Mental Health Informatics Industry Insights
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Talk I gave at Royal College of Psychiatrist's International Congress 2012 at Liverpool, UK
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Mental Health Informatics Industry Insights
- 1. Mental Health Informatics What we can learn fromindustry and where we can be… Himanshu Tyagi South West London and St Georges Mental Health Trust
- 2. How things have evolved 20 years ago We waited for our mail to arrive. Our best tool for updating our status was a “post-it” note. Forgetting was an option available to us (& time was a great healer).
- 3. How things have evolved 20 years ago Now We waited for our mail to arrive. Our email waits for us to arrive. Our best tool for updating our status was a “post-it” note. Asynchronous > Synchronous (1/10th humanity) Forgetting was an option available to us (& time was a great healer). We are storing our personal memories at an unprecedented scale.
- 4. How things have evolved 20 years ago Now We waited for our mail to arrive. Our email waits for us to arrive. Our best tool for updating our status was a “post-it” note. Asynchronous > Synchronous (1/10th human population) Forgetting was an option available to us (& time was a great healer). We are storing our personal memories at an unprecedented scale. NHS 2012 We are still posting letters to our colleagues We are now discovering the power of SMS communication Forgetting is still an option as we don’t really know an easy way to find the information we stored.
- 6. First Automobile - 1900
- 7. Automobile 30 years later
- 8. Can we wait for another 30 years? Pace of technology has accelerated Medical data explosion is happening Information power dynamics are shifting
- 9. State of play Healthcare sector is lagging behind other industries in adopting technology-enabled process improvements. 15-20 years Failure to capitalise on the full potential of technology* This trend would be amplified by: An aging population A further shift towards chronic care models Emergence of new, more expensive treatments Rapidly changing landscape in technology Potentially long timelines for implementing change Unsustainable *Co o kse y re po rt, 20 0 6
- 10. “The re is a stro ng case fo r incre asing the am o unt spe nt o n NHS IT. ” DoH White Paper, Information for Health 1998
- 11. “Larg e st no n-m ilitary IT pro je ct in the wo rld” National Program for IT (NPfIT) 2002-2011
- 12. "We've got lots of information technology. We just don't have any information."
- 13. Money is important, but just a small part of the big equation Most of the transformative technologies in the last decade had humble beginnings Implementing the technology is relatively easy, getting agreement on changing clinical practice is not. To reduce the risk of failure, we have to identify risks and barriers to technology and identify strategies for minimising or eradicating them.
- 14. Barriers to the identification of such a strategy itself: Creators usually are not the consumers Project leadership have to see the big picture across two separate industries Traditional management styles are being disrupted by the pace of technology Plenty of room for clinical leadership Some food for thought for future clinical information leaders
- 15. Challenges and barriers Expectations from technology The business of information – future proof solutions Information overload/Data explosion
- 16. Barrier: Expectations Clinicians are not interested in machine, latest technology, or fancy user interfaces, we are only interested in the information. Our expectation is to have a seamless flow of information, which integrates easily with our existing world.
- 18. We expect a sixth sense
- 19. But our reality is incongruous
- 20. Barrier: Expectations User => Information
- 21. Barrier: Expectations User => Information We don’t really need new objects into our world, or need to learn new ways to do things, but we make a compromise As the alternative was more ‘painful’
- 22. Barrier: Expectations User => Information We don’t really need new objects into our world, or need to learn new ways to do things, but we make a compromise As the alternative was more ‘painful’ User => Librarian/Medical Records/Index cards/ Grapevine => Time/Motivation/Resources => Information (hit and miss)
- 23. Barrier: Expectations User => Information We don’t really need new objects into our world, or need to learn new ways to do things, but we make a compromise As the alternative was more ‘painful’ User => Librarian/Medical Records/Index cards/ Grapevine => Time/Motivation/Resources => Information (hit and miss)
- 24. Barrier: Expectations Many points of friction, not frictionless But our problem is usually with the user interfaces User Science/Usability experts More intuitive, less complex 4.3 million years Program the machine, not human beings Produces end user’s resistance to adoption of technology – barrier to change
- 25. Innovate
- 26. “NHS is in the busine ss o f info rm atio n. O ne third o f NHS tim e is spe nt co lle cting , distributing , sto ring , transpo rting o r sharing info rm atio n. ” The NHS IT Pro je ct: The Big g e st Co m pute r Pro g ram m e in the Wo rld. Eve r! Book by Sean Brennan
- 27. Barrier: The business of information Before NPfIT - Software NPfIT – Service After NPfIT – Software or Service? Information strategy – decentralisation Risk of repeating the cycle at local levels?
- 28. Barrier: The business of information Immeasurable permutations and combinations of required software solutions YBOCS Can one size fit all? – conclusively not Can we customise? - Best solution for one, is the worst solution for another. A third model has emerged in the industry
- 29. Barrier: The business of information Big organisations have moved away from creating software. MDD - Model Driven Development “a so ftware de ve lo pm e nt appro ach that aim s at de ve lo ping so ftware fro m do m ain-spe cific m o de ls ” Within a few years, MDD has moved from a novel concept to a pragmatic business necessity in large corporations. Examples: App store by Apple Google play Amazon Kindle
- 30. Barrier: The business of information The case for taking MDD approach in NHS Lower the overall cost of building large internal applications Speed time to build large applications Lower the risk of large applications Simplify development Lower the required skill level needed to work on large applications Expand the pool of resources that can work on large applications Leverage open source
- 31. Barrier: The business of information Veterans Health Administration uses such a system over 160 hospitals, 25 million patients Eliminated entire classes of medical errors Improved efficiency Enabled detailed analysis of efficacy of specific treatments across a broad population VistA Ranked number one on a broad array of metrics in numerous studies Fully open source & MDD
- 32. Barrier: Data Data explosion Medical information doubles almost every five years Often, new knowledge makes established treatments obsolete Per year: 22 000 new journal articles 30 new drugs 6000 combinations of drug compatibilities to consider The number of drugs has grown 500% in just the last decade to over 17000 trade and generic names.
- 33. Barrier: Data We routinely discard most of the data we generate in healthcare Healthcare data Clinical Financial R&D Patient data (behaviour and sentiment) Four separate pools of data Not interconnected, rarely shared
- 34. Barrier: Data Data rethink Digitisation provides us with an opportunity to move away from a centuries old tradition of sampling Emergence of Big data models Why look at samples, when we can analyse the whole datasets
- 35. Barrier: Data 27000 avoidable cardiovascular events Rofecoxib – Statistical evidence of CVS side effects early on Proven only when the California-based integrated managed-care consortium Kaiser Permanente connected clinical and cost data Provided the crucial dataset – triggered one of largest medication recall in history
- 36. Clinical leadership in Informatics Need of the hour Plenty of room Trainee’s Health Informatics Network (THINK) Royal college informatics committee RCGP informatics forum himanshutyagi@nhs.net
Notas do Editor
- Thanks for giving this opportunity to give this very interesting presentation on a very interesting topic, that I personally find fascinating. Fascinating enough for it to be my main special interest as a SpR, it was so even as a SHO. This is the topic of informatics, which is usually defined as the art and science of information. Application of informatics in healthcare in not new, but it has affected our day to day clinical practice only in last decade or so. In future, when we would look back at this time, we would see healthcare informatics as the biggest revolution in our generation. Today both doctor and the patient have become voracious information consumers, using easily accessible knowledge to inform our decisions in millions of different ways. Literally millions. But it would be a bit difficult to get away by talking about a million things in a presentation on information overload, so I have filtered them down to two, two main issues that clinicians face every day. One is Electronic patient records (EPR) and the other is Information Overload. And no, it is not a presentation on problems with RiO. I am not even going to use that word, as I want us to take a step back and reflect on the background picture, look at some of the fundamental assumptions (or core beliefs as I would call them my role as a CBT therapist). RiO is just a tiny part of this big picture. This is not a workshop, so I am not going to talk about information management or tips. Let us start with EPR first.
- We got our mail once a day and we had rest of the day to deal with it. Synchronous communication (face to face, telephone) was still the dominant form of interpersonal communication. Time was regarded as a great healer as forgetting was an option available to us. Are we doing something about it? Common sense would tell us that we can spend more money. Most big orgabisations like IBM spend upto 25% of their budget on organisational IT solutions. It turns out that we have done it before.
- We got our mail once a day and we had rest of the day to deal with it. Synchronous communication (face to face, telephone) was still the dominant form of interpersonal communication. Time was regarded as a great healer as forgetting was an option available to us. Are we doing something about it? Common sense would tell us that we can spend more money. Most big orgabisations like IBM spend upto 25% of their budget on organisational IT solutions. It turns out that we have done it before.
- We got our mail once a day and we had rest of the day to deal with it. Synchronous communication (face to face, telephone) was still the dominant form of interpersonal communication. Time was regarded as a great healer as forgetting was an option available to us. Are we doing something about it? Common sense would tell us that we can spend more money. Most big orgabisations like IBM spend upto 25% of their budget on organisational IT solutions. It turns out that we have done it before.
- At the beginning of 20 th century, the primary medium of transport was this.
- (use automobile example to illustrate that point, but automobile could have coped with 40 years as the world was more or less unchanging, comparatively, there was no email, telephone, morse code was the dominant form of long distance communication, even distance between St Georges and Springfield at time qualified as long distance)
- New generation took over, and we are more happy with this model
- But I am not here to give you this obvious piece of bad news. The point of my presentation is to draw your attention to some of the things which all of us can identify in the technological landscape around us, and learn something from it. Unnatural split – technophiles at home, technophobes at work We hear that patient safety we are learning from airlines industry, Let us see what the other industries are doing? Health care, one of the largest sectors of the US economy, accounts for slightly more than 17 percent of GDP and employs an estimated 11 percent of the country’s workers. It is becoming clear that the historic rate of growth of US health care expenditures, increasing annually by nearly 5 percent in real terms over the last decade, is unsustainable and is a major contributor to the high national debt levels projected to develop over the next two decades. An aging US population and the emergence of new, more expensive treatments will amplify this trend. Thus far, health care has lagged behind other industries in improving operational performance and adopting technology-enabled process improvements. The magnitude of the problem and potentially long timelines for implementing change make it imperative that decisive measures aimed at increasing productivity begin in the near term to ease escalating cost pressures.
- Information strategy in not the first white paper on it in nhs, it is one in a series of many
- Our clinicians are overwhelmed. Medical information doubles almost every five years and, often, new knowledge makes established treatments obsolete. There are around 22 000 new journal articles per year, at least 30 new drugs per year, and more than 6000 combinations of drug compatibilities to consider. The number of drugs has grown 500% in just the last decade to over 17 000 trade and generic names. clinicians need sub-second rapid response rates from their clinical applications if we are to keep their support. Read more at location 2627 We have witnessed first-hand, or at least through this book, the success at sites such as Greenwich, Burton, Winchester and Wirral. Their success was not easily replicated in other sites, even with the same IT system. Why? Because the Burtons and Wirrals and Winchesters and Greenwichs had a very tailored solution. It was 'moulded' around their work practices, and the systems fit like a glove. Read more at location 2630 dumbing down of functionality in order to get consensus? That is the challenge. Changing existing work practices which have evolved over many years will not be easy. Implementing the technology is relatively easy compared to getting agreement on changing clinical practice In order to reduce the risk of failure, it is worth identifying those risks and barriers and identifying a strategy for minimising or eradicating them. NHS is in the information business. Read more at location 626 B003BVJMUE 20856 Note: Add a note It has been estimated that about one third of NHS time is spent collecting, distributing, storing, transporting or sharing this information.Read more at location 630 B003BVJMUE 21018 Note: Add a note
- User interfaces – do not change, conditioning Ecosystem argument – apple, google, msft, best solution for one is worst for another Open source, cost issues, peer to peer Dealing with IO - Big data Staffing – talent, small teams, good programmers = 20 X bad programmers, Digital immigrants Delhi – bangalore – sfo Clinical leadership Only NHS can do this Fits well with information strategy
- WYGINWYN principle: “What You Get Is Not What You Need” Perhaps we should call these technical objects, transitional objects, because they do not have a future.
- Seamless flow of information We want our information to merge seamlessly in our physical world
- But there is only one system which can do all of this for us i.e. one of our five senses, Can current information systems fulfil such expectations? Let us examine the reality here.. It should be as reliable as one of my senses. Like the five high tech sensors that we all carry around and which provide us with point of care decision support, information technology should provide us with a way to sense data.
- Transitional objects
- The psychological meaning of the word "inertia" implies an indisposition to change - a certain "stuckness" due to human programming. It represents the inevitability of behaving in a certain way - the way that has been indelibly inscribed somewhere in the brain. It also represents the impossibility - as long as a person is guided by his habits - of ever behaving in a better way. Psychological Inertia (PI) represents the many barriers to personal creativity and problem-solving ability, barriers that have as their roots "the way that I am used to doing it." In solving a problem, it is the inner, automatic voice of PI whispering "You are not allowed to do that!" Or, "Tradition demands that it be done this way!" Or even, "You have been given the information, and the information is true." Once we learn something and it is doing the job, we don ’t want to learn something else for that purpose i.e. we do not want to use something new just because it is bigger, better, shinier and may be more effective. Build on something we have already learned, not something new. The meaning of UI is much broader It includes how your computer sits on the table How it sits in relation to you and the patient, both users of the information “ Cool user interfaces don’t change” Psychological inertia Resistance Do not throw the baby out with bathwater Tapping on existing learned behaviours
- Intelligent data management Cost 10,000 USD The prospect of external (non human) computational powers has been one of the strongest fantasy for mankind in 20 th century Science fiction from first half of 20 th century has vivid descriptions of what mankind would do with the cognitive surplus, which is left when computers and machines have taken over our daily, mundane tasks. It has been described so many times that sometime it feels as if it has become a part of our collective unconscious, driving many of the realities that we see around us. One of its implications can be this dream to make healthcare more efficient by using IT. Technology has caught up with it, but are human being up to the mark to accept technology. Reactive vs proactive mode of dealing with information Don ’t try to drink from a fire hose, disconnect often Problem of the year 2008 Cost of unnecessary interruptions – learn as medical students NHS productivity – fall in last 10 years – I would love to see how much of that was because of IT.
- A fundamental principle of the NPfIT programme is that the NHS is contracting for the delivery of a service. In the past, the NHS has bought a system or series of systems from a supplier. If you wanted an EPR system you would go to an EPR software supplier like Torex or Northgate and this company would show up with their own people and their own software and they would install it and make it work. This was the model. It never occurred to anyone to separate the delivery of the service from the company who wrote the software - even though hospitals in the USA had been making just such a separation for years. In the NHS the practice was for the same supplier to be charged with the implementation, and contracted to develop the system in line with the changing needs of the NHS.
- We have witnessed first-hand, or at least through this book, the success at sites such as Greenwich, Burton, Winchester and Wirral. Their success was not easily replicated in other sites, even with the same IT system. Why? Because the Burtons and Wirrals and Winchesters and Greenwichs had a very tailored solution. It was 'moulded' around their work practices, and the systems fit like a glove.
- In the past decade, a single provider system of over 160 hospitals that treats 25 million patients annually has climbed to the number one ranking of numerous studies on a broad array of metrics covering quality of care and other performance measures. Thanks to a sophisticated healthcare information system and electronic medical record, this system has virtually eliminated entire classes of medical errors, improved efficiency by reducing paperwork for care practitioners, and enabled the detailed analysis of the efficacy of specific treatments across a broad patient population. This system is the Veterans Health Administration, and the healthcare information system is the open source software known as VistA. Open source is a software development methodology and philosophy characterized by freely redistributable source code, which is traditionally a closely guarded trade secret of proprietary software companies. Open source software turns this model inside out and encourages the free sharing of software blueprints. This sharing empowers a robust ecosystem of contributors who collaborate in advancing the development of software.
- Big data a SURE thing for healthcare Summary: The inability to share and analyse Australia's healthcare data has prevented researchers from using big data for analysis, but that's about to change. By Michael Lee | July 5, 2012 -- Updated 04:28 GMT (05:28 BST) Australia has one of the most comprehensive collections of population data on healthcare, but until now, analysing it has been quite limited. The data is distributed amongst various sources, and the systems on which these datasets are located are typically unsuitable for complex analysis. However, the Sax Institute has today launched a project called the Secure Unified Research Environment (SURE) that aims to overcome both limitations by providing a central datacentre where researchers can form connections between data sources and access the necessary computing power to perform big-data analysis. Health researchers will be able to securely access health information provided by hospitals, cancer registries, clinical trials, general practices and research studies. The project was funded by the Department of Industry, Innovation, Science, Research and Tertiary Education, as well as the NSW Government. While the environment was only officially launched today, it has already been used to analyse Australian habits on visiting the same general practitioner, or "consistency of care", which has been linked to the long-term quality of healthcare. Previously, data on consistency of care would have been analysed by looking at data from the Medicare Benefits Scheme to determine who does or doesn't use the same practitioner, but this doesn't provide much insight. By combining the Medicare data with the Sax Institute's own "45 & Up" study, as well as data from the Pharmaceutical Benefits Scheme, researchers were able to discover more. For instance, the analysis was able to confirm the intuitive beliefs that the older Australians get, the more likely they are to have higher consistency of care, and that remote areas of Australia have lower consistency of care. However, it also revealed that wealthier and more highly educated Australians have lower consistency of care — a finding that would not have been possible to determine by looking at a single dataset alone. Privacy in SURE Any time large sets of data are linked and mined for information, privacy concerns rise to the forefront. Recognising this, SURE divides personally identifiable information and the content of health records, such as medication information or hospital-admission information. Organisations called data-linkage units receive encrypted record ID numbers and personal identifying information from sources, but no healthcare records. The linkage units then create their own unique, randomly generated IDs for each person. When a research project requires the data, these randomly generated IDs are used as a basis to create project-specific IDs. Once the data-linkage units and the data source agree on what information a project is allowed, the data-linkage unit sends the encrypted record ID numbers as well as the new set of project-specific IDs to the source. The data source is then able to decrypt the record ID numbers and match them up to any healthcare records, free of personally identifiable information. The information is then made accessible on SURE's systems for analysis. The end result is that any researcher logging in can only identify an individual by a SURE-generated ID, unrelated to that person's original record ID. As the ID is specific to the researcher's project, it also means that researchers cannot collude with other researchers working on different projects to gain more personally identifiable information than originally permitted. Security in SURE To use SURE, researchers first need to have their project approved by the data owners, and also by a human research ethics committee. After this, researchers' access is limited to secure computers. These are scanned for malware prior to the log-on process, and a security certificate is installed on the permitted computer to limit access. To log in, the researcher's account has certain minimum-length password requirements and the necessity of a physical hardware token, which must be plugged in to the nominated computer via USB. If any of the three factors — the certificate, USB token or password — are missing, tampered with or incorrect, access to the system is denied. Although steps are taken to make the researcher's computer more secure than the average PC, analysis of data is still performed remotely. Researchers use their computer as a virtual terminal to tap into SURE's infrastructure, running a highly specified version of 64-bit Windows 7. These virtual workstations have a number of proprietary and open-source analysis tools pre-installed, or installed as needed after being assessed for security. This allows researchers to conduct their analysis using the larger computing power of SURE's facilities. As analysis may take time to complete, researchers can log off and leave their analysis running in the background, logging in from another secured location at a later date. The datacentre has a tier-3 ranking, and numerous other physical security features have been implemented, such as the removal of access to printers and removable media within the facility. Even then, the data flow of all files entering and leaving SURE passes through a privately developed audit tool called the Curation Gateway, providing administrators with the ability to flag any suspicious activity and take immediate action. Once research has been completed, any remaining data files are encrypted and then archived only for as long as needed. After this time, they are destroyed. Topics: Big Data, Government, Government AU, Open Source, Security, Servers, Virtualization
- The US health care system has four major pools of data within health care, each primarily held by a different constituency. Data are highly fragmented in this domain. The four pools are provider clinical data, payor activity (claims) and cost data, pharmaceutical and medical products R&D data, and patient behavior and sentiment data (Exhibit 14). The amount of data that is available, collected, and analyzed varies widely within the sector. For instance, health providers usually have extensively digitized financial and administrative data, including accounting and basic patient information. In general, however, providers are still at an early stage in digitizing and aggregating clinical data covering such areas as the progress and outcomes of treatments. Depending on the care setting, we estimate that as much as 30 percent of clinical text/numerical data in the United States, including medical records, bills, and laboratory and surgery reports, is still not generated electronically. Even when clinical data are in digital form, they are usually held by an individual provider and rarely shared. Indeed, the majority of clinical data actually generated are in the form of video and monitor feeds, which are used in real time and not stored.
- Despite statistical evidence in a number of small-scale studies (analyzed later in a metastudy), it took more than five years until the cardiovascular risks of Vioxx were proven. In August 2004, a paper at an International Pharmacoepidemiology meeting in Bordeaux, France, reported the results of a study involving a large Kaiser Permanente database that compared the risk of adverse cardiovascular events for users of Vioxx against the risk for users of Pfizer’s Celebrex. The study concluded that more than 27,000 myocardial infarction (heart attack) and sudden cardiac deaths occurred between 1999 and 2003 that could have been avoided.