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Health in the clouds
On Friday the company that provides the clinical software used by one in six British GPs announced a major shake-up of its service.
The software, Emis Web, will become “Emis-X”. This comes with a whole bunch of new features that catch up with current trends in primary care, such as AI triage, video consultations and federated appointment booking.
More significantly, Emis will move its software, along with the billions of documents and tens of millions of NHS patient records, from its own servers onto Amazon Web Services.
This will mean that roughly one in six GP patients’ records will be held on a service run by the second largest company in the world (by market value). Emis also holds patient records, albeit fewer, for community and acute NHS services.
This is not the first part of the NHS to shift onto public cloud services such as Amazon Web Services, Google Cloud and Microsoft Azure.
AWS customers already working with patient information in the NHS include Cerner, GE Healthcare and Babylon Health. So, while the scale is new, the move is not unprecedented.
And there are plenty of sound practical reasons for the shift.
AWS will almost certainly be more secure and reliable than running clinical software hosted on servers in hospital basements or even in a small data centre run by a mid sized IT company like Emis.
AWS customers include the CIA, NASA and UK Ministry of Justice, all of which attach value information security highly.
It will also be cheaper for Emis and, in theory, make it easier to upgrade and expand software and link it to other cloud-based digital NHS services.
So, what could go wrong were we to move NHS IT en masse onto the public cloud?
The big three cloud services may be less likely to succumb to a cyber attack than a hospital basement server, but they are also far more centralised.
Were one of these services to host the bulk of NHS data and digital services in future, a successful hack could be catastrophic. It would make WannaCry appear a minor inconvenience.
There is also a risk of market capture, essentially giving a few large global companies control of critical NHS infrastructure, with few alternative suppliers (not a problem unique to the NHS).
To an extent, the NHS already has this problem. Officials blame “market failure” in the GP IT market, effectively a duopoly presided over by Emis and TPP, for slow innovation and “inflexible pricing”.
The move to the public cloud could just shift this problem upstream, trading mid sized IT firms for global behemoths with little direct interest in the NHS.
The Emis shift still needs NHS Digital sign-off but it will almost certainly get it.
NHS leaders are deeply enthused about moving to the cloud. In his “tech vision” last month, health and social care secretary Matt Hancock said the NHS needed to “start with the assumption that all our services should run in the public cloud with no more locally managed servers”.
That shift is underway.
Great Ormond Street Hospital for Children has an international reputation and is famously very difficult to manage.
The high standing of its clinical teams, its research, teaching and private work make for a difficult set of agendas to reconcile.
This confluence was thought to be part of the reason it had a waiting times debacle a few years ago, with separate services having their own systems for keeping track (or not) of patients.
The trust has yet to move out of the shadow of major concerns about gastroenterology, with a second report into how children came to be given invasive treatment instead of talking therapies still unreleased.
Legal issues relating to a fractious department seem to have largely resolved earlier this year, but the animosities in the unit seem to extend back to at least the Baby P case.
So it’s good news that the trust has appointed a new chief executive, Matthew Shaw, the current medical director. It would have been embarrassing for such a well-regarded hospital to have had trouble filling the top role.
Mr Shaw is well thought of in London and it was significant that he was an external appointment to the medical director role, rather than a homegrown candidate.
One of his most significant tasks will now be to recruit a new medical director.