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Changing the Paradigm for Laboratory IT Systems

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Changing the Paradigm for Laboratory IT Systems Powered By Docstoc
					Yorkshire Centre for
Health Informatics


     ACB Focus 2008
     Foundation Lecture

     Laboratory Medicine in the Information Age :
                Reflections on the Future


Dr Rick Jones
Leeds Teaching Hospitals Trust
University of Leeds
Leeds UK
r.g.jones@leeds.ac.uk
Reflections on the Future
 1. When a distinguished but elderly scientist states that
    something is possible, he is almost certainly right. When
    he states that something is impossible, he is very
    probably wrong.

 2. The only way of discovering the limits of the possible is to
    venture a little way past them into the impossible.

 3. Any sufficiently advanced technology is indistinguishable
    from magic.
 4. For every expert there is an equal and opposite expert.

                                         Arthur. C. Clarke
                                         Profiles of the Future, 1992, 1999
ACB Foundation Lecture – May 22nd 2008                                   2
 Magic Numbers

                                          1000
           Notation              1000Decimal= 10
                                      + 10          Binary
             0                                  0     0
             1                                  1     1
             10                                10     2
             100                              100     4
             1000                            1000     8

                                              8
1908                                  1948                   2008
 ACB Foundation Lecture – May 22nd 2008                      3
 Lloyd-George, 1863-1945

 • Born in Manchester
 • The only Welsh prime minister
 • Responsible for the introduction of old
   age pensions, unemployment benefit
   and state financial support for the sick
   and infirm.

 • 1908 Pensions Act
   Foundation of the Welfare State



1908
 ACB Foundation Lecture – May 22nd 2008       4
Aneurin Bevan, 1897-1960

National Health Service Act
  July 5 1948
Core principles
• that it meet the needs of everyone
• that it be free at the point of delivery
• and that it be based on clinical need,
   not ability to pay

                                    Dr Thomas Jones (1870-1955), b Rhymney
                                    Deputy Secretary cabinet Lloyd-George
                                    Secretary of the National Health Insurance
                                    Commission (Wales).
                                     1948
ACB Foundation Lecture – May 22nd 2008                                           5
Sebastian de Ferranti, 1864–1930

Electrical engineer
Age 16, he built an electrical
  generator William Thomson
  (the future Lord Kelvin).
He worked for Siemens Brothers
  at Charlton, London.
He founded Ferranti, Thompson
  and Ince.

Manchester - 1948

                                     1948
ACB Foundation Lecture – May 22nd 2008      6
1960s - Magic of Computers

Flower power – Prague Spring
“White Heat of Technology”
Fortran Programming class
ICL - Mainframe
       real function densitycalc(i, step)
             implicit none
             integer i
             integer step
             real initd(6)
             data initd / 5., 6., 6.5, 6.8, 6.3, 5.4 /
             real dcalc
             if (step .eq. 0) then
               dcalc = initd(i)
             else
               dcalc = initd(i) * step * .8
             endif
            densitycalc = dcalc
             return
             end

                                               1968
ACB Foundation Lecture – May 22nd 2008                   7
BMB – Special Edition

   “The computer is causing a revolution. Some of its first
   applications may prove ephemeral, some may be wasteful
   and some could even be harmful. However, things are now
   possible that were not possible before and it would be an
   unusual experience in the history of science if such
   developments did not lead to major advances.”

                                                               JAB Gray,
                                          British Medical Bulletin, (1968)



                                         1968
ACB Foundation Lecture – May 22nd 2008                                 8
Medicine and Computers

Summer Job
Co-op Accounts
Honeywell 24k machine
    – Punch Cards
    – Tapes
    – TV Rentals Bills




                                         1968
ACB Foundation Lecture – May 22nd 2008          9
Medical Practice

House physician at Oxford Radcliffe
Computers research-based
CTL machine – accessible at night

  The Sun – “Crisis? What Crisis?”
Effect on house staff
• Callaghan replied:
   All urgent specimens by hand to the labs
• “Well, that's a judgment that you are making. I promise
   Taking patients to x-ray
   Collecting results at it from
• you that if you look at 6pm outside, and perhaps
  you're taking rather a parochial view at the moment, I
  don't think that other people in the world would share
  the view that there is mounting chaos.”
                                         1978
ACB Foundation Lecture – May 22nd 2008                      10
Early signs…




ACB Foundation Lecture – May 22nd 2008   11
Research Training

MRC Training Fellowship
• Derek Williamson – Hans Krebs Laboratory
    – DM: 'The role of insulin in the short-term regulation of mammary-
      gland lipogenesis: its relevance to substrate partitioning during
      lactation.„
    – Modelling blood flow
    – First PC in lab – still using carbon paper, scissors and cow gum!
• Diabetes – Robert Turner / David Matthews / Rory Holman
    –   UK Prospective Diabetes Study
    –   Recoding a Fortran model of an artificial pancreas
    –   Real time analysis of insulin secretion in humans
    –   Insulin resistance - Glucose clamping
                                                   1980
ACB Foundation Lecture – May 22nd 2008                                    12
Research & IT

Rory Holman / Stephen Walter / INCSTAR
ASTUTE Statistics Software winsDave Wiggins
Award at FOCUS 95 - Simon Huntington




                                         1980
ACB Foundation Lecture – May 22nd 2008          13
Medicine in Leeds

• Tutor in Professorial Medical Unit
    – General Medicine
    – Diabetes
• Computing
    – Glucose clamping – Peter Grant
    – Diabetic Foot Clinic database




                                         1983
ACB Foundation Lecture – May 22nd 2008          14
Chemical Pathology Training

Yorkshire Region Senior Registrar
• Memories
    – Leisurely pace
         • – lunch hours, study mornings
    –   Interesting science
    –   Variety of practice
    –   Great colleagues
    –   Lots of driving
• Surprises
    – French Computer System
         • Technicon LDM – “fin du jour” & “Oui et Non” commands
    – Prevalence of hyponatraemia
                                                    1985
ACB Foundation Lecture – May 22nd 2008                             15
Chemical Pathology – Jimmy‟s

• Computerisation
    – America Monitor
    – Hand cut reports
    – Digico paper tape
• New system
    – Ferranti first choice
• Telepath just released
    – Wolfson Labs
         •   Margaret Peters
         •   Ian Clarke
         •   Steve Murray
         •   Brian McCauley

                                         1988
ACB Foundation Lecture – May 22nd 2008          16
Pathology IT Retrospective

1964 - Tunbridge Report (Tunbridge, Flynn)
    –   Standardisation
    –   Preparation for „Mechanisation of Records‟
    –   Cost of A4 NHS filing cabinets – £200k
    –   Admin clerks costed at £700 pa




                                         1964
ACB Foundation Lecture – May 22nd 2008               17
Pathology IT Retrospective

Report of a working party of the Association of Clinical
  Pathologists - (Whitehead, Whitby, Flynn, Peters)
    – Covers entire Pathology information process
         •   Costs
         •   Procedures
         •   Knowledge
         •   Safety


    Data processing in clinical pathology. Report of a working party of the
    Association of Clinical pathologists. J Clin Pathol. 1968
    Mar;21(2):231-301. (Available free on PubMed Central)



                                         1968
ACB Foundation Lecture – May 22nd 2008                                    18
Report of a Working Party




ACB Foundation Lecture – May 22nd 2008   19
Recommendations

The Ministry of Health should:
    – Make money available for experimental automatic data processing
      systems
    – Set up a central advisory organisation as a matter of urgency
    – Make provision for the education of laboratory workers
    – Ensure that unique and concise patient identification is available on
      all requests
The Scientific Instrument Manufacturer Association and the
  National Research Development Corporation should:
    –   Take note of the growth of testing an dthe need for automation
    –   Create complete systems
    –   Use standardisation to eliminate interface problems
    –   Should make quieter and faster printers
    –   Work predominantly with the NHS

ACB Foundation Lecture – May 22nd 2008                                   20
Genetic Tree - UK Systems
Phoenix Programme - Six Labs
   – Trent
       • Silicon Lab
           – CILMS
                » APEX
   – Oxford                  Concepts and codes conserved
       • OPUS                     (electronic homology)
   – Wolfson
       • Telepath            USA Sunquest
           – TP2000               (parallel evolution)
Driven by:
    – Data processing - RIA
    – Demands of early automation
    – Data reduction
    – Laboratory management control as by-product

ACB Foundation Lecture – May 22nd 2008                      21
Early Development

  Early Design Assumptions
       –   Single disciplines – hospital base    Incremental
       –   One big analyser (+/- backup)         development
       –   Central processing (pre-PC)           possible
       –   Standalone - demographics + results
       –   Single database (per discipline)
       –   Fast and compact (MUMPS - „M‟)
  Maturation Phase
       – Inter-disciplinary links
       – Shared demographics - central PAS
       – Management information demands
                    (planning, contracting)
       – Increasing cost-pressure - increased automation

ACB Foundation Lecture – May 22nd 2008                         22
Leeds and Bradford Network

General and Specialist Services
• 9 Sites
    - 4 main
    - 5 peripheral
•   3m specimens - 20m reported tests
•   £52.7 million direct expenditure
•   900 WTE
•   > 1 million population
                                         SAS
•   4,200 beds
                                         • Steroids
•   180 Practices / 700 GPs              • Trace Metals

                                           1995           2008
ACB Foundation Lecture – May 22nd 2008                23
         10 miles
ACB Foundation Lecture – May 22nd 2008   24
Lack of Standards




                                         1995
ACB Foundation Lecture – May 22nd 2008          25
Change of Scale




                                         2002

ACB Foundation Lecture – May 22nd 2008          26
Leeds IT Architecture



                                     Executive
                                  Decision Support

                              Management Systems
                           Finance, Personnel, Statistics

                           Office Automation Functions
                                WP, email, WWW

                          Operational Systems
                LIS, POCT Network, Analytical sub-systems

ACB Foundation Lecture – May 22nd 2008                      27
Benefits

Linked to standardisation
    – Same equipment on all sites
    – Standardised methods
    – Reference ranges
Consistent results for every patient
Major cost saving
    –   No new capital – all within existing spend
    –   £100k per annum saving in maintenance charge
    –   Significant reduction of interface complexity
    –   Single GP feed
Major management time saving             “Please give
    – BMS‟s back to bench                generously”
                                                         2008
ACB Foundation Lecture – May 22nd 2008                  28
ACB-IT Group

Founded by Jonathan Kay
    – Bulletin Board System              • ACB Survey (paper)
    – Dial-up modems                         • Used PC      97%
• Members                                    • Internet use 50%
    –   Jonathan Kay                         • Medline use 64%
    –   Craig Webster
    –   Martin Holland
    –   John O‟Connor                    • Requirements
    –   Bill Godolphin                       • Rare assay list
    –   James Falconer-Smith                 • Computer aided learning
    –   James Hooper                         • Network help
    –   Ian Wells
    –   Jonathan Middle
                                             • Email list


                                                              1995

ACB Foundation Lecture – May 22nd 2008                               29
ACB-IT Group

Outcomes
    –   Jiscmail – Mailbase
    –   Assay Finder
    –   ACB Web Site
    –   IFCC Website
    –   NHS Developments




                                         1996

ACB Foundation Lecture – May 22nd 2008          30
ACB-CLIN-CHEM-GEN

 List Membership – year 1
      –   United Kingdom          74
      –   United States           188
      –   Australia               14
      –   Europe                  16
      –   Other                   6
 1000 messages




                                         1996

ACB Foundation Lecture – May 22nd 2008          31
ACB-CLIN-CHEM-GEN
United Kingdom 770       Belgium        5   Turkey       2
United States 287        Denmark        2   Israel       5
Australia      53        France         3   South Africa 2
                         Germany
                          Currently     7   Burundi      1
Canada         38        Portugal       3   Jamaica      2
Ireland        31        Spain
                       1321 Members     2   Japan        2
Netherlands    24 50 - 70Swedenper month
                          Topics        9   China        3
Hong Kong                Finland
               17 1200 Messages per year7   Malaysia     2
Italy          13        Iceland        1   Singapore 2
                         Czech Republic 3
                       Self maintaining     Mexico       1
New Zealand 12           Slovenia       2   Saudi Arabia 1
Isle of Man    3         Poland         1   Oman         1
                         Hungary        4
                                                        2008

ACB Foundation Lecture – May 22nd 2008                 32
ACB-CLIN-CHEM-GEN
Clinical Support - International

Please help me with the following case.
    A 60yrs female was diagnosed with hypothyroidism in Apr. 2002. She has
       been under Thyroxin therapy since then. Her TSH and FT4 results are
       shown as following table. Both TSH and FT4 have been monitored by
       Roche Elecsys 2010. On Apr.16, 2008, the patient came for annual check-
       up. The TSH was 80.1 and FT4 was normal. The same specimen was
       repeated in 12 days on the same analyzer as well as on different platform
       (Immulite 2500) and the TSH results were still very high (70.8, 58.5). The
       sample was also performed at the same run with the 5X dilution and the
       original specimen by the Immulte. The results indicated there might be
       HAMA interference. However, I think the interference is not great enough to
       contribute to this high degree of TSH. The patient is relatively normal other
       than this and did not show symptoms of hypothyroidism. She is considered
       as a reasonable patient with respect to her compliance to the treatment.
1. Is it a true TSH result? Can we adjust dose according to this TSH result?
2. What other methods can help identify the result?
3. Any other clinical issues for investigation?

ACB Foundation Lecture – May 22nd 2008                                           33
ACB-CLIN-CHEM-GEN
Science – Roger Ekins

This is not a trivial issue,
Having been involved in a number of public controversies relating to assay
   design and the concepts underlying the terms used to describe ligand
   assay performance, I am perhaps over-sensitized to the enormous
   impact that misunderstanding of these terms' meanings has had on the
   historical and present development of the so-called "ligand assay" field
   (which represents roughly 50% of clinical chemistry). But such a view is
   undoubtedly justified.
For example, these misunderstandings originally led to controversies
   regarding the relative performance of labelled antibody
   ("immunometric") assays, and of the use of MAbs in this context; also,
   more recently, they led to a failure by many to recognize that greater
   sensitivity and shorter performance times can be achieved using binding
   agent (eg antibody) concentrations that are orders of magnitude lower
   (i.e. ideally <0.01/K) than used in conventional assays of this type (i.e
   generally 20/K in non-competitive assays).
ACB Foundation Lecture – May 22nd 2008                                  34
ACB-CLIN-CHEM-GEN
Humour – Tim Reynolds

IMPORTANT: This email is intended for the use of the individual
  addressee(s) named above and may contain information that is
  confidential privileged or unsuitable for overly sensitive persons with low
  self-esteem, no sense of humour or irrational religious beliefs [if you
  want to believe in fairy stories and hug pixies that's up to you]. If you are
  not the intended recipient, any dissemination, distribution or copying of
  this email is not authorized (either explicitly or implicitly) and constitutes
  an irritating social faux pas. Unless the word absquatulation has been
  used in its correct context somewhere other than in this warning, it does
  not have any legal or grammatical use and may be ignored. No animals
  were harmed in the transmission of this email, though the kelpie next
  door is living on borrowed time, let me tell you. Those of you with an
  overwhelming fear of the unknown will be gratified to learn there is no
  hidden message revealed by reading this backwards, so just ignore that
  Alert Notice from Macroshaft. However, by pouring a complete circle of
  salt around yourself and your computer you can ensure that no harm
  befalls you and your pets. If you have received this eMail in error,
  please add some nutmeg and egg whites, whisk, and place in a warm
  oven for 40 minutes.

ACB Foundation Lecture – May 22nd 2008                                      35
1996 Internet conference
                                 “Just think what will happen when
                                 computing power is infinite and costs
                                 nothing; electronic storage is
                                 inexhaustable and very cheap; and
                                 telecommunications bandwidth is
                                 unfillable and very cheap.”
                                                     Graham Whitehead (BT)




                                                                1996

ACB Foundation Lecture – May 22nd 2008                                   36
Internet Growth




                                         1998

ACB Foundation Lecture – May 22nd 2008          37
Web Site Growth




                                         1998

ACB Foundation Lecture – May 22nd 2008          38
Moore‟s Law, infinity & beyond

           Log                                                               2x @ 6-12
                                                                               months


                                                            5 year gap
                                                            = 1000x !!!     2x @ 18-24
Performance/                                                                  months
    Price
                                        Now




               1995                    Now           2005                 2010 1998
                                              Time
ACB Foundation Lecture – May   22nd   2008                                            39
NHS 50 years Young




                                         1998

ACB Foundation Lecture – May 22nd 2008          40
Pathology EDI

Originated – Oxford – c 1990 – Jonathan Kay
By 1997
    – Running in 100+ labs, many since 1990
    – Mix of ASTM1238 (70%) / EDIFACT (30%)
Driven by
    – Professional interest / Fund-holding
    – Availability of technology & enthusiasm
Results
    –   Multiplicity of configurations
    –   Pockets of expertise
    –   Mixed standards
    –   No Interoperability
                                                1998

ACB Foundation Lecture – May 22nd 2008                 41
Pathology EDI

“….As a second step, by the end of 1999 all computerised GP
  surgeries will be able to receive some hospital test results
  over the NHSnet….”

Commonly perceived as a trivial task -
                “If I can email Bill Clinton,
            why can’t you email me my results?”
                                         attributed to Tony Blair 1997




                                                           1998

ACB Foundation Lecture – May 22nd 2008                            42
Pathology EDI

Ambitious scale
    – 10,000 practice systems
         • Connections / Firewalls
         • EDI Software
         • Training in new ways of working
    – 200 lab systems
         • Connections
         • Outboard interfaces


    – 26,000 visits by BT engineers alone




                                             1998

ACB Foundation Lecture – May 22nd 2008              43
    UN-Edifact Message
•    1 UNH+1+MEDRPT:0:1:RT:NHS003'
•    2 BGM+LSR'
•    3 DTM+137:200301140920:203'
•    4 S01+01'
•    5 NAD+MR+G0000017:900++DR VIRTUALONE'
•    6 SPR+PRO'
•    7 S01+01'
•    8 27 PNA+PAT++++SU:EDITESTPATIENT+FO:THIRTEEN'
•    28 DTM+329:19300514:102' 29 PDI+2' 30 S16+16' 31 SEQ++1'
•    32 SPC+TSP+:::Spec.Type?: Urine Site?: MSU'
•    33 RFF+STI:O,03.0001302.GA'
•    34 DTM+SCO:20030111:102'
•    35 DTM+SRI:200301111306:203'
•    36 GIS+N'
•    37 INV+MQ+4I16.:911::Micro, culture & sensitivities'
•    39 FTX+RIT+++ Clinical details?:'
•    41 FTX+RIT+++ test of readcode for dmluc: Antibiotic therapy?:'
•    42 FTX+RIT' 43 FTX+RIT+++ Microscopy?:'
•    45 FTX+RIT+++ White cells?: <10 x10^6/L: Red cells ?: <1 x10^6/L: Epithelial Cell s?: scanty: Cellular casts ?+?+ Numerous
     bacteria.'
•    47 FTX+RIT+++ Culture?:: Coliform species'
•    49 FTX+RIT+++ Bacterial count?: >10^5 cfu/ml'
•    52 FTX+RIT+++ Antibiotics?:: Amox/Amp S: Cefradine S: Ciprofloxacin S: Gentamicin S'
•    53 FTX+RIT+++ Nitrofurantoin S: Trimethoprim S'
•    55 FTX+RIT+++ This is a test of readcodes: on LGI system microbiology: Dave Lister: Note abs ence of pyuria'
•    57 FTX+RIT+++ Authorised by?: Dave Lister SJH 13.01.03:......................END O F REPORT..................................'
•    58 FTX+RIT'
•    59 RFF+ASL:1'
•    60 UNT+60+1'
    ACB Foundation Lecture – May 22nd 2008                                                                                   45
Costs

The original business case for pathology messaging was for a
  net present value of £40,627,000 over 8 years.
One off costs were forecast as £9,105,000 (undiscounted)
  over a three year period :
    – Trust costs of                     £6,145,000
    – GP systems costs of                £50,000
    – Central project costs of           £2,910,000




                                                        2004

ACB Foundation Lecture – May 22nd 2008                    46
The Challenge

How to move from fault-tolerant paper communication to
  fault-intolerant electronic information transfer.
               Technically easy - Culturally difficult




•   Intelligent human reader             •   Minimal experience
•   Decades of training                  •   Un-intelligent receiver
•   Lloyd-George compatible              •   receiver controls display
•   Permanent record                     •   Probably impermanent
ACB Foundation Lecture – May 22nd 2008                                   47
Coding Problems :
Fasting Blood Glucose

GPs / Clinicians :
    –    Request             „Fasting Blood Glucose‟
Labs :
    –    Measure             glucose
    –    in                  serum / blood / plasma
    –    drawn from          a fasted patient
    –    apply               units (mmol/L : mg/dL)
    –    add                 a reference range (low - high)




ACB Foundation Lecture – May 22nd 2008                        48
Coding Failure – GP Systems

E2 (Oestradiol) – mis-coded by GPs as Read code E2… -
  Neurosis & other mental disorder.
    –   329 practices (All EMIS)
    –   169 other coding confusions identified
    –   115,000 patient records compromised
    –   Compounded by patient flows – 10% turnover pa

    – This has never been cleaned up!




ACB Foundation Lecture – May 22nd 2008                  49
Reflection

162 Trust laboratories actively messaging all biochemistry &
   haematology data. Microbiology data also sent and
   radiology – both outside original scope
8,000 practices with a tested installation (109% of original
   target population)
8,000 practices signed receiving data

                       Key success factors
                       • Standards
                       Approximately 50 million
                       • Professional IT support
                           reports sent annually
                       • Strong business drive
                       • Scale
                                                                2008

ACB Foundation Lecture – May 22nd 2008                         50
University of Leeds

Senior Lecturer in Chemical Pathology
Joint post – teaching, research and service
Many multidisciplinary links:
    –   Clinical Information Science Unit – Tim deDombal, Susan Clamp
    –   Psychology – Mark Howes, Christine Parker-Jones, Joe Nichols
    –   IT – Nicholas Cook, Owen Johnson
    –   Computer-based learning – Andrew Cole, Rachel Pilkington
    –   Medical physics – Mike Smith, Martin Plumb, Tony Evans
    –   Design – Tom Cassidy
    –   English – Lynette Hunter



                                                    1990
ACB Foundation Lecture – May 22nd 2008                                  51
Screening, Elipse & Spinouts

                  NHS Academic Links
                       – NHS Screening service
                       – University research team

                  Cuckle H, Lilford R, Jones R. Maternal serum screening for Down
                     syndrome before 15 weeks. Am J Obstet Gynecol. 1994;170:959.
                  Cuckle HS, Jones RG. Maternal serum-free beta-human chorionic
                     gonadotrophin level: the effect of sample transportation. Ann Clin
                     Biochem. 1994;31:97-98.
                  ….
                  Reynolds T, Ellis A, Jones R. Down's syndrome risk estimates
                     demonstrate considerable heterogeneity despite homogeneity of
                     input. Ann Clin Biochem. 2004 Nov;41(Pt 6):464-8.
                  Maymon R, Cuckle H, Jones R, Reish O, Sharony R, Herman A.
                     Predicting the result of additional second-trimester markers from a
                     woman's first-trimester marker profile: a new concept in Down
                     syndrome screening. Prenat Diagn. 2005 Dec;25(12):1102-6.
ACB Foundation Lecture – May 22nd 2008                                                     52
Elipse (www.elipse.org.uk)

Elipse is a decision support engine which conducts the
   complex calculations used in prenatal screening risk
   assessment.
                                         Takes account of:
                                           • Maternal age
                                           • MoMs / Medians
                                           • Ultrasound Biometrics
                                           • Gestational age
                                           • Up to 10 markers
                                           • CE Marked



ACB Foundation Lecture – May 22nd 2008                       53
Elipse & PerkinElmer




ACB Foundation Lecture – May 22nd 2008   54
Reflection – Knowledge Transfer

Elipse
    –   Knowledge generated in academic environment
    –   Captured and engineered into software deliverables
    –   Includes educational support
    –   Distributed and disseminated by industry


•   Long and difficult road
•   No-one makes money!
•   Supports research
•   Feeds back into service improvement – QA



ACB Foundation Lecture – May 22nd 2008                       55
Information in the NHS

  “Better care for patients, and improved health for
      everyone depend on the availability of good
      information, accessible, when and where it is
      needed.” NHS Information Strategy


  Strategic role
       – Effectiveness
            • application in information intensive activities

       – Efficiency
            • cost reduction through better clinical control
                                                                1998

ACB Foundation Lecture – May 22nd 2008                                 56
NHS Information Strategy

Key commitments
    – lifelong electronic health records -
      EPR
    – round the clock on-line access to
      patient records and information on
      best practice
    – seamless care through information
      sharing
    – fast and convenient public access to
      information
    – the effective use of health resources
      by providing planners and managers
      with the information they need          2004

ACB Foundation Lecture – May 22nd 2008         58
CfH – Highlights
 Achievements to date 28/5/07 - Nationally
1.2 million        NHS employees have access to the new N3 network
252,347            Registered NHS mail users
469,856            Staff registered to use the NHS Care Records Service
153,188            Care Records on the NHS Spine
77.4 million       prescriptions transmitted using Electronic Transmission
                   of Prescriptions
7.9 million        Bookings made using Choose and Book – 50% GP activity
127                Picture Archiving and Communications Systems live
640 million        Images stored on PACS from 25 million patient studies
108,334            medical record transfers using GP2GP
28,365             Quality Management & Analysis Service (QMAS) users
                   across all 8,659 GP sites in England

                                                                        2008
ACB Foundation Lecture – May 22nd 2008                                 59
Politics with a big P.

Cameron's Conservative blog entry...
  "We'll champion open source software, not big clunking
  mainframe solutions. No more NHS computers, much more
  open platform projects that can be broken down into their
  component parts.“ 12.05.2008

                     http://www.conservatives.com/tile.do?def=webcameron.davidsdiary.page&obj_id=143447




         Can we trust the politicians – any of them?



                                                                                                           2008
ACB Foundation Lecture – May 22nd 2008                                                                    60
Pathology and CfH

Pathology not in CfH „Core‟ product set
Why?
   – Deliberate exclusion because:
      • Pathology Modernisation in progress
      • Business model uncertain
   – Large established Pathology IT base
      • „no need to change‟
      • little perceived business benefit
           Therefore freedom to buy based on business
              need and should be cost benefit – not
               replacement for replacements sake.
ACB Foundation Lecture – May 22nd 2008                  61
NHS Pathology Projects

Currently the DH is sponsoring several projects to create the
  infrastructure for the future :
    –   Harmony – Jonathan Berg
    –   POCT – Gilbert Weiringa
    –   Pathology FAQs – Stuart Smellie
    –   Benchmarking – Helen Ogden, Keele
    –   Laboratory Handbook – Rick Jones
    –   Order Communications – Ian Barnes
    –   LabTest Online – Ian Godber
    –   Genetics LIMS - StarLIMS – Stuart Bayliss
    –   Pathology IT Summit – Gifford Batstone


                                                                2008
ACB Foundation Lecture – May 22nd 2008                      62
Pathology Clinical Benchmarking

Efficiency - laboratory focus
    – Cost reduction
    – Turnaround
Effectiveness - clinical focus
    – Right test
    – Right time
    – Positive patient benefit

                        Challenges
                        • Changing clinical behaviour
                        • Maximising value-added benefit
                        • Improving overall test-performance
                                                                2008
ACB Foundation Lecture – May 22nd 2008                         63
Linking into the Clinical Domain




             Laboratory                  ‘Audit   Clinical
              Database                   space’   Database




ACB Foundation Lecture – May 22nd 2008                       64
 Robert Aurand Moon
 1917 - 2001

Inventor of the ZIP code
   – Zoning Improvement Plan

Father of Junk Mail
                                           Meta-analysis

                                   Zip Code
                                 NHS Number
              Bank
             Account
                                                             Social
                                          Credit Card      Class Data
              Insurance
               Records                       Info

 ACB Foundation Lecture – May 22nd 2008                                 65
U
Current Pathology IT Challenges

Darzi – the NHS context
Carter Review – the Business Model
Pathology IT Summit – the next 5 year plan
Stabilising the IT workforce
Renewing the technology
Working
    – at the appropriate scale
    – across the relevant boundaries




                                              2008
ACB Foundation Lecture – May 22nd 2008       70
Functional Architecture

Level Type               Clinical                       Management                Content
4       Executive        Decision Support               Performance Monitoring    Knowledge
                                                        Planning                  Systems
                                                        Quality Management




3       Intermediate     Ward Requesting                Workload Systems          Aggregate
                         Clinical Reporting             Supplies / Contracting    Information
                         R&D                            Quality Assurance
                         Statistics


2       Operational      Analytical Control Reporting   Word processing           Operational
                         Data e.g. LIMS                 Web Browsing              Data
                         POCT Networks                  E-mail


1       Infrastructure   Servers / PCs / Printers / PDAs / VPNs / Voice & Image   Infrastructure
                         management


ACB Foundation Lecture – May 22nd 2008                                                          71
N-Tier Conceptual Architecture
                                       End User Functions

       Order           EHR                Planning           Laboratory   Performance
      Comms           Support            Contracting         Handbooks    Management

                                       Business Services
               Order &         Lab 2           Contracting         Knowledge
               Results          Lab           Benchmarking          Support

                                 Foundation Data Services

                                        Data Management
                  Result                     Service               Knowledge
                Repositories                Catalogues               Sets

                                         Data Architecture
                   Data             Data            Metadata       Rule Models
                Standards          Models            Models


ACB Foundation Lecture – May 22nd 2008                                                  72
Path IT Training Levels

Skill Level Competencies             Examples                   Job Functions
Basic          EDCL                  Data access                A&C
                                     and data entry             Technical

Intermediate   Application use       Word Processing            Supervisory staff
                                     Spreadsheets               Scientific leaders
                                     Databases                  A&C

Advanced       Application use       Statistical analysis       Scientific Leaders
                                     Modelling                  R&D
                                     Web site design            Management

Specialist     IS development        Specialist applications    System managers
                                     Bespoke systems            IT Support
                                     Decision support systems
                                     Management Application




ACB Foundation Lecture – May 22nd 2008                                               73
Path IT Training




ACB Foundation Lecture – May 22nd 2008   74
Reflections on the Future




                                         Bio & Health
                                         Informatics

ACB Foundation Lecture – May 22nd 2008                  75
The Information Age in Medicine

Accelerating pace of change
    – Growth in medical knowledge
    – Globalisation of access to information
Breakdown of institutional hegemonies
    – Primary / secondary care
    – Pharmaceutical / diagnostic industry involvement
Challenges to professional status / rights
    – Security / confidentiality / openness
    – Patients as informed as professionals




ACB Foundation Lecture – May 22nd 2008                   76
Laboratory Information

“The value of information is equal to the enhanced value of
  outcomes based on that information."
                                           Flagyl (1973)
"The only product of the Clinical Laboratory is information. The
  generation of that information is the end product of
  appropriate test selection, specimen collection, analysis,
  result reporting and interpretation.
To achieve this sequence requires the harmonized interaction
  of a variety of personnel with a spectrum of expertise. Such
  is the domain of Medical Informatics."

                                           William Dito (1979)

ACB Foundation Lecture – May 22nd 2008                           77
Darzi Pathways


      A&E          Tertiary              18 weeks


                                              Diag
       GP               OP                    (IP)          OP               IP          OP
                                         Diag
                                         (OP)                                OP
        Assess
                                                                           Other
                   1st Outpatient        Diagnostic       Decision       Treatment/
                                                                                       Follow-up
                   Appointment             phase           to treat      Discharge

                                     Data flows
   Choose                     Future        Outpatients      Elective       Admitted
   and         A&E            Care          (Care            Admission      Patient
   Book                       Activity      Activity)        List           Care

ACB Foundation Lecture – May 22nd 2008                                                     78
Health Economics




ACB Foundation Lecture – May 22nd 2008   79
The Information Space
                                                 Health Intelligence                                       Health Management
                                                                                                                      Decision
                                              Quality & Efficiency                                                    Support
Demand for Information-Enabled Health




                                                                                                                                 Chronic Care
                                                Management             Health                              Provide               Management
                                                                        Plan                                  r
                                                                                                                        Health Plan        Medication
                                   Health
                                                       Provider                                                                             Therapy
                                  Outcomes
                                                                                     Integrated                                           Management
               Services




                                & Economics
                                                                                     Electronic
                                                                                  Electronic Patient                             Employ
                                                         Life                          Patient
                                                                                Information Network                                er
                                         Clinical                                     Records
                                                       Science                                                                              Health &
                                         Research
                                                          s                                                                Public           Wellness
                                        Optimization
                                                                                                                           Sector          Management
                                                 Safety                                Clinical,
                                                Surveillanc        Public Sector                           Consumer
                                                    e                                Financial &
                                                           Disease/                                                      Personal Health
                                                             Bio-
                                                                                     Operational                         Records (Shared
                                                          Surveillance                  Data                             Decision Making)
Network
Data




                                        Health System Research Network National        Regional Health     National         Data             Payor
                                                                      Association   Information Exchange     Lab          Aggregator

ACB Foundation Lecture – May 22nd 2008                                                                                                               80
Clinical Records - Scale

Blue Health Intelligence – 79m
CMS – 40m
Ingenix – 30m
Vanderbilt - 1.8m
Partners Healthcare - 2.5m
Intermountain Healthcare - 2m
Regenstrief – 3m
Mayo Clinic - 4.4m
AMGA/Anceta – 12m              Opportunities for Diagnostics
UK NHS - 55m                   • Clinical care
                                         • Research – trials, Biobank
                                         • Surveillance – microbiology
                                         • Intelligence & Knowledge

ACB Foundation Lecture – May 22nd 2008                                   81
Personal Philosophy

                                         Service




             Academe                               Industry


ACB Foundation Lecture – May 22nd 2008                        82
Acknowledgements

      Robert Turner, Rory Holman, Brian Payne, Andrew Grant, Colin
     Toothill, Sherry Faye, Mike Cummerbatch, John Cooney, Simon
     Huntington, Drew Morgan, Dave Holland, Helen Ogden, Keith Gailer,
     Andrew Little, Julian Barth, Steve Goodall, Muir Gray, Derek
     Williamson, Vera Ilic, Andy Ward, Liz McNamara, John Whicher, Ian
     Barnes, Chris Price, Graham Beastall, Hugh Mitchell, Craig Webster,
     Jonathan Kay, Andrew Moore, Stephen Walter, Dave Wiggins, Kevin
     Page, Mark Howes, Christine Parker Jones, Carol Chu, Graham
     Isaacs, Caroline Bellini, Mike Smith, Liz Berry, Tim deDombal, Chris
     Burke, David Ramsay, Terry Thrasher, Stephen Taylor-Parker, Howard
     Cuckle, Indera Sehmi, Carol Wilson, Es Will, Joe Nicholls, James
     Falconer-Smith, Bill Godolphin, Glenn Edwards, Bob de Jong, Donald
     Saum, George Philp, Steve Walker, Stephen Pill, Roy Lambley, Carol
     Longthorne, Faye Storey, Ian Watson, Lyn Sharman, Geoff Auchinleck,
     Yvonne Parker, Lynette Hunter, Derek Cramp, Ewart Carson, Alison
     Friday, David Robinson, Nick White, Derek Hockaday, Roger
     Blackburn, Mary Jones, John Jones, Viv Jones, Anna Jones, Luke
     Jones, Phil Wiles, Mike Toop, Hazel Wilkinson, Brian Roberts, Bob
     Oakey, Marion Cawood, Alison Jennings, Tim Branch, Dave Beaven,
     Paul Risdon, Keith Taylor, Rob Young, Martin Jones, John O‟Connor,
     Margaret Peters, Brain McCauley, Alistair Cartwright, Ted Woodhouse,
     Phil Molyneux, Martyn Forrest, Susan Clamp, Liz King, Sue Davis,
     Owen Johnson, Teddy Cooper, Ray Davies, Brian Gill, Mike
     Bosomworth, Gordon Cook, Tony Child, John Wales, Andrew Davies,
     Brian Jewell, Karen Lee, Deirdre Feehan, Mike Hallworth, Darren
     Green, Timmpa Honkosala, Morgan Feely




ACB Foundation Lecture – May 22nd 2008                                      83
Reflections on the Future

        “If men could learn from history, what lessons it might
        teach us! But passion and party blind our eyes, and
             “You can never plan the future by the past.”
        the light which experience gives is a lantern on the
        stern to light the waves behind” (1729-1797)
                              Edmund Burke
                                         Samuel Taylor Coleridge (1772 - 1834)




ACB Foundation Lecture – May 22nd 2008                                           84
                                                                               Gracias
        Hindi                                                                                                     Thai


                                                      Traditional Chinese


                        Russian                                                          Spanish




                                                                                                    Obrigado
       Arabic
                                            Thank You                                                        Brazilian Portuguese




                        Grazie                                                 Danke
                                  Italian
                                                                                German

                                                                                                            Merci  French




                                               Simplified Chinese
                Tamil

                                                                                                   Korean




                                                                    Japanese




ACB Foundation Lecture – May 22nd 2008                                                                                              85
ACB Foundation Lecture – May 22nd 2008   86
Perspective




              “Everything which can be
            invented, has been invented.”
                                         - U.S. Patent Office Official, 1897

                Dr Rick Jones, Leeds, UK
                  r.g.jones@leeds.ac.uk
           http://www.ychi.leeds.ac.uk/rgjones
ACB Foundation Lecture – May 22nd 2008                                         87
Challenges




ACB Foundation Lecture – May 22nd 2008   88
Challenges - safety




ACB Foundation Lecture – May 22nd 2008   89
Safety? - Personal experience




ACB Foundation Lecture – May 22nd 2008   90
Current technology


                                                    2-dimensional bar code
                                                    has more data.




                                                     Radio-frequency CHIP
                                                     emits patient’s ID




                  Photo courtesy of Precision Dynamics, Corp.
ACB Foundation Lecture – May 22nd 2008                                  91

				
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