Dissecting Digital Health — with Keith McNeil

The UK’s NHS first Chief Clinical Informatics Officer and soon-to-be Queensland’s deputy Director General and CMIO, Professor Keith McNeil just wants to help clinicians look after patients better.

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This is the full transcript of the podcast Dissecting Digital Health with Dr Louise Schaper, interview with Professor Keith McNeil, Chief Clinical Information Officer Health and Social Care and NHS National Director of IT.

Guest: Prof Keith McNeil, NHS
Host:
Dr Louise Schaper, HISA
Tweet Louise
@louise_schaper
Production: This podcast is produced by Ivan Juric


Show Notes

[1:32] Opening remarks by host Dr Louise Schaper

[1:42] Today’s guest, Keith McNeil shares the story of his journey to his current role, starting as a chest specialist in Queensland up until eventually implementing the biggest electronic health record rollout in the UK.

[3:07] Louise asks Keith what led him to his interest in studying medicine and eventually technology. Keith talks about his original interest in marine biology, and how a guidance counsellor put him on the path towards medicine. Keith also talks about his interest in strategy and engagement rather than the technical side of technology.

[4:47] Keith talks further on the critical need to engage clinicians in any digital health journey through a discussion on his views on the UK’s NPfIT program. Keith noted the poor clinical engagement in the program but also notes its success in helping GPs in the UK to become digital.

[7:49] Louise asks about whether primary care in the UK has predominantly home-grown systems or global systems, leading to Louise and Keith discussing the idea of interoperability.

[8:52] Louise asks Keith to continue talking about the positive things that came out of the NPfIT program. Keith speaks of the robust architecture behind the ‘Spine’. Louise brings up social care’s lack of system connectivity and Keith discusses the barriers for social care, as well as the UK’s progress in working through the obstacles.

[11:19] Louise asks Keith about the goals behind the NHS’ current investment in digital and how success will be measured. Keith touches on obstacles to the assessment of outcomes and their current work on devising 5 cascading metrics to measure success.

[16:25] Louise references Keith’s speech from earlier that day where he describes healthcare as complex, adaptive and chaotic. Keith emphasises the patient-driven focus in system change as a way of ensuring success. Louise encourages Keith to touch more on the domains he mentioned and Keith elaborates on improving the patient digital experience and access to emergency/urgent care.

[20:04] Louise asks about the role, if any, that artificial intelligence might play in implementing system changes. Keith continues to talk about the different domains, in depth, revealing a very patient-friendly focused approach in their goals.

[21:54] Keith touches on the other domains, including everything from online referrals to e-prescribing. Louise enquires as to the focus on workforce and Keith talks about improving the digital maturity and capability of all members of the healthcare workforce, particularly those in clinical leadership positions.

[24:47] Keith touches on the NHS Digital Exemplars program and the final of the 10 Domains, which deal with data, infrastructure, and information governance.

[27:38] Keith credits Tim Kelsey for the strategy which was co-produced with the community.

[28:38] Louise begins bringing the discussion to a close by asking Keith about what he thinks are the key learnings regarding clinical engagement. Keith talks about the constant need for more engagement. He also discusses the evident need to rectify ineffective older systems, which should be replaced with clinically co-created systems.

[31:42] Louise asks Keith what advice he would give to young doctors interested in the work he’s doing. Keith shares his belief that interested, and emerging doctors should make it known that they are interested in the informatics side of the field, and speaking to those already involved will bring opportunities for them.

[33:36] Louise asks Keith a final question about where he feels he has contributed most in healthcare informatics. Keith responds with a touching answer about just being able to contribute through helping another human being. Louise agrees with Keith’s sentiment and discusses the individual patient as the ultimate beneficiary of improved healthcare.

[36:41] Closing remarks.


Keith McNeil & Louise Schaper having a post-DDH coffee

Full Transcript

Opening remarks by host Dr Louise Schaper

[01:32] Louise: Welcome to this week’s episode of Dissecting Digital Health. I’m your host, Louise Schaper, and I’m sitting here in Queensland with…guest, would you like to introduce yourself?

Today’s guest, Keith McNeil shares the story of his journey to his current role, starting as a chest specialist in Queensland up until eventually implementing the biggest electronic health record rollout in the UK.

[01:42] Keith: Hi, Louise. Thanks for having me on the show. My name’s Keith McNeil and I’m the Chief Clinical Information Officer for Health and Social Care in England and Head of IT for the NHS.

[01:54] Louise: And how long have you been in that role?

[01:56] Keith: About nine months, now. I started in July, last year. I think that adds up to nine months.

[02:00] Louise: Okay, and of course our listeners would have noticed that you have a very Aussie accent, so tell me about your journey. You’re a doctor, I believe?

[02:08] Keith: I am. I’m a professor of medicine here at Queensland Uni, which is where we’re sitting at the moment, and I was originally trained as a chest specialist and graduated into transplantation of hearts and lungs, and from there, ran a couple of transplant units and ended up being a CEO here at the Royal Brisbane Hospital, and then that gravitated into being a CEO of the Health District here in North Brisbane, one of the biggest in Australia. From there, at the end of 2012, I was lured back to Cambridge to run the Cambridge University Hospital, Addenbrook’s Hospital in Cambridge, which is the centre of the big biomedical campus there. I did that, and during that time, I implemented a big electronic health record, the biggest ever in the UK. I ended up leaving that role at the end of 2015, and taking up this role about six, seven months later.

Louise asks Keith what led him to his interest in studying medicine and eventually technology. Keith talks about his original interest in marine biology, and how a guidance counsellor put him on the path towards medicine. Keith also talks about his interest in strategy and engagement rather than the technical side of technology.

[03:07] Louise: Okay, well that’s a fly-by! Okay, let me take it back. Were you always interested in studying medicine? Was that a passion of yours when you were growing up?

[03:18] Keith: Yeah. I loved biology and systems and medicine. I actually wanted to be a marine biologist. I’ve told this story a couple of times, but my school guidance counsellor at that time, I was at Cairns State High School, said, “Marine biology is not about diving on the reef. It’s about studying orange ruffies off the coast of Tasmania.” He said, “You’ve got good marks, do medicine.” So, I did.

[03:45] Louise: Alright, so you took that on board. [light laughter] When did your interest in technology — considering that’s the roles you’ve had in recent years, and been very successful, can you pinpoint a time or an experience you had where that interest came about?

[04:01] Keith: Well, curiously, I’m not terribly interested in technology, in and of itself, and I don’t know much about IT as such. I don’t know the technical side of it.

What I’m interested in is how technology can underpin systems sustainability and how to get people engaged.

So, I would describe my role in the UK now as one of strategy and particularly, clinical engagement, with the whole transformational piece. I have a co-worker, a guy called Will Smart who is the Chief Information Officer, so we are two sides of the same coin, really. As I keep reminding him, I’m the head, he’s the tail, that we are a pigeon pair. He does the technical side of things, and I do the strategy and engagement.

Keith talks further on the critical need to engage clinicians in any digital health journey through a discussion on his views on the UK’s NPfIT program. Keith noted the poor clinical engagement in the program but also notes its success in helping GPs in the UK to become digital.

[04:47] Louise: So, your first role involving the clinical engagement side of the technology piece, that would have been while you were in Australia, then?

[04:55] Keith: Yes. So, everywhere you go, you’re faced with technology — both information technology and other technology, and certainly getting people to engage in the e-health agenda, that started for me when I came back from the UK in 2001 to take up the transplant role at Prince Charles Hospital. I got involved in the whole Queensland e-health technology piece, and I was the clinical lead for that for some years, and actually went to the UK in 2003, I think it was, to do an assessment of what was then called Connecting for Health, the National Program for IT (NPfIT).

[05:38] Louise: Yeah, I mean, that program was huge. I remember when that started. I mean, looking back now, it was a while ago, but they were one of the first massive health jurisdictions in the world to take on a project of anywhere near that scale, and I remember the sort of money that they invested..

[05:55] Keith: It was £12 billion to start with, yeah.

[05:58] Louise: Yes, so not an insignificant investment.

[06:01] Keith: No, not at all.

[06:02] Louise: So, you went over to check it out?

[06:05] Keith: Yeah, it was a very interesting experience. So, they had taken a very top-down approach. They sort of carved the country up into about five regions, and said who was going to do what to whom, but the one thing that came across to me loud and clear, and this was really why I went over there, was that

they didn’t have any clinical engagement or buy-in to what they were trying to do, and they weren’t taking the clinicians on the journey with them.

[06:30] Louise: And, at the time, I know in retrospect it’s different, but at the time, would your assessment be that it just didn’t cross their radar, or were they actively thinking it wasn’t necessary?

[06:40] Keith: I think a bit of both. They didn’t spend enough time doing the engagement, and of course you often look back and say no matter how much engagement you do, it’s never enough, but they had done very little, in terms of having it co-created, if you like. They were dictating what people were going to do, and

doctors particularly don’t like to be told what to do. They’re fine when they get involved and make decisions, and of course the skill in all this is to have them engaged and in control of it all along.

[07:09] Keith: I can say that because I’m a doctor. But, seriously, they just didn’t engage them at all, and so when it was rolled out, people didn’t use it. The implementation, having implemented a big health record at Addenbrooke’s, I know absolutely

you cannot implement these things without having the buy-in of your clinical staff on the ground, otherwise it will just flounder, and part of that system floundered because of that.

Now, there were many good things that came out of it. .. Over 90% of GPs became digitised, so the UK has now one of the widest populations of GPs to be fully digital.

Louise asks about whether primary care in the UK has predominantly home-grown systems or global systems, leading to Louise and Keith discussing the idea of interoperability.

[07:49] Louise: In Australia, most of our primary care, well, especially GP practices, have a home-grown/Australian system that they use. What’s the case in the UK? Are they using UK home-grown systems or are they global?

[08:01] Keith: Well, I’m not sure where they came from, but there are four main systems supplies, and two of them have over 80% of the market, EMIS and TPP. I think they may have grown up in the UK, but I don’t know the history of those systems.

[08:18] Louise: I was just curious, because from an interoperability perspective, that’s something that we discuss all the time — that it’s great to have the 98% of people using the computer to capture clinical information, but if it just sits within that computer and not within a shared system, then it has limited value.

[08:35] Keith: Well, that’s absolutely spot-on, and interoperability is a big piece of work for us within the National Information Board domains. There’s ten domains of work in the program that we’ve got running now. We only have £4.7 billion for this particular one.

Louise asks Keith to continue talking about the positive things that came out of the NPfIT program. Keith speaks of the robust architecture behind the ‘Spine’. Louise brings up social care’s lack of system connectivity and Keith discusses the barriers for social care, as well as the UK’s progress in working through the obstacles.

[08:52] Louise: Actually, we’ll come back to that…You were talking about the positive things that did come out of the NPfIT program being GPs connectivity and use of clinical systems.

[09:09] Keith: So, there was that. There was what we called The Spine. It’s a phenomenal piece of architecture and it was built in-house by the NHS — they’re now NHS Digital, HSCIC. It handles more transaction a day than all of the financial institutions in the UK combined, on a daily basis. So, it’s hugely busy, never had a hiccup, it’s always gone smoothly and it’s a Rolls Royce piece of technology. There was the whole health and social care network, the plumbing, or the piping that connected the system up right around the country, and so lots of good things came out of that program.

[09:56] Louise: Did they connect social care as well? Because while we might talk about the connectivity issues in healthcare, and that’s all true and very relevant and important, but at the same time, if you look at social care, and the social determinants of healthcare which we all know are so critically important, their connectivity to systems is almost non-existent, generally speaking. Is the UK leading in that regard?

[10:24] Keith: No, I wouldn’t say it’s leading. I mean, the intentions were certainly there, then the 2012 health reforms came in, the Health and Social Care Act, and that fragmented the system and social care kind of got left out on a limb. So, there’s actually data protection rules or data sharing rules which prevent us from sharing with social care. So, we’ve got to find ways around that and

we’re trying to work through that now to get social care information joined up, and it’s proving to be a problem — not a technical problem, but then again, the sort of legacy systems that a lot of the U.K. have make it difficult to collect data in a modern, standardised way.

But, the technical issues are not so much a problem as the information governance issues, which we’re working through now.

[11:11] Louise: Yeah, yeah. I often say that we won’t be bored anytime soon in this field. Obviously, there’s work to be done.

[11:18] Keith: There is indeed.

Louise asks Keith about the goals behind the NHS’ current investment in digital and how success will be measured. Keith touches on obstacles to the assessment of outcomes and their current work on devising 5 cascading metrics to measure success.

[11:19] Louise: So it’s been a while since the Grainger and NPfIT days, so what is spurring on the signficant investment the NHS is now spending on digitalisation?

[11:38] Keith: Well, it comes back to when you look at systems and what we’re trying to do from a clinical point of view,

the changing nature of healthcare with an ageing population and chronic disease, in a resource constrained environment — a system transformation is needed, and the only game in town really is the information and technology that can underpin that.

We’ve done everything we can outside of that, and that is going to be the thing that drives system change. Now, why do I say that? Well, what has become very apparent, I think, is when you can get information flowing in a sensible construct, if you relate the patient flows within a geographical area, you start to break down silos and information will bring a system together and align it. You can start to address things like unintended variation, duplication, look at benchmarking, all that sort of stuff in a much more effective way. So,

people have realised that the power of this type of technology, because we have the ability to generate more data, we need the technology to be able to interpret that data, to be able to use it, make it actionable.

So, kind of pushing open doors, from that point of view, and then the government, to its credit, recognised that this was a really important agenda, and then they put the money into the system. It’s not all new money; some of it’s used to run things like the Spine, but there is a considerable amount of new money available to improve the digital capability right across the NHS, and into social care.

[13:10] Louise: The funders of this effort, the government, how are they going to judge success of this investment? I believe there are not just increasing pressures, as there are on health systems around the world, but there are almost…I’ve been told by friends in England that there’s nightly news broadcasts about waiting lists for hospitals and the sort. Now, the media likes to beat everything up of course, but is the NHS looking for quick wins, or did they learn from the NPfIT days that this is a process, and an important one that needs to be…

[13:51] Keith: Yeah, look, it’s a very good question. I think assessment of outcomes is really tough in these kinds of environments. As you would know, the direct monetisation of benefits from IT, for health IT in particular, is a difficult scenario, and that will take a minimum of five to eight years, seems to be what the literature would say. I think from the government’s point of view, they always want quick wins, because that’s the kind of timeframe that they work on, but they do realise that in fact they’re not necessarily going to get them, and what they do need to leave is something of a legacy, but

there is a leap of faith saying putting this in is going to result in an improvement in the way the system functions.

[14:35] Louise: And is it bipartisan in support for this?

[14:39] Keith: Yes, pretty much. I mean, both sides recognise the need for IT. I mean, just one case in point which I mentioned today was that simply by putting in electronic prescribing systems, even if they were standalone, will reduce medication errors at the flick of a switch by 50%. Now, that’s an immediate win for doing that, but it’s going to take us a while to get that right across all of the NHS. But, there’s something tangible that would come out of that straight away, which is good. As for the rest of it,

the outcome assessment is really hard, because input and process measurement doesn’t necessarily give you what you want in terms of what the outcome is going to be.

So, we are currently going through a kind of internal debate or discussion within the team and within some of the regulators as to what are the cascading metrics that we can look at to say that actually, we’re being successful. Things like,

  • Are we actually able to give people an alternative to things like turning up at the front door of the hospital, to the A&E, or to a GP?
  • Are we really effectively and tangibly getting patients engaged in their healthcare journey?
  • Are we able to get people to embrace prevention in any significant way?
  • Can people interface with the NHS electronically and find their way through the system to give them alternatives and give them the information that they need to help their health journey?

So, things like that, but they’re not easy things to come to agreement around, but we’re trying to find five cascading metrics that people from the top to the bottom of the system have, we want to look at that, can use and say, “Oh yeah, I get that. I get why you’re looking at that and I get how technology is going to help us achieve that.”

Louise references Keith’s speech from earlier that day where he describes healthcare as complex, adaptive and chaotic. Keith emphasises the patient-driven focus in system change as a way of ensuring success. Louise encourages Keith to touch more on the domains he mentioned and Keith elaborates on improving the patient digital experience and access to emergency/urgent care.

[16:25] Louise: In your talk today, you spoke about healthcare being a complex, adaptive, and quite chaotic system. Do you feel that there’s been a growing level of maturity and sophistication in the understanding of complexity of health going digital?

[16:51] Keith: Well, it’s getting there. It’s a journey, to use that hackneyed phrase, so people are getting there, but rightly, frustrating that things don’t happen as fast as they should, although some of that’s our own processes that we put in place, the procurement that the treasury sign off, the business casing, etcetera, which is interesting, because everybody recognises the need to do it quickly in a much more agile way, but that’s not something that big systems is good at nor comfortable with. So, we’re working our way around and through and over and under and all those kind of things to move it forward, because

we do need to do it for our patients, because they’re the ones at the end of the day who will benefit, and their clinicians who are looking after them, and if those two groups are benefiting, then at the end of the day, we’ll know we’ve done a good job.

[17:42] Louise: So, you talked before about the ten domains. So, did you want to touch on what those are?

[17:51] Keith: Yeah, so, they’re all labelled alphabetically, so domain A is looking at, predominantly digital experience for patients, people who are going to interface with the system. We’re looking to build a front-end that is really user-friendly, using modern web-based design.

[18:08] Louise: Was that on purpose — to put patient experience at number one, or A?

[18:13] Keith: I think it probably was, and that’s a really good thing, and I’ve often said that it’s totemic that it is number one, as

that’s been the piece that’s been so lacking, is how to get patients involved in this agenda.

We all know that people are out there with their smartphones and their FitBits and whatnot. How can we get the — I don’t know, 10,000 apps on the AppStore…

[18:40] Louise: I was told it was 42,000.

[18:41] Keith: 42,000, however many it is, how are we going to be able to get people to interface with the system to bring this data they’re collecting. We want to give them access to their health record. We want to give them access to how their information is being used by the system, so we have transparency in data sharing, we want them to be aware of what research is going on, if they want to sign up they can give electronic consent, all those sorts of things are part of that domain.

[19:10] Louise: Having clinical trials included is really important.

[19:00] Keith: Yeah. Well, being an academic myself, it’s very important, so that’s something that I’m pushing very hard to do. But, it’s good for patients — patients love to be involved in trials, but critically, they need to know what the outcome is going to be.

So, Domain B is about urgent emergency care, so we’re looking at intelligent triage systems that we can do, people can do online and over the phone, and giving them alternatives, things like how they can re-order their medicines online, how they can go to a pharmacy and get care and we can provide their record to a pharmacist, to a community pharmacist, so they can be aware of their allergies, etcetera, etcetera, so that’s all about how we’re going to improve the effectiveness of urgent emergency care and take the reliance away from accident emergency departments and GPs, so providing a wider pallet of options for people.

Louise asks about the role, if any, that artificial intelligence might play in implementing system changes. Keith continues to talk about the different domains, in depth, revealing a very patient-friendly focused approach in their goals.

[20:04] Louise: Are you looking at artificial intelligence as a part of that? I know we’re not there yet, but there’s interesting developments.

[20:10] Keith: Well, look, there are. Artificial intelligence is not there yet, you’re right, but

we are looking at how we could use intelligent triage, which is using that sort of machine-learning to join up disparate, wide data sets to inform the decisions or inform the advice given to people when they interface with the health system.

That’s where we’ll be using so-called artificial intelligence in that space.

So, Domain C is about the sustainability of general practice, primary care and general practice, and that’s about their systems, how their systems work, how patients interface with their systems, how they can sign up to get their prescriptions and their appointments online so they don’t have to turn up face-to-face.

[20:56] Louise: Do you still have the Choose and Book system?

[20:58] Keith: Choose and Book, yes. That’s Domain F. All of that is about joining up primary care systems and making it easier for patients to use, and making the systems more amenable to sharing data with the system-wide.

Domain D is all about interoperability and standards, so that is about how we’re going to join the system up, how we’re going to have agreed national standards, and that’s being done in collaboration with the users on the ground, so

we’re not going to dictate what they are, but what we are going to do is once the people decide what they should be, then we’ll apply them across the system.

[21:37] Louise: Are you working with the international standards bodies on that as well?

[21:40] Keith: Yes, some of them. Certainly, the big vendors are involved in that discussion, SNOMED CT, and a couple of others, FHIR standards for interoperability, that sort of thing.

Keith touches on the other domains, including everything from online referrals to e-prescribing. Louise enquires as to the focus on workforce and Keith talks about improving the digital maturity and capability of all members of the healthcare workforce, particularly those in clinical leadership positions.

[21:54] Keith: So, that’s interoperability, and we’re looking at a regional platform for populations of between three and five million, and then aggregate nationally when we need to, but to use that regional platform for local data sharing for direct care and also population health analytics and that sort of thing. So, that’s where we’re going with interoperability.

Domain E is digital medicines, so it’s about e-prescribing, making sure we’ve got that embedded in.

Domain F is the online referrals, e-referral system, so that’s Choose and Book, for want of a better term, so that needs to be more user-friendly and more effective, and associated with a decision support tool for people in terms of referrers to make sure they’ve been through the right sequence before someone gets sent into an outpatients department or referred to a hospital, so that what needs to be done is done to reduce the redundancy.

Domain G is about provider digitisation. So, this is about taking the 160 acute providers, the big hospitals and DGHs across the country and improving their digital maturity so they can also participate in this whole agenda.

[23:09] Louise: Is workforce part of that?

[23:11] Keith: Workforce is part of that. So, some hospitals, there’s a thing called the exemplar program, these are hospitals that have invested already in IT so they’re at a reasonable place, there are a whole lot of others that going through the journey but aren’t quite there yet, and there’s a third of them down at the bottom end who are really way, way behind. Now,

complementing this is the whole workforce piece, which is a digitisation ready workforce. There are two components to that. The first one is about the whole workforce, how we’re going to, through health education right across the country, improve the digital maturity and digital capability of every single member of our workforce,

particularly our clinical workforce — embed it into medical schools, nursing schools, allied health courses, etcetera. That will obviously take a long time to start to bear fruit, but we need to get that started now.

At the other end of the spectrum, we’re starting a thing called the NHS Digital Academy with an academic partner, first cohort will go through in September of this year, where we are giving people a professional career path in clinical informatics.

This is for CIOs and CCIOs and CNIOs, so that they can really improve their digital capability. Some will go on to do clinical informatics at PhD level, some will go on to become professional CCIOs or CIOs within a hospital, and we’re working with the Royal Colleges to make sure that if you’re a doctor, that could be part of your training program, recognised as part of that.

[24:46] Louise: Great.

Keith touches on the NHS Digital Exemplars program and the final of the 10 Domains, which deal with data, infrastructure, and information governance.

[24:47] Keith: That compliments the exemplar program, where we’ve picked — we’ve announced 12 but we’ve picked 16, hospitals, and we’re giving them money to get them to world-class standard. What we’ve said is HIMSS level 7 or equivalent, and these are all ones with electronic records already in place. There are seven different providers, I think, in those electronic health records, and we want to give them money to see how good they can get, and then use them as a ‘shop window’ for the rest of the Trusts, to say, “This sort of record, that’s what I want to be like. I’ll go for that one,” or “That one’s more appropriate to my care.” So,

we’re looking at build-your-own systems, we’re looking at some small DGHs who have got a wide community spread already, we’re looking at big academic teaching hospitals with big research programs.

It’s giving people a bit of a ‘potpourri’ to come choose from.

Domain H is about data, so underpinning all this, of course, is data, so this is about how we collect, aggregate, and analyse data. This is where big data analytics platforms come in, how we work with interoperability, and you can see there’s a lot of interdependencies between these domains.

[25:55] Louise: Absolutely. As for the previous one around workforce, because of course we know in our field, even if we’ve got the systems, if people put in crappy data, you’re not going to get the value that you need.

[26:05] Keith: Yes, exactly, and in fact, with machine learning, you’ve got to have high quality, complete data sets for it to do its job. So, that’s the data domain, and that takes on that role as to how we look, and what do we do with novel uses of data, and that’s where we’re starting to get into the artificial intelligence at different levels. This is also where we start to look at how we analyse genomics, all the -omics, pharmacogenomics, etcetera, and how we drive this towards precision medicine, so there’s a whole domain there. Domain…where am I up to? I. [light laughter]

[26:41] Louise: I’m impressed — sorry, just so people know at home listening to this, poor Keith is incredibly jet lagged, and he’s so nice to sit down and have a chat with me, and I’m like, “It won’t be long, it’s okay,” and now you’re going through all your ten list in alphabetical order. I’m very impressed, so thank you!

[26:55] Keith: Yeah, I’m sort of struggling now, I think I is information governance, that would be good. No, it’s not I, is infrastructure. I for infrastructure.

[27:04] Louise: Infrastructure, alright.

[27:05] Keith: So, this is the domain that keeps the lights on, this is the spine in the health and social care network, and all of the stuff that underpins and keeps the whole lot working. So, that’s kind of work that was already done, and it’s just normal business for the system. Then, J is all about information governance, so it’s getting the data sharing policies, getting the Caldicott Guardian work done, so that we can share data effectively across the system. So, in a nutshell, they’re the ten programs.

Keith credits Tim Kelsey for the strategy which was co-produced with the community.

[27:38] Louise: Very impressive. How long did it take for the teams of people, the powers at be to come up with the list of ten? It’s a very comprehensive strategy.

[27:46] Keith: Yeah, it is, and look, I’d love to take credit for it, but it doesn’t have anything to do with me. It was all Tim Kelsey’s great work.

[27:53] Louise: But, you’ll get credit for it going so well.

[27:54] Keith: Well, I’ll get credit for implementing it, maybe. So, it was done through a thing called the National Information Board, which was pulled together from representatives, from industry, from information rights groups, from charities.

[28:14] Louise: So, it’s really more of a consultation.

[28:16] Keith: Yeah, a really wide consultation, and so it was co-produced with the community, both of whom have a direct interest and a vested interest in getting the whole digital space right. So, I don’t know how long it took, but essentially it was put together, and I tinkered with it when I came in, but basically left it alone.

Louise begins bringing the discussion to a close by asking Keith about what he thinks are the key learnings regarding clinical engagement. Keith talks about the constant need for more engagement. He also discusses the evident need to rectify ineffective older systems, which should be replaced with clinically co-created systems.

[28:38] Louise: Yeah, yeah. Can I ask you two more questions?

[28:39] Keith: Sure, sure, of course.

[28:40] Louise: Then I’ll let you go and have a nap, [Laughter] if you need to.

[28:42] Keith: No, it’s fine, I’ll go and have a cup of coffee.

[28:43] Louise: Okay, I’ll get you a cup of coffee, yes.

So, in all this time that you’ve…from your time in Australia to the various positions you’ve held, and of course, you’re the NHS’s first CCIO, as well, what are the key things you would say, key learnings about clinical engagement? The importance of it, but also how do we get clinicians more engaged in the agenda, and owning it as well?

[29:08] Keith: So, really good question.

The first thing I would say is however much clinical engagement you do, you never do enough.

That’s the first thing. So, just keep doing it. I mean, it has to be genuine, so it can’t just be a tokenistic thing, and we’re just so much pushing against open doors here because this whole agenda just pervades our personal lives — everybody’s got smartphones and we’re all on the internet all the time, we’re ordering taxis and apartments overseas and air travel and all this sort of stuff, so it’s just normal for people now. Of course, everyone’s saying, “Well, why the hell can’t we do this work?” and so it’s kind of crazy. So, it’s not as if people are resisting it now, whereas I think if you went back five or ten years, maybe it wasn’t quite as front of mind. So now, it’s right in front of everybody, and people are recognising we need to do it, especially as the old systems the legacy systems start to fall apart, so they don’t work as well as they should and people are getting very frustrated with them. So, it is about recognising that, and it’s just sitting down with people, asking them what they want.

I think “clinically designed” is not the right term, I think it’s clinically co-created, so we need multi-disciplinary teams of people who understand technology, people who understand human factors, people who understand what the clinical needs are, what do patients need,

so the National Information Board has done some really good stuff. I now chair that, so I’ll take credit for this, and there is just published a list of 20 things that clinicians expect, doctors in particular, expect out of a clinical system. How’s it going to make their life easier? So, what’s the point if it’s not going to make it easier for them to deliver to patients? And, equally, we’re getting the patient groups to come up with what they want out of a digital system.

[30:56] Louise: Oh, we’ll look for that info and put it on the blog page when we publish the podcast, too. I’ll put the URL link, so people can check that out.

[31:01] Keith: The clinician one has been published, but not the patient one yet, and then we’re doing the same with researchers: what do researchers need out of the system? So that when we’re designing, when I go to the domain, the people that are running the domains in their work, I can say to them, “Here are your frames of reference, so that when you build something, when you deliver something, just make sure it ticks off these things, or importantly, and just as importantly, doesn’t stop any of these things from happening,” because quite often, in the past, the criticism has been that we deliver technology to clinicians and they go, “Well, that’s really great, but it’s not what I want and I’m not going to use it, because this is what I want, and you didn’t listen to me.” So, we just need to get that balance right.

Louise asks Keith what advice he would give to young doctors interested in the work he’s doing. Keith shares his belief that interested, and emerging doctors should make it known that they are interested in the informatics side of the field, and speaking to those already involved will bring opportunities for them.

[31:42] Louise: Absolutely. So a young doctor who’s listening to this podcast and enthralled with the work that you’re doing, and of course your own career journey, any advice you’d have to young doctors when they come up to you, or other clinicians, to say, “Hey, I’m interested in your stuff. Where do I start?” What would be your advice to them?

[32:02] Keith: A young doctor. So, I mentor a couple of young doctors, which is curious, because I know nothing about IT, but I mentor some of them who are just getting into this space. I think if they’re interested in it, then they should make that known at whatever level they’re working. There are huge opportunities here for people, and just make yourself known, and get involved. Take the opportunities to get involved, and there will be…keep your ear to the ground. I mean, people are not going to spoon feed you, so you need to take opportunities when they come up, but

talk to people like me, talk to the CIOs and the CMIOs and the CNIOs in your hospitals and let them know that you’re really interested, and you’ll find places to get into and start influencing and start getting involved.

I don’t really know what’s available in Australia in terms of courses. We will have the Digital Academy developing in the UK, and maybe something similar will be developed here, but I think we’re going to have to…every jurisdiction is going to have to do that, because the value of data and data analytics and informing good quality care is just…the imperative is just growing and growing and growing, and I would hope that all medical schools would eventually incorporate it so that people can use that to really influence and inform their practice on a day-to-day, hour-by-hour, patient-by-patient decision.

[33:23] Louise: And we will get there, but it’s just going to take a lot longer. You have to have patience in this field, might be some advice to give people as well [Light laughter].

[33:30] Keith: You have to have patience and you have to have patients, yeah.

[33:33] Louise: Yeah, yeah, yeah, okay.

[33:34] Keith: INC and IENTS.

Louise asks Keith a final question about where he feels he has contributed most in healthcare informatics. Keith responds with a touching answer about just being able to contribute through helping another human being. Louise agrees with Keith’s sentiment and discusses the individual patient as the ultimate beneficiary of improved healthcare.

[33:36] Louise: Very good, alright. Okay, so, let’s fast forward, you’re like, in your 90s, because we’re all living…by that stage, it’ll probably be 100s. But, anyway, you’re looking back at your career. What would you say would be…where would you be sitting really happy with yourself, thinking, “I contributed to that, or contributed to progress being made in this space?”

[33:57] Keith: You mean, talking about the digital space, in particular?

[33:59] Louise: Well, yeah, or just how healthcare would work in the future, and what sort of contributions are you looking to make to it, because I know you’re being very humble, but you’ve had quite an inspiring career journey, and that doesn’t come about from accident.

[34:12] Keith: Well, look, honestly, the fact that I could have helped one person breathe easier, I’d die happy tomorrow. That’s fine. So, anything I can do on top of that is great, and it’s always nice to go around to places like here and see things you’ve helped happen, buildings that have gone up, people whose careers you’ve helped develop, and things like that.

To me, it always comes back to patients, and I love reading through the cards and things they send at Christmas, “Thanks for helping me out,” and that’s all I need to take away. I don’t need anything more.

Someone said to me about this job that it really…that it was a high-profile international thing and yada, yada, yada, and I said, “Thanks very much, I’ve had a high-profile international career. I’m just doing this to help people on the ground, really. I don’t want any bells or whistles or medals for it. I just want to help people look after patients better.”

[35:10] Louise: Yeah, but isn’t that interesting, because just as an external person, I’ve known you for…I met you this morning [Laughter], but…

[35:17] Keith: Like three hours.

[35:18] Louise: Yeah, [Light laughter], but maybe that’s one of the ways of actually looking at success, is you just want to be able to help one person, and if you help…and if you always take that perspective when you do have a senior role where you actually are in charge of a system level focus, but if you always take that focus back to how what we’re doing, helping the individuals, whether it’s patients or clinicians, then…because if you take that, it’s a really holistic way of looking at the nature of your job, to really take it back to the individual, which you’re obviously doing, even if you’re not necessarily even thinking about it.

[35:52] Keith: Well, I suppose I’ve been in a privileged position that I’ve been able to look after people through a whole lot of different scenarios, so I have that frame of reference to use, and I kind of use it interestingly in many conversations when people say, “Oh, this is urgent, you’ve got to do this,” and I say, “Look, this is not urgent. There’s nobody’s life on the end of this. It’ll be there tomorrow or the day after, so chill out. Don’t worry about it. It’ll be fine.” People ask me, do I lose sleep? It’s a big complex job, does it keep you awake at night? I say, “No. It’s there in the morning. Patients kept me awake at night, I worry about them. This doesn’t keep me awake at night, because it’s there in the morning. It’s not that time sensitive.” So, I have a particular frame of reference that I use to judge all this stuff.

Closing Remarks.

[36:41] Louise: Well, thank you very much for sharing your thoughts and some of your journey, as well as what you’re currently working on with us today at Dissecting Digital Health. I really appreciate your time, Keith.

[36:49] Keith: Oh, it’s been a pleasure. Thank you.

[36:51] Louise: Thanks so much. I will go buy your coffee now.

[36:52] Keith: Thank you.

[36:53] Louise: [Light laughter] Thank you, see ya.



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Dr Louise Schaper, PhD

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On a mission to fix healthcare. CEO @HISA_news. Advocating, supporting and fostering the digital health ecosystem in Australia. Yes, I do have the coolest job!