Performers, publishers, polyphony and the Pope What can medicine learn from the music business?

To Err is Human (IOM, 1999) Up to 97,000 unnecessary deaths p.a. in the US are due to medical error –“even using the lower figure [48,000] deaths due to medical errors exceed the numbers attributable to the 8 th leading cause of death … more than from motor vehicle accidents (43,548), breast cancer (42,297) or AIDS (16,516) Total national costs … between $17B and $29B

… and the UK 10% of acute admissions to NHS Hospitals result in adverse events which cause patient harm. C Vincent et al, BMJ, 322: , 2001 Perhaps 16,000 lives could be saved if all current knowledge of cancer were properly applied ICRF Vision for Cancer, 1995

Disseminating medical knowhow… Cochrane Library of systematic reviews Scottish Intercollegiate Guidelines Network UK National Institute for Clinical Excellence US National Guideline Clearinghouse BMJ publishing’s Clinical Evidence

… but  Busy clinicians have little time to read … converting paper to electronic pages may not change this reality.  Even if a clinician has time to read the content may not be correctly absorbed and applied in practice.  Conventional published guidelines do not provide recommendations that are tailored to the needs of individual patients.

A new option? IT Support for “best practice” –Electronic patient records –Rapid access to guidelines –Prompts and reminders –Decision support –Scheduling and workflow –Support for communication and coordination

Crossing the quality chasm "reorganization and reform are urgently needed to fix what is now a disjointed and inefficient (healthcare) system … use of information technology is key … if a substantial improvement in quality is to be achieved over the coming decade.” US Institute of Medicine, March 2001

Music, a historical precedent

Guido d'Arezzo was a Benedictine monk, musical theorist and teacher. His name is associated with the most comprehensive rationalisation of the myriad, ad hoc and often imprecise means of musical notation that had developed amongst the monasteries of Europe from around the 7th century onwards.

Representing medical guidelines Arden syntaxHripcsak et al ASBRUShahar et al EON/ProtégéMusen et al GLIFIntermed consortium GUIDEPavia ProdigySowerby Centre PROformaICRF

PROforma process modelling language Decisions Plans Actions Enquiries

A PROforma guideline: management of suspected breast cancer by GPs

Some PROforma performances Das Alte Werk

Genetic risk assessment and counselling

Breast Cancer screening

Composing and publishing

PROforma

Publet library Publet technology

Transpositions, arrangements and instruments

John Kingston’s PROforma browser

InferMed’s MACRO Clinical trials manager

REACT interactive care planner

Polyphony

SIGN, BrCa GP referrals Screening Triple assessment Surgey Radiotherapy Systemic therapy Follow-up Information & support

Cancer, the score PROforma library Prevention Screening Primary care Specialist care Research Home care Hospice RAGs, REACT CADMIUM RAGs. ERA REACT MACRO Arno

Managing the orchestra Players –Shared score, common notation Voices –Parts as separate but coordinated plans Communication and coordination –Conductor, leader or none? Performance –Interpretation not execution

The audience

REACT: empowering the patient?

Performers, publishers, polyphony and the Pope

Pope John XIX “summoned Guido of Arezzo to Rome [In 1028] … and urged him to instruct the Roman clergy in music.”

With thanks to … Jon Bury, Andrew Coulson, David Glasspool, Michael Humber, Ali Rahmanzadeh, Margarita Sordo, David Sutton, Richard Thomson Imperial Cancer Research Fund Paul TaylorUCL CHIME Robert WaltonOxford U Jon EmeryCambridge U Robert Dunlop, Nicky Johns, Michael Morris, Andrew Newbigging InferMed Ltd John KingstonEdinburgh U Subrata Das CRA Inc.