Tag Archives: NHS

NHS Hackday and the oPortfol.io

This weekend I was at NHS Hackday. Doctors, other healthcare workers, students, patients, organisations and software developers came together in their free time to make stuff that could make the NHS better.

Thanks to @londonlime

Thanks to @londonlime

I was astounded by the last Hackday. I didn’t think my expectations could be surpassed. They were.

The projects were diverse, aiming to solve everyday problems at all levels of the NHS. You can see the list on the Google doc and they’ll be on the wiki soon. The highly deserved winner was OpenHeart. The team used the amazing open source electronic health record at Moorfields Hospital, Open Eyes, and adapted it for use in Cardiology. The end result was stunning. It will save hours of doctors’ time, will create patient records that are much more understandable for patients themselves and for GPs, and will improve communication and therefore the quality of care.

Another favourite was Dementia scrapbook, an app to allow family and friends to contribute to a virtual scrapbook of memories and reminders. It has an easy to use touch interface that can be used by carers or people with dementia themselves. Dementia is common and this takes a very patient-centred approach to solving problems many of us may face in the future. I hope to see it available soon on the app store.

Cellcountr, initially hacked at the Liverpool hackday, was built on with additional features such as data visualisation and a customisable keyboard. It will be launched in the next month at a Pathology conference, and will then make a real difference to doctors, and their ability to accurately diagnosis patients with haematological conditions.

So what did we do? We created oPortfolio, an open API which allows trainee doctors to record learning events online, offline and on the go. It includes a webapp, a mobile-friendly site, an iPhone app, and an android app that all synch data. From nothing to all this in 36 hours! The team were incredible: full of talent, patience, and creativity.

Oportfolio

What does it do?

It solves an immediate need to log learning events on the go (see examples below). It lays the foundation for a more complex system to log assessments and meetings. With (quite a bit) more work it could be a simple open portfolio that doctors who are not currently in a training programme (eg LATs, people doing fellow jobs in between F2 and speciality training) could use to track their professional development. The funding model would have to be clarified as development and hosting is not free! It could also be an arena to experiment with and showcase new ways of organising a professional portfolio that could usefully feed into the debate on what and who a portfolio is for. It could highlight how different systems talking to each other and 3rd party apps and plug-ins have the potential to improve a core product. Another fabulous creation was Quicklog, an app to log personal development in performing procedures on the go. They built in data visualisation to encourage reflection and chart progress. It would be fantastic if the data from Quicklog could be integrated into a portfolio system. Anyone who is interested (and understands it!)  should look at the code on github for oPortfolio and Quicklog!

Screen Shot 2013-01-28 at 11.55.34

What does it not do?

It is not a replacement for the current ePortfolio system(s). The NES ePortfolio and others (eg surgical portfolio) are complex structures build up over years, with thousands and thousands of pounds of investment. Many have questioned whether they are value for money and I can’t answer that but good software does cost. Existing systems have  layers of access rights and methods of data extraction since these were priorities for the bodies who paid for them. They have cloud hosting and data security. People have spent years making them do what they do and it would be crazy to think they could be replicated in a weekend. They have their problems and must be improved but they are here to stay until a better alternative exists.

The focus of building a model Oportfolio was the user experience. If it was developed further it could fulfil a need for trainees who are not in a current training programme, who currently use various cobbled together documents on Evernote, phone notes apps, word documents and paper to record their learning and showcase their achievements when applying for jobs. With regular end-user input it could be beautiful, and a joy to use!

I am sure that our exploits this weekend will appear highly challenging and controversial to some. But I am not controversial. I have always highlighted the frustrations felt by trainees (which are well known) but advocated for engagement with all interested parties: individual trainees, trainers/educational supervisors, LETBs, Trusts, Royal Colleges, current ePortfolio provider NES, the GMC and HEE. We need to get our heads together and think about what the future of training will look like, what tools are needed to enhance learning, and how they will be funded.

The NHS can’t keep putting up with unintuitive, inflexible IT that doesn’t match the realities of practice. As demonstrated at NHS Hackday; intelligence, enthusiasm, creativity, a few humous sandwiches and some coffee can create magic. But that magic needs support and investment to make it sustainable. Muir Gray says change in the NHS will come from the bottom up. He is one of a few inspirational people at the top supporting projects in which frontline staff make a difference. We could do with a few more like him….

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The perfect ePortfolio

Thanks to @londonlime

Thanks to @londonlime

This weekend I am at NHS Hackday in Oxford. I have written about hackdays before. I am a huge enthusiast. It is amazing to see doctors, other healthcare workers, patients, organisations and software developers coming together in their free time to make stuff that could make the NHS better. A hackday IS agile software development, speeded up, with people motivated not by profit but by intellectual curiosity and a desire to make the world a little bit better.

There are some amazing people coming to NHS Hackday Oxford. Some of them are interested in rethinking a professional ePortfolio. The one we have currently is competent. It does a job. The creators at NES are great, but they are constrained by their history and location. In my opinion an IT project that supports thousands of healthcare professionals’ development should not be run by project managers in a Scottish NHS health board. Their customers are Royal Colleges, not ePortfolio users. However great NES are at their job are they really the best people to make the perfect ePortfolio?

As trainees we want more. In relation to the software we want seamless functionality, we want flexibility, we want personalisation, we want visualisation of data, we want speed, we want interoperability, we want openness and APIs, we want mobile offline data entry, we want intuitive navigation, we want reliability, we want to be encouraged and inspired, we want beauty.

Too much to ask? I hope not. 

I need to form these vague statements into some specifics between now and tomorrow. Wish me luck!

My 15 mins of fame

I am having some brilliant and highly productive meetings about the ePortfolio this week, which I will write about as soon as I can.

In the meantime, you can see my 15mins of fame in the NHS Hackday video:

NHS Hackday 2012: Geeks who love the NHS

“It’s an amazing atmosphere when you can come with a problem as a physician and say ‘I know nothing about any of this stuff, but I know what I want to be able to do.’ And then to have a room full of people who have the know-how and the enthusiasm to go ‘we can do that.'”

I love @wai2k‘s quote, which really sums up the weekend and the project: “with collaboration between the people who create the software and the people who use the software you can potentially create something quite magical.”

The ePortfolio needs exactly this. We are getting there.

A Comment Cloud

This is a wordle, made up of all the comments left on this site:

The prominent words are those that have featured more frequently, and include: ePortfolio, think, learning, NHS, work, trainees, system, need, training, good, open source, evidence, use, app and people. 

Interesting.

What to do with all that data?

I encourage you all to read the blog of NHS ePortfolio developer @zingmatter, and look at the presentation he presented at AMEE 2012 (a recent Medical Education Conference) “Assessing NHS ePortfolio behaviour: variations in the online activity of doctors as they progress through training.”

With thanks to http://www.acunu.com/ for the badge!

I was at the presentation at AMEE 2012 and, although the presentation title may nor sound gripping, I was fascinated to hear what could be learnt from the vast amounts of data ready and waiting to be analysed on NHS ePortfolio site use. The development team (including @zingmatter) had done a great job of drilling down into some of the data, using Google Analytics and internal tracking,  in order to filter out some meaningful information from the thousands and thousands of logins and episodes over a year.

The Prezi can be seen in the “elastic elephant” blog

However, my first thoughts on seeing the conclusions of the presentation were “they’re asking the wrong questions” and “if they wanted to know that they should have just asked the trainees.” Many of the peaks and troughs seen on the graphs were entirely predictable (ie pre-ARCP), and some of the conclusions drawn by the developers on “depth of use” were weak. I could explain away many of the findings, as I know how trainees use the site is a function of what hoops are put in front of them to jump through. I was also sceptical about the conclusion that trainees change their behaviour in relation to the ePortfolio over the course of their training. FYs and ST6s may interact differently with the site, but there are so many confounders that a snapshot comparison is not a valid way to assess this: a longitudinal study would be required.

Despite these reservations, reading @zingmatter’s blog gives me hope for the future, as the developers at NES are committed to engaging with the needs of users. In our often passionate discussions on social media (including this blog and twitter) we must remember that we come from very different perspectives, and have unique sets of knowledge and skills.

As @zingmatter points out:

“There is a balance between college needs and trainee needs in the design of an e-portfolio and possibly this type of data can help inform this debate.”

We also have to make sure we are not misdirecting our frustration at the wrong people, and potentially alienating them:

“while I’m happy to ask simple questions about user flow, user experience and so on, questions about the educational implications of this data have not been well addressed as it’s not really in my sphere of knowledge (or in my job description). I would see the research I presented at this conference as a ‘this is the kind of thing we can do’ exercise that should lead on to better designed questions that will allow us to understand how best to develop an e-portfolio that supports effective learning and development through the effective delivery of a training programme.”

I really hope we can work together to ask the right questions and use all the data we have to inform the process. All we need now is the Royal Colleges on board and we can really maximise the potential of the ePortfolio.

Just imagine a world in which trainees didn’t hate the NHS ePortfolio. It has the potential to be a useful tool to encourage self-directed learning, provide evidence of experience and achievements, act as a showcase for job applications and excellence awards, and strengthen the relationship between trainee and trainer. This world is far away, but perhaps we are starting to see the path forward…

Surgical spirit: what the surgeons think of their ePortfolio

An article published recently in the Journal of Surgical Education looks at the experience of surgical trainees and their ePortfolio. As a Medical Registrar I am in danger of being disowned by my colleagues for suggesting that we may be able to learn something from the surgeons! But in relation to ePortfolio use, many parallels can be drawn between the experience of surgical and physician trainees.

The surgical ePortfolio (ISCP) became mandatory for British surgical trainees 5 years ago, with a compulsory £125 annual fee. In 2008 widespread dissatisfaction was reported. This article (by Pereira and Dean) surveyed 359 users across all specialities and geographical areas. Although ratings improved between 2005 and 2008 trainees were underwhelmed overall. Unfortunately the article is not open access, and is behind a paywall, so I have selected some quotes for discussion below.

My love don’t cost a thing (but my training does….):

“An evaluation by ASiT estimated conservatively the upward spiralling costs of surgical training to the trainee to be £130,000 even before the introduction of MMC, with ISCP and its mandatory annual fee amounting to an additional £1000 over 8 years of surgical training.”

No medic would claim to be poorly paid, but there must be honesty and transparency with regard to the significant financial burden placed on trainees. This is likely to become more pressing as graduates leave medical school with escalating debts. Value for money is high on the agenda.

The current cost of the physician ePortfolio is only £18 per trainee per year, but perhaps this needs review, especially in the context of calls for investment to improve functionality. Trainees have a poor understanding of the costs of training and there is a disconnect between payment of JRCPTB fees and any visible outcomes in terms of education and training. Surely a lesson for all Colleges and higher bodies is that greater engagement and consultation with trainees could help prevent widespread and growing resentment.

A teacher affects eternity; he can never tell where his influence stops 

Sir William Osler, a great clinical teacher

“..incentive for trainer and assessor engagement remains lacking. It is important that trainers are properly recognized and rewarded for the time that they spend assessing and supervising trainees if obliged to use increasingly time-consuming methods, and we would welcome any system that encourages them.”

We must spare a thought for the Consultants who are striving to support us in our professional development. Demands on their time come from all directions and, unfortunately, postgraduate education and training is often the thing that loses out and gets pushed to the bottom of the mounting to-do pile. The system needs to reward and encourage senior clinicians so that they make time to give high quality feedback to trainees during WPBA completion. But this is a long term aim that feels intangible and unattainable. In the short term, reducing the time it takes to complete WPBA paperwork will make everyone happer. An app seems the quickest way to achieve this.

A call for EBT: Evidence Based Training

“Recently the JCST has specified a minimum of 40 WPBAs per year to be completed as a ‘quality indicator’ for surgical training and career progression…Regional training programs have set directives for mandatory WBAs per annum, ranging from a minimum JCST dictat of 40 to the 80 required in London. These present a great challenge upon time available to any practicing surgeon.”

“…a recent systematic review that includes our first survey suggests that there is no evidence that they [WPBAs] improve physician performance. It goes on to conclude that multisource feedback may be helpful, but that individual factors, context of feedback, and presence of facilitation (ie mentoring) may improve trainee responses.”

These sentiments will sound familiar to physicians, many of whom also feel frustrated at the widespread adoption of WBPAs, for which there is limited evidence of value for trainees in the real world. Valid concerns have been raised about the difficulties of applying theoretically helpful frameworks and tools to the realities of clinical life, and it is unclear where the numbers set by training boards have come from.

“ISCP has improved its interface, but it and other electronic portfolios deliver an increasingly overwhelming bureaucratic burden of WBAs and domains of evidence to include in a portfolio. These have rapidly become entrenched in postgraduate physician training in the UK, spreading a plague of box-ticking exercises that continue to increase year on year….It is of particular concern that so many trainees (80%) felt that ISCP did not improve their training after a modal average of over three years using it.”

Again these feelings will be familiar to many of those who have commented on this site and engaged with the debate on twitter. Time is precious. Many feel that the current demands on trainees, coupled with inadequate technology, steals  it away from busy trainees and trainers.

Perhaps it is time to ask the question, who is the ePortfolio for? Is it a learning tool for trainees? Is it an evidence vault for Royal Colleges to check off competencies of registered members? It is unclear to me what the aims of the NHS physician ePortfolio was at its inception. Has this been reassessed as it has expanded and evolved? These is great potential to improve the ePortfolio so that it serves the needs of trainees, trainers, assessors and higher bodies better. We have an opportunity to seek clarification and contribute to making the aims and expectations explicit. Let’s not let it pass us by.

The authors of the paper conclude:

“The performance of ISCP has improved in the 4 years since its inception with proportionately less negative feedback. British surgeons remain dissatisfied with several of its tools, in particular its workplace-based assessments. Half a decade on, these assessments remain without appropriate evidence of validity despite increasing demands upon trainees to complete quotas of them. With reduced permitted training hours, the growing online bureaucratic burden continues to demoralize busy surgical trainers and trainees.”

These conclusions should ring alarm bells not only for the Royal Colleges, but for the wider community of healthcare leaders. The NHS faces many challenges, and a demoralized workforce will struggle to face them. Physician and surgical trainees feel overburdened and undervalued. The system needs to change. Who will lead this change? And where will the ePortfolio fit in? Answers on a postcard…..

E.A. Pereira B.J. Dean.British SurgeonsExperiences of a Mandatory Online Workplace Based Assessment Portfolio Resurveyed Three Years On. Journal of Surgical Education. J Surg Educ. (2012) doi: 10.1016/j.jsurg.2012.06.019

A. Miller, J. Archer Impact of workplace based assessment on doctors’ education and performance: A systematic review. BMJ, 341 (2011), p. c5064

E.A. Pereira, B.J. Dean British surgeons’ experiences of mandatory online workplace-based assessment J R Soc Med, 102 (2009), pp. 287–293

S.A. Welchman Educating the surgeons of the future: The successes, pitfalls and principles of the ISCP. Bull R Coll Surg Engl, 94 (2012) online

W.C. Leung. Competency based medical training. Review, 325 (2002), pp. 693–696

Can we make ePortfolio open source? a guest post from Karen Beggs

My first question is WHY?

Here are the main issues I hear about:

  • A lot of trainees aren’t happy with workplace based assessments
  • Internet speed is an issue in some NHS locations
  • Some people don’t like using an ePortfolio
  • Some people want to have more input into ePortfolio design
  • Some trainees want their seniors to be more engaged with their learning
  • There is a common misunderstanding that College membership fees are used solely to pay for the ePortfolio

So what are we already doing about these issues?

  • We are eliciting feedback directly from the wider ‘user’ community through social media to find out what usability improvements we can make…and get them done.

We’ve started this already… following a conversation last month with a trainee who was frustrated by the curriculum linking process, our architect made a simple change that was deployed a few days later (see demo here), reducing the number of clicks needed to make multiple links. We have also introduced a twitter feed, visible on the www.nhseportfolios.org home page).

We are moving to a more elastic hosting environment so that as the system gets busier it can engage more resources to deal with the increased load. We aim to have this fully implemented by autumn 2012.

The NHS ePortfolio team do not make decisions about assessment processes, training requirements or the use of specific workplace based assessments. Expertise in these areas usually lies with the Colleges, Postgraduate Deans and the Academy of Medical Royal Colleges. However, we can:

  • Help connect trainees with ideas (or complaints) with the relevant people, whether College, user group, developers or others. In July 2012 I attended the AoMRC Trainee Doctors Committee, and as a result will recommend to the Chair of the specialty ePortfolio User Group that a representative from the committee sits on that group. Some trainees are not aware of their own College decision making processes, and we will pass on contact details as required.

Would open source address any of these issues?

As far as I can see, NO!

But why don’t we just hand over the code to the large community of willing, enthusiastic OSS developers?

  • It’s not as easy as just handing out ‘the code’. Open source software must comply with a number of criteria (see www.opensource.org), many of which would contradict the current NHS ePortfolio license terms.
  • Who would fund re-writing and re-negotiating software licenses for the existing 25 or so organisations using the NHS ePortfolio? What if one of these organisations objects? It’s an integrated application with many shared features, so to separate out one ‘Customer’ would require a large-scale re-write. That seems to defeat the purpose.
  • The ePortfolio is integrated with a number of external (usually College run) systems and moving to an OSS model would have implications for each of these systems. Would Colleges want to pay to conduct a thorough risk assessment before signing up? And would they then want to pay for any adjustments needed to maintain the integrity of their own systems?
  • There would still have to be stringent controls over the quality of the code submitted. This would require a quality control team – possibly a larger one than we have at the moment. Who would pay for this?

I’m not sure I quite follow the argument… get rid of our current team of developers (some of whom have been with us for over 4 years), keep fingers crossed that some OSS developers can meet our commitments, beef up our QA team so they can check the code of the unknown OSS developers…. Seems that we increase our risks (of not meeting SLAs), decrease predictability (how can we hold anyone to a delivery date if we don’t employ them?) and end up with a QA team but lose our development expertise (the current team wouldn’t hang around for long – why would they?). I can’t see a sustainable business model in here unless we were to maintain a large core team – and if we do that, where are the assumed cost savings of OSS?

I have heard arguments that OSS is cheaper overall, but I don’t really see that cost is the problem (see My first question is WHY? above). It seems to me that the per capita charges for the ePortfolio are pretty reasonable. There is currently no charge made for any supervisor (educational or clinical), programme director, administrator, ARCP panel member or assessor using the ePortfolio. Per capita charges are based only on trainees at present. Would OSS have any impact on this? I can’t see that it would.

Final thoughts

If we were starting from scratch we would look at OSS as one of the options. We would probably look at an off-the-shelf ePortfolio too. We would be foolish not to. But we are not starting from scratch. We have an established, bespoke ePortfolio that is used across the professions (we have versions for Dentists, Nurses & Midwives, Pharmacists, Doctors and Undergraduates), is integrated with a number of external systems and capturing over a million forms submitted by ‘assessors’ every year. Each version has a custom set of features, making it adaptable and cost effective (sharing an underlying code base and database).

Many of the problems we hear about relate to complaints about the educational processes, and changes are already underway to address these (eg move to Supervised Learning Events in Foundation from August 2012). We contribute to these discussions when appropriate.

We have developed good relationships with our broad range of Customers, and continue to work with them to improve our change control and development processes. We work within the constraints of the NHS, which impacts our management of finance, procurement, stakeholder management, technology and decision making, as well as our governance arrangements.

We have an established application and an experienced team, whose expertise and commitment cannot be underestimated. Our development costs are at the lower end of the market, and maintenance charges are extremely good value. We can bring in additional specific expertise as and when we need to.

I can’t help but think the suggestion to move NHS ePortfolio to OSS is a solution to the wrong problem.