Jan 192017
 

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Untitled drawing

1) Executive Summary

An NHS open digital platform challenge fund will stimulate the development of an open platform in the NHS. Open digital platforms are independently forecast by McKinsey and Co to reduce the delivery of care costs across the NHS by 11%. They will support widescale entry and growth of suppliers into the market, injecting innovation at all levels of service delivery to support improved care outcomes for our patients.

In the context of an NHS struggling through a perpetual winter, open digital platforms present a realisable opportunity to massively stimulate new ways of working, process innovation and a new digital health and care market, based around services. This is independently forecast by McKinsey and Co who predict a positive financial impact in excess of 11% across the whole of health and social care.

By creating an open digital platform and a move towards a services market, the NHS opens up the market to innovative commercial and social enterprises who presently have great difficulty breaching the significant barriers to entry. At the same time it creates an environment where health and care professionals can readily create, contribute and share new digital tools to support transformational new models of care, radically improving the care outcomes of our patients and building a sustainable care ecosystem that is fit for the future.

There is little disagreement that platforms represent the future for digital health. Rather the present debate is about who should own them, and how and when they will emerge. The “status quo” retains the closed platform frameworks, introducing open interfaces for exchange of information. This provides a short term stimulus, supporting improvements in patient care and operational efficiencies. However in the longer term, by seeking to control the rules of engagement and restricting the mobility of data, the retention of closed platform frameworks will stifle competition, impede innovation, and continue to drive-up costs.

Open digital platforms are a radical alternative that overcome the serious shortcomings of closed platforms.
They present the most assured approach to achieve consistent, long term and affordable growth in innovation-led service transformation across the complexities of health and social care. They will enable the full competitive aspects of market supply to be exploited, with associated benefits of the injection of innovations on a massive scale. For this reason, open digital platforms are manifestly in the interest of both the NHS and its patients.

The purpose of the proposed Open Digital Platform Challenge Fund is to stimulate the development of an open platform ecosystem through kick-starting the creation of open platforms, building on work already well underway, and the development of exemplar applications to exploit them.

We propose that the fund is created through diverting 1% of the investment each year in NHS digitisation into the challenge fund. This fund would be made available via an annual open competition in the form of relatively small awards to innovative organisations (public, private and third sector). The selection of projects will be balanced to stimulate and develop an open ecosystem of shareable and reusable applications to service across health and social care. We are inviting submissions of expressions of interest into this Open Platform Fund. In so doing, we will gauge the wider interest in this Open Platform fund proposal to then quickly bring these related responses to the attention of both NHS Digital and NHS England by the end of February 2017 and seek the related funding.

2) Current Situation

To introduce this bid for funding we need to review the current situation with important context on the bigger picture issues that are at play. We need to acknowledge and understand the current mediocre state of health IT, as an immature and problematic market with mixed/relatively poor value for money and results seen from billions of £ and $ of investment from the UK to the US and elsewhere.

We also need to recognise the related digitisation of the NHS has been over promised and under delivered for some considerable time. Compounding this people/process/technology problem is the ongoing and perpetual winter faced by the frontline in the NHS that is in the news.

We restate the need to continue the critical push towards more personalised, integrated care at home and in the community to meet the 2020 vision. This clearly requires an underpinning patient centred infrastructure to do so. Last February Jeremy Hunt announced £4.2 billion for NHS Health IT. In the last 18-24 months while there have been plans in the form of Integration Pioneers, Vanguards, Local Digital Roadmaps (LDRs), Sustainability Transformation Plans (STPs), there has been little/no allocated funding to date to make these happen.

In Autumn 2016 we were able to read and digest the latest review of the NHS IT, authored by US physician Dr Bob Wachter. Dr Wachter built his reputation as establishing the hospitalist as a medical specialty in the US. In recent years he has become a fearless and honest critic of the state of Healthcare IT in the US, with his book “Digital Doctor : Hope, Hype & Harm at the Dawn of Medicines Computer Age” (2015) exposing the real mediocre state of the health IT market in the US. The book and related opinion pieces on the state of health IT industry he explains some of the real problems with the current supplier market is clear. In a New York Times Op Ed piece on “Why Health Care Tech Is Still So Bad” (2015) he highlights that

“In today’s digital era, a modern hospital deemed the absence of an electronic medical record system to be a premier selling point...That hospital is not alone. A 2013 RAND survey of physicians found mixed reactions to electronic health record systems, including widespread dissatisfaction. Many respondents cited poor usability, time-consuming data entry, needless alerts and poor work flows”.

However in the NHS, Dr Wachter’s recent review led to funding being provided to “digital exemplars” all of which are a small group of hospital trusts in the NHS who will invest in those very same health IT monoliths. While understandable as a means to “do something”, rather than nothing, given the state of affairs is understood, it is sadly limited in its thinking and perpetuates the usual tactics that we have seen in the NHS IT for years, i.e. investing in the same 20th Century monoliths of old. We know that doing the same thing over and over and expecting different results is futile.

Simply put, if a small elite are getting the focus of funding for investments in 20th Century health IT monoliths over the next years then inequity within the system will increase, while original ideas in the sector to bring care into the modern era will decrease.

We have been left asking where has the requirement for integrated person centred care gone, that is ingrained in the other plans that NHS and local authorities have been working towards with STPs and LDRs etc.

What is sorely missing is the open patient centric platform that Dr Wachter looks forward to and that healthcare awaits. As this is a glaring omission, our paper recommends a focussed investment towards that end as part of a bimodal strategy for NHS IT at this challenging time.

3) What can be done

The changes required are radical, if we are to simply survive, yet alone thrive in the years ahead. We know we need a mix of people + process + technology changes. We know too that the leaders of the NHS understand and value the role of innovation and the crucial role of information technology in achieving same.

3.1) The role of an open platform

For some time now leading thinkers on both sides of the Atlantic, in the NHS and indeed the US has been calling for a move towards a more open platform approach. From within the US market, the establishment of Healthcare Services Platform Consortium aims to address the mediocrity of the “big 6” monoliths and the concurrent problem of the thousands of small unrelated vendors.

“EHRs are becoming commodity platforms. The winner will be the EHR vendor that provides the best platform for innovation – the most open and most extensible platform.”

In this we wholeheartedly agree and concur with our US colleagues.

We believe there is now a compelling case for a small but useful investment in Health IT from the bottom up, to the princely sum of 1% of the planned £4 Billion NHS IT expenditure, aimed deliberately at the integrated, patient centred care vision of Personalised Care 2020, based on the principle that all projects should aim to leverage elements of a common open platform.

4) 1% Case for an open platform

We are making a case for an investment of just 1% of available NHS IT funds to offer a way forward to improve the care of 99% of the population. To do so we have highlighted Dr Watchers analysis and writings to focus on the key problems and issues we seek to address;

Usability

“This principle of user-centered design is part of aviation’s DNA, yet has been woefully lacking in health care software design.

Interoperability

“[There are] Political obstacles to overcome, put in place mostly by vendors and healthcare systems that remain reluctant to share.”

Vision for patient centred care

“In essence, there will no longer be an EHR in the traditional sense, an institution-centric record whose patient portal is a small tip of the hat to patient-centeredness. Rather, there will be one digital patient-centered health record that combines clinician-generated notes and data with patient-generated information and preferences. Its locus of control will be, unambiguously, with the patient.”

So in order to address these real issues and support the national ambitions - usability, interoperability and patient centred care we will use the investment fund available to benefit the broader public. We wish to draw attention to that part of the population who could be better served by the NHS with an improved patient centric platform today. We are also mindful of the need to support;

  • Prevention, Self care and management
  • GP patients
  • Community Care Patients
  • Mental Health Patients
  • Social Care

We look to the leadership provided by the Gov UK Digital Service standard to highlight the principles to underpin the approach we commend.

Pursue User Centred Design & Agile Development

Leverage Open Source & Open Standards

In our work to date (on the Ripple programme and Code4Health platform based on openEHR) we have deliberately pursued these principles to useful effect and recommend them to others who wish to transform healthcare with information technology. We welcome wider scrutiny of our open platform work to date. Our work and the leading work of others (such as the Endeavour Foundation and the INTEROPen CareConnect API Collaborative) in this field, leads us to believe there is now a real, significant appetite for wider and deeper moves towards an open digital platform in the NHS.

By creating an open digital platform ecosystem, the NHS opens up the market to innovative commercial and social enterprises who presently have great difficulty breaching the significant barriers to entry. At the same time it creates an environment where health and care professionals can readily create, contribute and share new digital tools to support innovative new models of care.

We firmly believe that a small but focussed 1% investment can deliver against some of the key challenges in Personalised Health and Care 2020 on an open service oriented platform- to stimulate the public & private sector. An open healthcare platform fit for the 21st Century.

 

5) What is an Open Platform?

Platform based architectures power the internet, with the platform providing the plumbing (the infrastructure, data and services) that applications need, freeing the application developer to focus their efforts on their application without the need to build the infrastructure it needs to operate. Platform approaches speed development, make applications more robust and interoperable and open up a new services market in healthcare IT, where suppliers compete on services and the value they add rather than on the proprietary nature of their software.

An Open Platform is based on freely available open standards, so that anyone can play. As no one party can control the platform - they must collaborate - just like the Internet.

An Open Platform has the following characteristics:

  • Open Standards Based - The implementation should be based on wholly open standards. Any willing party should be able to use these standards without charge to build an independent, compliant instance of the complete platform;
  • Share Common Information Models - There should be a set of common information models in use by all instances of the open platform, independent of any given technical implementation;
  • Support Application Portability - Applications written to run on one platform implementation should be able to run with either trivial or no change on another, independently developed;
  • Federatable - It should be possible to connect any implementation of the open platform to all others independently developed, in a federated structure to allow the sharing of appropriate information and workflows between them;
  • Vendor and Technology Neutral - The standards should not depend on particular technologies or require components from particular vendors. Anyone building an implementation of the open platform may elect to use any available technology and may choose to include or exclude proprietary components;
  • Support Open Data - Data should be exposed as needed (subject to good information governance practice) in an open, shareable, computable format in near to real-time. Implementors may choose to use this format natively in their persistence (storage) layer of the open platform itself or meet this requirement by using mappings and transformations from some other open or proprietary format;
  • Provision of Open APIs - The full specification of the APIs (the means by which applications connected to the platform a should be freely available.

The key to an open platform is the definition of a set of standard interfaces (APIs) to the range of services that might be provided on a platform defined by an open process that all interested parties can participate in (like Internet standards) and that are freely available for all to use.

While it may be encouraged, not all elements in an open platform need to be open sourced. We believe that “infrastructural” components that are generic, reusable and utility like (e.g see Appendix 1 below) should be open sourced, while the overlying applications do not necessarily need to be open sourced, as long as they leverage open data models and offer open APIs.

6) Why an open digital platform?

We have seen across all sectors how platforms are changing the way people lead their everyday lives, from how we communicate and interact, how we travel and where we stay, how we manage our finances to how we shop, to name but a few. Platforms transform. An open digital platform supports:

  • Unconstrained innovation – ideas and ambitions can be shared by people across the office, street or globe
  • Collaboration - clinicians and care professionals inherently want want to share their good work with the rest of the medical world.
  • Alignment to medical science progression, been based on the spread of ideas - health IT can do the same.
  • “Publish or perish” culture of modern medicine demands that healthcare advances are laid open for scrutiny by our peers
  • Grassroots progress - Complex adaptive systems require decentralized control so people can locally innovate. Amendments and improvement can come from the grassroots and bottom up, without the bureaucracy that innovators often face.
  • A shift in the market towards a healthy, commercially sustainable, services oriented marketplace.

7) Open Platform Fund mechanism

The main aim of this Open Platform bid is;

Support the development of services towards Personalised Care 2020 -

support the development of an NHS ecosystem around an open digital platform

To be clear, while we do not currently have any secured funding for an open platform fund, our aim is to gauge interest in this approach and make the evidence based case to NHS Digital.

The fund is intended to support innovative projects that stimulate the creation of an open digital ecosystem and as such aims to support a large number of small projects that are unlikely to be supported as part of “business as usual” investment by health and care organisations. The aims are to driving innovation and transformation that is scalable, shared, flexible and adaptable and ultimately improve health IT for clinicians and improve care outcomes for patients. Winners will show that they will concentrate their efforts on usability, interoperability, patient centred care that meet the vision. To do so we suggest;

7.1) Request for Expressions of Interest

We initially invite the submission of expressions of interest into this Open Platform Fund. In so doing, we wish to gauge the wider interest in this Open Platform fund proposal to then quickly bring these related responses to the attention of both NHS Digital and NHS England by the end of February 2017 and seek the related funding .

Please submit a brief expression of interest (1-3 page) via this Google forms link; https://goo.gl/forms/4SaNvAgkAe2AfLZ82 by Friday 10th February 2017.


We will acknowledge expressions of interest, collate and feedback the results of our findings, pass on related submissions and summary findings to the Apperta Foundation CIC which we believe is ideally placed to independently oversee this process and support the case for funding from NHS Digital and NHS England. The Apperta Foundation is a not-for-profit community interest company supported by NHS England and NHS Digital led by clinicians to promote open systems and standards for digital health and social care.

While the focus of this paper relates to the NHS in England, we know that colleagues in the health systems of Scotland, Wales, Northern Ireland and indeed the Republic of Ireland are facing the same challenges at the frontline, while aware of the same opportunity on offer from an open platform from a 1% investment, particularly if done openly and collaboratively. Therefore we invite related submissions towards an open platform fund on an All Islands basis - which we also will pass onto the Apperta Foundation and the UK and Ireland CCIO Networks.

7.2) Outline of Proposed Allocation

A) Infrastructural component projects

45% of £40m = £18m over 3 years (until 2020)
Open source tooling & infrastructure components - underpinning standards and compliant components that provides services useful in an open ecosystem (See Appendix 1 examples)

B) Personalised Care: Innovation Incubation and Exemplar Implementations

50% of £40m = £20m over 3 years (until 2020)

Open APIs & open data models based projects as showcases of an open platform in action. (e.g. may include open APIs (e.g. INTEROPen CareConnect FHIR based APIs) + open data models +/- open source data repository (e.g. openEHR based). Examples may include Person Held Records/Electronic Patient Record/Integrated Digital Care Record etc. related projects.

C) Oversight/Custodian of process by an independent CIC such as the Apperta Foundation

Along with the CCIO Network and INTEROPen Collaborative to oversee clinical merit and technical connectathons.

5% of £40m = £2m over 3 years (until 2020)

7.3) Eligibility

We suggest that this open platform fund is open to:

  • UK Registered for-profit commercial entities (Companies and LLPs) and
  • UK Registered not-for-profit entities (CICs,Trusts,Companies limited by guarantee and other recognised forms) meeting UK definition of an SME (In the UK a company is defined as being an SME if it meets two out of three criteria: it has a turnover of less than £25m, it has fewer than 250 employees, it has gross assets of less than £12.5m)
  • UK Public Sector bodies (NHS Bodies, Government agencies and local authorities etc.) irrespective of size.

7.4) Match funding obligations

We suggest that applicants will be required to match fund any award from the fund as follows

  • Social or commercial micro-enterprises 1
    -
    No match funding obligation
  • Social or commercial SMEs 2
    -
    Match funding equal to 50% of the award
  • Public sector bodies - Match funding equal to 100% of the award

 

1 A business with less than 10 employees and (a turnover < £2 million euro or a balance sheet total of less than £2 million euro)
2 A business with less than 250 employees and (a turnover < £50 million euro or a balance sheet total of less than £43 million euro)
These are the current official definitions applying in the UK

8) Criteria

We suggest that an Open Platform fund is open to projects that stimulate and support both the creation and adoption of an open digital ecosystem which meet the definition in section 5 of What is an Open Platform.

While the main aim of all projects will be to improve NHS services towards personalised health and care 2020, the criteria by which the funding from this fund will be allocated will depend on the concurrent creation of value add in the form of;

  • Collaborative - all projects must establish open channels of communication and means of engagement with other parties in the bid at the time of their application (e.g. INTEROPen Ryver etc).
  • Transparent - all projects must be willing and evidence how they will partake in regular clinical and technical reviews. We suggest these should be in the form of bi-annual CCIO Network led review along with INTEROPen led Connectathons with a minimum of 3 out of 6 Connectathons undertaken.
  • Share Ideas, Knowledge, Experience - i.e. willing and able to openly collaborate with others in this initiative (e.g via online community building via tools such as the Open Health Hub, Ryver etc) and partake in Open Data connectathon against INTEROPen FHIR APIs

9) Judging process

Initial Bid and Review Point Principles

We suggest the related submissions into this fund will need to evidence the following as part of their bids and progress at agreed review points:

  • Clinical merit - against the Personalised Health and Care 2020 Vision
  • Technical merit - against the open platform principles outlined
  • Clinical gap / need / demand
  • Clinical Leadership - all projects need nominated clinical lead
  • User Centred Design - include/demonstrate a commitment to open publish UX design
  • Alignment with Agile Development methodologies
  • Business readiness (preparatory work, governance etc in place)
  • Collaboration with other parties in the open platform bid
  • Open Source track record

10) Conclusion

If public monies are for one purpose, they should be for the common good. Our proposal aims to ensure the efficient and effective allocation of public monies to projects that can impact the health and care of millions of citizens in England, supporting local NHS & Social Care organisations in their hour of need, while leveraging Britain's long held reputation for industry and innovation to enable a new global open platform fit for the 21st Century.

Our proposal for an open platform technology fund aims to offer a means towards the integrated care vision of Personalised Care 2020 that is in the best interests of the NHS. In aligning patient, clinical and care needs with the investment potential offered by open platforms in healthcare, we believe there is a clear win-win on offer here.

At times of challenge and change the natural instinct may be to withdraw from risk or novel action, yet all our instinct is telling us that now is very time to embrace this challenge and seek the opportunity - which is why we are taking a public lead in getting this Open Digital Platform for Healthcare into action and welcome your interest and support in this effort.

Dr Tony Shannon, Ewan Davis
14th January 2017

Questions or Comments?
Email us at 1percentfund@ripple.foundation or tweet @rippleosi with #1percentfund

11) Declarations of Interest

Both of the authors are unashamedly proponents of an open platform in healthcare for some time. One might argue that this constituents a conflict of interest with the proposed approach. Rather we would suggest that our track record in leading the effort to disrupt the market towards an open platform, equates to a confluence of interest with the approach now required.

Dr Tony Shannon, Director - Ripple Foundation C.I.C
Director - Frectal Ltd

Ewan Davis, Director - Synapta C.I.C
Director - Handi Health C.I.C
Director - Open Health Hub C.I.C
Director - Operon Ltd
Director - Woodcote Consulting Ltd

12) Related Links

Ripple Foundation Community Interest Company http://rippleosi.org/
HANDI Health Community Interest Company http://handihealth.org/
Synapta Community Interest Company http://synapta.org.uk/
Endeavour Health Charitable Trust http://www.endeavourhealth.org/
Apperta Foundation Community Interest Company http://www.apperta.org/
INTEROPen Collaborative http://www.interopen.org/
openEHR Foundation http://openehr.org/
HL7 FHIR https://www.hl7.org/fhir

Appendix 1 - Open Platform Infrastructural Component Candidates

The aim here is to initially outline examples/suggestions of a “top 10” set of federated service components in a Service Oriented Architectural world that would be useful to in healthcare. In doing so we welcome further suggestions and related expressions of interest that would aim to provide open source solutions to plug gaps / provide enhancements towards the open digital platform movement. The fund may support the open sourcing of existing components or their development.

Identification & Authorisation
Master Patient Index
User Interface framework
Integration technologies
Clinical Data Repository
Terminology services
Workflow services
Rules engine
Scheduling
Business intelligence
Clinical content collaboration/authoring tools (i.e. openEHR/FHIR etc)

Applications for these open source infrastructure projects are encouraged to state their preferred OS license (weighting towards non copyleft (Apache 2/MIT/BSD) or AGPL licensing)

 



 

 Posted by on January 19, 2017 at 12:43
Sep 172014
 

OPENeP has selected the HANDI-HOPD to built its initial prototype app. It will provide further proof of concept and is the most ambitious project to be attempted on HANDI-HOPD so far.

OPENeP is an open source project intended to deliver a suite of medicines management apps to improve the safety and efficiency of prescribing and medicines management and demonstrate how new business models can create commercial opportunities for vendors focussed on delivering high quality service.

Medication errors and one of the biggest single cause of harm to patients in NHS Hospitals, causing death, disability and suffering and represent a significant cost to the NHS with wider negative economic impacts.  Many errors are amenable to mitigation through the application of digital technology and OPENeP is intended to help address these problems.

There are already a number of digital tools that support various aspects of the medicines management process, most are proprietary products and many of these are of good quality, but they are not designed to fit in the emerging open digital health ecosystem or take advantage of the latest technology.

OPENeP is intended to  explore how we build apps for the emerging digital ecosystem and  to enhance, not replace, existing EHR and Pharmacy systems and create new opportunities for vendors of such systems, who we hope might  include these components to enhance their existing product and service offerings. OPENeP apps  will be designed to facilitate integration with PAS, EHR, order communication and  pharmacy systems as well as proprietary  knowledge and decision support components.

The starting point for OPENeP will be the ePrescribing and Medicines Administration modules of  Think!Med Clinical which its creators Marand have agreed to release under the GPL open source licence. This product which is based on OpenEHR provides a proven solution using the latest technology  already successfully deployed in a large hospital and gives us a great starting point for our work. Our aim is to develop this to provide the suite of apps described below which will initially be deployable via a common interface (API) as either the eP/eMA component of a OpenMaxims EHR or as a "standalone" solution which will operate on any OpenEHR backend

The focus of OPENeP is on the hospital inpatient setting, where it is intended to integrate with existing systems and other apps to deliver digital care at the beside. However, it is designed so that it can be extended to deliver facilities in other settings.

The currently identified components of the OPENeP suite are:

  • Medicines reconciliation – With modules for both the patient and healthcare professionals to ensure an accurate view of a patient’s medication at handovers of care.
  • ePrescribing – To help ensure safe, efficient and appropriate prescribing compliant with national guidance and local policies.
  • Medicines Administration – To help ensure safe, accurate and timely medicines administration.
  • Personal Medication Record – To give patients a view of their medication to support self-care, concordance and the safe and effective use of their medication.
  • Medicines Utilisation and Audit – To support pharmacists and others in the review totality of a patient’s medication and monitor and audit medication usage, administration and patient concordance.
  • Medicines supply management  – To support the transfer of orders for medication both for individual patients and for local stock to pharmacies, including support for orders for discharge medication to hospital or community pharmacy.

The Initial focus with be on prescribing and administration and we intend to use HANDI-HOPD to build some initial prototypes. Like everything on HANDI-HOPD these prototypes will be purely experimental and will not be used with real patient data. However, because HANDI-HOPD uses open standards we expect others to take them and deploy them in an operation environment.

Our priority is to create a user interface (UI) that delivers a user experience (UX) that make the apps a joy to use and in doing some makes the processes they support more efficient, easier and safer. To do this we want to bring together domain expertise in medicines management, frontline clinicians and patients with engineers, designers and informaticians working together using user centred design techniques.

In order to operate effectively and efficiently OPENeP apps will need to interoperate with a range of others systems including:

  • GP Systems – To support medicines reconciliation on admission and discharge
  • Patient Administration Systems (PAS)  - To identify and track patients
  • EHR Systems (EHR) – Access the clinical data about patients needed for safe, effective prescribing.
  • Hospital Pharmacy Systems – To manage medication orders and supply
  • Community Pharmacy System – To support delivery of discharge medication in the community.

We will use existing open interface and define new open interfaces where none exist, ideally in collaboration with target system vendors.  The OPENeP apps will be designed to work with FHIR APIs on target systems (with openEHR archetypes mapped to FIHR resource profiles) but we will provide middleware components to allow interworking with APIs based on other standards.

Basic functionality can be implemented without interfaces to most of the above systems, but certain basic EHR data is essential for safe prescribing and OPENeP will provide basic EHR functionality, using openEHR to allow these data to be recorded with within the OPENeP suite when an external EHR data source is not available.

Partners in the project are:

  • NHS England Open Source and e Prescribing Programmes
  • Fivium http://www.fivium.co.uk/ - A mid-sized SME with experience of delivery solutions based on source to Government in the UK and elsewhere including the provision of the system to operate the Pharmacy Benefit Scheme to the Australian Government. http://www.fivium.com.au/health.html
  • First Data Bank http://www.fdbhealth.co.uk/ –The UKs most experienced provider of drug knowledge for use in ePrescribing systems.
  • Neova Health www.neovahealth.co.uk/  – A UK based SME successfully delivering open source solution in the NHS include eObs a nursing observation app which is a natural companion to OPENeP at the bedside.
  • Marand  www.marand-think.com/   – A Slovenian SME that already provides much of the technology for HANDI-HOPD and who have delivered ePrescribing for the Slovenian Health System
  • IMS Maxims - http://www.imsmaxims.com/opensource/ - Original authors of OpenMaxims open source EHR

 

Aug 072014
 

An appreciation of the current situation and identification of requirements.

Prof Mike Martin - KITE (Centre for Knowledge, Innovation, Technology and Enterprise) Newcastle University

The impact of current developments

The stated aim of the Public Services (Social Value) Act 2012 is to strengthen the social enterprise business sector and make the concept of social value more relevant and important in the placement and provision of public services. The context of this initiative is a wider policy to shift service delivery responsibilities from public sector organisations, particularly Local Authorities and to encourage an expanded social enterprise sector, and the private sector, to provide service delivery capacity.

The NHS represents a complex cluster of distinct procuring authorities operating at many different levels from the centralised and outsourced NHS Supply Chain to locally and regionally operating Trusts and the new local CCGs. The act applies to the NHS at all of these levels.

The small scale survey and analysis reported here has been undertaken in the context of local developments in health and social care in a period where the introduction of the Social Value Act, has coincided with the inauguration of CCGs, the introduction of personal budgets in health and social care and the development of social prescribing. In addition to these organisational, legislative and social changes, we have also seen a growth in interest in, and the use of electronic channels, services and devices in delivery and management of caring services providing opportunities for participation in, and coordination of, services at home and in the local community. They have also increasingly been the medium for discussion and debate about these services and the experiences of service users.

The mandates and opportunities of social value commissioning , however, represent only a very minor aspect of the legal, managerial and governance challenges that are being faced by the newly forming CCGs. The first report of the King's Fund and the Nuffield Trust joint project to assess the implementation and impact of CCGs[1], identifies member relationships, the relationship with HNS England and the demarcations of responsibility for the procurement of primary care services, as the major issues and the significant challenges which have been dominating the agendas of the CCGs in their first phase of operation once the challenges of achieving the basic capability and capacity requirements under which they are approved for operation have been met. It is clear that uncertainty and the demands for change that are being experienced in this context mean that any creative response to the opportunities of social value commissioning will, at this stage, be local and fragmentary at best: this is not an issue which is able to command the attention of key players in the CCG arena.

The longer term perspective

If we accept the situation as described above and recognise that now is not an appropriate time to be addressing CCGs collectively and directly about the challenges of Social Value in their commissioning approach, we are then faced with the further question regarding what can be done now to prepare the ground and accelerate the processes by which such innovations could come to fruition as early as possible.

The implementation of a sustainable, social value based approach to commissioning and procurement[2] (SVP) involves a series of conversations between commissioners, potential and active service providers, service users and wider community beneficiaries. There are a number of pre-conditions for such conversations to be possible and fruitful. Some work and investment is required by all the parties to achieve these pre-conditions and to establish the required connections and relationships. All of this implies that work is required to achieve a community based readiness for SVP.

Commissioning Processes

The basic legal constraints of commissioning have not been changed with the Social Value Act. Their dual purposes are to protect the public financial interest and to provide fair access and competition among suppliers. The change implemented by the Act concerns what is allowed to be taken into account, and to which a value can be attached, in the selection between bids. A feature of procurement rules and processes, which is relied upon to achieve this fairness and protection, is the partitioning of the process into strict phases which are defined by the sorts of conversations and information exchanges that are allowed to take place within them and are not allowed between them. This results in four phases:

  1. Pre-procurement: In this phase potential procurers and potential bidders can talk to each other about what might be needed and what could be supplied. Such conversations may be public or may be in confidence but public procurers have the responsibility to demonstrate transparency and fairness and that preferential relationships are not being formed.
  2. Initial Procurement Phase: In this phase, a procurer announces the intent to procure in a particular area of supply and conversations can take place to clarify the needs, specifications and evaluation criteria and processes.
  3. Tendering phase: The procurement document is fixed, tenders are prepared by bidders and submitted within the deadline and are then opened and evaluated. The selection process defined in regulations and in the procurement document is executed to select a supplier and produce a contract.
  4. Delivery phase: The supply processes and relationships of the contract are delivered, reviewed and evaluated. This phase may then merge into phase 1 above as the term of the contract approached.

An important observation which must be made in the context of SVP under the new act is that phase 3 does not change in any way. The only things that can be taken into account in the selection process are the criteria explicitly defined and published in phase 2.

This implies that the precise definition and scoring methods of the Social Value dimensions for each procurement but have been defined and published beforehand: new concepts of social value cannot emerge in the evaluation process.

This factor is critical in the understanding of the pre-conditions required for SVP. If the legal requirements of the public procurement are to be respected while at the same time the creativity and innovation potential and social value are to be realised then both generic (phase 1) and specific (phase2) conversations and debates about what could count as social value and how precisely it will be valued, must be instigated, facilitated and sustained. They must also be informed by the experiences of phase 4.

Two further, related factors then come to the fore regarding these debates and the channels, media and mechanisms that support them. The first of these is participation: the four grouping identified above: commissioners, suppliers, users (carers and the cared for) and third party, community beneficiaries all need a voice and need to demonstrate a willingness to listen in this process. The second factor concerns the aegis, channels and media under which such debates can be conducted and trust in the provenance of the content guaranteed.

As stated in the first section, this survey and analysis has been undertaken in the context of a cluster of developments including personal health and social care budgets. The debate about social value, priorities and outcomes, which is key to both personalisation and localisation, is dominated by, but not limited to, Health. The remit of the CCG, under the current definitions, covers the clinical needs of:

  • Mothers and newborns
  • People with need for support with mental health
  • People with learning disabilities
  • People who need emergency and urgent care
  • People who need routine operations
  • People with long-term conditions
  • People at the end of life
  • People with continuing healthcare needs

All of these groups also have social care needs of one sort or another and these must also be included in the evaluation and decision making about outcomes and priorities if a user centred and joined up approach is to be delivered. In this conversation about priorities and outcomes, the individual and community perspectives as well as the clinical and social perspectives must all be taken into account.

Conclusions

We have observed that the current state of accommodation to significant reorganisation and redistribution of responsibilities in the NHS means that a creative and constructive response to Social Value in service commissioning is unlikely to be high on the present agenda. We have also observed that any longer term approach to developing good practice and sustainable operation in this area requires a wide and on-going engagement in conversations and debates about what count’s individually and locally as social value and individual benefit. Such a debate must be mediated through a variety of media and modes and must be conducted under appropriate aegis. While Local Authorities are designated as “market makers” and “place shapers” in the rhetoric of current policy, they are not well placed to provide the mediation and infrastructure for this wide ranging and multi-agency participation. Similarly, the CCG, Local Commissioning Boards or Senates cannot be expected to deliver this wide ranging remit on their own.

There is, therefore, a need to develop a partnership concept around social value commissioning and multi-agency care which provides a “stake holder engagement service” to the commissioners of personal health and social care services. The precise scope, possible providers and the means and mechanisms for the operationalisation of such a service, which could be defined and jointly commissioned by CCGs and Local Authorities, would require some careful thought, consultation and design.

Jan 302014
 

HANDI are looking for panel speakers and session facilitators for the HANDI Spring Symposium on Wednesday May in London.

The HANDI Health Apps Spring Symposium builds on the successful event run at EHI Live in November. Again working with EHI The HANDI Spring Symposium will take place at the Royal College of GPs, Euston Square, London on Wednesday 14th  May.

The symposium will provide an opportunity for the audience to discuss issues of concern to health and care app developers amongst themselves and with leading experts. Each session will consist of brief (5 minute) presentations from a panel of  three leading experts and practitioners after which the audience will be able to ask questions and make their own contribution which we hope will lead to a lively and informative discussion.

The sessions will be cover the following issues:

  • Finance, business models and startups
  • Quality assurance, safety and regulation
  • Informatics standards and interoperability
  • Tech and tools for app developers
  • User centred design
  • Digital Mental health and Wellbeing
  • Open source apps
  • UI, UX and information design

Were looking for experts and those currently struggling with the issues above who are willing to share their expertise and experience as well as a facilitator for each theme.

If you think you can help, or want to propose alternative themes please email ewan@handihealth.org outlining your interest

Jun 082013
 

GPSoC is the the procurement framework under which IT in for GP practices is funded. The existing arrangements have a narrow  focus and are of little interest outside of the core  GP clinical systems market. However the new GPSoC procurement which has just started has a much broader scope and provides an important opportunity for app developers and indeed anyone who wants to sell products or services in or which interoperate with UK general practice.

The OJEU Contract Notice was published on 28 May and has now been followed by more information including the Memorandum of Information and a link to request the pre-qualification questionnaire (PQQ). The deadline for submission of the PQQ is noon on 4th July

This framework is very broadly drawn and while its core purpose in the provision of GP Clinical Systems to English general practice it provides a procurement vehicle which could provide a route to market for a wide range of apps, digital tools and services for use in general practice or related to interoperability with general practice from other parts of the care system , with the framework available for use by any public sector body across all the home countries in the UK.

There are three lots.

Lot 1 is centrally funded and relates to GP Clinical Systems and certain high priority subsidiary products and apps. In particular lot 1 covers apps that provide patients with GP record access and access to GP transactional services (appointment bookings, prescription requests etc) - an area of potential interest to many HAND members

Lots 2 and 3 are not centrally funded but provide a flexible procurement route for local NHS or other public sector bodies wanting to procure the products and services covered. Lot 2 covers additional GP IT services while lot 3 covers cross-care setting interoperable services. My reading is that these lots could also include patient facing apps and services which GP Practice, CCG or CSU wish to procure for use by patients they serve.

The future GPSoC Contract also place a requirement on principle system suppliers to provide open interfaces to third party products and services, which together with the procurement framework provided create a very significant opportunity for vendors large and small in this key market, which all vendors should investigate.

This post is adapted with permission from a post by HANDI founder Ewan Davis on the Woodcote Consulting web site. Woodcote offer consultancy services to those seeking help exploring opportunities under the new GPSoC arraignments.

Feb 082013
 

HANDI are planning a series of regional workshop to be run by our growing network of regional clusters during the year commencing  April 2013.

See our events diary for those events already scheduled

We have secured funding which will allow some of these to deliver free and would like to know what subjects HANDI members would like us include in the programme.

We have three themes in mind but are open to other suggestions. These themes are:

  • Understanding the Market - Helping members of the community understand health and social care and the market opportunities for apps and digital tools
  • Business models and Finance – Raising investment and creating sustainable business models for apps for Health and Care - Practical advice for both commercial and social entrepreneurs.
  • Ensuring app quality - What are the regulatory obligations and voluntary opportunities to demonstrate app quality? How can developers meet and exceed these to differentiate their products and build market share?
  • Playing nicely together - Ensure apps play nicely with others and with the broader health and care IT ecosystem - Interoperability, orchestration and user interface design.

Our expectation that there will be more that one workshop looking in detail at specific issues under one of these themes. Our aim is to provide actionable, practical guidance for teams developing and implementing apps in Health and Care.

Please share any ideas you have as comments below and if you have not registered with us please sign up here so you get details of the events we decide to deliver

Nov 022012
 

One of the most frequent questions we get asked at HANDI is "How do I fund my app?"

Developing that first working prototype of an app can be a quick and therefore fairly cheap process which many individuals or small companies can easily afford, but turning this first version into a product that is sustainable and supportable and able to reach a wide audience can soon become much more expensive process and either spending you own money on this of seeking support from investors requires that app developers have a clear idea of their business model.

Government also needs to understand this. Presently there is great hope that the app community will deliver for free what the NPfIT failed to deliver for £12bn and that all the NHS has to do is encourage a few healthcare professionals to code, offer some prizes and an opportunity for glory. Sadly, much as I believe in the power of the app community and the app paradigm to transform the way we deliver health and care it's not quite this easy and the centre will have to invest in support and infrastructure if it wants the app community to thrive, but most of all it needs to understand the possible business models that exist and ensure that it doesn't unintentionally or inappropriately inhibit those that could support a vibrant app ecosystem.

So what are the business models available to app developers? Well from my discussions it would seem they are these.

Just for the hell of it – Many apps are produced by developers just because they can with no expectation of a direct or indirect commercial return.

This is the realm of the hobbyist and lots of great ideas and innovation will emerge on this basis, but this approach is rarely sustainable as the pressures of family life and the day job close in. If an apps open source someone else may pick it up but normally such apps die or switch to a more sustainable business model.

User pays – Users pay a one-off charge, takes out a subscription, pays per use or even makes a voluntary donation.

There are very few examples of commercially successful patient facing apps for which users pays. Most chargeable apps sell for well under £5, but even this small charge seems to put people off and unless an app has mass appeal the volumes achievable at this sort of price rarely generate enough revenue to be sustainable.

User pays for service including app - Here what attracts the user to pay is the service of which the app is a just a part. For the app developer the opportunity is to be paid by the service provider to create the app that supports their service or to take on the broader role of service provider. There are a number of app enabled health and care service for which there seem reasonable prospects of commercial success based on the user paying for the service.

NHS/care provider pays An NHS organisation or care provider pays for apps that are made available free to appropriate  service users. Here the payer sees value to itself in making an app available and meets the cost of doing so.

There are a number of potential variations on this model. The payer may fund a developer to create an app which they then own (or open source) or they may buy licences, subscriptions or pay-per-use to enable an app to be provided free to users  with the developer bearing the commercial risk and opportunity.

This approach can create sustainable business models where the value of app to the payer is sufficient. Given the potential of many apps to substantially reduce payers costs and improve quality of service this approach should work in many cases.

However, the app developer faces two challenges. Making the business case to the potential payer and finding a route through the procurement jungle, both of which can be challenge for a typical small and innovative  app developer and an area where Government could help.

Non-commercial sponsorship. Many self-help and charitable organisation have paid for the provision of apps and services that are made available free of charge to the community that they serve – Organisations concerned with specific patients groups or conditions may well fund the development of apps or buy licences or subscriptions to provide apps free to those in their communities.

Commercial sponsorship – A commercial organisation sponsors an app in the hope of a direct or indirect commercial return. There is significant interest from pharmaceutical and other healthcare companies in sponsoring apps which relate to a clinical area in which they have an interest or draw users into services they offer.  There are a number of potential variations on this model which include funding development of an app they then own, paying for licences or subscriptions for an app to be available free to a target audience they define or pay-per-use (possibly linked to "click-throughs" to a service they offer. Commercial sponsorship is likely to be an attractive business model for many app developers.

Advertising – Apps are made available free to user but carry advertising. This approach is used by a number of health web sites and apps. Typical this approach uses services like Google Adsense or PlacePlay which provide advertisements relevant to the apps target users and shares revenue with the app developer. This is low effort for the developer but means they have little control of the advertisements that appear.  Targeted advertising has been one of the most successful business model for many web sites and the same is likely to be true for popular health apps, particular those that can attract user valuable to advertisers.

There is some understandable concern about some of the more commercial business models which could results in apps with a commercial bias towards particular products and services and  in apps not being so easily available to those in the groups that might benefit most from them as either they won't be able to afford the app or associated service or because they are not attractive to commercial sponsor and advertisers. However, Government need to decide if it wants to support commercial models for the delivery of health and care apps or fund them from the public purse.

However, beyond all this lies the challenge for the app community to demonstrate that apps bring value in terms of reduced cost and improved quality in the healthcare system. I'm firmly convinced that with the right support and infrastructure that apps can do exactly this and it then  becomes simply a matter of designing business models which enable those who get value from apps to pay for them, which in the context of a publicly funded health and care system is predominantly the tax-payer.