Improving adoption of open interoperability standards

The Government’s April 2018 Policy paper on the principles of Open Standards rightly asserts that “Open Standards are one of the most powerful tools we have to open up government. They make it possible for the smallest supplier to compete with the largest.”

The NHS is a large part of Government as it is second-largest area of all government spending after welfare spending. From an IT perspective though, the NHS is probably the least innovative area of Government with a closed IT market. On the one hand Healthcare IT is perhaps the biggest cottage industry in the world as IT has been purchased very piecemeaI. On the other it has spent a lot of money on different national IT transformation programmes from the infamous National Programme for IT (NPfIT) to Global Digital Exemplars and now Frontline Digitisation. There has also been associated huge spending on centrally developed platforms to serve the frontline such as the NHS Spine and all its associated applications. All of these programmes have replaced many of the small suppliers and to a greater or lesser extent resulted in the market being served by an oligopoly of suppliers signed up to long contracts. This has resulted in the NHS having the least effective IT marketplace that works in direct opposition to what it needs. The IT market is not vibrant, has high barriers to entry thereby locking out other vendors, stifles competition with little incentive to collaborate.

This is felt acutely in interoperability as poor information flow between applications reduces the safety of patients, increases the workload of staff, reduces productivity, and increases the cost of care. It stops the patient being at the centre of care and prevents Health and Social Care being citizen centric being both empowered and genuinely able to be an active part of the care delivery team. The IT suppliers understand the clinical need to collaborate but their commercial instincts, the technical debt in their software and lack of trust makes it difficult for them to do.

In 2018 in response to these seemingly intractable problems a small group of suppliers got together to work out how they could collaborate in a way that was best for both the NHS and themselves. Initially they wanted to share integration work they had successfully implemented to create a library so companies did not have to recreate integrations every time. This would save vendor’s time and money and would give the NHS better outcomes. This small seed germinated further ideas on how to do this at scale. With the NHS wanting to implement national interoperability standards the group expanded to become INTEROPen to define and drive the adoption of open interoperability standards. We were all so committed to this that everyone gives their time voluntarily.

We knew interoperability was one the most long-standing wicked problems that had to be solved across the NHS and we therefore knew that everyone who had the problem had to be part of the solution. Solving the problem of interoperability is far more a social than technical problem. The NHS was going to be a very early adopter of the new worldwide HL7 interoperability standard called FHIR (pronounced FIRE) – Fast Healthcare Interoperability Resources so we assembled all the stakeholders we believed suffered this problem which included vendors, NHS digital transformation directors, standards bodies, professional IT associations (BCS), The Professional Records Standards Body (PRSB), Chief Information Officers, Chief Clinical Information Officers, NHS England and NHS Digital (as was). 2 co-chairs were elected; one from NHS IT and another a clinician. Soon after this the clinical co-chair moved on and a co-chair was appointed from the supplier community. We formed ourselves into Community Interest Company (CIC) with the two co-chairs as directors.

Unlike Fight Club we only had two golden rules in the creation of this INTEROPen:

• Do not be afraid to say anything you want as it is a safe space
• Vendors, leave your business cards at the door

From the start we had very uncomfortable conversations, we expressed divergent views, avoided things we felt had to be protected, but we quickly came to understand different partys’ issues and from there we built trust and defined workable compromises. 6 years later INTEROPen is still going, its focus has changed but the representation of all parties makes us stronger together and is now part of the DNA of interoperability across the NHS. It is not perfect, but the advances we have made could never have been achieved previously.

The adoption of open interoperability standards now has a foothold. Technically we are making huge progress, technical debt is reducing, but technical collaboration has only minor barriers and we realise that having good interoperability makes the size of “the pie” bigger rather than sticking with the mentality to lock each other out.

Today, INTEROPen runs two types of event to improve the adoption of open interoperability standards.

1. We have “Learnathons” that are education sessions for system suppliers, NHS staff, etc to bring everyone up to a consistent level of knowledge around a particular focus on interoperability.
2. We have “Hackathons” which come maybe 2 months after a Learnathon where we use emerging or established open interoperability standards and test that system suppliers can provide and consume the content using the required distribution mechanism. Today that is FHIR and mostly through Rest APIs.

The advantages of the Hackathons are that:

• They make sure that the standards are implementable within a system suppliers software
• They help system suppliers understand what works and what doesn’t work
• IT helps system suppliers design how they will implement this into product and where this can fit into their product roadmap.

This work never ends, but it means the relationships across all stakeholders remain strong. Open interoperability standards are being adopted and the market is slowly being changed to be far healthier for both the NHS and suppliers. The work has also expanded into Social Care. INTEROPen has a seat on every important NHS board and group involved in interoperability, often the only organisation with vendor representation.

Open standards are vital for opening up the NHS for system vendors, but also citizens whilst building a far healthier and collaborative environment for IT development. For INTEROPen, the quote from Churchill is strangely apt:

“We make a living by what we get; we make a life by what we give”