1 ACB Focus 2008 Foundation Lecture Laboratory Medicine in the Information Age : Reflections on the Future Dr Rick Jones Leeds Teaching Hospitals Trust University of Leeds Leeds UK

2 Reflections on the FutureWhen a distinguished but elderly scientist states that something is possible, he is almost certainly right. When he states that something is impossible, he is very probably wrong. The only way of discovering the limits of the possible is to venture a little way past them into the impossible. Any sufficiently advanced technology is indistinguishable from magic. For every expert there is an equal and opposite expert. Arthur. C. Clarke Profiles of the Future, 1992, 1999

3 1000 1000 + 10 = 10 8 Magic Numbers Notation Decimal Binary 0 0 00 0 0 1 1 1 = 10 8 1908 1948 2008

4 Lloyd-George, 1863-1945 Born in ManchesterThe only Welsh prime minister Responsible for the introduction of old age pensions, unemployment benefit and state financial support for the sick and infirm. 1908 Pensions Act Foundation of the Welfare State 1908

5 Aneurin Bevan, 1897-1960 National Health Service Act July 5 1948Core principles that it meet the needs of everyone that it be free at the point of delivery and that it be based on clinical need, not ability to pay Dr Thomas Jones ( ), b Rhymney Deputy Secretary cabinet Lloyd-George Secretary of the National Health Insurance Commission (Wales). 1948

6 Sebastian de Ferranti, 1864–1930Electrical engineer Age 16, he built an electrical generator William Thomson (the future Lord Kelvin). He worked for Siemens Brothers at Charlton, London. He founded Ferranti, Thompson and Ince. Manchester 1948

7 1960s - Magic of Computers Flower power – Prague Spring“White Heat of Technology” Fortran Programming class ICL - Mainframe real function densitycalc(i, step)       implicit none       integer i       integer step       real initd(6)       data initd / 5., 6., 6.5, 6.8, 6.3, 5.4 /       real dcalc       if (step .eq. 0) then         dcalc = initd(i)       else         dcalc = initd(i) * step * .8       endif   densitycalc = dcalc       return       end 1968

8 BMB – Special Edition “The computer is causing a revolution. Some of its first applications may prove ephemeral, some may be wasteful and some could even be harmful. However, things are now possible that were not possible before and it would be an unusual experience in the history of science if such developments did not lead to major advances.” JAB Gray, British Medical Bulletin, (1968) 1968

9 Medicine and ComputersSummer Job Co-op Accounts Honeywell 24k machine Punch Cards Tapes TV Rentals Bills 1968

10 Medical Practice House physician at Oxford RadcliffeComputers research-based CTL machine – accessible at night The Sun – “Crisis? What Crisis?” Callaghan replied: “Well, that's a judgment that you are making. I promise you that if you look at it from outside, and perhaps you're taking rather a parochial view at the moment, I don't think that other people in the world would share the view that there is mounting chaos.” Effect on house staff All urgent specimens by hand to the labs Taking patients to x-ray Collecting results at 6pm 1978

11 Early signs…

12 Research Training MRC Training FellowshipDerek Williamson – Hans Krebs Laboratory DM: 'The role of insulin in the short-term regulation of mammary-gland lipogenesis: its relevance to substrate partitioning during lactation.‘ Modelling blood flow First PC in lab – still using carbon paper, scissors and cow gum! Diabetes – Robert Turner / David Matthews / Rory Holman UK Prospective Diabetes Study Recoding a Fortran model of an artificial pancreas Real time analysis of insulin secretion in humans Insulin resistance - Glucose clamping 1980

13 Research & IT ASTUTE Statistics Software wins INCSTAR Award at FOCUS 95 - Simon Huntington Rory Holman / Stephen Walter / Dave Wiggins 1980

14 Medicine in Leeds Tutor in Professorial Medical Unit ComputingGeneral Medicine Diabetes Computing Glucose clamping – Peter Grant Diabetic Foot Clinic database 1983

15 Chemical Pathology TrainingYorkshire Region Senior Registrar Memories Leisurely pace – lunch hours, study mornings Interesting science Variety of practice Great colleagues Lots of driving Surprises French Computer System Technicon LDM – “fin du jour” & “Oui et Non” commands Prevalence of hyponatraemia 1985

16 Chemical Pathology – Jimmy’sComputerisation America Monitor Hand cut reports Digico paper tape New system Ferranti first choice Telepath just released Wolfson Labs Margaret Peters Ian Clarke Steve Murray Brian McCauley 1988

17 Pathology IT RetrospectiveTunbridge Report (Tunbridge, Flynn) Standardisation Preparation for ‘Mechanisation of Records’ Cost of A4 NHS filing cabinets – £200k Admin clerks costed at £700 pa 1964

18 Pathology IT RetrospectiveReport of a working party of the Association of Clinical Pathologists - (Whitehead, Whitby, Flynn, Peters) Covers entire Pathology information process Costs Procedures Knowledge Safety Data processing in clinical pathology. Report of a working party of the Association of Clinical pathologists. J Clin Pathol Mar;21(2): (Available free on PubMed Central) 1968

19 Report of a Working Party

20 Recommendations The Ministry of Health should:Make money available for experimental automatic data processing systems Set up a central advisory organisation as a matter of urgency Make provision for the education of laboratory workers Ensure that unique and concise patient identification is available on all requests The Scientific Instrument Manufacturer Association and the National Research Development Corporation should: Take note of the growth of testing an dthe need for automation Create complete systems Use standardisation to eliminate interface problems Should make quieter and faster printers Work predominantly with the NHS

21 Genetic Tree - UK SystemsPhoenix Programme - Six Labs Trent Silicon Lab CILMS APEX Oxford OPUS Wolfson Telepath TP2000 Driven by: Data processing - RIA Demands of early automation Data reduction Laboratory management control as by-product Concepts and codes conserved (electronic homology) USA Sunquest (parallel evolution)

22 Early Development Early Design AssumptionsSingle disciplines – hospital base One big analyser (+/- backup) Central processing (pre-PC) Standalone - demographics + results Single database (per discipline) Fast and compact (MUMPS - ‘M’) Maturation Phase Inter-disciplinary links Shared demographics - central PAS Management information demands (planning, contracting) Increasing cost-pressure - increased automation Incremental development possible

23 Leeds and Bradford NetworkGeneral and Specialist Services 9 Sites - 4 main - 5 peripheral 3m specimens - 20m reported tests £52.7 million direct expenditure 900 WTE > 1 million population 4,200 beds 180 Practices / 700 GPs SAS Steroids Trace Metals 1995 2008

24 10 miles

25 Lack of Standards 1995

26 Change of Scale 2002

27 Leeds IT Architecture Executive Decision Support Management SystemsFinance, Personnel, Statistics Office Automation Functions WP, , WWW Operational Systems LIS, POCT Network, Analytical sub-systems

28 “Please give generously”Benefits “Please give generously” Linked to standardisation Same equipment on all sites Standardised methods Reference ranges Consistent results for every patient Major cost saving No new capital – all within existing spend £100k per annum saving in maintenance charge Significant reduction of interface complexity Single GP feed Major management time saving BMS’s back to bench 2008

29 ACB-IT Group ACB Survey (paper) Used PC 97% Internet use 50%Founded by Jonathan Kay Bulletin Board System Dial-up modems Members Jonathan Kay Craig Webster Martin Holland John O’Connor Bill Godolphin James Falconer-Smith James Hooper Ian Wells Jonathan Middle ACB Survey (paper) Used PC 97% Internet use 50% Medline use 64% Requirements Rare assay list Computer aided learning Network help list 1995

30 ACB-IT Group Outcomes Jiscmail – Mailbase Assay Finder ACB Web SiteIFCC Website NHS Developments 1996

31 ACB-CLIN-CHEM-GEN List Membership – year 1 1000 messagesUnited Kingdom 74 United States 188 Australia 14 Europe 16 Other 6 1000 messages 1996

32 ACB-CLIN-CHEM-GEN United Kingdom 770 United States 287 Australia 53Canada 38 Ireland 31 Netherlands 24 Hong Kong 17 Italy 13 New Zealand 12 Isle of Man 3 Belgium 5 Denmark 2 France 3 Germany 7 Portugal 3 Spain 2 Sweden 9 Finland 7 Iceland 1 Czech Republic 3 Slovenia 2 Poland 1 Hungary 4 Turkey 2 Israel 5 South Africa 2 Burundi 1 Jamaica 2 Japan 2 China 3 Malaysia 2 Singapore 2 Mexico 1 Saudi Arabia 1 Oman 1 Currently 1321 Members Topics per month 1200 Messages per year Self maintaining 2008

33 ACB-CLIN-CHEM-GEN Clinical Support - InternationalPlease help me with the following case. A 60yrs female was diagnosed with hypothyroidism in Apr She has been under Thyroxin therapy since then. Her TSH and FT4 results are shown as following table. Both TSH and FT4 have been monitored by Roche Elecsys On Apr.16, 2008, the patient came for annual check-up. The TSH was 80.1 and FT4 was normal. The same specimen was repeated in 12 days on the same analyzer as well as on different platform (Immulite 2500) and the TSH results were still very high (70.8, 58.5). The sample was also performed at the same run with the 5X dilution and the original specimen by the Immulte. The results indicated there might be HAMA interference. However, I think the interference is not great enough to contribute to this high degree of TSH. The patient is relatively normal other than this and did not show symptoms of hypothyroidism. She is considered as a reasonable patient with respect to her compliance to the treatment. 1. Is it a true TSH result? Can we adjust dose according to this TSH result? 2. What other methods can help identify the result? 3. Any other clinical issues for investigation?

34 ACB-CLIN-CHEM-GEN Science – Roger EkinsThis is not a trivial issue, Having been involved in a number of public controversies relating to assay design and the concepts underlying the terms used to describe ligand assay performance, I am perhaps over-sensitized to the enormous impact that misunderstanding of these terms' meanings has had on the historical and present development of the so-called "ligand assay" field (which represents roughly 50% of clinical chemistry). But such a view is undoubtedly justified. For example, these misunderstandings originally led to controversies regarding the relative performance of labelled antibody ("immunometric") assays, and of the use of MAbs in this context; also, more recently, they led to a failure by many to recognize that greater sensitivity and shorter performance times can be achieved using binding agent (eg antibody) concentrations that are orders of magnitude lower (i.e. ideally <0.01/K) than used in conventional assays of this type (i.e generally 20/K in non-competitive assays).

35 ACB-CLIN-CHEM-GEN Humour – Tim ReynoldsIMPORTANT: This is intended for the use of the individual addressee(s) named above and may contain information that is confidential privileged or unsuitable for overly sensitive persons with low self-esteem, no sense of humour or irrational religious beliefs [if you want to believe in fairy stories and hug pixies that's up to you]. If you are not the intended recipient, any dissemination, distribution or copying of this is not authorized (either explicitly or implicitly) and constitutes an irritating social faux pas. Unless the word absquatulation has been used in its correct context somewhere other than in this warning, it does not have any legal or grammatical use and may be ignored. No animals were harmed in the transmission of this , though the kelpie next door is living on borrowed time, let me tell you. Those of you with an overwhelming fear of the unknown will be gratified to learn there is no hidden message revealed by reading this backwards, so just ignore that Alert Notice from Macroshaft. However, by pouring a complete circle of salt around yourself and your computer you can ensure that no harm befalls you and your pets. If you have received this in error, please add some nutmeg and egg whites, whisk, and place in a warm oven for 40 minutes.

36 1996 Internet conference “Just think what will happen when computing power is infinite and costs nothing; electronic storage is inexhaustable and very cheap; and telecommunications bandwidth is unfillable and very cheap.” Graham Whitehead (BT) 1996

37 Internet Growth 1998

38 Web Site Growth 1998

39 Moore’s Law, infinity & beyond6-12 months Log Network Bandwidth 5 year gap = 1000x !!! months Computer Processors Performance/ Price Now 1995 Now 2005 2010 1998 Time

40 NHS 50 years Young 1998

41 Pathology EDI Originated – Oxford – c 1990 – Jonathan Kay By 1997Running in 100+ labs, many since 1990 Mix of ASTM1238 (70%) / EDIFACT (30%) Driven by Professional interest / Fund-holding Availability of technology & enthusiasm Results Multiplicity of configurations Pockets of expertise Mixed standards No Interoperability 1998

42 “If I can email Bill Clinton, why can’t you email me my results?”Pathology EDI “….As a second step, by the end of 1999 all computerised GP surgeries will be able to receive some hospital test results over the NHSnet….” Commonly perceived as a trivial task - “If I can Bill Clinton, why can’t you me my results?” attributed to Tony Blair 1997 1998

43 Pathology EDI Ambitious scale 10,000 practice systems 200 lab systemsConnections / Firewalls EDI Software Training in new ways of working 200 lab systems Connections Outboard interfaces 26,000 visits by BT engineers alone 1998

44

45 UN-Edifact Message 1 UNH+1+MEDRPT:0:1:RT:NHS003' 2 BGM+LSR'3 DTM+137: :203' 4 S01+01' 5 NAD+MR+G :900++DR VIRTUALONE' 6 SPR+PRO' 7 S01+01' 8 27 PNA+PAT++++SU:EDITESTPATIENT+FO:THIRTEEN' 28 DTM+329: :102' 29 PDI+2' 30 S16+16' 31 SEQ++1' 32 SPC+TSP+:::Spec.Type?: Urine Site?: MSU' 33 RFF+STI:O, GA' 34 DTM+SCO: :102' 35 DTM+SRI: :203' 36 GIS+N' 37 INV+MQ+4I16.:911::Micro, culture & sensitivities' 39 FTX+RIT+++ Clinical details?:' 41 FTX+RIT+++ test of readcode for dmluc: Antibiotic therapy?:' 42 FTX+RIT' 43 FTX+RIT+++ Microscopy?:' 45 FTX+RIT+++ White cells?: <10 x10^6/L: Red cells ?: <1 x10^6/L: Epithelial Cell s?: scanty: Cellular casts ?+?+ Numerous bacteria.' 47 FTX+RIT+++ Culture?:: Coliform species' 49 FTX+RIT+++ Bacterial count?: >10^5 cfu/ml' 52 FTX+RIT+++ Antibiotics?:: Amox/Amp S: Cefradine S: Ciprofloxacin S: Gentamicin S' 53 FTX+RIT+++ Nitrofurantoin S: Trimethoprim S' 55 FTX+RIT+++ This is a test of readcodes: on LGI system microbiology: Dave Lister: Note abs ence of pyuria' 57 FTX+RIT+++ Authorised by?: Dave Lister SJH : END O F REPORT ' 58 FTX+RIT' 59 RFF+ASL:1' 60 UNT+60+1'

46 Costs The original business case for pathology messaging was for a net present value of £40,627,000 over 8 years. One off costs were forecast as £9,105,000 (undiscounted) over a three year period : Trust costs of £6,145,000 GP systems costs of £50,000 Central project costs of £2,910,000 2004

47 Technically easy - Culturally difficultThe Challenge How to move from fault-tolerant paper communication to fault-intolerant electronic information transfer. Technically easy - Culturally difficult Minimal experience Un-intelligent receiver receiver controls display Probably impermanent Intelligent human reader Decades of training Lloyd-George compatible Permanent record

48 Coding Problems : Fasting Blood GlucoseGPs / Clinicians : Request ‘Fasting Blood Glucose’ Labs : Measure glucose in serum / blood / plasma drawn from a fasted patient apply units (mmol/L : mg/dL) add a reference range (low - high)

49 Coding Failure – GP SystemsE2 (Oestradiol) – mis-coded by GPs as Read code E2… - Neurosis & other mental disorder. 329 practices (All EMIS) 169 other coding confusions identified 115,000 patient records compromised Compounded by patient flows – 10% turnover pa This has never been cleaned up!

50 Approximately 50 million reports sent annuallyReflection 162 Trust laboratories actively messaging all biochemistry & haematology data. Microbiology data also sent and radiology – both outside original scope 8,000 practices with a tested installation (109% of original target population) 8,000 practices signed receiving data Approximately 50 million reports sent annually Key success factors Standards Professional IT support Strong business drive Scale 2008

51 University of Leeds Senior Lecturer in Chemical PathologyJoint post – teaching, research and service Many multidisciplinary links: Clinical Information Science Unit – Tim deDombal, Susan Clamp Psychology – Mark Howes, Christine Parker-Jones, Joe Nichols IT – Nicholas Cook, Owen Johnson Computer-based learning – Andrew Cole, Rachel Pilkington Medical physics – Mike Smith, Martin Plumb, Tony Evans Design – Tom Cassidy English – Lynette Hunter 1990

52 Screening, Elipse & SpinoutsNHS Academic Links NHS Screening service University research team Cuckle H, Lilford R, Jones R. Maternal serum screening for Down syndrome before 15 weeks. Am J Obstet Gynecol. 1994;170:959. Cuckle HS, Jones RG. Maternal serum-free beta-human chorionic gonadotrophin level: the effect of sample transportation. Ann Clin Biochem. 1994;31:97-98. …. Reynolds T, Ellis A, Jones R. Down's syndrome risk estimates demonstrate considerable heterogeneity despite homogeneity of input. Ann Clin Biochem Nov;41(Pt 6):464-8. Maymon R, Cuckle H, Jones R, Reish O, Sharony R, Herman A. Predicting the result of additional second-trimester markers from a woman's first-trimester marker profile: a new concept in Down syndrome screening. Prenat Diagn Dec;25(12):

53 Elipse (www.elipse.org.uk)Elipse is a decision support engine which conducts the complex calculations used in prenatal screening risk assessment. Takes account of: Maternal age MoMs / Medians Ultrasound Biometrics Gestational age Up to 10 markers CE Marked

54 Elipse & PerkinElmer

55 Reflection – Knowledge TransferElipse Knowledge generated in academic environment Captured and engineered into software deliverables Includes educational support Distributed and disseminated by industry Long and difficult road No-one makes money! Supports research Feeds back into service improvement – QA

56 Information in the NHS “Better care for patients, and improved health for everyone depend on the availability of good information, accessible, when and where it is needed.” NHS Information Strategy Strategic role Effectiveness application in information intensive activities Efficiency cost reduction through better clinical control 1998

57

58 NHS Information StrategyKey commitments lifelong electronic health records - EPR round the clock on-line access to patient records and information on best practice seamless care through information sharing fast and convenient public access to information the effective use of health resources by providing planners and managers with the information they need 2004

59 Achievements to date 28/5/07 - NationallyCfH – Highlights Achievements to date 28/5/07 - Nationally 1.2 million NHS employees have access to the new N3 network 252,347 Registered NHS mail users 469,856 Staff registered to use the NHS Care Records Service 153,188 Care Records on the NHS Spine 77.4 million prescriptions transmitted using Electronic Transmission of Prescriptions 7.9 million Bookings made using Choose and Book – 50% GP activity Picture Archiving and Communications Systems live 640 million Images stored on PACS from 25 million patient studies 108,334 medical record transfers using GP2GP 28,365 Quality Management & Analysis Service (QMAS) users across all 8,659 GP sites in England 2008 59

60 Can we trust the politicians – any of them?Politics with a big P. Cameron's Conservative blog entry... "We'll champion open source software, not big clunking mainframe solutions. No more NHS computers, much more open platform projects that can be broken down into their component parts.“ Can we trust the politicians – any of them? 2008

61 Pathology and CfH Pathology not in CfH ‘Core’ product set Why?Deliberate exclusion because: Pathology Modernisation in progress Business model uncertain Large established Pathology IT base ‘no need to change’ little perceived business benefit Therefore freedom to buy based on business need and should be cost benefit – not replacement for replacements sake.

62 NHS Pathology ProjectsCurrently the DH is sponsoring several projects to create the infrastructure for the future : Harmony – Jonathan Berg POCT – Gilbert Weiringa Pathology FAQs – Stuart Smellie Benchmarking – Helen Ogden, Keele Laboratory Handbook – Rick Jones Order Communications – Ian Barnes LabTest Online – Ian Godber Genetics LIMS - StarLIMS – Stuart Bayliss Pathology IT Summit – Gifford Batstone 2008

63 Pathology Clinical BenchmarkingEfficiency - laboratory focus Cost reduction Turnaround Effectiveness - clinical focus Right test Right time Positive patient benefit Challenges Changing clinical behaviour Maximising value-added benefit Improving overall test-performance 2008

64 Linking into the Clinical DomainDatabase Laboratory Database ‘Audit space’ 15

65 Robert Aurand Moon 1917 - 2001 Inventor of the ZIP codeMeta-analysis Inventor of the ZIP code Zoning Improvement Plan Father of Junk Mail Bank Account Credit Card Info Zip Code Social Class Data Insurance Records NHS Number

66

67

68 U Site homepage 68

69 Royal Statistical Society Uses of performance dataPurpose What works? (research role) Identify well[/under]-performing services (managerial role) Hold Ministers to account for stewardship (democratic role) Performance schemes should be: Well-designed (avoid perverse behaviours) Sufficiently analysed (context / case-mix) Fairly reported (measures of uncertainty) Shielded from political interference (rigorous and independent)

70 Current Pathology IT ChallengesDarzi – the NHS context Carter Review – the Business Model Pathology IT Summit – the next 5 year plan Stabilising the IT workforce Renewing the technology Working at the appropriate scale across the relevant boundaries 2008

71 Functional ArchitectureLevel Type Clinical Management Content 4 Executive Decision Support Performance Monitoring Planning Quality Management Knowledge Systems 3 Intermediate Ward Requesting Clinical Reporting R&D Statistics Workload Systems Supplies / Contracting Quality Assurance Aggregate Information 2 Operational Analytical Control Reporting Data e.g. LIMS POCT Networks Word processing Web Browsing Operational Data 1 Infrastructure Servers / PCs / Printers / PDAs / VPNs / Voice & Image management

72 N-Tier Conceptual ArchitectureEnd User Functions Order Comms Planning Contracting EHR Support Laboratory Handbooks Performance Management Business Services Order & Results Contracting Benchmarking Lab 2 Lab Knowledge Support Foundation Data Services Data Architecture Data Standards Metadata Models Data Models Rule Models Data Management Result Repositories Service Catalogues Knowledge Sets

73 Path IT Training LevelsSkill Level Competencies Examples Job Functions Basic EDCL Data access A&C and data entry Technical Intermediate Application use Word Processing Supervisory staff Spreadsheets Scientific leaders Databases A&C Advanced Application use Statistical analysis Scientific Leaders Modelling R&D Web site design Management Specialist IS development Specialist applications System managers Bespoke systems IT Support Decision support systems Management Application

74 Path IT Training

75 Reflections on the FutureBio & Health Informatics

76 The Information Age in MedicineAccelerating pace of change Growth in medical knowledge Globalisation of access to information Breakdown of institutional hegemonies Primary / secondary care Pharmaceutical / diagnostic industry involvement Challenges to professional status / rights Security / confidentiality / openness Patients as informed as professionals Turning to the future. I have already highlighted the accelerating pace of change. This relates not only to the growth in medical knowledge but also the increasing globalisation of the milieu in which knowledge is accessed and used. In my own field of laboratory diagnostics I now work in a health environment conditioned by a global market which is dominated by a rapidly consolidating, small group of North American companies. We will see profound changes in institutional activities with a breakdown of traditional relationships. Through the commonality of the information space the relationships between the individual participants in the health market will change. Patients will have the same access as professionals presenting many obvious challenges. For the Education and Training community the principal challenge will be to ensure that developments and initiatives are appropriately coordinated.

77 Laboratory Information“The value of information is equal to the enhanced value of outcomes based on that information." Flagyl (1973) "The only product of the Clinical Laboratory is information. The generation of that information is the end product of appropriate test selection, specimen collection, analysis, result reporting and interpretation. To achieve this sequence requires the harmonized interaction of a variety of personnel with a spectrum of expertise. Such is the domain of Medical Informatics." William Dito (1979) 6

78 1st Outpatient AppointmentDarzi Pathways Tertiary A&E 18 weeks Diag (IP) GP OP OP IP OP Diag (OP) OP Assess Other 1st Outpatient Appointment Diagnostic phase Decision to treat Treatment/ Discharge Follow-up Data flows Choose and Book A & E Future Care Activity Outpatients (Care Activity) Elective Admission List Admitted Patient Care

79 Health Economics

80 The Information Space Health Management Health IntelligenceIntegrated Electronic Patient Records Health System National Association National Lab Data Aggregator Clinical, Financial & Operational Data Demand for Information-Enabled Health Services Data Network Electronic Patient Information Network Health Informatics Provider Health Plan Employer Public Sector Consumer Offerings Channels Life Sciences Research Network Regional Health Information Exchange Payor Chronic Care Management Safety Surveillance Disease/ Bio-Surveillance Health & Wellness Management Medication Therapy Management Personal Health Records (Shared Decision Making) Clinical Research Optimization Quality & Efficiency Management Health Outcomes & Economics Decision Support

81 Clinical Records - ScaleBlue Health Intelligence – 79m CMS – 40m Ingenix – 30m Vanderbilt - 1.8m Partners Healthcare - 2.5m Intermountain Healthcare - 2m Regenstrief – 3m Mayo Clinic - 4.4m AMGA/Anceta – 12m UK NHS - 55m Opportunities for Diagnostics Clinical care Research – trials, Biobank Surveillance – microbiology Intelligence & Knowledge

82 Personal Philosophy Service Academe Industry

83 Acknowledgements Robert Turner, Rory Holman, Brian Payne, Andrew Grant, Colin Toothill, Sherry Faye, Mike Cummerbatch, John Cooney, Simon Huntington, Drew Morgan, Dave Holland, Helen Ogden, Keith Gailer, Andrew Little, Julian Barth, Steve Goodall, Muir Gray, Derek Williamson, Vera Ilic, Andy Ward, Liz McNamara, John Whicher, Ian Barnes, Chris Price, Graham Beastall, Hugh Mitchell, Craig Webster, Jonathan Kay, Andrew Moore, Stephen Walter, Dave Wiggins, Kevin Page, Mark Howes, Christine Parker Jones, Carol Chu, Graham Isaacs, Caroline Bellini, Mike Smith, Liz Berry, Tim deDombal, Chris Burke, David Ramsay, Terry Thrasher, Stephen Taylor-Parker, Howard Cuckle, Indera Sehmi, Carol Wilson, Es Will, Joe Nicholls, James Falconer-Smith, Bill Godolphin, Glenn Edwards, Bob de Jong, Donald Saum, George Philp, Steve Walker, Stephen Pill, Roy Lambley, Carol Longthorne, Faye Storey, Ian Watson, Lyn Sharman, Geoff Auchinleck, Yvonne Parker, Lynette Hunter, Derek Cramp, Ewart Carson, Alison Friday, David Robinson, Nick White, Derek Hockaday, Roger Blackburn, Mary Jones, John Jones, Viv Jones, Anna Jones, Luke Jones, Phil Wiles, Mike Toop, Hazel Wilkinson, Brian Roberts, Bob Oakey, Marion Cawood, Alison Jennings, Tim Branch, Dave Beaven, Paul Risdon, Keith Taylor, Rob Young, Martin Jones, John O’Connor, Margaret Peters, Brain McCauley, Alistair Cartwright, Ted Woodhouse, Phil Molyneux, Martyn Forrest, Susan Clamp, Liz King, Sue Davis, Owen Johnson, Teddy Cooper, Ray Davies, Brian Gill, Mike Bosomworth, Gordon Cook, Tony Child, John Wales, Andrew Davies, Brian Jewell, Karen Lee, Deirdre Feehan, Mike Hallworth, Darren Green, Timmpa Honkosala, Morgan Feely

84 Reflections on the Future“If men could learn from history, what lessons it might teach us! But passion and party blind our eyes, and the light which experience gives is a lantern on the stern to light the waves behind” Samuel Taylor Coleridge ( ) “You can never plan the future by the past.” Edmund Burke ( )

85 Thank You Gracias Danke Obrigado Merci Grazie Thai HindiTraditional Chinese Russian Spanish Obrigado Thank You Brazilian Portuguese Arabic Danke Grazie Merci Italian German French Simplified Chinese Tamil Korean Japanese

86

87 Dr Rick Jones, Leeds, UK [email protected]Perspective “Everything which can be invented, has been invented.” - U.S. Patent Office Official, 1897 Dr Rick Jones, Leeds, UK

88 Challenges

89 Challenges - safety

90 Safety? - Personal experience

91 Current technology 2-dimensional bar code has more data.Radio-frequency CHIP emits patient’s ID Barcoding is currently the most widely used autoidentification technology. One disadvantage is that the code must be within the line of sight of the scanner. This may be a constraint in some clinical scenarios such as operating theatres. Radiofrequency identification (RFID) tags uses small chips with an antenna that communicate over short distances with a transponder. They do not require ‘line-of-sight’, and thus have an advantage over the use of barcodes in some clinical settings. The cost of RFID is rapidly dropping, and WalMart have recently specified that all shipments from suppliers to their stores must use RFID by 2006. Photo courtesy of Precision Dynamics, Corp.