"Benefits Realisation" or "Impact Analysis"

Far too many projects have no follow-up at all.  The job is done and everyone moves on.  "Benefits Realisation" is an improvement - but there is a risk that in focusing on benefits the overall impact of the project is missed - and that lessons learned are missed.  Any project that is self-aware enough to have committed effort to "Benefits Realisation" should be self-aware enough to realise that "Impact Analysis" would be more useful and clear sighted.

SNOMED is good for health records, but why not also for Policy, Regulaton, and Evidence

The NHS has rightly said that having a standard terminology will make a real difference to the ability to analyse electronic health records and really get value out of their contents.
What is weird is that this enthusiasm for SNOMED coding of Electronic Health Records does not extend to NHS Health Policy Documents, Regulations, or Guideline documents.
Why are these not SNOMED coded -- this would:

• make it easier to compare different policy documents
• remove ambiguity form the documents (what cancer is being talked about, what is the definition of Diabetes, etc)
• Make it easier to link indicators to the policy - how will we know whether the policy has been enacted, and how will we know if it has worked.  What are the intended benefits, and what are the metrics that will be used as evidence for those benefits?
• Make it easier for groups within and beyond the NHS to show that what they are doing (or propose to do) delivers of the Policy.
• Make it easier for commissioners to purchase in line with policy (or to knowingly deviate)

This seems to be an area where leading by example would work wonders - and would deliver immediate benefits.  
The rich semantics of SNOMED CT is ideally suited to such documents -- if SNOMED CT will add value to individual health records, how much more value will it add to health service organisations under constant organisational change that much provide care plans for their populations.

Healthcare is a Complex Adaptive System with different perspectives and ways of seeing

Healthcare can be seen as a complex adaptive system, as can the information that underpins, permeates and radiates from it.

According to the TED talk below,  complexity implies that the system cannot be understood from one perspective alone, or using a single language. 
Adaptive means that the behaviour of the system cannot be fully anticipated, but that its behaviour  is determined by its previous state, and the changing environment that it is in.  Of course for healthcare the environment is complex and adaptive too.



Healthcare information provision can be seen, categorised and described from a vast number perspectives.

The following list can be read in two ways.  One is as a set of perspectives.  How the health service looks to me as a patient and how it looks to me as a programmer are different.  How it impinges on the life of a tumour or what the health service looks like from the perspective of a tumour is different again.

The other way of reading the list is as a set of categories - what is being looked for from a particular perspective.   As a patient I may be totally unaware of the costs and money flows associated with my treatment - or I may be very sensitive to it.   From each perspective there are many different ways of seeing.

The list is not intended to be exhaustive - in two significant ways - the set of categories / perspectives is not complete, and nor is is the only way of categorising the space.  Indeed the selection/discovery of categories/perspectives is part of the process of engaging with subject matter, and is an area where good choices can help to make that engagement more fruitful.

• The actual people involved (who does what when and why)
• The job descriptions / roles of the people involved (patient, doctor, parent, friend, guardian, nurse, programmer, venture capitalist, politician, voter, neighbour, manager, ...)
• The products (software, hardware, intellectual property, etc)
• The projects and programs involved
• The money involved (who pays how much for what, the result of a particular payment, etc)
• The activities (treatments, tasks, events, actions, encounters, processes)
• The subjects of care (genes, tumours, organs, patients, families, groups, populations, citizens, etc)
• The organisations involved (providers, suppliers, payers, interest groups etc)
• Purposes and Outcomes (what is the point - comfort, autonomy, health, care, QALY,  social cohesion, individual care, public health,...)
• Metrics (what can be measured?  what can be compared?  what questions can be answered?)
• Information Standards and Specifications, and the organisations that maintain them.

In a complex adaptive systems we should be cautious of single perspectives overshadowing all others, and becoming a dominant ideology. 

• "Evidence-based medicine" is a way of seeing healthcare that has a lot of value, but it is not the only way of seeing.  We do not insist on evidence-based marriage, or evidence-based cooking.  In both cases there is relevant research but for most of us that is not the best language to use.  The research indirectly informs us, but we do not see it as the basis of how we love or feed each other.
• Patient-centric.  The patient's is a valuable perspective to consider.  However if I need an operation on my knee, I want to know that the place I am going to will do a good job on my knee.  I want them to really care about doing great operations, and that the staff want to be working there.  As a potential patient, I care less about it being patient focused, and more about it doing a great job.

Evidence-based medicine is great. Patient-centered care is great.  What I am suggesting is that healthcare is bigger and more diffuse than either of them alone.  

As we engage with healthcare information we seeing in a particular way from a particular perspective and can strive to achieve particular outcomes.  This involves working with others who have different perspectives and ways of seeing.  Healthcare Informatics is about helping to build and sustain those bridges, as well as making it easier to deliver outcomes from a particular perspective and way of seeing. 

Information standards and specifications fit into this complex adaptive system as  tools that can be used, and as points around which collaborative momentum can be built.   They emerge as part of the complex adaptive system where and when there are the resources and engagement necessary for their creation and maintenance.  Different perspectives and ways of seeing will engender different metrics for evaluating them, and different outcomes to expect from their use.

How this diversity of perspectives and ways of seeing impacts specific information standards or healthcare outcomes  are topics for another day.

Written in reaction to:

  TEDxRotterdam - Igor Nikolic - Complex adaptive systems