Here and now, the desktop for many health providers—in its logical form—is still the closest thing they have to the integrated clinical moment. It is more of a container coupling free data together than elegant third-generation context, location awareness, and prescriptive EPR. Everyone is at different levels of maturity. Even those at HIMMS level six, five years into executing their applications strategy, are taking the time to consolidate. When it comes to mobile applications, we are all still somewhere between initiation and evolution. It is still easier to onboard new applications than offboard legacy ones, and whilst every every organisation may face the same problems, starting positions differ greatly.
Consolidating into one EPR isn’t necessarily a desire or reality. The large acute UK hospital trusts are not that large. The lack of financial autonomy granted to foundation Trusts means acting as entrepreneurs to an extent. The large acute is too small to scale and still too public to redesign its business model or reduce activity to free local resources to implement change. Managing large supplier contracts is a challenge in itself. Vendors, in turn, may not want to localise their global products, or they cannot due to frustrations with the national systems or the costs of dealing with many smaller sites. This is when local products and system integrators can provide a viable alternative.
Operations management has applied evidence-based medicine via EPR implementations to standard practice to reduce variation and uncertainty in the outcome of care. However, standard procedures are not all applicable to solving health problems. They don’t suit the uncertainty or the experimental nature of some healthcare environments. As Bohmer points out, in any system, the framework we build will need to be able to accommodate and exploit changes in the knowledge of care and its impact on process and practitioner roles. The tactile knowledge, experience, and support of colleagues and patients, regardless of physical presence, all contribute to the caregiving process. In this clinical operating system, the secure messaging application, web conference, federated directory and document search tool all add value to creating a unique, patient-engaged electronic clinical moment and the creation of evidence.
For a doctor, surgeon or community nurse, it’s largely about the personalised experience, which is probably one of the reasons they chose medicine as a career. Also, the one-size-fits-all approach isn’t necessarily a good strategy for the organisation. As Millennials begin to dominate the workforce, along with the move to seven days of working and round-the-clock support for the electronic systems, organisations are going to have to empower their resources to survive. Decentralisation, self-service, and workforce empowerment are all going to develop formally and informally as IT departments struggle to meet the operational support required for the 24-7-365 electronic clinical environment on paper-oriented budgets. The challenge here is how to synthesise the data captured from these ad hoc moments into insights, which in turn develop into standard practices. How do we establish who is doing what from which location and for how long? How do we build learning into the system?
Multiple clinical data input applications, suppliers, and vendors within the environment are a reality and even a desired strategy for many. That is if you wish to provide adaptive and personalised electronic clinical moments, which transcend physical locations, and channel the context back into the moment and learn the process. It’s the investment in a secure coherent infrastructure platform which allows the deployment of new processes and applications quickly. We need to develop the EPR as a platform framework.
The platform will need to do more than deliver the logical desktop. It will need to deliver and manage applications on the device by integrating identity, application, and enterprise management, on and off premise. It will need to span form factors as the end devices become more varied and mobile. It will need to traverse hostile infrastructure as the point of care moves closer to the patient. Whether a unified or diverse platform, IT teams need to be skilled and comfortable with its toolset. This is all good if the browser develops into the new end device. However, in the short term, the logical desktop will remain because health enterprise applications need it to share a platform that integrates physical devices such as microphones, third-party applications, and location-aware listening agents. Of course, the platform will iterate. Mobility, cloud services, and Office 365 will influence it. It may be logical; it may be via HTML5, but it will remain because it will contain and enable functionality and, of course, be capable of tapping into all the possibilities of mobility-enabled IoT solutions.
The platform, however, needs to have depth. It can span, but the framework will need to layer. For on-premise, in- and outpatient areas, where the logical meets the physical medical device, the vertical integration of the wireless stack into the framework is paramount for providing availability. This is becoming more and more important as patients and care providers cease to recognise the difference between wired and wireless. With the majority of new mobile devices enabled for Wave 1 of 11ac, some might think the problems are resolved. To a point, this is true; however, for those of you who have deployed wireless networking in a clinical environment, you’ll know that you have to take a holistic approach that factors into the end device, battery, existing infrastructure, and constant motion of clinical floor space. Depth will also add value. The ability to leverage indoor location services from the network layer to locate the practitioner or patient with mobile medical equipment will enhance service and efficiency.
In addition to adding value to the organisation in terms of data analytics, it also adds contextual awareness and personalisation to the clinical practitioner. Traditionally, this is at the application delivery when the user interacts with the application. However, as we move closer to concepts such as Slippy UX, where information is triggered at the system level based on a location, then we will truly have a layered framework. Whatever the layer, the solutions provider will add more value here than the span, which will be more vendor-centric.
This all needs to be secured but accessible. When private data becomes public, it ceases to be private. But again, depriving the clinical user access to vital information is also a risk in itself. However, secure doesn’t necessarily mean restricted access if you take the EPR-platform approach. It’s the subverted work around which clinical practitioner that compromises governance. Federated Identity services therefore, need to span the medical device, traditional desktop, and public SaaS. Strong coherence and loose coupling will enhance the user experience without compromising the security. The ability to use the same token, whether it be an ID card or your existing OTP for remote, and procedure witnessing will enable all to an ease of use without comprising security – a step closer to truly integrated clinical moment.