary, commercial or open source components and their licensing, security, quality and supplier attributes. Furthermore, the results obtained at the conclusion of this step are compared against the established policies and components and can be blacklisted/whitelisted as a result for future projects.
  4. Assessment of all code delivered to the project by contractors and outsourcing suppliers against the policies using automated tools, and extending the software inventory map that was established during the baselining process of step 3.
  5. Regular scanning and examination of the project code library. This can be done by scripting an automated policy-based scanner to review the complete library for any changes at regular intervals, for example, every weekend, and highlighting content that violates a policy component.
  6. Optional real-time assessment of code as it is checked into the organization’s Source Control Management (SCM) system against the policies, and taking appropriate action if a violation is detected. This step ensures that the project repository contains only acceptable code.
  7. An optional real-time automated scanner residing on the developer’s workstation. Similar to a virus checker, the content that is downloaded from the web, brought in through, for example from a USB memory card or simply assembled on the developer’s workstation is continually scanned against the project policies. Any violations against the policy can be highlighted to the developer (and the developer only), allowing for either quick remedy at the source or a comment to be inserted against the offending code (e.g. “will be used for testing only”).
  8. Final build assessment, usually through an automated process tied into the build (for example
    Jenkins) process.

The purpose of steps 2-7 is that all the code that could potentially end up in a project is logged and approved in that it satisfies the project IP, security and exportability policies. By the time the final application is built at step 8, there will be no surprises if steps 2-7 are diligently followed.

Conclusion

There is a significant opportunity to advance the caliber of healthcare by applying intelligent software solutions to electronic health records, delivery of consumer health information, and the provision of mobile and virtual health services. Leveraging open source software and drawing on the associated groups accelerates the identification and development of healthcare applications, creates a level playing field for all ecosystem communities, and allows the sharing and re-use of efforts across a wide range of healthcare domains and geographies. The distributed and crowd-based nature of the open source development can be managed by applying a structured open source software adoption process that will ensure quality, security and legal compliance to the re-use obligations inherent in any open source code.

Download this article as a PDF

 

List Of Additional Resources

Open Source Software Adoption Process (OSSAP) | Best practices that enable organizations to effectively leverage open source software in their projects.
Infographic, Measuring Open Source Management ROI | As open source adoption becomes mainstream, open source compliance management is maturing. Organizations are moving away from manual code audits to real time, automated open source scanning tools.
Ensuring Responsible Open Source Use with Software Audits | This paper explains how organizations can responsibly adopt and manage open source software in order to remain innovative and competitive.

 

The word ‘opportunity’ is defined as ‘a time or set of circumstances that makes it possible to do something’ which help to introduce our story of now.

As one of 25 Integration Pioneers, we have been given the opportunity to blaze the trail for change and new ways of working to support Health and Social care. With our successful bid to NHS England’s Integrated Digital Care Fund (IDCF), as mentioned in  our earlier story (the story of us), we have been given the opportunity to work with and support Integration Pioneers and the wider community on their own journeys towards integrated digital care records.

Across health and social care organisations, the top priority is to provide the very best care for people, to improve their care outcomes and ultimately to improve the lives people lead. We recognise that to do so we need to support the practitioners working across health and social care by giving them better information and better tools in order for them to provide the very best care.

Integrated digital care records therefore play an important role in the drive towards improving care. They bring together information from various care settings to provide a more joined up view of a person’s care. Without, there is a disconnect in care journeys as the information doesn’t flow between care settings, causing delays, inefficiencies and potentially impacting the care provided. With this technology change begins as people and process evolve to truly deliver integrated and thereby improved care.

The 25 Integration Pioneers on this journey recognise the need for integrated digital care records, as an important part in this change equation, allowing staff to work smarter to provide improved sustainable care in their respective cities and regions.  Each are at different stages on this road, some just starting out and some well on their way.

There are two common patterns appearing in the early work we have undertaken with Integration Pioneers in this area;

  1. the disconnect between the pressing need for change and the maturity and capability of care systems to meet these demands
  2. as pioneers, we are each doing our own thing, ploughing our own unique path and potentially encountering the same problems, when actually we all have the same core need – we need to work together

An open, collaborative and joined up approach is needed in the journey towards integrated digital care records. As Integration Pioneers an open approach allows us to act together, tackling the problems and learning once and sharing with all so everyone can benefit.

We have begun the Ripple community effort to support this approach. Key to that community effort, our experience has shown that there are six core components needed to support the delivery of an integrated digital care record system, explained here along two key themes outlined below:

Foundations

Open Requirements – Working with Integration Pioneers, we will identify the common requirements and capabilities needed for an integrated care record, along with their associated benefits. The identified aspects will be shared with all Integration Pioneers to save time and effort and to provide a consistent strategic direction to the community.

Open Governance – we will work with Integration Pioneers to standardise the governance arrangements for the sharing of information across care settings. At the moment this is seen as a real barrier to progress. Working with Integration Pioneers and with the support of NHS England we will provide standard governance templates and guidance to ensure the right arrangements are available and shared across the Pioneers and this emerging community across England.

Open Citizen – we will work with other Integration Pioneers on citizen engagement in sharing care information. It is essential to build trust as well as talking about care records openly, communicating widely and clearly. Working with Integration Pioneers and their respective communities, we will provide the common information and core tools  needed to support engagement in and communication of care record initiatives. In addition to this we will undertaken citizen engagement with the Integration Pioneers around the needs and requirements of a personal health record (citizen access to an integrated care record) and other key healthcare apps as a demonstration of this community effort in action.

Open source platform

Open Viewer – based on the Open Requirements identified by pioneers we will develop and deliver regular enhancements for an open source viewer for the community to use. As ease of use is critical at the front line of care, we will be working towards an Open Source care record viewer that makes the navigation around care records intuitive.

Open Integration –  In between the viewing and the storage aspects of any platform is an important element of bringing information together from the various systems Pioneers currently work with. To meet this need, we will be providing an Open Source Integration Engine which will be connected to those core systems that emerge from the Integration Pioneer analysis delivered by a series of related Open Application Programme Interfaces (Open APIs) to the community.

Open Architecture – Our learning to date has shown that many clinical groups require similar elements of clinical content, although they use them in slightly different ways to meet their own local need.  The current market offers a huge number of applications to accommodate this however these are very difficult to integrate. To move away from this approach and into the 21st century we need a more adaptive, modular, building block approach that allows the community to collaborate. Working with the pioneers we will provide a collaborative forum to develop these key building blocks, in line with international best practice, known as openEHR. With this in mind, we are working towards an open source storage mechanism to support this approach.

 

Why open source?

We believe Open Source and Open Standards are key to innovation and an alternative to traditional ways of purchasing systems from software suppliers.  Open source is owned by the Integration Pioneers and related community, though it can be reused by others across the health and care community.

We see the key features of an open source approach to Healthcare IT as;

  • Unconstrained Innovation – Ideas and ambitions can be shared by collaborators who work in different ways, in different organisations, different communities and different skills and experiences, including those not directly employed in healthcare IT
  • Transparent credibility – Allowing immediate detailed scrutiny immediately boosts credibility within the community
  • Decentralized control – amendments and improvement come from the community, bottom up

Based upon the findings from the initial survey issued we are now formulating programme plan around these six strands, aiming to deliver a release to the community every two months for the first 12 months of the programme. All the deliverables will be made available in the public domain under a recognised open licence.

Now is the opportunity to deliver a real change to care in the 21st century, to remove the barriers to progressing and to give the practitioners the tools they need to deliver more joined up care.

Ripple has begun, the community effort has started.

Hands up if you’re in!


 

Integration Pioneers in the 21st Century

There is a widely held view that 21st century care is under pressure, in a state of near-crisis in many places (ref #NHSwinter) where the burden of disease and the limitations of current health and social care systems are becoming ever more apparent.  We know that at the frontline, staff are already working under immense pressure, in unsustainable ways and that change is needed. We must find ways to “work smarter, not harder”.  So we must also find ways to improve the quality, safety, timeliness and cost effectiveness of 21st century care.

Of course,  the change that 21st century care needs will require strong leadership and changes in the way staff work at the coalface, and one question that presents itself is around the role of technology and specifically information technology.

Health and care commentators are, for the most part, all agreed that Information Technology is a key driver for change, while many are also aware that its great potential remains untapped. The gap between the hope and the reality of the promise of improving care via effective IT remains one of the key challenges facing us today.

In exploring this challenge, there is a view that the health and care IT market is not as good as it could be, lacking leadership and a mixed bag of technologies on offer with vendor lock-in a real issue.

Quite often it is still too hard to;

  • share citizen and patient information between providers and across city and district boundaries
  • adapt care pathways in a way that combines Lean thinking with a flexible information system
  • support the audit of care and research which for the most part is done by duplicating effort with cumbersome “back-room” processes.

It would be hard to contest the fact that the current state of the health IT market is holding us all back from the advances that 21st Century health and social care demands.

So is there an alternative path?

Leeds is one of 25 integration pioneers chosen to lead the way on the integration of health and social care through; new ways of working for staff, process redesign and integrated digital care records. Many are at early stages for this work but all with the same focus to improve care and work smarter.

Leeds, as part of an effort to positively disrupt the market, has ploughed its own pioneering path in this field via a mix of open source and open standards to underpin the Leeds PPM+ platform which now powers the Leeds Care Record. Great progress continues to be made on both fronts and positive feedback from both users and citizens alike is emerging, but Leeds believes it would benefit by contributing to and working with a broader community.

Recognising this need for change, to collaborate and to support integration pioneers, Leeds City Council on behalf of the city and with the support of the integration pioneers submitted a successful bid for the second phase of NHS England’s Integrated Digital Care Technology Fund. With the clinical leadership of Dr Tony Shannon, we are now reaching out to work with those 24 other integration pioneers who want to be part of Ripple community which is focussed along 6 open strands:

  1. Open Requirements
  2. Open Governance
  3. Open Citizen
  4. Open Viewer
  5. Open Integration
  6. Open Architecture

We hope that in sharing our challenges, our learning and our efforts, we can kickstart a real health and social care community effort. We are keen to collaborate with all others who recognise this story and share this vision, who choose to take this path together.

Photo of Tony Shannon

Tony Shannon

Repost from Tony Shannon’s Frectally speaking blog at frectal.com

 

My first blog of 2015 mentioned a word that is key to all change – culture.

Cultural change is a challenging thing and yet if we examine history, there is a noticeable pattern across all human culture over countless generations, from tribes to chiefdoms to city states to modern nations; the power of a story.

Often, scientific training teaches us that facts come first and therefore ones initial reaction may be to dismiss the power of stories. They can’t be scientific; there may be few specifics, no hard numbers or evidence base involved. I have many years of scientific training yet I realised as important as a scientific discipline is, any medical doctor will be able to recount a “good clinical case” – an individual patient story – that had a very important influence on their medical training and education.
Certainly in the early part of my medical career I could not quite reconcile the power of these stories with the factual evidence base that we were trained to focus on and refer to. However as time progressed, I began to appreciate the real power in stories and what is also called “narrative” as an important element of the art and science of fields such as medicine or management. Clearly, there must be something about stories that we need to better understand.

So when I heard of a recent webinar by the Faculty of Medical Leadership and Management on “Stories of Us: …. using public narrative to …. inspire change” I was keen to tune in. The series of webinars run by a medical colleague Dr Claire Marie Thomas (who did a great job) brought an approach to my attention which immediately resonated. Exploring the “Story of Self, Story of Us, Story of Now” it was quickly clear that, as a means of leading change and particularly cultural change, such an approach to stories and narrative offers invaluable help..

The principle, as I understand it, is that all real change starts with one person, who leads and takes on that change. To do this they need to tell their own story, a Story of Self. For that person to work with others to achieve real change, that story of self needs to become a Story of Us, and for that change to begin to gain momentum the story needs to become a Story of Now.

So if you’re sitting comfortably, then I’ll begin … my own short story, my Story of Self.

My own background is from a deeply medical family in Ireland, my great-grandfather on my mother’s side was a doctor, both my grandfathers were doctors, both my parents were doctors, all of my uncles are doctors, my only brother is a doctor. Within that environment I did consider taking other paths, including a look at engineering in my last year in school, yet in the end I also wanted to become a doctor and graduated in 1993 from medical school, University College Dublin.

Once qualified, my first job was in emergency medicine and although I considered a variety of other options I quickly realised that in terms of clinical practice, emergency medicine was the most challenging, diverse, stimulating and rewarding of all clinical environments – nothing else came close to holding my interest and attention and so I chose it as my own medical field.

While doctors are understood as a privileged profession who work hard, most enjoy the push and the pressure that goes with the work, especially as it so readily offers a way to “give back”, in looking after your fellow man, your patients’, as a real means to make the world a better place.
Certainly there are few places on the planet quite like an Emergency Department/Emergency Room, where “all of life is here”, literally from cradle to grave, where rich and poor are equal and care is provided based to whoever has the greatest need. The most moving moments in this intense setting.. are not those dramatic moments of the life or limb saved, but those moments after the event when patients and partners or family come together, quietly aware of what could have been, they are special moments to witness and stories not to be forgotten.

Over 20 years practising in Emergency Departments I can explain them as perfect examples of “complex adaptive systems” where you are constantly juggling patients from major resuscitation to minor injuries and everything in between, never sure what will come in next, always working to balance issues of the quality, safety and timeliness of a patients care.

Within that complexity and over time, I noted patterns emerge. Every emergency physician on the planet will know what I mean by the A/B/C approach to resuscitation, a simple yet vital tool to guide a team involved in the complex care of a patient by looking after: A – Airway, B – Breathing, C – Circulation. This process is essential to bring order from the edge of chaos. Another pattern I found involved asking a few key questions with every patient encounter: Was there anything I hadn’t covered? Had they any questions? Were they happy with their care plan?

One key pattern that leapt out from my early days as a doctor was the information intensive nature of work at the frontline. Every shift I have done has reinforced the point that to bring emergency medicine into the 21st century, we need much better information tools to allow staff to work smarter, not harder. My interest in this challenge meant that I slowly and steadily moved into medical leadership roles in Informatics and I have worked between emergency medicine and Informatics for most of the last 10 years.

So over the last ten years I have worked to lead and represent my clinical colleagues in the changes many of us believe are now required across healthcare in this 21st Century. I have listened to their stories whilst aware of my own and it has become increasingly clear to me that we are being hindered from making major progress in this field by the state of the health IT industry.
Those who know me, who have heard my story before, will have heard me say that I believe the industry has much to offer and I know there are many good people working in health IT, but that the health IT market is way behind the rest of the software industry and holding us back. Simply put, we need better Health IT.

Today, in 2015… many patients journeys through our health systems are too cumbersome and time consuming. Today in 2015, clinical staff often find it difficult to work effectively with current health IT solutions, it remains hard for disparate clinical groups to deliver integrated patient centred care and it is too hard for clinicians to keep up with the latest evidence based practice without better information and better tools. In essence the Health IT market needs major change to deliver and develop those systems which are required to support 21st Century high quality, safe clinical care and self-care.

In recent years I have moved to lead on some of the change required by promoting the role of open source and open standards in work that has underpinned the development of the Leeds Teaching Hospitals PPM+ platform and the related Leeds Care Record. I think that this work has gone well and thankfully in recent times we have seen the market starting to change.

Yet there is much more work to do and it has become increasingly clear that my journey needs to take this mission further and wider, to support the development of an enabling “open platform” that I believe will transform 21st century healthcare via the Ripple Open Source Initiative. So it was with that mission in mind that I completed my last shifts in Leeds ED last weekend, a new journey is in store, a new chapter in the story of self.

Dr. Tony Shannon
February 28th 2015

Link to the original post The Story of Self at frectal.com here