EHI interview: Tony Shannon

So says Tony Shannon, emergency medicine consultant at Leeds Teaching Hospitals NHS Trust, and an open source advocate and activist for more than ten years. He will be joining the open source skunkworks at EHI Live 2011 in November to talk about why this needs to change.

Standards, code, code, standards

Dr Shannon tracks his journey towards open source evangelism back to 2004 when he joined NHS Connecting for Health as a clinical lead. “The assumption was that the market combined with standards would be enough to achieve the connected service we needed,” he says.

Events proved otherwise. “Most of the people who go out and buy clinical systems think their own environments are unique, so they buy systems that are unique and difficult to connect, and therefore joining systems up is a challenge,” he explains.

“The standards business is a problem because there are so many standards and bodies tend to develop them as PowerPoint presentations or on paper, without developing the source code which proves that they work.”

The result, he says, is a disconnect. “The healthcare IT market wants to join up systems but does not have the standards. The standards community wants to join up systems but does not want to develop the code.” He sees more openness and sharing of code as the way forward.

Open source tried in the USA

It’s an approach that has worked well outside health, as Malcolm Newbury, the founder of Guildfoss who is developing the skunkworks, pointed out in an article for EHI in September.

Open source applications include the Apache web server, which runs in around 60% of the world’s websites, and content management systems such as Joomla, Drupal, and Wordpress, which already power more than 10% of the world-wide web.

Open source is used in business communications, while open source tools, operating systems and browsers, (such as HTML, Perl, PHP, Javascript, Ubuntu, Android, Firefox and Chrome), have become a permanent part of the software supply chain.

The examples in ehealth are fewer and further between. But they include the United States Veterans’ Association’s use of VistA to build its highly respected electronic health record, which is now also used by the US Defense Department.

The VA recently began modernise this system and launched an open source track to allow users not just to share the code but to feedback their experiences and ideas.

Peter Levin, VA chief technology officer, told the newsletter Government Health IT in August: “You can take that codebase from us, make changes and we now have a mechanism where they can give it back to us.

“The big idea is to make it easy, transparent and accessible for anybody whether it’s a large defense contractor or a kid in a garage in Nebraska. We want everyone pulling down code and looking at it, and being able to say, I know a fix, I have an improvement, I found a bug, I can extend the capabilities.”

Then there is the US Nationwide Health Information Network Direct project and CONNECT software. This open source initiative was launched in March 2011 to develop standards and support for secure information sharing between healthcare organisations.

“It’s the US version of the NHS interoperability toolkit,” says Dr Shannon. “They gave away the source code and allowed people to use it without having to worry about understanding the standards. It’s been successful and it’s growing.”

Interest in the NHS

In the UK, the mantra of “connect all” rather than replace all has taken over DH thinking in the past two years and the Cabinet Office has made what Dr Shannon calls “encouraging noises” about open source. But the NHS remains firmly behind the curve.

The culture of the National Programme for IT in the NHS has led many of the people working in it to expect to buy off the shelf - and discouraged them from becoming co-developers of systems with commercial partners, he suggests.

Nevertheless, he detects an early interest in open source in the UK ehealth community. The interoperability toolkit, while far from perfect and still paper based, is beginning to encourage a shift in that culture as commercial partners and NHS IT departments develop proofs of concept for sharing – but this is far from open source and code sharing.

“People are beginning to understand the challenges of interoperability,” says Dr Shannon. “The economic climate internationally means people are having to work a bit harder and to look at options they have not looked at before. I do not make the case that open source is cheaper but it does make collaboration easier.”

An open source portal at Leeds

He speaks from practical experience. Over the last six to nine months he has been working to develop an open source clinical portal. “Leeds is a typical large teaching hospital with upwards of 200 disparate systems that do not connect,” he says. “We have explored the option to rip and replace and it’s not popular. So the middle approach is integration and a portal.”

The portal has been developed collaboratively, from scratch, as open source with a commercial company, ReStart Consulting, and has the potential to sit on top of the big Clinical 5 systems in use at the trust.

At the moment it is in test mode and showing data from the patient administration system, an oncology system, and the Bluespier acute medical system. Recently the team demonstrated a link to EMIS and the emergency care system.

“The feedback clinically has been very positive,” says Dr Shannon. “People like the feel of it and the clinical value it adds. It has been judged to useful and we now have a business case for phase two to get further integration and functionality.”

The key difference between this in-house solution and a proprietary solution is the collaboration that underpins it, he explains. “Without that approach it would have been more challenging to be able to bring in the team working on our in-house oncology system. Because it is open source, we can collaborate and everyone can be part of the team.”

In terms of fostering the eco-system, Leeds Teaching Hospital and Leeds University recently took on the running of eHealthOpenSource.org to act as a forum for sharing and developing open source in the NHS, which will hold its first public meeting at the EHI Skunkworks event.

And this is his core message about open source. It’s not necessarily cheaper, it may not be easier, but it is more collaborative.

“What we need is to encourage local people to collaborate for local needs. That’s where open source is so powerful. People need to feel that they can try this. They might fail but that’s part of the process. Vendors need to understand that this is not a threat – that what we need is a hybrid of open source and proprietary components that work together.”

Tony Shannon chaired the clinical review board of the openEHR Foundation from 2008 to 2011. You can see more of his work here and here.

EHI readers are invited to send in challenges and questions for the open source experts taking part in the skunkworks at EHI Live 2011, and get the answered at the show.

EHI Live is taking place at the NEC in Birmingham from 7-8 November. Registration for the conference and free exhibition – of which the skunkworks is a part – is open now.