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Spotlight MobiSys 2012 Keynote: Paul Jones on Mobile Health Challenges Mark Rouncefield

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aul Jones gave the keynote address at this year’s 10th International Conference on Mobile Systems, Applications and Services (MobiSys), held in the English Lake District. Jones, the Chief Technology Officer of the UK’s National Health Service (NHS), is responsible for the Technology Office in the Department of Health Informatics Directorate. The Technology Office must provide technical assurance of nationally delivered healthcare solutions; develop and manage NHS technology and data standards; and provide test-support services to ensure compliance with contracted standards. In a wide-ranging, unscripted talk, Jones covered healthcare systems and the NHS, IT as part of the answer to the problems of healthcare, and the challenges and “interesting problems” of healthcare delivery.

The National Health Service Jones began by providing some background to his own work, introducing the international audience to the history and development of the NHS in the UK and the increasing role of technology. Within the NHS, IT support for delivering healthcare involves a £1.4 billion national infrastructure. Every 36 hours, there are 1 million patient contacts. Furthermore, the NHS has some 1.4 million employees—roughly the same amount of McDonalds employees in the world or number of soldiers in

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the Chinese army. Jones compared it to “an infinite universe” where you need to expect the unexpected—“anything that can happen, will happen [in] the NHS.” According to Jones, the NHS was part of the UK’s post-war transformation, so it has a special place in the hearts of the UK population and has become part of the fabric of society. Additionally, the NHS can be characterised as a “knowledge organisation”— its employees are well educated and passionate about their work. For these reasons, change is always highly charged and political. As Jones said, “In seven years of listening to the Today current affairs radio program, the number of times I’ve not heard anything about the NHS can be counted on one hand.” In fact, Jones had been on the job just three weeks when he had to take on his first project—delivering a cancer screening system—and he quickly learned that it had to go live in April “because the Prime Minister said so.”

(In its first year, the system saved 2000 lives.) One of the major difficulties of the NHS, funded through taxes and thus free at the point of care, is the perception that it’s expensive. The UK spends around £110 billion a year on healthcare—which is 7.8 percent of the gross domestic product (GDP). In comparison, Jones said that the US spends 14 percent of its GDP on healthcare. Other countries approach healthcare in different ways, using different combinations of public and private provision. But the current cost of healthcare is only part of the problem. Globally, the twin challenges are rising health costs combined with an aging population, so we’ll need to spend more or offer fewer services. As Jones said, “This is obviously unsustainable. We can’t afford to keep delivering health in this way.”

A Prescription for IT According to Jones, “technology seems to be part of the answer. Many industries have invested in IT [to] drive down costs and prices, and we have to do [the same] in healthcare.” Technology will be critical in providing future healthcare through more efficient systems. Often, simple system changes can make a difference. Jones used a small community hospital he once visited as an example: “They ran a clinic for minor ailments, and the average wait for a first appointment

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was six months. It was all done on paper.” After the NHS installed a basic information system, he said that within six months, the waiting time came down to two weeks. In another case in Lincolnshire, the NHS gave laptops to community nurses. This saved the nurses six hours per week—nearly an entire day—by reducing their need to travel back to the office. Jones also discussed the need to get healthcare out of the hospitals and into the community and how technology could help. To illustrate his point, he discussed some of the mental healthcare challenges encountered in Eastern England, where there was a lack of counsellors for the large geographic area that needed to be covered. The NHS addressed this by creating a relatively simple online solution designed around public and private chat rooms. Jones talked about one young lady with mental health problems who initially didn’t think she could go to college because of her health problems. However, when she realized she could “maintain her relationship with her counselor using this system, she went to the university and got her degree.” Technology is also proving useful in monitoring and motivating patients. For example, nurses have traditionally monitored vital signs, calling a junior doctor if the signs fall below set para meters. The doctor is then supposed to respond within a certain timeframe. Of course, in reality, nurses often must call the doctor numerous times before getting a response. However, mobile devices can log the data, automatically page the doctors, and audit their response times—which has improved performance and positively affected patient outcomes.

Healthcare Delivery Challenges However, some important challenges remain for healthcare delivery that technology alone can’t address. Outdated attitudes toward technology must also change. In many instances in the

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NHS, it remains the case that “the pen is mightier than the computer,” because some consultants regard computers as devices for their secretaries. Furthermore, the sheer vastness of the NHS, separated into different departments doing things in different ways, means that it’s a fragmented problem space where technical innovations aren’t always transferable. Jones said they installed a system in one hospital and it worked well, so they decided to roll it out to another hospital 10 miles away. The next day, he said, “there were newspaper reports about ‘clinically unsafe system installed in London hospital.’” This fragmentation also affects the commercial provision of healthcare systems: “SAP has 2,000 applications. How many apply to healthcare? None—which I believe is because of the fragmentation of the market.”

It’s nonsensical to expect a laptop to radically improve the nurses’ work if it’s just one more thing for them to carry. Jones then spent some time outlining the kinds of problems that the MobiSys conference participants might be able to help resolve. The first of these was the assumption that simply giving nurses or doctors a computer or laptop was the answer. Jones argued that this is just a starting point and definitely not the best we can do. Mobile computing has the potential to create solutions better suited for the real working environment of users and patients. Giving someone a laptop might be the answer—but sometimes it’s completely inappropriate because of the circumstances in which healthcare is delivered. For example, community nurses already carry loads of equipment and bandages and so on, and they often enter a house where there’s nowhere to put anything. After accompanying a community nurse, Jones realized that it’s nonsensical to expect a laptop to radically improve the nurses’ work

if it’s just one more thing for them to carry. Another related problem is the handover and sharing of information. Even when ambulance personnel have laptops, when they eventually get to hospital, they often must print that information. This also relates to the seemingly perpetual issue of medical records and paperwork. Jones once visited a Victorian-era hospital where the lift to the medical records department was out of service because the shaft had become jammed with lost papers. As Jones argued, the amount of paper records in a hospital is massive, and they’re not as reliably stored and saved as many people think. Consequently, a digital solution (even if it’s not perfect) might be better. Finally, Jones reflected on the tricky issues surrounding standards and the safety and testing of technology: “You need to go to the hospital where you get the right clinical engagement, the right technical support, and the right director who thinks it’s worth doing.” One problem here is the dominance of the classical “double-blind” trial in existing medical standards. When it comes to technology, this approach simply takes too long. By the time the results are in, the technology is obsolete. So the challenge is to bring other ways of assessing safety into healthcare—in particular, engineering standards might be considered. As Jones said, can you imagine a double-blind trial being used to assess jumbo jet safety?

Engaging the MobiSys Audience Jones concluded his keynote by taking questions from the MobiSys audience. One person asked about the challenges of healthcare in the community and if the problems were related to networking, security, or identity management? Jones responded “all of the above.” He explained that “it’s not just about the technology—it’s about creating a system. The whole system needs to be considered … holistically.” Furthermore, the “business case for more complex


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monitoring at home is more difficult.” But, he argued, one of the main challenges for the MobiSys community arises from this need to provide mobile and distributed information systems that work in the context of home care and within the community. Another person asked how individuals concerned about their health can keep healthy by monitoring themselves in their daily lives. Jones suggested that the “worried well” should expect the market to provide these solutions rather than the NHS. Nevertheless, this is part of the fundamental direction of the NHS, putting people in control of their health: “We’re trying to drive through the agenda of patients being in control,” but this faces cultural challenges within the NHS. Finally, Jones answered questions about technophobia and the challenge

of getting people to accept technology: “In part, it’s lazy thinking, but it’s also a generational thing. You can’t expect a nurse who’s been doing work the same way for 30 years to suddenly change.” At the same time, people should understand that the agenda isn’t only about new technology: “In some sense, we have too much innovation. There are more pilots in the NHS than in British Airways.” The issue is about diffusion and adoption of these ideas at scale. Part of our current role is to stop worrying about IT systems and ensure that standards are developed that allow innovation to flourish: “We have to ignore the IT systems that people have and concentrate on standards. We say to hospitals, ‘you must expose this data in this way … and these are the standard interfaces.’”

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he audience was clearly surprised and captivated by Jones. We all knew his keynote would be informative, but his detailed knowledge of everyday aspects of NHS life, and his enthusiasm and passion for the work to come, was inspiring. He challenged us with his assertion: “You have it in the grasp of your hand to make a difference.”

Mark Rouncefield is a senior research fellow in the School of Computing and Communications at Lancaster University. Contact him at m.rouncefield@ lancaster.ac.uk. Selected CS articles and columns are also available for free at http://ComputingNow.computer.org.

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