November 2016 - I am cycling in The Galilee, Northern Israel, to raise money for Nazareth Hospital Paediatric Department. Nazareth is the largest Arab town in Israel; the people are lovely, and the kids are awesome. They need your help! Go to my sponsorship page to find out more and see what you can to do help!

21 August 2016

Training for #shanenaz2016: GLENARM

You already know that I'm heading to Nazareth, the largest Arab town in Israel, in November. I'll be joining a fine group of folks cycling to raise money for the Paediatric Unit in Nazareth Hospital.

So today (21/8/2016) I did a training ride up to Glenarm in Co Antrim. The Antrim coastline is one of the most scenic in on the planet, and very accessible. Today's ride was up to Glenarm, the southernmost of the famous Nine Glens of Antrim, with its historic castle and harbour.

Here are a few Virtual Reality images from my trip - same as before - download them to your phone or tablet, and view with Google Cardboard. I think they came out pretty well - what do you think? A truly immersive Antrim Coast experience!

FILE 1: BALLYGALLY VIEW. Yes, Northern Ireland has some pretty variable weather, but it's precisely because of that weather that we can enjoy views like this!

FILE 2: GLENARM HARBOUR. A view over the foot bridge towards the harbour.


FILE 3. GLENARM MARINA 1. Little boats rocking in the gentle breeze.

FILE 4. GLENARM MARINA 2. They're still there and they're still rocking.

Please leave me a comment in the box below - I'd love to know how these make you feel.

Here's the Strava map for my journey - this is a lovely ride - do try it out.

And please sponsor my bike ride for Nazareth! Thanks :-)

17 August 2016

How the Clinical Note has to change

How not to do it.
Everything is wrong about this image of clinical noting in the digital age. White coats are an infection hazard. He's not bare below the elbow, presumably in a clinical area. The device is a big clunky useless piece of crap that's a pain to type on using this stylus. Why is he typing anyway?

So here is the problem. When Electronic Health Records were first designed, their job was to replace and carefully emulate what we had been doing with paper records. The concept was that the paper record was something of a Gold Standard, and our objective was to leverage the benefits of electronic onto this gold standard.

However, as Larry Weed pointed out FORTY FIVE YEARS AGO, there is a deep problem with the way we structure clinical records, and I'll be honest here - in my journeys around hospitals and clinics, and even in my own note-taking (even? Good grief!), our notes are not fit for purpose.

Here's a typical example of a note on a baby on day 3 in the Neonatal Unit (I've made this up, but if anything it's better than most): "Thanks for referral; Hx noted. D3. b38/40 twin 1. Other twin OK. bwt 3.21kg. Meconium at delivery, req resus. Resp now OK; off vent. NG feeds. Dysm features: hypertelorism, small mouth, crumpled ears, clinodactyly V, abn palmar creases, hypospadias. Suggestive of genetic syndrome. DNA for array. Will RV. Pls get clinical images & skel surv."

Now in the context of a busy NICU that's going to get buried in loads more clinical notes very quickly. If do that in an electronic system it's going to take me longer to type in (I could have scribbled that in half the time it took me to type it, even with the abbrevs), BUT again it's going to be lost in the load of other observations, consultations and notes that get added in.

As if that wasn't bad enough, just look at it - there's little structure to it. A computer is going to have to be pretty smart to parse even that highly lucid (in my opinion) text into something it can analyse or search on. It's free text. Furthermore there's a load of duplication there - much of that info is recorded elsewhere, similarly in free text. Maybe I've just jotted it down to persuade some lawyer some day that I've actually read the record (not necessarily understood the clinical case - those are different concepts).

So let's say we ditch the paper (YES!) and go digital - how do we change our practice and train doctors, nurses and AHPs to bring the clinical note up to date?

It's not an impossible task. For one thing, if we can crack the login/ID problem it should become easy to see who has made a note, and when (yes, we're supposed to sign and date/time all notes, but that is often missed, or people miss their IDs eg GMC number). It should also become easy to contact that individual through the secure EHR system. So in that area the clinical note is a good "stamp" to focus at least some clinical care around.

We surely don't need to repeat the basics - that should all be in a summary box every time we open that patient's EHR. But who curates that? How do we turn the mass of data that we generate into a coherent story that outlines the scenario relating to that patient, and that all the professionals AND the patient/family can group around and agree? Moreover, how do we turn that summary into something we can perhaps share with tertiary or supra-regional professionals outside our local (or in Northern Ireland's case, we hope) regional EHR?

And (critically) how do we ensure that electronic notes actually bring benefit, not just to the patient, but to the staff using the system? We need it to free up time. We need it to be a pleasure to use. But I feel that our approach to noting has shackled us to the past in such a way that we have lost sight of the purpose and function of The Clinical Record.

In the digital era we need to actually enter things manually to a computer as LITTLE AS POSSIBLE. Voice recognition is still pretty damn basic, but it's making headway. But my clinical note should be short and to the point. If I need to enter something quantitative I should be able to do that, but I'm not writing a legal document here. I want to construct a digital record that is dynamic and positively contributes to good clinical management and outcomes for my patient.

So like clunky tabs and white coats, perhaps the clinical note itself needs a major overhaul before we start replicating in electronic form the mistakes that Larry Weed pointed out to us all those years ago, but nevertheless persist in our training and practice.

12 August 2016

Virtual Northern Ireland

Have you ever wanted to visit Northern Ireland, but haven't got around to it yet? Now you can get a feel for it in #VR prior to booking your trip(s).

VR panorama: Waterfront Hall & Law Courts, Oxford St, Belfast. *Doesn't lead to Oxford.

I've been playing with Google CardboardCamera - an app that allows you to take 3D Virtual Reality pictures on your smartphone and view them with a Google Cardboard Viewer.

Anyway, the lovely people at VisitBelfast gave me one of their special viewers, produced for the new Belfast Go Explore VR app (check it out on Google Play or Apple Store), so in honour of the occasion, here are some of my own VR shots of Northern Ireland for your Virtual pleasure!

Simply download the file from the link (these are DropBox) - you should get a file ending in .vr.jpg - then add the file into a folder on your Android device called /DCIM/CardboardCamera and then launch the CardboardCamera app. It should automatically detect the files, and if you have a VR viewer such as the one above, you can be magically transported to a mystical world of wonder (i.e. Northern Ireland). Enjoy!

Let me know in the comments what you think of these, and don't forget to sponsor my cycle ride to Nazareth for the Paeds Department in Nazareth Hospital! Spread the word - thanks!

30 July 2016

Sponsor me to Cycle the Galilee for Nazareth Hospital

Stubborn to the last. Jordan Valley, 2009.


Nazareth is the largest Arab town in Israel, and home to its largest Christian community. Its hospital is the oldest in the country, founded by the remarkable Dr P.K. Vartan from Constantinople in the days of Ottoman Palestine. I became an honorary Nazarene when I did my elective there as a medical student back in 1993, and saw at first hand the great work being done, using healthcare to build bridges between people.

The Nazareth Trust is raising money to provide much-needed refurbishment for the Paediatric Department, and a group of us are cycling through the ancient terrain of the Galilee in November 2016. Christians, Atheists, Muslims, Jews and others - all are welcome. So please go over to my Justgiving page and sponsor me! Also share on Facebook and Twitter: #shanenaz2016 - and thanks so much for your support!

19 June 2016

Digital doctoring for #EHR4NI

I'm currently reading Dr Bob Wachter's fantastic book "The Digital Doctor" - a hard-hitting and insightful analysis into the whole field of the computerisation of medicine. Medicine has undergone a profound transformation in the past decades, and computerisation was, in many circles, felt to be the Next Big Thing that would deliver better care at lower cost for a greater number of people. The impact of digital in other industries - and indeed in our social lives - was felt to be translatable across to the messy world of Medicine, and we'd swiftly be on our way to a new and safer healthcare world. Billions were spent on this promise, and the big IT contractors gleefully piled in to address the issue.

And of course the reality was that Healthcare is much more complex than they imagined. Rather than this being a *technical* challenge, that could be sorted by wheeling in the appropriate tech and software, we are faced with an *adaptive* challenge, where the problem lies in the people, processes and indeed culture of the healthcare world. If we want to use IT to help us build better healthcare, we have to start with what is going on at the coal face. It's not enough (indeed it's positively fatal) to engage the CEOs and Medical Directors of healthcare delivery organisations (e.g. Trusts in the UK), and expect adoption and improvement to automatically follow.

I'm still something of a newbie at this, despite blogging about various aspects of our Northern Ireland journey over the past few months (in between digressions into biking and virtual reality). However at a recent meeting to discuss our plans for a unified Electronic Health Record for Northern Ireland (#EHR4NI), I heard a senior decision-maker (not a clinician) actually state that the road to clinical engagement would be to speak to the Chief Executives and Medical Directors of the Trusts; this would be how we would deliver the necessary buy-in from the doctors, nurses, AHPs and others that would make the process a success.

Bob Wachter's findings would very much suggest otherwise.

The good news is that NI has appointed Chief Clinical Information Officers for each hospital Trust, to join established colleagues in the Public Health Agency, the Health and Social Care Board and the NI Ambulance Service. There are five HSC Trusts; Belfast is one, and I have the pleasure of being the CCIO there. However, I and my colleagues also have busy clinical jobs also, and this clearly limits what we can actually deliver.

So what do we need to deliver? The "Clinical Engagement Piece" is one element, but exactly what are we asking our clinical colleagues to engage with? One possibility is that NI will go to market to purchase an all-in-one monolithic computer system on the basis of uniting primary care, community services and hospital based care. I have written about this Standard Model before, and it's one that I have a number of deep concerns about. The principal concern is that if we presuppose that we're looking for a computer system, we'll turn this into an IT project rather than a programme to improve the quality of clinical care. This sort of thing has been done plenty of times worldwide, and the common element seems to be that it generally doesn't work - sometimes spectacularly. The systems are beset by problems, the re-design of processes becomes an exercise in fitting the clinical workflow to the software, rather than reimagining both to actually do a better job. [See this 2-part article from Heather Leslie for some excellent learning.]

Another model might be to continue to purchase multiple "Best of Breed" solutions - software written by subject experts, and tailored as best as possible to the clinical process that we're trying to improve. Whether many of the systems we use would qualify as even mediocre, never mind Best of Breed, is debatable. And we're locked into contracts that are difficult to escape from, while our patients' data remains fossilised in systems that are reluctant to give it up again, much less to interoperate across the silos they were engineered to sit atop. It's pretty clear that this way lies madness; patient care is not markedly improved, but we end up spending a whole lot of money anyway, and digging ourselves into an even deeper hole.

So let's see how we resolve this problem. It turns out that farming these important issues out to IT professionals and consultants (not the clinical type!) is a critical error because these people cannot understand the clinical world. How can they? They're not trained. Nor can we just hand over to clinicians, because without the necessary background in quality improvement, change management and multidisciplinary vision, we just end up consolidating irrational variation (based often on whim) and making decisions that end up reinforcing silos, and indeed multiplying them. We need to find ways to get all these people - clinical, IT, managerial, and (most crucially) the patients - collaborating.

I'm still working my way through Bob's book (reading and re-reading each chapter - it's worth it!), but it's reinforcing some thoughts that I and my CCIO colleagues seem to be rapidly coalescing around. One is that we need to get the Data Interoperability issue highlighted (Bob calls it "baked in") from the outset. I'm going to suggest that we very explicitly and at an early stage in the process - now's good - state that we are NOT going to go down the route of a single electronic system to replace all the systems and functions of a healthcare IT infrastructure. Instead, we must create an ecosystem where the patients' data forms the core resource, and multiple developers and vendors can work on refining the interfaces that serve the clinical, management and analytical needs of the health service.

In effect, this seems to imply (and I am continuing my research, so this represents my current view, which may change according to new evidence and arguments) that we address the data first, then progressively migrate the apps to the data, instead of the old ways of migrating the data to the apps. We need evolution, not revolution. Plenty of Positive Pops rather than Big Bang.

What will this allow us to do? Firstly, it should encourage standardisation around best clinical practice - since we will be collecting the same data, we can assess variation, and analyse processes to see how best we can remap them to the most solid evidence base. Secondly, it will encourage innovation - agile software development will make it easier to quickly adapt interfaces to new clinical developments, without the need to change an entire system. Thirdly (and as a result of these), it will allow frontline staff and patients to get much more involved in refinement of the apps and systems that are being used. Fourthly, since the apps will be using the same data according to agreed definitions, data can be reused across clinical scenarios, reducing duplication, waste and errors.

Now these are very logical benefits, but will they actually pan out in practice? That is the million dollar question (or in the case of the UK's largely-failed National Programme for IT, 16 BILLION dollar question). There is good reason for scepticism that all the advantages that come from magical thinking will actually appear in the short term. They call this the "Productivity Paradox" - computerisation should help, but it usually requires a long time before it actually delivers, if at all. Our budgetary decision-makers in NI need to be aware of this - if we are going to go digital, it will cost money up front that may take years to deliver a return.

But let me get back to the main point - our prime objective here is NOT to computerise Health & Social Care - it is to improve the care of our patients. If we keep that principle front and centre, and build in the absolute requirements for an open and interoperable data platform supporting multiple partners, then we can do something pretty special here.  One model that I am very keen on is #OpenEHR, and we are actively exploring what we can do with this approach (and I think we should be doing more).

Is Northern Ireland up for this challenge? Well, before we head too far up this loanen, (old Ulster Scots term - look it up), I suggest we need to invest a good deal more resource (still cheap!) in freeing up some more of the time of the young (or at least not too senior) doctors, nurses, AHPs etc who will explore these waters and energise their clinical teams. I feel we CCIOs need significantly more time in our job plans to be CCIOs (one day a week? seriously?!), and we need clinical colleagues funded within our organisations who will join clinical informatics groups. We also need the CCIO role beefed up in terms of where it sits in the organisational hierarchy. We need specific specialty and patient focus groups that are structured around actual delivery, rather than merely producing wordy documents. We need a workable governance framework for the data, and we need money to do the groundwork and to experiment with various implementation models. This has to involve links with academia and IT industrial partners. We need to take risks. We need to be prepared for multiple Plan/Do/Study/Act cycles, supported by rapid innovation and rigorous data analysis. And we need to be ready to put our backsides on the line.

We have already had remarkable success with the Northern Ireland Electronic Care Record (NIECR) - that rare beast of an IT system that clinicians love, and that has had a dramatic effect on the practical delivery of patient care. Most hospital doctors now use NIECR as their first port of call when trying to find clinical information (letters, lab reports, radiology, medications) on patients, and it makes a real difference. It has shown us what is possible, and now we have to take things to the next level.

It's going to be a lot of work, but by the time Bob writes the second edition of "The Digital Doctor" (or maybe by the third - let's be realistic!), I want Northern Ireland to be one of his shining examples of what is possible when a country gets things right. So let's make sure we do that, rather than ending up as yet another cautionary tale of what happens when you try to turn a quality improvement process into a large scale IT project.

07 June 2016

Slovenian cycling bliss - again in Virtual Reality

We went cycling in Slovenia. The event was the Single Speed European Championships - mountain bikes specifically modded to have only one gear setting. It's all the rage among the kids these days, and certainly imposes an interesting discipline on one's ride.

Anyway, Slovenia is utterly beautiful. And of course I took my phone and captured some fantastic immersive 360 degree virtual reality images of the scenery. You'll really like this one, from the heights of the idyllic Soca Valley near the fantastic little town of Kobarid.

Click here to download the vr.jpg file. Put it on your Android phone and view in the Google CardboardCamera app.

Oh, and in the race I came 4th. Along with about 300 other people. There is no 5th in this race. In the short video below you'll get a flavour of events, and you'll see my brother Rick, and friends Hugh and Davy - as well as a load of new friends. And stuff.

05 May 2016


A beautiful evening in Greenisland. This is a 3D panorama for @GoogleCardboard Virtual Reality, in the vr.jpg format. It has audio and a true 3D still image. You need an appropriate smartphone (I use a Galaxy S7) and a Google Cardboard viewer (£4 on Amazon - seriously). Get ready for an amazing immersive experience - it's just like being ME beside my BIKE! Beside a ROAD and a FIELD! You'll notice that the software compresses moving vehicles into rather strange abberations, but the immersive virtual reality effect is pretty darned good.

I'm getting quite besotted by Virtual Reality and @GoogleCardboard in general - I think it's potentially a fantastic educational tool. Plus, I want to make sure as many people as possible share in my Nazareth experience, so when I do that, I'll be posting plenty of VR pics too. So make sure you get your Cardboard before then... 

[NB. This photo works in Google Cardboard Camera app on Android smartphones. You need to place the image in the Device Storace \DCIM\CardboardCamera folder, and then view it via the app itself. Have fun!]