 .com forward slash d-r-c-j-r forward slash e-m-f-20-14. So, I'm going to first of all try to persuade you that NHS IT really could be a lot less bad either that it's not in a great state at the moment. Then I'm going to speculate as to why that might be, hopefully in a plausible way and then I'm going to let you know about what we've been up to so far trying to sort this out and hopefully persuade you to get involved. Can anybody see something on the screens near them or online, just black? If it's just black then the puzzle will be a bit hard. Okay, so it's a picture of a chest x-ray and the question is is the nasogastric tube in place? If you could see it, can anybody see it? Does anyone want to speculate an answer? No, it's not. Maybe. Maybe. It's in the lung, yeah. So your stomach's on the left-hand side and the tube's going over to the right the way the film is, so it's definitely in the wrong place. And I start with this, I mean just there's a little puzzle, but we're actually, we're dealing with concrete things in healthcare and this is an example of a bit of health information that not having access to might have real consequence. So, we're at the stage where I'm persuading you that it's not as good as it could be. I'm going to tell you three short stories about that. One of them involves that picture you saw a moment ago. Not so long ago, I was working in an intensive care unit. I'm a doctor and a geek, by the way. And I was the responsible doctor for the intensive care unit in the night time and intensive care doctors essentially put tubes into tubes and measure what goes through the tubes. And from time to time you need to make sure the tube is in the right place, usually just after you put it in. That's quite important, having a tube that's for feeding in your lung rather than your stomach is highly suboptimal. And it happened to me in 2014, this year, earlier this year, it happened about four o'clock in the morning. I wasn't able to see any of the x-ray system was down, I wasn't able to see any of the images. And I had several unwell patients that we've been doing things to. And it mattered a lot for me to be able to see what was going on. And the system let me down. That's a shame, but what's even more of a shame is that the mechanisms for learning from that failure also let me down. So I followed an incident at the time and there was supposedly somebody that would get back to me within an hour, there was a hotline that I called, they didn't get back to me. I filled out an incident form and I'm not at all convinced that this wouldn't happen again. It will happen again. And that's the problem. The second tale was when I was a bit more junior, I was working in Basildon and there was a patient who had had a fractured neck of fema that had fallen over, that had broken their hip. And unbeknownst to the team looking after them, they had also very, very recently within the last week or so, had a camera test because there had been anemic and someone had put a camera down and had a look into their stomach and they'd also had a look into their bowel. And this lady, after she'd had her hip fixed, was very slow to get better. And we were really encouraging her to move around but she had pain that was really not in keeping with the sorts of pain that people normally have after their hips were broken and fixed. Unfortunately, when they had done the camera test, they had perforated her bowel and we didn't know about that because when we look at what's going on with the patient at the moment in the NHS, we frequently have to look at lots and lots of different systems. It's very fragmented. So the blood results will be in one place, the x-rays will be in another. Endoscopy reports at this particular hospital were uploaded after some arbitrary time frame into another online shared folder. And that situation is dangerous because you can very easily, in this sort of human factors problem, you can very easily, if you make it really difficult to see a comprehensive view of somebody's problems, you can very easily have people working with an incomplete view and then you can have something like this being missed. So that lady died. She, nobody realised that her bowel was perforated until it was too late. And I think there is a, it would be much, much more likely that we would have worked out what was going on if we had known the recent events that happened to her. The third tale kind of follows into the question that's after it. Communication breakdown, it's always the same. So this is just the case, unfortunately, that frequently we are communicating, using things like pages and fax machines. And there is not capture of the, there's not good digital capture of the communication. And not infrequently people are lost to follow up or tests that doctors wish their patients had don't happen. They initiate the request for the test, but it's just lost to the system. The fax machine breaks, something like this. And that's another very, very real day-to-day problem. So we have these sorts of, really they seem intractable almost issues. It was only my practice four years I've been working as a doctor in the NHS. It doesn't, there's not an appreciable feeling that it's getting better. The people on the front line really want to make it work. And the question follows, I think highlights this, that there's immense pressure on the people in the front line to get it right. So how does the receptionist fax the referral card that's too thick for the fax machine? Anyone know? She frozen copies it, yeah. And then this is the, this really sad that there is a fax machine, but that I think that's sort of innovation. The people on the front line are desperate to make it work because if you don't make it work, then your patients do less well. You have to stay longer in the hospital because it's inefficient. There is a spectacular amount of goodwill and energy being applied to cope with a broken system. So I think fundamentally, if the system were able to be a learning system and to more quickly evolve, then lots of these problems would get better quite quickly. But why these problems here? I mean, I see surely someone just files a bug report and the stuff gets fixed. Well, there isn't really a bug reporting system for the NHS. The closest that we have is a safety system called the National Reporting and Learning System. There's actually a bolestri recently, but they've maintained the function, so it's still kind of there, which is a system for whenever something untoward or unexpected happens that a healthcare professional recognises, to a patient, they fill out an incident form and supposedly that would be then collated centrally and anything that's actionable or learnable from these events would be fed back to the system and the system would be fixed. Now I work for the National Patient Safety Agency that maintains the system for a year on secondment, and I was doing a health informatics masters at UCL at the time, and I picked the subset of safety incidents that relate to healthcare information systems, so software essentially, as an area to look in a bit more depth. And there were 7,273 incidents. This is, if you can see, the slightly pretty picture, I think. This is a lingo cluster analysis of the free text of the incidents, which is a lingo's hierarchical clustering algorithm that's typically used for web result snippets, so if you search for something like Apache, you would hope that it clusters Apache helicopters and Apache Indians and so on. So this is entirely automated and it comes up with the sorts of things which do resonate with frontline healthcare professionals. The computers aren't able to do stuff. You can't communicate, you can't access the systems, stuff falls over frequently. So the limitations of that are that often the person reporting the incident is ignorant, so the sort of granularity that you're going to get in your bug report is it didn't do what I wanted it to do. There's no, it's going to be difficult to reproduce these bugs or actually drill down and see what's going on. Also there's massive under-reporting because there's very little incentive to report in a system where you don't get anything back. A common search string that I found in this dataset is still not fixed, broken again, immense frustration probably before people give up and don't bother reporting at all because there are lots of ongoing issues and there's not adequate mechanisms to fix them with respect to broken software and the NHS. Bleeps failing was a big problem. We're still using bleeps pages, that's how it is. So why is it like that? You could say it's easy to say leadership lacks digital now, so I think that's part of the problem. It's probably a bit more subtle than that. The market is broken or performing suboptimally. The end user lacks influence, so there's no means to make the broken system better frequently. There's no, you can't vote with your feet as you can in the consumer market. You have a middle layer in the hospital or the administration that buys the software and then a coercive implementation that leaves the end user with no choice with respect to what they have to use. There's also a granularity problem where software is commissioned at the wrong level. I think it doesn't meet the specialist needs of the individual clinical teams, which is why you often have trouble getting people to use the electronic systems rather than just sticking with their paper processes that frequently are a lot more optimised for their particular needs. Then there are structural barriers. So there are really quite archaic procurement processes, again not set up for the right level of granularity of buying software. There's information governance, which always is bandied around as a block and there's lots of... I think there is a cohort of professionals within the NHS IT administrative function who really have been brought up in very close relation with the larger vendors and are very quick to prefer bigger, more enterprise solutions and information governance minutiae perhaps rather than focusing on usability and what the actual needs that the software meets. N3, they have rather than using the internet and secure means of communicating over the internet is their own secure network N3, which is a big barrier to entry if you're a smaller entity trying to do business in the NHS. And then there's the fact that if you're trying to do something like web apps that most of the hospitals or many hospitals still use IE7 is a problem just technically when you're trying to make a JavaScript application run faster that's really another barrier to entry. So I think lack of user focus would be a big bugbear that you have as an end user is a picture of an unfriendly teapot there. You may or may not recognise from a nice book on usability, user design. So final part, hopefully I've persuaded you that things definitely could be a lot better. I've speculated as to some of the reasons why that might be that they aren't as good as they could be. Hopefully you're persuaded that it is important to optimise healthcare digital services as far as possible, given that most of us value our health quite highly. So what can we do? I think championing the health promotion aspect of the health service. So what's the health service for? Ideally looking after everybody, making sure that they don't get sick as far as possible, treating them appropriately when they are sick. Asking the question of whether or not the systems we have in place meet that need as well as they could do I think is a really important starting point and citizens, patients and clinicians can be champions of that. We have a thing called the NHS Hack Day, which is www.nhshackday.com, which is an event we set up a couple of years ago under the banner of Geeks who love the NHS. Absolutely everybody is welcome to come along to this event. We have a format where people pitch problems that they have experienced in the healthcare service and then we sort of prototype solutions to them. But it's a lot of fun and lots of different people from different specialties meet and it's quite a positive thing. We sort of showcase how much you can get done with open source software and open governance as part of that. And then finally, I have a start-up called Open Health Care UK. I'm the CEO and co-founder of it. And we have a real-life NHS open source, open governance project at UCLH where we have a contractual relationship with them. They're paying for us to develop software there and we're developing the software in an entirely open source and open governance fashion. So github.com forward slash open healthcare forward slash opal. You can see individual healthcare professionals, doctors, nurses raising issues, requesting new features and you can see us responding to them. You can help if you have the means to. That would be awesome. Get involved, disclaimer as I said, it's ours. And that's it. So I'd love to hear your thoughts on what I've said. If you think there's anything else that we should be doing, could be doing that I've missed, thank you very much for listening. So the next NHS Hack Day is next month away actually. So it's 27th and 28th, I think. Check on NHShackday.com and it's going to be in Leeds. So we do them roughly every four months and they're placed where they are, there is. Any other questions? Hi. So it's all very well having an open source project to solve a health problem. How difficult have you found it taking something that's been developed and actually getting it implemented within the NHS? Yeah, so the product that we mentioned, OPAL, is in the NHS. And you have to, well you have the same challenges to any commercial software vendor has in the NHS. So you have to find a customer, you have to satisfy the customer that you can meet all of their information governance requirements and you have to overcome some of these barriers that I mentioned in terms of N3 and browsers and so on. So, you know, it's hard but I think the one means for doing it is to harness the dissatisfaction of the end user and in particular there's a powerful group of end users in NHS hospitals which is the medical body, the consultant body in particular. That's kind of been our route in where we can meet their needs and they can see that we're helping them to look after their patients in a more efficient way. They're able to then push forward to the relative pressure on the relevant administrative functions of the hospital that are involved with procurement of software. Another question. Yeah, can you tell us a little bit more about what OPAL is and what it does within the NHS IT system? Yeah, so OPAL is a framework for looking after lists of patients and managing wards that have patients on them. And then we have, using the framework, we customise it and we charge for customisation and deployment and support. And at UCLH they have something that they call it L-SID which is their own customised version of our thing OPAL. And that stands for the Electronic Clinical Infections Diseases Database. They use it to keep a list of all of the patients that have an infectious disease that the infectious diseases team looks after and to keep track of the progress that the patients are making, both as inpatients and as outpatients. And the value proposition for them other than it being more efficient than having a paper list or a list in a Word document or Excel spreadsheet is that it gives them an audit trail that they can have concurrent access and that they can use it for research. So to my knowledge, there aren't any other open source, open governance projects in the NHS that would welcome your contribution to them today or tomorrow that you could raise an issue with in a public way as an end user today or tomorrow. And for the particular list problem, no, I don't think... Well, there are arrival solutions, but there isn't anything that's universally adopted. Probably the most commonly used thing for this problem is a Word document or an Excel spreadsheet. And I think that's because of the customisation that individual clinical teams need that you get when you have a blank sheet like a Word document. Ah, yeah. Did those customisations get put back into the project so that they can be used elsewhere at other hospitals? Yeah, so it's all on, so github.com. 4 slash open health care 4 slash opal. Everything that we're doing is... The business model, as I say, is we want to just charge for customisation, deployment and support. There's no... It's all open under an open licence and also it's all open governance. So I would welcome contributions from people outside of our organisation. What do the big players like your GE, your Draga, like static systems, think of you with an open source movement? Like how do they handle that? I think I'm far too small to hurt them at this stage. There have been... So there has been in NHS England, possibly partly as a result of our efforts, there's now an NHS open source programme. So I think some of them are paying lip service to open standards and open APIs and things at this time, rather than going as far as actually embracing openness and having open source and open governance stuff. But I think we're too... We're not hurting them enough. They're still winning too many multi-million pound contracts for delivering not good enough software, unfortunately. Hi. What you're doing sounds really amazing, but I was wondering if it really needs something like GDS, the equivalent of the GDS to come in and really revolutionise kind of IT within the NHS. Something with that level of clout. Yep. That would be brilliant. I think the the set-up for making that happen is difficult because of the the way hospitals are set up. I mean, you know, that could change, but they have money ultimately does come centrally from the Department of Health through NHS England and so on. So, I mean, there could be some means for doing that. Another way, and I would fully support that as a doctor, I would work in for the NHS with a great amount of loyalty to the NHS, I would love to be doing what I'm doing with my start-up inside the NHS in a GDS equivalent or something like that, if it were possible. Alternatively, I think trust may, some trusts may just get the value proposition that actually you can do better care and reduce your costs by have stuff work by using more open source software in the mix and more open governance and so on. There really is, it's kind of a win-win, so it's better for the patient, but it's also commercially strategic. So, I think it may be that that's the way that this change happens rather than GDS coming and getting involved with health, although I would welcome that. Yeah, that'd be good. Any other questions? Thank you very much.