01 July 2017

Interoperability the Encompass Way

Northern Ireland has had great success with the Electronic Care Record (NIECR), which is a mainly read-only portal that allows health professionals across the region to get access to vital information on their patients. Letters, appointments, X-rays, lab results and more are all available at the point of care via the NIECR, and it's fair to say this has been revolutionary. I use it in my clinic all the time, and it allows me to have a far more valuable session with my patients, and to bring them up to speed with their own care across the system.

However, we are still stuck with largely paper-based systems for most of the activities relating to the patient's record, and this means that we cannot fully take advantage of the opportunities that a truly digital system would give us. For example, we are still prescribing on paper. Most clinical notes are physical charts with paper filed within them, covered in clinicians' scrawled handwriting. Communication between professionals and from professionals to patients, is still hugely dependent on dictated letters. Indeed, even synchronising information across the myriad electronic systems - databases, registers, ward whiteboards, GP records etc. - is still often mediated by paper transactions, with all the risks and problems that are associated with that.

So, armed with the experience gained via the NIECR, we in Northern Ireland are embarking on a new project - Encompass - an ambitious effort to unite Acute and Community (and eventually Primary) Care into a single patient-centred structure that merges data and workflow, and allows information to seamlessly follow the patient through the system. In addition, we want to allow patients to access their own data and to play a key part in how their care experience unfolds.

All this is in pursuit of the Quadruple Aim - four transformational principles that underpin where healthcare in Northern Ireland (and elsewhere) needs to go if it is to survive the mounting challenges that threaten to undermine sustainability of the entire enterprise:

  • Better healthcare
  • Better population health
  • Lower per-capita cost
  • Better staff experience
I could go on at serious length about how proper health transformation is not possible without digital transformation, but maybe that is for another post. But there is another aspect. One of the main challenges of digital transformation is making sure information is available right across the healthcare system, and that data has to be accurate, complete, and tightly linked to the care scenario. With the multitude of health systems out there, one approach has been to get a "megasuite" of software from a single software vendor to try to do it all. Where there are gaps, the megasuite vendor can work on stop-gap solutions, the care system can develop workarounds, or third-party developers can try to plug their solution into the megasuite itself. Or the systems can remain in separate data silos, synchronised by hand or by some other interfacing engine. This model is superficially attractive, and can deliver major benefits in many areas, but experience over the years has shown that there will always be a considerable bloc of the health data world that remains outside the megasuite, reducing the overall benefits and return-on-investment.

And there's more. It may seem churlish - or even a bit paranoid - to point this out: if you have all (or most of) your data being looked after by a megasuite in the megasuite vendor's system, when you come to contract renewal, or even when you want to change things to adapt to new conditions, you find yourself "locked in" to that vendor's solution. To get out of this lock-in, even if the contract has expired, can be very complicated, very costly, and put your patients' data at risk. So you do all you can (including perhaps paying over the odds) to stick with the same vendor's system, rather than tender for something cheaper or better. This really restricts competition in this space, and hampers development and innovation.

What's to be done? Well, there is another strategy, and this involves looking at how we design the overall project. In the Encompass Programme we are explicitly stipulating that patient data be placed in a parallel vendor-neutral archive (VNA) employing open data formats. The data transactions with the VNA must be bidirectional (read and write) and complete, using standard recognised interchange protocols. The types of data we are storing will include coded clinical concepts and core data, eg using the OpenEHR format and linking with SNOMED-CT, patient documentation in a clinical document archive (CDA), patient images including scans & X-rays and pathology pictures, and other pieces of data appropriate to management of the patient through the system.

If we do purchase a megasuite to do most of the heavy lifting (and that is certainly one of the options), this Open Data Format layer will be vital to ensure that we have control over access to our data, and that we can, with other partners, rapidly develop innovative solutions to the clinical and administrative challenges that we will inevitably face during our health transformation journey. In particular, security and confidentiality are critical.

I have been calling this open interoperability layer "OCEANIC" ("Open Core Engine for Accelerating NI Care"), but the name isn't important. It's a key integral part of the Encompass Programme, not an alternative, and not a bolt-on. It's almost a philosophy - one based on agility, sharing, consent and openness.

Another term that has been used to describe such implementations is "Bimodal" - a central megasuite core to bring together critical elements of patient data and the workflow structures to support its use, and a robust and open interoperability layer to support agile innovation, advanced analytics and seamless integration across the entire health system. A truly open approach to integration is being increasingly recognised as a critical element in joined-up care (eg see http://interopen.org )

It turns out that NIECR has already done a lot of the background work for us, and it is entirely logical (maybe even inescapable) that the next step should be to build the interoperability layer at an early stage in the Encompass Programme. A particular advantage of this approach is that it allows us to seriously engage our local technology ecosystem (NI companies and researchers) in our digital journey, developing apps and analytics to allow us to meet the Quadruple Aim, and transform healthcare for the future. Our patients (who after all are us and our families too) must be firmly at the centre of this. We need to talk to them, get their views, explain what we are trying to do, involve them in the delivery and decision-making. When I explain this to them, I am invariably met with significant enthusiasm.

Our goal is nothing less than to make the Northern Ireland healthcare system the best and most connected on the planet. Everyone - patients and professionals - on the same page. Ambitious? Yes. Crazy? Yes. Impossible? Only if we don't make the effort.

Encompass. Delivering the best care. The most connected care. The most comprehensive care. Together.


  1. OpenEHR is a great idea and I have been voiciferous about this for some time. But something is missing. Who has tried to look through the UK CKM? Who has tried to build an archetype? Who has developed a front end capable of using such a vendor neutral data layer? Not many people. There are a few experts which means OpenEHR is as bad as vendor lock in - as it currently stands. Have been making some progress on this front. But getting stuff done requires front line clinicians and informaticians to do some work on this. Unfortunately time is money. Many industry partners back off when it comes to the crunch. Because the crunch equals cash. Unless we ring fence some resource this idea is really idealistic rhetoric and we will end up with a solution hailed as a success because a shed load of cash has been spent on it. Although at least that beats wasting shed loads of cash on heating the country side and lining the pockets of a few.....

  2. Shane, what a fantastic vision. I am the business analyst for Leeds Care Record, and I can endorse every one of your comments re vendor buy-in, clinicians reluctance to change, incredibly wasteful workarounds etc. My email is nigel.hodgson@nhs.net if you ever want a chat. Nigel

  3. Hi Sandy, I disagree that OpenEHR is as bad as vendor lock-in, but you have a valid point that clinicians need to be engaged in order for the benefits to get out there. The chicken-and-egg situation is that they won't get engaged until a/ they've got something to engage with and b/ that engagement translates into making things better. It's not just a matter of "build it an they will come" - it's creating the platform that allows innovation to take place. The platform is not itself the ultimate goal. It's the enabler. We need to engage multiple people - professionals, patients, IT companies, 3rd sector etc to build upon the platform. But yes, if we just treat it like a standard EHR model, it'll not deliver the extra benefits.

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