Patients want high quality healthcare and, where knowledge is concerned, this means obtaining the best available information within the most appropriate healthcare process. Process and information go together: without an appropriate process it is difficult to place information in a care pathway and relate it to other knowledge; without the best information treatment may be sub-optimal even when supported by a perfect process.
Technological advances have dramatically increased the raw material of healthcare knowledge. Huge amounts of unstructured and semi-structured healthcare information exist on the Internet. Smaller but significant amounts of structured knowledge in the form of medical ontologies and knowledge bases have been built. Many healthcare-related processes have been specified formally or have been encapsulated within automated systems for patient support. Given these raw materials, how does one create markets by which these may be assembled and refined into high quality healthcare services which combine the best information with the most appropriate healthcare processes?
Regulated markets
One answer to this question is to establish a closed and tightly regulated market, focused on processes, in which trusted specialists use their expertise to craft knowledge services that combine well understood processes with carefully curated information. This approach typically involves vertical integration of services by centralised providers supported by governments, which tend to be closed to external providers. The centralised integration of NHS healthcare services, using NICE clinical guidelines and other content, running on a BT patient record and communication platform could be said to be an instance of vertical integration in healthcare. The problem with basing markets solely on trusted experts is that these are high cost and low supply, placing an upper limit to the range of processes that any single closed market can supply and also limiting the capacity of the market to react to external availability of new raw material (in the form of information and processes from the broader community).
Open markets
A second, contrasting, answer is to promote an open and unregulated market, focused on information supply from “grass roots” communities. This brings people closer to the raw material of healthcare information but typically leaves it to consumers of that raw material to ensure that it is placed within an appropriate healthcare process. This laissez faire attitude gets information into the public arena in large volumes (witness the proliferation of web sites offering patient information, patient networking and support, and some primitive decision support capabilities) but at the cost of losing our grip on trusted healthcare processes. In many cases quality judgements are made in the commercial digital economy by assessing the popularity of the services within the broad community in which they is used – the stereotypical example being the ranking mechanisms used in Web search engines.
A digital economy in healthcare
Neither of these two answers is convincing for the case of healthcare. The former neglects the global and rapidly growing bocy of information about current research, best clinical practice, care guidelines etc - a resource that is vastly larger than any one provider can create and maintain, even one the size of the NHS. The latter neglects the need for sophisticated and controlled healthcare processes which assure quality and safety of service provision. A third answer, now being articulated in the service orchestration community is to develop, new services on top of existing ones (selected from both the closed and open markets). The effectiveness of this approach depends on whether service aggregators can maintain quality through combining best information with appropriate process. How would we ensure this?
The traditional answer to this question is that we establish a closed market for aggregators. As with the closed model described above aggregators are dependent on trusted experts even though they are working a step removed from the raw material. This is a significant step towards larger scale but, ultimately, experiences the limiting effects we described earlier – and expert aggregators are very scarce. This raises a final, and as yet untested, question. Is there an open market framework and associated business modelsfor healthcare service aggregators?
The answer to this question might be “yes” if we can find mechanisms that allow aggregated services (combining healthcare information with appropriate processes) to be freely shared and assessed for quality within the broad community of consumers. The systems built in Safe and Sound demonstrate that, technically, we can build such systems so we know that this sort of open market could exist. Key to this aspect of the Safe and Sound approach is that healthcare process specifications can be shared/traded like market commodities and that part of the quality assessment of these commodities can be derived from information derived automatically from their use within the consumer community. What we do not yet know is whether the techniques and algorithms we have invented in this early stage are the right ones for the sort of open market that could function in practice.
For a deeper discussion of this view of open knowledge sharing in healthcare and other contexts see the Open Knowledge project web site
The open knowlege sharing approach can be seen as an instance of the digital ecosystem concept developed by the World Economic Forum. In the "Digital Ecosystem users evolve from mere consumers to active participants and governments face major policy and regulatory challenges. Those who live and work in this space must be prepared for a variety of futures. To gain a better understanding of the possible outcomes, along with key trends and events that might shape them over the coming years, a series of scenarios on the future of the Digital Ecosystem to 2015 were developed as part of a two-year project run by the World Economic Forum’s joint Industry Partners
For a discussion of some of specific pros and cons of the traditional approach to healthcare service orchestration and the open model being developed by the Safe and Sound team click on the Case for Choreography in the techologies section on the right.
