Interview, NP

“Should we even be talking about interoperability anymore?” James Davis, CEO at inicio health

Next up in our interview series, we’re sharing our chat with James Davis, founder, CEO and chief innovation officer of inicio health and previous chief innovation officer at Royal Free London NHS Foundation Trust.

Hi James, can you tell us a bit about your career and some of the projects you’ve worked on?

Classroom-based education wasn’t for me – I started an advanced IT qualification in college because I knew I wanted to do something digital, but from there I moved into an apprenticeship in voice and data networking. I’m a huge advocate for the apprenticeship scheme and I think there’s a lot of benefits that come from it. It gave me a great grounding in terms of fundamental understanding of technology – I spent a number of years being able to understand the fabric upon which digital architecture is built, for operational use within a building. It really helped to shape the start of my career.

After that I developed my experience in IT management and infrastructure management, and became an IT director within the NHS. From there, I became chief innovation officer at the Royal Free, which took all of that background knowledge along with the desire to continue to push the boundaries of what’s possible, and combined them by leveraging the latest and greatest in terms of technology

When I arrived at the Royal Free, it was clear to me that the NHS as a whole has a desire to consume technology, to use it, to draw on it, to leverage the best that it has to offer. But there are a number of barriers that sit in the way – appetite to risk, for example. What happens if this goes wrong? Can we afford to go on this journey? Who has gone before us? This is the way we’ve always done it, why would we change?

They also have the barriers of the technical understanding and digital literacy, which come alongside leveraging new pieces of technology. There can be financial barriers too – it costs too much to implement, and you have to employ a team to do it.

I set up the innovation directorate at the Royal Free in order to answer those questions and provide an NHS-to-NHS service, providing access to niche and expert skillsets at a price in line with Agenda for Change. That was hugely successful.

In terms of digital projects that I’ve worked on, obviously the pandemic had a big impact. One of the things I’m most proud of is a national COVID testing platform that we built for the system in the pandemic. It’s still up and running at the moment. That involved an alternative testing method for COVID; the individual would spit into a post and their saliva would go into a machine that would analyse it and produce the same level of certainty as a PCR test. We rolled that out to just under 30 different organisations in the country, which was really cool.

It took a lot of time and effort in design, thinking in terms of how to build a platform, how to build a digital wrapper for sample collection. As an end user, how is it that I can interface with this digital solution to deposit my sample, to track it and understand where it is in its process. Then from the perspective of the engineer or the laboratory, how do I receive this sample, note on the system, make sure it’s checked properly? From the data and analytics viewpoint, or the person responsible for monitoring it, how can I assess how we are doing and what our performance looks like at scale?

It had a really positive impact – the programme lasted for nearly two and a half years. It was all built and delivered through us at the Royal Free and we collaborated with the Department of Health, NHS England, NHS Digital and Track and Trace to do it. I’m very proud of that one.

The other project I’d highlight is the work we’ve done in intelligent automation, and the releasing of capacity for the NHS by automating mundane repetitive tasks. We’ve worked with 70 different NHS trusts and organisations on this. We’ve won a number of awards for this work and we’ve been able to release over 300,000 hours back to the NHS within a year through automation. As part of that, I was sat on the national RPA Advisory Board that Tim Ferris chaired, to help set the national direction on RPA (robotic process automation) and how we can best leverage it.

Current priorities in health tech

There’s a lot that has come out in terms of a national picture on priorities. You can’t escape the priority around integrated care systems and collaboration for ICSs. How is collaboration around the improvement of digital health going to come into fruition?

There’s the priority around the setting up of trusted research environments within different ICS regions, which I think will be key to the development of digital health solutions. That will also be key to how we facilitate research and development of different approaches, technologies, pathways and interventions.

I’d also point to the work that is being led by Sonia Patel in terms of electronic health records and getting the country as a whole up to a basic level. That’s really important – without everyone having an EHR in place, we can’t layer on all the other pieces of technology.

I think another priority will be balancing out telehealth or remote consultations. There was obviously a huge rise in the peak of the pandemic, and it almost seems to have plateaued off or declined. I recently saw a GP tweet a photo of an empty chair in her consultation room and she had captioned it, ‘This is the result of insisting on 100 percent face-to-face consultations’. There’s a balance to be found between remote and in-person care and finding that balance should be a priority.

The other priority is the buzz around AI and generative AI. It’s definitely a priority, but a lot needs to be done in terms of being able to understand the governance that sits around it, and also the security and data privacy around it.

That’s another priority area in itself – security and data privacy. Cyber security and threats are only getting worse. I heard a story last week about people starting to wear implants under their skin that can clone the ID tags that NHS staff wear around their necks, and then gain access to buildings. It’s scary stuff. The NHS needs to prioritise and really start putting additional resources where possible to guard against cyber security threats.

The last priority in my view is around workforce – the development of the NHS workforce with digital skills and digital literacy. We need to invest in digital literacy of professionals whether they are clinical or non-clinical and support their development using tools and technologies. It’s all very well saying that we want EHR, we want AI, but if the workforce don’t know how to get the most out of it or even just use it at its most basic and fundamental level, then these tools won’t be adopted. They won’t be scaled. They won’t achieve the benefit of return on investment that the business case originally specified.

What does the NHS need to be successful in delivering digital? 

I’ll focus on the word ‘delivering’. What actually needs to happen to make it tangible?

The first thing on the list is interoperability. We’ve been talking about this forever and my challenge is: should we even be talking about interoperability anymore? Is it really this Nirvana that everyone’s been going on about for the past ten years? Seamless integration, data sharing between systems, is unarguably critical for the development of health services. But interoperability is still not a tangible thing.

So instead of interoperability, is there something else that we should be talking about that delivers the same outcome? What does that look like? For want of a better term, what does a multi-lingual integration platform or middleware look like, so we can deliver this outcome? Getting vendors to create or develop interoperability standards for their products hasn’t delivered fruit. I very much think that the NHS needs to drive that integration to be successful, and interoperability is perhaps something that we will now never achieve.

The other thing that the system needs is a better sense of understanding of user-centric design or design thinking. I think there’s a pushback; within the system, I’ve come across lots of people who have been with the NHS for a long time and they haven’t been exposed to the private sector, so terms like this just end up coming across as a collection of buzz words. But the power of user-centric design is vast. For digital solutions to land and deliver, they really need to be designed with the end users – professionals and patients – in mind. User-friendly interfaces and accessibility are functions to drive that adoption and satisfaction curve, to truly unlock all the benefits.

All too often solutions are designed with best intentions in mind, without the people who are actually going to be using them at the end of the day. It’s not that they are completely ignored – they might feature briefly in a strategy, but to what level are organisations drilling into the different personalities and personas that will be interacting with this product?

One of the projects I was finishing up at the Royal Free before I left was around providing a more useful interface to the HIE for London for London Ambulance Service. It’s built on Cerner, on a tableau environment – but the ambulance staff use iPads, and the solution didn’t render for them. The problem lay in the fact that there hadn’t been enough focus on working out who exactly would be using it. When we looked into who would be using it, we discovered that there were 17 different personas who needed to interact with the platform. We spent time working with each group, working out who needed to use it and why. Building out that list meant that we could build a product that was fit for purpose, that was adopted, and that met the satisfaction criteria. We built a native IOS app for them to integrate with the HIE, which enabled them to achieve their role in a more frictionless way. That is what user-centred design delivers.

When people pick up their favourite brand of smartphone, they often say that it is intuitive. They just know how to use it. We should be developing health applications, platforms and systems in the same way.

We’ve already touched on cyber security and data privacy – building on that, in terms of what the NHS needs to be successful in delivering digital, is infrastructure and connectivity. Infrastructure for legacy buildings remains unloved – I think it’s a bit of a boring subject that no-one really likes to talk about. The New Hospital Programme hopes to address some of this by building a number of new buildings, or revamping them. Upgrading the infrastructure sits alongside it.

Then there’s collaboration and innovation. That means encouraging collaboration between health care providers and technology companies, as well as other stakeholders, to go further and faster. I think this is really key to deliver successful solutions. It’s a sticky situation because of course money becomes involved at some point, but unless we can foster an environment that enables collaboration between industry and the NHS, then we are continually inhibiting progress.

As an example of that, we can look at how GCHQ manages innovation. GCHQ are charged with protecting our country and our borders from the biggest threats that we may come across. In order to do so, they must have a highly secure environment. But they realised years ago that you can’t have a highly secure environment that is cut off from the rest of the world but also be up-to-date with the latest threats. So they created a high side and a low side to how they manage protection of the country. That low side has a lower security layer but also enables them to go out to the internet, to work with the industry, to understand what are the latest and greatest tools to protect us. No-one cares or complains about GCHQ working with the best of industry to keep our borders safe. Why do we have the same ambivalence when it comes to our healthcare? We need to get rid of the ‘them and us’ between the NHS and the wider system. There are lots who embrace this and bring the two together, but I think there are still large pockets where it doesn’t happen. That needs to be addressed and brought together.

inicio health: who, what, why, when and where?

inicio is designed to be a clinically-led, patient-focused healthcare technology company. My co-founder Amanda Sparks is still a registered nurse with 25 years of experience. Having that clinical voice from somebody who has delivered services, run wards and experienced emergency settings as well as running a HIMSS level seven elective site is really important and at the core of our company.

Given my own background, Amanda and I now work together to create innovative solutions designed to improve patient outcomes and experiences for everyone involved. We work to bring together all of these technologies that we have both worked on over the years – AI, automation, data and analytics – as well as the strategic planning and real-world experience of implementing technologies into an operational, clinical workflow.

The new product that we have launched within Cerner Millenium is designed to enhance that clinician experience, journey and outcomes. We are building into the EHR, natively, functionality that didn’t exist. Soon we’ll be launching an online form platform for Cerner Millenium which will allow our client base to not only store their own forms but also to pull down additional forms into their EHR so that they can remove paper from their workflow. This means they can also remove their reliance on other third-party systems – they’ll be able to generate their own forms and capture their own data so it remains within the EHR. The forms can also be used to work on clinician-to-clinician workflows to completely transform how they manage things like pre-operative assessment and informed consent.

Alongside that, we’ve developed an integration solution for the EHR that means that data can be written back to the patient record, to the right place at the right time, helping to maintain that single source of truth within the EHR. That’s a huge gap at the moment and clinician experience struggles as a result. Ultimately, if that happens, then the patient experience suffers too.

Looking at other examples of our work within Cerner’s EHR, we’ve made simple charting improvements – they can now capture infant bilirubin levels natively within the EHR which has been really powerful. The information in captured in such a way that the clinician can interact with the data via the end page. We’re also working on tackling data challenges around diabetes, so that clinicians will be able to track and monitor glucose levels within the EHR.

Next, we’ll be working on bringing real-time alerting to clinicians for degenerative conditions such as acute kidney injury alerting.

Life as a start-up

It’s challenging, scary and fun all rolled into one. What’s really exciting is that we have the ability to develop solutions for problems that actually exist, as opposed to developing a solution and then trying to find a problem that marries to it.

I think the key challenge is working to be seen as a value-adding partner, there to fight the same fight; breaking down those ‘us and them’ barriers. We know that we’ve got great things to offer. Fortunately for us, we’ve been able to secure pre-seed funding which we’ll be able to officially announce soon, and that’s really given us the platform that we need to explosively go forward.

The challenges that I see now as a start-up are the same challenges that were played back to me when the sector when I was within the NHS – all the usual stuff. Bureaucracy, complex procurement processes, the NHS being slow to respond, frameworks which exist but aren’t always useful, NHS budgetary constraints; when you want to bring new things to the system, you often have to work with organisations to find pots of money or funding that are often non-recurrent or capital-based, or based around a specific challenge. Many other start-ups that I’ve spoken to have problems with accessing NHS data and integrating properly, often because data teams are stretched as it is doing their day-to-day jobs.

If we look at ways in which we can ease these challenges and support start-ups, we need to support Jacqui Rock (chief commercial officer for NHS England) and the national commercial team on streamlining the procurement process and the frameworks. We need a better way to manage funding opportunities, and more transparency. For example, at the moment, every year we have the Target Investment Fund. It comes out, it goes to ICSs, and the ICSs then work out who wants to do what, and how much that will cost. They collate that information, shortlist the requests, and send out another form specifying where that money will be spent.

There are organisations and agencies that work towards fostering a culture of innovation – the National Innovation Accelerator, AHSNs, the Clinical Entrepreneurs Network, and more – but it still doesn’t feel like there is a central theme to fostering a culture of innovation within the NHS. I don’t think that has been felt tangibly. There’s multiple different ways for an innovator to connect with the NHS but it can be confusing in terms of where to go or what to do.

I also think we need to set up technical support for innovators who are wanting to build within the system. Internationally, we’re seen as really opaque and confusing in terms of how we do things. If you’re a clinician, unless you enter into one of those schemes I just mentioned, where do you go? Where do you get the technical support to develop, iterate, bring to life or establish the viability of your project? We’ve got already got some collaboration platforms like NHS Futures – we need to capitalise on these further as forums for innovators and professionals to share ideas.

Exciting innovations, present and future

The first innovation that I find really exciting is virtual reality. We have an offering that enables immersive, metaverse-based training for nurses which removes the need for physical simulation labs. It transforms the educational experience and saves a lot of money.

It’s not a new thing, and the benefits have been documented; however it’s failed to be adopted at scale within the NHS. I’m intrigued and puzzled as to why that is. At the moment, we’re in the early stages of securing our NHS partner to try and address that problem, and to bring metaverse and virtual reality training at scale for specific use cases. We can build environments using simulation where there is a deteriorating patient within urgent and emergency care, and you can roleplay that scenario. You can roleplay difficult conversations. Also, looking at diversity and inclusion, we can use that same environment to experience what it feels like to be the sole female in a room surrounded by a table of men, or the only person of colour in a wholly white environment. There’s a lot that can be done with virtual reality to change medical education and training and patient care.

I’m really exciting about where machine learning and AI will go for diagnostics. I saw that a quantum computing platform has recently been unveiled in a clinic – it’s going to be really interesting to see what that does in terms of research and development. I have concerns about leveraging large language models within UK healthcare – I think we’ll get cases of clinicians firing triage questions at large language models, if only to experiment, and that could cause a bit of a stir in terms of patient data being shared with open AI. There will be lots of positives to come as well, but I think AI organisations just need to think carefully and tactically about how they work and collaborate with the NHS.

Finally, I think wearables and Internet of Things (IoT) for virtual remote monitoring is a really exciting space. We need to keep developing hospitals without walls and we need to keep rolling out and developing what effective virtual wards look like. We need to make hospitals into places that you only go to when you really need treatment, and the only way to do that is to expand virtual wards. We need to get better at understanding how we manage various pathways, the technologies to implement them, the securities around them, the implications thereof, and everything else. I think there’s still a long way to go on realising what what an incredible virtual ward infrastructure would look like.

Many thanks to James for sharing his time and thoughts.