This blog post is written in response to a brief twitter comment reproduced below:
@martinmurphy001 more support for ditching primacy of WCP as only interface for users. Break up WCP and let us leverage underlying systems!
— Mark Wardle (@mwardle) February 21, 2013
The reason for writing that was to point out that breaking up the data models, controllers (business logic) and the user interface is vitally important for medical applications – following a strict MVC (model, view, controller) paradigm, even if the data model may be a summary view of many other internal systems. One obtains considerable benefits from this approach and, salient to that twitter comment, means that one can support new ways of working – for example, touch-based devices and BYOD (bring your own device).
There are many common components required for all electronic patient record systems including patient demographics, laboratory results, radiology results, appointment scheduling, paper case note tracking, document creation, editing, signing and storage (and sending).
The current Welsh Clinical Portal project (WCP) is making great strides in some important areas – test results and requesting, medicines transcription and electronic discharge (MTeD) letters. However, I would note that a traditional project management approach is still being used, with project development teams “completing” the development, being disbanded and ongoing development under strict change-control procedures via a different set of management groups. I would suggest that developments such as these are never complete and require continuous improvement and development – a much more agile approach to healthcare systems development.
Healthcare IT is complex, particularly when multiple organisations are involved with multiple patient identifiers and different groups of users with different needs. In addition, there are important governance requirements and while NHS hackdays are an exciting development, some quality assurance is required to be sure that systems, both real-life and electronic, are safe for the management of patients. These issues create a threshold that impedes new small-scale development in favour of larger, more established companies or products and stifle innovation. Clearly, these opposing factors need to weighed carefully to ensure systems can evolve to meet changing needs and yet be safe for clinicians and patients.
If underlying health systems such as a master patient index (in Wales this is the EMPI as supplied by IBM Initiate for example) can be made easily accessible to third-parties subject to appropriate governance and safety requirements, then such systems can leverage these core services in new and innovative ways.
Unfortunately, IT professionals are frequently (and correctly) wary of opening up services to third-parties so that they can mash-up or present data in different ways. As such, my experience has been a war of attrition in order to gain access to different services. My original tweet was perhaps a reflection on how difficult it has been to gain support or access to different services. That said, with limited resources, how much should IT departments support rogue clinicians wanting greater access to healthcare data.
We are creating a register of patients known to our epilepsy and multiple sclerosis services. With the appropriate access to underlying health systems, we’d be able to pull out salient investigation results and even generate alerts so we know when the patient is admitted to A&E even before the admitting doctor has chance to pick up the phone and tell us. I can now access our system on smartphones when out and about while the existing national systems are not functional on these devices yet.
The pace of change demands an end to monolithic applications in favour of a mash-up of core services combined into speciality specific portals. Such an approach is the opposite of that originally planned for by the National Programme for IT (NPfIT) in England which planned on centralisation driven mainly by political will rather than clinical need. The strategy in Wales has been about small incremental improvements and adopting common systems when this makes clinical sense (e.g. laboratory systems). This approach will, in the end, create better systems for clinicians and patients alike.