As we had been indicating in recent posts, 2020 looked set to be a year of change for the Ripple Foundation. Certainly it was clear that change was coming, of some sort. So  it has turned out to be.. little did we know that the pace of change would accelerate quite as fast as it did.  

Despite all the unfortunate suffering and the downsides that 2020 has brought, it has at least jump started thinking and some action towards the major changes needed in our societies and economies.


Within the sector we have been most focussed on in recent years, healthcare, the need for changes in the way systems work have never been more needed. 

Clearly there has been a heroic response from those at the frontline, all over the globe.

We hope that the systems that patients and staff must navigate will now move into the digital age in a more user centred, agile and effective way to improve the health of all. We can only see the role of an open platform in healthcare becoming more important and essential to see this future realised.


For now though, it is our view that the work the Ripple Foundation has been leading of late, i.e. open source improvements in usability, interoperability and vendor neutral open standards remains years ahead of where most stakeholders are at across the healthcare domain. That is the sector still has a lot of learning and growing up to do. Meanwhile related challenges across the broader socio economic landscape also need attention.


So for these reasons ,amongst others, the founders of the Ripple Foundation have chosen to move onto new challenges this year.

Dr Tony Shannon has recently made a move into the GovTech sector, towards improving digital services for citizens and public sector professionals in Ireland

Phil Barrett has recently made a move into the Housing sector, with his company Real Living Homes to ensure that the most essential of human needs, shelter, is made more affordable whilst adopting carbon neutral, modern methods of construction. 


Of course all the good work that the Ripple Foundation has pioneered remains openly available for others to reuse, improve and build upon..

Indeed the leaders behind PulseTile, QEWD and EtherCIS are still available and working in the fields of usability, interoperability and data persistence/querying (inc openEHR) should you wish to get their help to address these key challenges. 

As with Ripple Foundation, they all believe in the power of free software and free documentation but are not able to operate by offering free support. If you are wanting to explore any of the technologies further or need help getting started, please be aware of the Makers and Takers challenge that needs to be better understood as the world shifts towards a more sustainable future. 


If you are still interested in further education/support/advice on the open source “Ripple stack” and choose to explore further, please make contact via this online form and we will connect you to the key technical advisor behind this work.


The Ripple Foundation site and resources will remain openly available as a signpost to the future of healthcare technology. We appreciate your support and interest in this work. 

2020, its been a challenging time…. for everyone.


Now its the end of the Summer 2020, and time for the new term to start.

There is no doubt that challenges are ahead.


As we move forward, the best way to frame this time, is of one of opportunity. So lets not look at what we have lost or not able to do, but what we have and are able to do.

The world needed major changes at the start of 2020, it needs them now as much/more than ever before.


The time has come to Build Back Better…

As part of that push, as one small effort towards that end, see our recent work on Open Source TeleHealth.

We have been contacted from far and wide in 2020 asking for an update on our earlier Open Source TeleHealth work and looking for open solutions that may help make remote/tele care possible.

We have a been a very small team, but we believe in open source for the greater good, so check out the results of our efforts, using the latest leading open source technologies, making an open source telehealth solution openly and freely available to all.



We hope this open source work may be useful to you, wherever you are – as part of a global team working to Build Back Better..!

PS If you would like to join the related (open) discussion, please visit

In my last post I was briefly looking at some of the successes that the Ripple Foundation has enjoyed over the last few years. In fostering change in the field of healthcare and in promoting the role of open source, openEHR and an open platform in healthcare its been challenging work so great to see uptake of our ideas, methods and tools taken up and in action England, Scotland, Germany , Finland, India etc… hard not to be proud..

Of course we know that change in a complex system such as healthcare takes time and doesn’t happen overnight, we know there are many people challenges, process challenges and technical challenges on the way to further scale and further success.

We know too that our work is set within big picture issues of the societies and economies of our time. We recognise the brilliant work of Kate Raworth and her Doughnut Economics manifesto for a better world -resetting the relationship between the State, the Market, the Commons and the Household as the key players in any society/economy.

We want to make the world a better place and have been working to foster an open commons in healthcare for the last 5 years, seeding and supporting the development of open source tools in 3 key areas affecting healthcare… (1) usability of systems, (2) integration between systems and (3) persisting life long patient centred and vendor neutral data.

We have been developing open source code for quite some time now, sharing our work openly with the rest of the world. We can be understood as Makers. Our successes are framed in the context of those others who have taken our work and are using it to positive effect in healthcare settings around the world, in England, Scotland, Germany, Finland, India as I’ve mentioned.

So far so good.. we wanted and encouraged people to take our work and use it for their own needs to address health and care challenges around the world. Yet we have a problem, a failing so to speak, we aren’t getting contributions, in code or commercial support, we are not getting stuff back.

We expected that 1/10, 2/10, 5/10, 9/10 would be takers … so long as 1/10 see the bigger picture and is willing to give back. But our recent experience is that 10/10 are taking, without consideration for the ongoing maintenance of the open source tools they are leveraging and that is simply not sustainable.

Most importantly, we are not alone.. this challenge of Makers and Takers is a major challenge to the open source approach, to the right approach for healthcare.

We are aware of the Maker versus Taker challenge across the open source world as explained by Dries Buyteart of the global Drupal community.

We know that the global platform cooperative community, who are trying to build sustainable local services on open platforms are all up against challenges for investment and capital.

We know from colleagues in the open source world of healthcare, providing critical services in other parts of the world such as those that underpin the Global Goods agenda, that they do are facing the same sustainability challenges.

The reasons are clear enough..

At this time, the Market is ruled by shareholders rather than stakeholders, though it is now increasingly recognised that that needs to change.

At the same time, as the State has ceded significant aspects of its innovation agenda to the Market, in key areas it has neglected to look after the Commons on which we all depend on for collaboration. In treating the work of healthcare information systems as just a commercial commodity and paying out for mediocre services on proprietary platforms, rather than quality services on an open platform, the lack of State leadership on this agenda is in fact a part of the problem. That too needs to change.

So we in Ripple Foundation need to take stock and consider what we do about it. As we do, we need to consider the bigger picture, the broader context of our work .. we need to consider the big movements of our day, from Doughnut Economics to We4All to Platform Coops and share our rethinking, shifting our ideas and our efforts more broadly.

Watch this space..

As many of you will know, following positive developments on the ground in Leeds, the Ripple Open Source Initiative began in 2015 and moved into the not for profit, Ripple Foundation shortly thereafter. In targeting and supporting the development of key open source components to address usability (PulseTile utilising Marmelab’s React-Admin framework), interoperability (Rob Tweed’s QEWD) and vendor neutral data persistence (Christian Chevalley’s EtherCIS), we have tackled some of the most difficult challenges in healthcare and shown how they can be addressed together, with tools that work.

Its gratifying to know that these tools from leaders in their fields  have now been leveraged and are in use in projects in England, Finland, Germany, India , Scotland and more.. such is the power and potential of open source technology.

In Yorkshire, England, the open source Ripple stack has been key to the development of a Person Held Record for the Leeds and Yorkshire region, as well as key open source dimension to an integrating “system of systems” network to underpin that regions Yorkshire & Humber Care Record / NHS Local Health Care Record Exemplar (LHCRE) programme.

In Scotland, the open source Ripple stack has been central to their efforts to get up and running a National Digital Platform for the Scottish NHS. They started off their work with a series of sprints using the principles of user centred design, agile development and open source + platform technology to get their national plans underway.

In Germany, the HighMed consortium have taken a fork of one of the Ripple Stack tools , the openEHR compliant EtherCIS system and worked to improve it before recently giving it back to the open source community as EHRbase. This open source tool is aimed as being central to their Research & Development efforts across 14 partner organisations throughout Germany

In Finland, the national Una Core eHealth platform is also leveraging the open source openEHR tooling we have fostered to build the basis of their national integrated care record platform to serve the people of Finland.

In India, an innovative team has used the Ripple open source stack to build an information system to support the Ayurveda care system , know as AyushEHR.

We will look shortly at the challenges these initiatives face, each large regional/national efforts in their own right, for now at least as we close out 2019 we acknowledge these small stories as success stories and take a little pride in what we have started….

It’s encouraging to see Matthew Gould, the CEO of the newly formed NHSX is spending time at  

the clinical frontline before he formally starts in his post in July.  After reading Matthew Gould’s most recent blog, it’s clear his time so far with care professionals is helping inform his views; recognising that health IT is frustratingly clunky, siloed and way behind other sectors.

We recognise that there is some important new thinking and messages with his most recent welcome declaration;

“we’re going to focus on standards and platforms, keeping the centre as ‘thin’ as possible”. 

This shift is an acknowledgement that the health IT market is underperforming, one size doesn’t fit all and we need a new approach to health IT.

This latest initiative by NHSX, has a good deal in common with the work of the Ripple Foundation. In advocating user centred design, the use of open standards and open source for healthcare, and now this focus on the platform approach in healthcare, these principles resonate with us very much. This more open approach is a good fit with the clinical community too, where sharing knowledge and research for the betterment of health outcomes is understood as a public good. 

While we welcome this shift towards a healthcare platform by NHSX, our experience has taught us this is non-trivial challenge, so would urge NHSX to learn from others in this field tackling this same challenge, both in the UK and abroad such as the Global Goods initiative from Digital Square. 

The state has an important role to play in supporting companies tackle this fragmented market that is dominated by a few big tech players.  If done right, a platform based approach can help to stimulate new entrants to the market and drive innovation. 

One particular challenge NHSX will face will be finding the balance between coordination and control of platform development while letting innovators innovate at the frontline, to get the right information, at the right time, to help care professionals deliver the best possible care. 

What does the NHS mean by a platform in healthcare anyway?

We believe NHSX, should be working towards the definition of an open platform, as defined by Apperta Foundation and  therefore start the move away from closed platform/monoliths, which both Yorkshire & Humber LHCR and NHS Scotland are already working towards. 

Open platforms liberate both data and applications making them portable and interoperable across different platform implementations…. The open platforms approach is vendor and technology neutral, eliminates lock-in, facilitates innovation and competition, and forces vendors to compete on quality, value, and service”. 

Indeed the Apperta paper on Defining an Open Platforms, defines 8 core platform principles:

  1. Open Standards Based 
  2. Shared Common Information Models 
  3. Supporting Application Portability 
  4. Federatable 
  5. Vendor and Technology Neutral 
  6. Supporting Open Data 
  7. Providing Open APIs 
  8. Operability (as in DevOps) 

So as well as continuing to meet care professionals at the frontline, we, Ripple Foundation and Apperta Foundation, would welcome a conversation with Matthew Gould and NHSX colleagues to discuss our learnings and expertise in this field as well as to discuss strategic investment into open platform innovation via the 1% Fund to enable a small safe start, the iterative curation of common platform components and collaboration between the frontline and NHSX.

INTEROPen have launched a paper outlining the differing approaches and goals of FHIR and openEHR.  We highly recommend reading the attached to understand the differing approaches and goals of each standard, and why they both have a valid and complementary place in the challenges faced in digitising health and social care.  Please share with colleagues.


Authors: Dr Ian McNicoll of openEHR Foundation; Dr Amir Mehrkar of INTEROPen; Dr Tony Shannon of Ripple Foundation


Ripple Foundation is partnering with the Discovery Data Service (DDS) and driving success for the NHS by transforming digital healthcare and contributing to the interoperability agenda.  The cultural fit of working collaboratively with open source solutions has allowed the development and delivery of innovative solutions.

The DDS uses a publish and subscribe model. Subscribers are health and care organisations who express an interest in accessing a subset of data for a particular purpose. Publishers are health and care provider organisations who control their data and agree to publish their data once, in a way that can be accessed by many subscribers. Only systems can interact with the data service; users do not directly interact with the service and can only obtain data through the system(s) of their choice.

Regionally based data sharing agreements match multiple publishers to one or more subscribers for particular pre-agreed purposes. Data cannot be provided without adherence to a set of rules derived from the data sharing agreement. The data service receives data from a number of publisher systems; the data is either sent automatically or transmitted on request by the service. The data within the service remains under the direct control of the data controllers with each item of data stamped by the data controller. The data is then converted to a common format that is directly compatible with FHIR and Snomed-CT. Depending on the data sharing rules, prior to transmission, the service links the data at a patient level by NHS number. A subset of the data, for example a cohort of patients, is then made available to subscriber systems. Data is provided either in an identifiable form for direct care, or is de-identified for secondary uses, depending on the agreement. Person level consent is managed according to GDPR and Caldicott policies.

The DDS team is working with the Ripple Foundation to deliver patient level data from a single source, in order to populate the Helm Patient Portal.

For more information see

We are pleased to update the openEHR community on the outcome of our EtherCIS international camp held over 3 days in London, December 2018.

A group of 12 individuals, representing 8 nationalities from academia, commercial and non-profit sectors came together to explore, discuss and plan the growth of EtherCIS and the open source openEHR community via an EtherCIS MkII plan. See here for the related roadmap that was agreed by the group as the way forward.

EtherCIS Camp attendees (left to right): Ricardo Goncalves, Jake Smolka, Birger Haarbrandt, Thomas Beale, Stefan Spiksa, Christian Chevalley, Ralf Schneider, Ian McNicoll, Stefan Schraps, Phil Barrett, Seref Arikan, Tony Shannon

We are grateful for the help and support of Tom Beale (Ars Semantica & openEHR Foundation) who is now leading an EtherCIS MkII subgroup, working to coordinate this effort towards the public open release of EtherCIS MkII within the next few months.

More information on EtherCIS is available at , and

We welcome interest and involvement from any others who wish to get more involved in this important effort. If you are interested in becoming involved please contact us at

Dr Tony Shannon

Hello and welcome to our Digital Commons Academy, a set of open access videos, which you are free to use and and share with colleagues.

At Ripple Foundation we appreciate that digital advancement in health and care is complex so we’ve broken down the issues into a series of short but thorough videos for you to explore.  Our hope is that by watching the films on your own or as part of training within a team we can help to share our learning with you.

Each film is less than 5 minutes and covers a range of topics including clinical leadership, implementing change and the state of the current market place.  We hope that they provide you with information and raise discussions for you to debate as a team, board or organisation. Full list of videos is available here or on vimeo.

We are a non-profit making organisation that was established a few years ago to support the adoption of an open platform for health and care.  We believe that the future of digital health and care is not one single technology firm providing all the solutions but a vendor neutral market place where organisations large or small can compete fairly because they are developing solutions that meet a set of open standards in pursuit of an open platform.

We hope you enjoy the topics covered and please do get in touch with your feedback – we are always learning and developing at Ripple Foundation so we welcome your views.  

It was a great pleasure to meet the Health Secretary on his recent visit to Leeds after launching his new “tech vision” for the health service. I met Matt Hancock MP at the ODI in the centre of Leeds on Friday 19 October 2018 and talked him through our development for Helm – an open platform solution for a person held record.

I was able to share with him the UI/UX experience of Helm as it looks right now and was pleased to hear very positive responses both from the Health Secretary and his Chief Technology Advisor, Hadley Beeman.  Helm has been in development for a number of months to ensure that we’ve got strong foundations for people accessing and contributing to their own health and wellbeing information. It has involved passionate work from a number of highly experienced technical people as well as clinically direction from Dr Tony Shannon, along with strong creative development from Simon Gamester.


Helm benefits from a number of innovative technologies supported by Ripple Foundation, namely, PulseTile, QEWD.js and EtherCIS and is underpinned by the internationally leading open standard for healthcare,  openEHR.  It also conforms to the well received paper “Defining an Open Platform” by Apperta Foundation.  

The exciting journey of Helm being tested by people in Leeds starts very shortly.  People are at the heart of this product and they will now lead the way in its future development.  Users of Helm will be able to tell us what works and what doesn’t, what would be useful, what is missing and Ripple Foundation is very excited to be a large part of this new innovation with the city of Leeds, led by Leeds City Council.  The plans for Helm are for rapid expansion into the Yorkshire and Humber region. We will keep posting news on the Ripple Foundation website but do get in touch if you would like to understand more about our open platform approach for addressing some of the issues faced by Health IT.  

Thank you to ODI Leeds for supplying the photos taken during the session with the Health Secretary.

By Phil Barrett


Ripple Foundation


Ripple Foundation is delighted to announce we have been officially approved as a supplier for cloud support on the UK government framework called G-Cloud 10.  It is a national framework that shares the agreement between the government and suppliers who provide cloud-based services.

To be accepted onto G-Cloud framework we have provided information about the company and the way we work, we also added information about the services we offer.  

Phil Barrett, Director at Ripple Foundation said, “Our open source and open standards based work within Ripple Foundation is very well aligned to the GDS design standards so this is a natural fit for us. To be on the G-Cloud framework is an important step in the UK market by removing perceived barriers to procuring services and further realising our mission for the adoption of an open platform in health and care.  We support three open source technologies with our open standards based approach:

  • a leading edge UX/UI framework in both Angular.js and React.js – PulseTile.
  • incredible versatility Node.Js based middleware – QewdJS
  • plus the powerful openEHR compliant backend of EtherCIS
  • “We are looking forward to hearing from buyers within the public sector that would like to use our range of support services.” Click here to find out more Digital Marketplace G-Cloud 10 services 

    For further information about the Ripple Foundation please contact


  • Ripple Foundation is a community interest company that is supporting the adoption of an open health and care platform.  It is a clinically led team that working with communities to support using an integrated digital care platform for today and the future. Open source, open standards and underpinned by an open architecture that can be used worldwide.
  • For media enquiries about Ripple, please contact or visit the website for more information

    We are proud to be supporting Yorkshire and Humber’s successful bid to become a Local Health and Care Record Exemplar with our technical solution for a Person Held Record called Helm. This is a credit to their national and international leadership in this field and a sign of a change in the health IT marketplace.  

    The delivery of an open standards and open platform based person held record was originally supported by the city of Leeds thanks to the leadership of Dylan Roberts, Chief Digital and Information Officer at Leeds City Council, but will now be made available to the geographical footprint that makes up Yorkshire and Humber, involving over 70 organisations.  It is also being discussed in other Local Integrated Care Record Exemplar areas including Greater Manchester with Salford Royal GDE moving to explore the technology.

    The benefits of supporting an open platform approach allows Helm to be built in such a way so that it will becomes accessible across geographies and care providers regardless of the clinical system in use.

    Helm puts users in control of their own health and care data by allowing them to view and add to key information, starting with medical data and growing to include wider public services. For the first time, the public will be able to see and interact with their own records and data on an easy to use, secure, online platform that encourages them to take control of their own health and wellbeing.  Helm reflects this new position with a “Take Control, Take the Helm” strapline and call to action.

    Dr Tony Shannon, Director at Ripple Foundation added, “Over the past few months we’ve noticed a real shift in emphasis within the Health IT sector towards adopting an open platform with open standards.  At Ripple Foundation we truly believe this is the only way to stop the mediocrity of an underperforming health IT sector. By building Helm on an open platform, in line with the international openEHR standard, we are working to support a transformative move to future proof healthcare IT systems.

    Tony continued, “Ripple Foundation’s mission is to improve the care of patients and citizens alike by providing technology that supports their needs and delivers easy to use systems that are scalable and cost effective.”

    Helm will adopt the Ripple Foundation’s showcase stack which can be broken into three levels:

    PulseTile – leading edge UX/UI framework developed by Ripple Foundation

    QewdJS  – versatile middleware led by Rob Tweed of MGateway Ltd

    EtherCIS – powerful openEHR compliant backend/data repository led by Christian Chevalley of ADOC Software Development.   ****

    Each component harnesses the power of open source and aims to demonstrate open standards in action to show that there is a different way to provide technology into the health and care systems and ultimately to the users of Helm.

    For further information about the Helm and open platform technology please contact



  • Ripple Foundation is a community interest company that is supporting the adoption of an open health and care platform.  It is a clinically led team that working with communities to support using an integrated digital care platform for today and the future. Open source, open standards and underpinned by an open architecture that can be used worldwide.
  • For media enquiries about Ripple Foundation, please contact or visit the website for more information
  • EtherCIS Clinical Data Repository is developing at pace with radical new improvements in its latest V1.2 release including enhanced security, more complex querying, federation,  improved configuration capabilities and much more. EtherCIS is the leading open source implementation of the openEHR standard in action (including AQL support) and these new developments make the use of EtherCIS even more compelling in the marketplace.  

    EtherCIS development is supported by the non profit Ripple Foundation and is a key component of their “showcase stack” and work towards an open platform in healthcare.  It is led by Christian Chevalley of ADOC Software Development who said, “We’re thrilled with the latest release of EtherCIS and proud that our work combines contributions by the community across the globe.  It is helping Health IT to become sustainable, open, vendor neutral and delivers patient centered clinical data handling with knowledge engineering.  Helping to deliver this message to key decision makers and leaders has been part of Ripple Foundation’s mission and we are excited to be part of the action.”

    Dr Tony Shannon, Director of Ripple Foundation said, “We welcome the work that Christian and his company is continuing to deliver for EtherCIS, it’s a great achievement and really helps to ensure that open platforms are the future of Health IT.   We are also thankfully that cities like Leeds in Britain are implementing EtherCIS in their area for Helm, the adoption of an open platform Person Held Record.  EtherCIS is helping to contribute to the global endeavour of improving data quality, access, storage and research which is fit for 21st Century care.”

    Below is some further information on the enhancements made or if you require an indepth understanding please visit Github at .  

    Enhanced Security

    EtherCIS upgrade ensures sensitive data is further protected against eavesdropping and it controls access to the database, so users can only access the data they have been authorised to see.  

    Enhanced openEHR querying (AQL)

    Users can now perform more complex querying due to new enhancements using openEHR templates for meta data. The openEHR standard has been adopted and implemented across healthcare systems throughout the world, representing the future of health IT.


    Improved federation which allows information retrieval technology to simultaneously search in multiple resources. This means that a user can make a single query request which is then distributed to the search engines, databases or other query engines participating in the federation.

    More configuration capabilities

    EtherCIS REST server now supports a full set of parameters for basic HTTP, SSL, low resource monitoring and request logging.

    Under the hood improvements

    There has been an upgrade to a number of critical components including REST server, DB programmatic interface and XML handling. EtherCIS libraries have been cleaned up and simplified to reduce dependency conflicts and many unit tests have been finalised

    To find out more about Ripple Foundation please visit



  • Ripple Foundation is a community interest company that is supporting the adoption of an open health and care platform.  It is a clinically led team that working with communities to support using an integrated digital care platform for today and the future. Open source, open standards and underpinned by an open architecture that can be used worldwide.
  • EtherCIS Clinical Data Repository. More info available at  ethercis/
  • openEHR: openEHR Foundation. More info available at
  • AQL: Archetype Query Language. More info available at
  • For media enquiries about Ripple, please contact or visit the website for more information
  • For technical enquiries about EtherCIS, please contact

    Developments in recent months have brought the leading work of QEWD.js to even greater heights. Three key areas bring the technology led by Rob Tweed of M/Gateway Ltd bang up to date in the refactoring of the Ripple-QEWD solution:

  • Shift towards a microservices based architecture
  • Leveraging the power of JSON Web Tokens (JWT) to secure the technology
  • The Dockerisation of the solution to enable ease of install for this powerful technology
  • QEWD.js is a lightweight yet very powerful open source technology. The recent improvements make it even more appealing and central to Ripple Foundation’s open platform adoption mission.

    For more information about QEWD.js and the QEWD-Ripple microservices infrastructure please check out these links:

    Ripple Foundation is proud to introduce PulseTile – transforming usability with a clinically led UX/UI framework to support 21st Century care.

    Ripple Foundation is aiming for PulseTile to be one of the most useful UX/UI frameworks in healthcare.  PulseTile is the user interface that sits within the showcase stack that Ripple Foundation is promoting as part of its vision for supporting the adoption of an open health and care platform.  

    PulseTile is transforming usability because the clinically led user designed interface is easy to use – freeing up time for frontline health and care professionals in their day to day work.  Designed with the user in mind, it ultimately allows clinicians to spend more time looking at their patients in the eye instead of inputting data into a clunky IT system.  PulseTile is open source, modular and abides to open standards which allows for flexbility and scalability, can be used and shared across the world.

    PulseTile has been crafted over the past couple of years by a clinical and technical group from across the globe.  Learning was gathered from many previous health IT projects ensuring you get the best engineered user interface in the development of PulseTile.   

    Ripple Foundation have created five reasons why they believe that PulseTile should be the UX/UI framework of clinical choice:

  • Clinically Led –  Healthcare needs change. Clinicians must lead that change.
  • User Centred – Usability sucks in Health IT. Our work is User Centred by design.
  • Patterns based – Amidst complexity patterns emerge. Our UX harnesses key patterns.
  • Modular – Scalable yet Flexible. We balance reuse with innovation.
  • Open Source –  Healthcare is open. We’re sharing our code with the world.
  • Dr Tony Shannon, Director of Ripple Foundation and clinical lead of PulseTile said, “I’m proud we’re able to launch PulseTile to the world.   PulseTile can be traced back to the challenges of working as a Consultant in busy Emergency Departments in the UK and USA.  On every busy shift, one key issue, time and again was the need for better usability in healthcare information systems – hence the push towards a UI/UX framework that you would simply want to use. PulseTile fulfills this gap and is fit for the highly complex modern day health and care system.

    “If you combine PulseTile with the rest of Ripple Foundation’s supported showcase stack – QewdJS and EtherCIS – they offer the basis of an open platform that can be used across the world – large or small scale.  Being modular, the flexibility is yours – please use it, get involved, build upon it and share the learnings”, continued Tony.

    To learn more about PulseTile please visit the newly launched website –  To find out more about Ripple Foundation’s work please visit

    Defining an Open Platform – Thought-provoking collaborative document from the Apperta Foundation that we highly recommend reading.  

    The paper has pulled together with the experience and knowledge from a wide range of clinical, health informatics and health system economics including our very own Dr Tony Shannon but also….   

  • Ewan Davis – Woodcote Consulting
  • Dr Ian McNicoll – openEHR Foundation
  • Dr Roland Appel – Maycroft Consulting
  • Silas Davis – Monax
  • Dr Rebecca Wassall – Apperta Foundation
  • Peter Coates – NHS Digital Code4Health
  • We believe that the thinking within the report is relevant not just to the UK and Ireland but across the globe so please share this document with colleagues.


    Leeds is leading the way in developing and piloting an open platform based Person Held Record (PHR) for local people.  It follows extensive engagement with individuals, care professionals and stakeholders across the city to understand their needs and aspirations. It is believed a PHR will help people to better manage and control their own care and wellbeing and help prevent further health issues.

    The PHR programme will be led by Leeds City Council in partnership with NHS organisations across the city.  The technology will be built on an internationally leading open source platform for the health and care sector, developed in Leeds by the Ripple Foundation.  Leeds’ philosophy around digital technology of simplify, standardise and share allows flexibility and scalability with the intention to share easily with others across the nation.

    Phase one will enable people to register, verify their identity and log into their PHR. It will let people contribute and update information about themselves, for example, a top three things to know about me.  It will also integrate with the Leeds Care Record that is widely used by care professionals across the city.

    Councillor Rebecca Charlwood, Chair of the Leeds Health and Wellbeing Board said, “Leeds is the second largest city in the UK outside London, with a diverse population of over 770,000 people. We need to nurture a health and care system where people have more conversations and opportunities to help unlock the best solutions for them. The Person Held Record programme is a key enabler of this work.”


    “The city of Leeds has the skills and ability to create cutting edge technology for its citizens. The decision to develop a Person Held Record is another clear example”, said Dylan Roberts, chief digital and information officer for Leeds City Council.  “We will work closely with the people of Leeds, care professionals and national organisations to ensure any technology we build and implement can be reused across the nation.”


    Dr Jason Broch, GP partner at Oakwood Lane Medical Practice and Chair of the Leeds Informatics Board said, “Patients need to access their record to allow them to understand their health and wellbeing better and input their own information to take a more active role. It is the missing piece of the jigsaw towards truly integrated care.  In Leeds we believe a Person Held Record will be central to this change.”


    Leeds is also hoping the market will help create apps and functionality that will work with the open platform because they conform to the standards set. For example, if you have a chronic long term condition, you will be able to personalise your PHR with this information, allowing for a more joined up view.

    Dr Tony Shannon, Director at Ripple Foundation added, “Healthcare is suffering from an underperforming health IT sector which makes it harder for care professionals to work with their patients efficiently and effectively.  By building their Person Held Record on an open platform, in line with the international open EHR standard, Leeds has started a transformational move to future proof its healthcare IT systems.

      <span style="font-weight: 400;">Tony continued, “Ripple Foundation’s mission is to improve the care of patients and citizens alike by providing technology that supports their needs and delivers easy to use systems that are scalable and cost effective.”</span>


    For further information about the Person Held Record in Leeds please contact If you are interested in the technology of an open platform please contact

    Ripple Foundation is proud to be leveraging the multi-purpose QEWD.js as a world leading integration framework to meet the increasing demands of Healthcare IT.  

    QEWD.js is an incredible versatile middleware that Ripple Foundation, a not for profit organisation, is endorsing as part of its showcase stack in the pursuit an open health and care platform to improve clinical systems.  It offers an integration framework that can link the UI components you need with the APIs you want and the database you use.  QEWD.js is a framework that is perfect for web integration challenge because it is fast, capable, flexible and scalable.

    Ripple Foundation have five reasons why they believe that QEWD.js is a great choice for the 21st Century demands that clinicians and technicians face:

  • Web Integration Framework – ready, willing and able
  • Quick and Easy Development –  gets you up and running quickly
  • Quality for Enterprise – built to be superfast, solid, secure and scalable
  • Javascript and JSON Based – QEWD.js leverages NodeJS and JSON
  • Open Source – openly shared to be publicly and freely accessible
  • Rob Tweed, the technical leader behind QEWD.js and co-owner of M/Gateway Developments Ltd said, “I’m acutely aware of the issues that health and care is facing not only in Britain but also around the world.  I am encouraged that Ripple Foundation see the value of our quality web enterprise development platform – QEWD.js – to help tackle some of the issues facing HealthIT.  It’s open source, super-fast, scalable and adaptable – what’s not to like?”

    Dr Tony Shannon, Director of Ripple Foundation said, “QEWD.js is a key component of the Ripple Foundation’s showcase stack and should be taken very seriously.  It’s been cleverly crafted by Rob Tweed and it’s an incredibly versatile integration framework that is swift, agile and flexible.  If you combine QEWD.js with the rest of Ripple Foundation’s showcase stack – PulseTile and EtherCIS – they offer the basis of an open platform that can be used across the world – large or small scale.  Being modular, the flexibility is yours – please use it, get involved, build upon it and share the learning”.

    To learn more about QEWD.js please visit the newly launched website –  To find out more about Ripple Foundation’s work please look around this website



    The world of healthcare can now begin to leverage the power and potential of the EtherCIS Clinical Data Repository. EtherCIS development has been supported by the non profit Ripple Foundation and this leading technology now provides the key foundation of its “showcase stack” and work towards an open platform in healthcare.  EtherCIS development is led by Christian Chevalley of ADOC Software Development and the EtherCIS technology is now the leading open source implementation of the openEHR standard in action (including AQL support). The openEHR standard has been adopted and implemented across healthcare systems throughout the world, representing the future of health IT.

    Christian Chevalley of ADOC Software Development said, “EtherCIS being open sourced is not accidental, it is organically inherited from its fundamental components and philosophy. It is based on the open standard openEHR that specifies an open, vendor neutral, patient centred clinical data handling and knowledge engineering. Its implementation has been feasible due to the remarkable progress of the open source database PostgreSQL supporting the combination of relational and document typed data efficiently. Most of EtherCIS components have been derived from open source building bricks: service architecture, object oriented database querying, data serialisation, Web communication etc. As such, it is the result of the contributions of hundreds of analysts and developers.

    Christian continued to say, “Open Source entitles anybody to have access to the source code, uses and copies the software and contributes to it; it is technically extremely convenient, however to promote successfully EtherCIS into the highly competitive Healthcare IT arena, it had to be free as in Libre. As a free and open software platform, it gives the freedom to anyone to create copy and run a clinical applications that is respectful of the fundamental right to store, query and interchange medical information without being tied to a specific vendor, proprietary encoding or physical location.

    “Ripple Foundation has been instrumental to make this achievable; it has not only provided the necessary means to achieve EtherCIS development, but has also stimulated the collaboration, contributions and reviews by clinicians and IT peers, internationally. The result is a solid and relevant IT platform that is now naturally and logically fully integrated into the Ripple Foundation, supporting the adoption of an open health and care platform. The mission and values that Ripple Foundation is abiding by firmly sits with my own views, so I’m thrilled that EtherCIS is now officially part of the Ripple Foundation family.”

    Dr Tony Shannon, Director of Ripple Foundation said, “We are honoured to be supporting EtherCIS as a key element of the Ripple Foundation’s open platform showcase stack.  We know to improve health IT we need data, information and knowledge to support the complex and highly pressurised health and care system.  EtherCIS ensures that information and data can be accessed, stored and exchanged securely because it a world leading open source example of the vendor-neutral & technology-neutral openEHR standard in action, developed and tested in the context of a highly usable clinical application. EtherCIS is a Clinical Data Repository fit for 21st Century Health and Care.”  



  • Ripple Foundation is a community interest company that is supporting the adoption of an open health and care platform.  It is a clinically led team that working with communities to support using an integrated digital care platform for today and the future. Open source, open standards and underpinned by an open architecture that can be used worldwide.
  • Ripple Foundation is supporting and promoting the #1percent open digital platform challenge fund that is hoped will stimulate and support both the creation and adoption of an open digital ecosystem for the nation.
  • EtherCIS Clinical Data Respository. More info available at  ethercis/
  • openEHR: openEHR Foundation. More info available at
  • AQL: Archetype Query Language. More info available at
  • For media enquiries about Ripple, please contact or visit the website for more information
  • For technical enquiries about EtherCIS, please contact

    Ripple Foundation is launching a series of three videos that introduces viewers to openEHR. openEHR is an open, clinically lead approach to creating a standards based healthcare platform for the 21st Century. This includes standardised clinical content and information models for the health and care market.  Allowing vendors and developers of front-end and back-end solutions to leverage a common set of standards to help design, store and querying rich clinical information sources.  openEHR is leading the international field in this effort, with benefits for stakeholders and key decision makers which allows them to :

    •   let their clinical experts be directly involved in solution development, via archetype authoring
    •   built a patient centred record while avoiding technology and/or vendor lock-in
    •   retain ownership of the data for primary and secondary use

    Put another way… it is an open data standard, both vendor and technology neutral, that’s been designed to support the needs of 21st Century Healthcare. 

    Each video is approximately two minutes long and can be shared with anyone who wishes to understand more about openEHR.

    Watch. Learn. Share. #openEHR


    This short video is part 2 of a 3 part series to help explain openEHR, the future of healthcare IT.

    Watch. Learn. Share. #openEHR


    This short video is the last of a 3 part series to help explain openEHR, the future of healthcare IT.

    Watch. Learn. Share. #openEHR

    Ripple Foundation’s showcase stack encompassing three open source elements – front end UX/UI framework, middleware and backend/data repository.  Each component harnesses the power of open source and aims to demonstrate open standards in action to show that there is a different way to provide technology to our care professionals and patients.

    Ripple Foundation was established in 2016 to support the adoption of an open health and care platform internationally.  As part of its mission, the team has supported the development of a leading edge UX/UI framework which they’ve recently launched called PulseTile. The clinically led team has also been reviewing complementary products and components that meet the increasing demands of the modern day health and care system.  They are proud to support and promote the incredible versatility of both the middleware – JSON API oriented QewdJS framework led by Rob Tweed of MGateway Ltd, plus the openEHR compliant backend of EtherCIS led by Christian Chevalley of ADOC Software Development.   

    Dr Tony Shannon, Director of Ripple Foundation said, “We are promoting Ripple Foundation’s showcase stack to demonstrate how health IT can be done in the complex and highly pressurised health and care system.  For years care professionals have had to put up with inadequate, antiquated clinical systems and we believe this showcase stack shows what can be applied to any health and care setting to help provide a better solution for both the clinical requirements but also the business needs of health and care technology.  Information and data that you can access, store and exchange securely is an option if you adopt an open source, open standards underpinned by open architecture approach.

    “I’m calling out to the health and care community to take a look at our showcase stack and have a play with what’s now openly available to reuse.  At Ripple Foundation we are here to support you and can answer any questions you may have and help to move health IT into the 21st Century.  

    Tony continued, “We are also appealing for an open digital platform challenge fund that we have called #1percentfund.  Diverting 1% of available healthcare IT funds to an open digital challenge fund we believe could improve the care of 99% of the population by stimulating and supporting both the creation and adoption of an open digital ecosystem internationally.  We hope this Open Platform Challenge Fund could help any interested clinical and technical leaders out there to implement a different approach to issues we are facing.”

    It is clear that Health IT is not good enough to support 21st Century care, Ripple Foundation believe their showcase stack components, used separately or in combination will help to meet the needs of clinical systems that are easy to use but also communicate and interoperate using open source and open standards.

    The showcase stack can be explored from the Ripple Foundation website, including full “showcase stack” documentation.

    1) Executive Summary

    An NHS open digital platform challenge fund will stimulate the development of an open platform in the NHS. Open digital platforms are independently forecast by McKinsey and Co to reduce the delivery of care costs across the NHS by 11%. They will support widescale entry and growth of suppliers into the market, injecting innovation at all levels of service delivery to support improved care outcomes for our patients.

    In the context of an NHS struggling through a perpetual winter, open digital platforms present a realisable opportunity to massively stimulate new ways of working, process innovation and a new digital health and care market, based around services.  This is independently forecast by McKinsey and Co who predict a positive financial impact in excess of 11% across the whole of health and social care.

    By creating an open digital platform and a move towards a services market, the NHS opens up the market to innovative commercial and social enterprises who presently have great difficulty breaching the significant barriers to entry. At the same time it creates an environment where health and care professionals can readily create, contribute and share new digital tools to support transformational new models of care, radically improving the care outcomes of our patients and building a sustainable care ecosystem that is fit for the future.

    There is little disagreement that platforms represent the future for digital health. Rather the present debate is about who should own them, and how and when they will emerge. The “status quo” retains the closed platform frameworks, introducing open interfaces for exchange of information. This provides a short term stimulus, supporting improvements in patient care and operational efficiencies. However in the longer term, by seeking to control the rules of engagement and restricting the mobility of data, the retention of closed platform frameworks will stifle competition, impede innovation, and continue to drive-up costs.

    Open digital platforms are a radical alternative that overcome the serious shortcomings of closed platforms.
    They present the most assured approach to achieve consistent, long term and affordable growth in innovation-led service transformation across the complexities of health and social care.  They will enable the full competitive aspects of market supply to be exploited, with associated benefits of the injection of innovations on a massive scale.  For this reason, open digital platforms are manifestly in the interest of both the NHS and its patients.

    The purpose of the proposed Open Digital Platform Challenge Fund is to stimulate the development of an open platform ecosystem through kick-starting the creation of open platforms, building on work already well underway, and the development of exemplar applications to exploit them.

    We propose that the fund is created through diverting 1% of the investment each year in NHS digitisation into the challenge fund.  This fund would be made available via an annual open competition in the form of relatively small awards to innovative organisations (public, private and third sector). The selection of projects will be balanced to stimulate and develop an open ecosystem of shareable and reusable applications to service across health and social care.  We are inviting submissions of expressions of interest into this Open Platform Fund. In so doing, we will gauge the wider interest in this Open Platform fund proposal to then quickly bring these related responses to the attention of both NHS Digital and NHS England by the end of February 2017 and seek the related funding.

    2) Current Situation

    To introduce this bid for funding we need to review the current situation with important context on the bigger picture issues that are at play.  We need to acknowledge and understand the current mediocre state of health IT, as an immature and problematic market with mixed/relatively poor value for money and results seen from billions of £ and $ of investment from the UK to the US and elsewhere.

    We also need to recognise the related digitisation of the NHS has been over promised and under delivered for some considerable time.  Compounding this people/process/technology problem is the ongoing and perpetual winter faced by the frontline in the NHS that is in the news.  

    We restate the need to continue the critical push towards more personalised, integrated care at home and in the community to meet the 2020 vision.  This clearly requires an underpinning patient centred infrastructure to do so. Last February Jeremy Hunt announced £4.2 billion for NHS Health IT. In the last 18-24 months while there have been plans in the form of Integration Pioneers, Vanguards, Local Digital Roadmaps (LDRs), Sustainability Transformation Plans (STPs), there has been little/no allocated funding to date to make these happen.

    In Autumn 2016 we were able to read and digest the latest review of the NHS IT, authored by US physician Dr Bob Wachter.   Dr Wachter built his reputation as establishing the hospitalist as a medical specialty in the US.  In recent years he has become a fearless and honest critic of the state of Healthcare IT in the US, with his book “Digital Doctor : Hope, Hype & Harm at the Dawn of Medicines Computer Age” (2015) exposing the real mediocre state of the health IT market in the US.  The book and related opinion pieces on the state of health IT industry he explains some of the real problems with the current supplier market is clear. In a New York Times Op Ed piece on “Why Health Care Tech Is Still So Bad” (2015) he highlights that

    “In today’s digital era, a modern hospital deemed the absence of an electronic medical record system to be a premier selling point…That hospital is not alone. A 2013 RAND survey of physicians found mixed reactions to electronic health record systems, including widespread dissatisfaction. Many respondents cited poor usability, time-consuming data entry, needless alerts and poor work flows”.

    However in the NHS, Dr Wachter’s recent review led to funding being provided to “digital exemplars” all of which are a small group of hospital trusts in the NHS who will invest in those very same health IT monoliths.   While understandable as a means to “do something”, rather than nothing, given the state of affairs is understood, it is sadly limited in its thinking and perpetuates the usual tactics that we have seen in the NHS IT for years, i.e. investing in the same 20th Century monoliths of old. We know that doing the same thing over and over and expecting different results is futile.

    Simply put, if a small elite are getting the focus of funding for investments in 20th Century  health IT monoliths over the next years then inequity within the system will increase, while original ideas in the sector to bring care into the modern era will decrease.

    We have been left asking where has the requirement for integrated person centred care gone, that is ingrained in the other plans that NHS and local authorities have been working towards with STPs and LDRs etc.

    What is sorely missing is the open patient centric platform that Dr Wachter looks forward to and that healthcare awaits. As this is a glaring omission, our paper recommends a focussed investment towards that end as part of a bimodal strategy for NHS IT at this challenging time.

    3) What can be done

    The changes required are radical, if we are to simply survive, yet alone thrive in the years ahead. We know we need a mix of people + process + technology changes.  We know too that the leaders of the NHS understand and value the role of innovation and the crucial role of information technology in achieving same.

    3.1) The role of an open platform

    For some time now leading thinkers on both sides of the Atlantic, in the NHS and indeed the US has been calling for a move towards a more open platform approach.  From within the US market, the establishment of Healthcare Services Platform Consortium aims to address the mediocrity of the “big 6” monoliths and the concurrent problem of the thousands of small unrelated vendors.

    “EHRs are becoming commodity platforms. The winner will be the EHR vendor that provides the best platform for innovation – the most open and most extensible platform.”

    In this we wholeheartedly agree and concur with our US colleagues.

    We believe there is now a compelling case for a small but useful investment in Health IT from the bottom up, to the princely sum of 1% of the planned £4 Billion NHS IT expenditure, aimed deliberately at the integrated, patient centred care vision of Personalised Care 2020, based on the principle that all projects should aim to leverage elements of a common open platform.

    4) 1% Case for an open platform

    We are making a case for an investment of just 1% of available NHS IT funds to offer a way forward to improve the care of 99% of the population. To do so we have highlighted Dr Watchers analysis and writings to focus on the key problems and issues we seek to address;


    “This principle of user-centered design is part of aviation’s DNA, yet has been woefully lacking in health care software design.


    “[There are] Political obstacles to overcome, put in place mostly by vendors and healthcare systems that remain reluctant to share.”

    Vision for patient centred care

    “In essence, there will no longer be an EHR in the traditional sense, an institution-centric record whose patient portal is a small tip of the hat to patient-centeredness. Rather, there will be one digital patient-centered health record that combines clinician-generated notes and data with patient-generated information and preferences. Its locus of control will be, unambiguously, with the patient.”

    So in order to address these real issues and support the national ambitions – usability, interoperability and patient centred care we will use the investment fund available to benefit the broader public. We wish to draw attention to that part of the population who could be better served by the NHS with an improved patient centric platform today. We are also mindful of the need to support;

    • Prevention, Self care and management
    • GP patients
    • Community Care Patients
    • Mental Health Patients
    • Social Care

    We look to the leadership provided by the Gov UK Digital Service standard to highlight the principles to underpin the approach we commend.

    Pursue User Centred Design & Agile Development

    Leverage Open Source & Open Standards

    In our work to date (on the Ripple programme and Code4Health platform based on openEHR) we have deliberately pursued these principles to useful effect and recommend them to others who wish to transform healthcare with information technology. We welcome wider scrutiny of our open platform work to date. Our work and the leading work of others (such as the Endeavour Foundation and the INTEROPen CareConnect API Collaborative) in this field, leads us to believe there is now a real, significant appetite for wider and deeper moves towards an open digital platform in the NHS.

    By creating an open digital platform ecosystem, the NHS opens up the market to innovative commercial and social enterprises who presently have great difficulty breaching the significant barriers to entry. At the same time it creates an environment where health and care professionals can readily create, contribute and share new digital tools to support innovative new models of care.

    We firmly believe that a small but focussed 1% investment can deliver against some of the key challenges in Personalised Health and Care 2020 on an open service oriented platform- to stimulate the public & private sector.  An open healthcare platform fit for the 21st Century.


    5) What is an Open Platform?

    Platform based architectures power the internet, with the platform providing the plumbing (the infrastructure, data and services) that applications need, freeing the application developer to focus their efforts on their application without the need to build the infrastructure it needs to operate. Platform approaches speed development, make applications more robust and interoperable and open up a new services market in healthcare IT, where suppliers compete on services and the value they add rather than on the proprietary nature of their software.

    An Open Platform is based on freely available open standards, so that anyone can play. As no one party can control the platform – they must collaborate – just like the Internet.

    An Open Platform has the following characteristics:

  • Open Standards Based – The implementation should be based on wholly open standards. Any willing party should be able to use these standards without charge to build an independent, compliant instance of the complete platform;
  • Share Common Information Models – There should be a set of common information models in use by all instances of the open platform, independent of any given technical implementation;
  • Support Application Portability – Applications written to run on one platform implementation should be able to run with either trivial or no change on another, independently developed;
  • Federatable – It should be possible to connect any implementation of the open platform to all others independently developed, in a federated structure to allow the sharing of appropriate information and workflows between them;
  • Vendor and Technology Neutral – The standards should not depend on particular technologies or require components from particular vendors. Anyone building an implementation of the open platform may elect to use any available technology and may choose to include or exclude proprietary components;
  • Support Open Data – Data should be exposed as needed (subject to good information governance practice) in an open, shareable, computable format in near to real-time. Implementors may choose to use this format natively in their persistence (storage) layer of the open platform itself or meet this requirement by using mappings and transformations from some other open or proprietary format;
  • Provision of Open APIs – The full specification of the APIs (the means by which applications connected to the platform a should be freely available.
  • The key to an open platform is the definition of a set of standard interfaces (APIs) to the range of services that might be provided on a platform defined by an open process that all interested parties can participate in (like Internet standards) and that are freely available for all to use. 

    While it may be encouraged, not all elements in an open platform need to be open sourced. We believe that “infrastructural” components that are generic, reusable and utility like (e.g see Appendix 1 below) should be open sourced, while the overlying applications do not necessarily need to be open sourced, as long as they leverage open data models and offer open APIs.

    6) Why an open digital platform?

    We have seen across all sectors how platforms are changing the way people lead their everyday lives, from how we communicate and interact, how we travel and where we stay, how we manage our finances to how we shop, to name but a few. Platforms transform. An open digital platform supports:

  • Unconstrained innovation – ideas and ambitions can be shared by people across the office, street or globe
  • Collaboration – clinicians and care professionals inherently want want to share their good work with the rest of the medical world.
  • Alignment to medical science progression, been based on the spread of ideas – health IT can do the same.
  • “Publish or perish” culture of modern medicine demands that healthcare advances are laid open for scrutiny by our peers
  • Grassroots progress – Complex adaptive systems require decentralized control so people can locally innovate.  Amendments and improvement can come from the grassroots and bottom up, without the bureaucracy that innovators often face.
  • A shift in the market towards a healthy, commercially sustainable, services oriented marketplace.
  • 7) Open Platform Fund mechanism

    The main aim of this Open Platform bid is;

    Support the development of services towards Personalised Care 2020 –

    support the development of an NHS ecosystem around an open digital platform

    To be clear, while we do not currently have any secured funding for an open platform fund, our aim is to gauge interest in this approach and make the evidence based case to NHS Digital.

    The fund is intended to support innovative projects that stimulate the creation of an open digital ecosystem and as such aims to support a large number of small projects that are unlikely to be supported as part of “business as usual” investment by health and care organisations.  The aims are to driving innovation and transformation that is scalable, shared, flexible and adaptable and ultimately improve health IT for clinicians and improve care outcomes for patients.  Winners will show that they will concentrate their efforts on usability, interoperability, patient centred care that meet the vision.  To do so we suggest;

    7.1) Request for Expressions of Interest

    We initially invite the submission of expressions of interest into this Open Platform Fund. In so doing, we wish to gauge the wider interest in this Open Platform fund proposal to then quickly bring these related responses to the attention of both NHS Digital and NHS England by the end of February 2017 and seek the related funding .

    Please submit a brief expression of interest (1-3 page) via this Google forms link; by Deadline now passed.   

    We will acknowledge expressions of interest, collate and feedback the results of our findings, pass on related submissions and summary findings to the Apperta Foundation CIC which we believe is ideally placed to independently oversee this process and support the case for funding from NHS Digital and NHS England. The Apperta Foundation is a not-for-profit community interest company supported by NHS England and NHS Digital led by clinicians to promote open systems and standards for digital health and social care.

    While the focus of this paper relates to the NHS in England, we know that colleagues in the health systems of Scotland, Wales, Northern Ireland and indeed the Republic of Ireland are facing the same challenges at the frontline, while aware of the same opportunity on offer from an open platform from a 1% investment, particularly if done openly and collaboratively. Therefore we invite related submissions towards an open platform fund on an All Islands basis – which we also will pass onto the Apperta Foundation and the UK and Ireland CCIO Networks.

    7.2) Outline of Proposed Allocation

    A) Infrastructural component projects

    45% of £40m = £18m over 3 years (until 2020)** ** Open source tooling & infrastructure components – underpinning standards and compliant components that provides services useful in an open ecosystem (See Appendix 1 examples)

    B) Personalised Care: Innovation Incubation and Exemplar Implementations

    50% of £40m = £20m over 3 years (until 2020)

    Open APIs & open data models based projects as showcases of an open platform in action. (e.g. may include open APIs (e.g. INTEROPen CareConnect FHIR based APIs) + open data models +/- open source data repository (e.g. openEHR based).  Examples may include Person Held Records/Electronic Patient Record/Integrated Digital Care Record etc. related projects.

    C) Oversight/Custodian of process by an independent CIC such as the Apperta Foundation

    Along with the CCIO Network and INTEROPen Collaborative to oversee clinical merit and technical connectathons.

    5% of £40m = £2m over 3 years (until 2020)

    7.3) Eligibility

    We suggest that this open platform fund is open to:

  • UK Registered for-profit commercial entities (Companies and LLPs) and
  • UK Registered not-for-profit entities (CICs,Trusts,Companies limited by guarantee and other recognised forms) meeting UK definition of an SME (In the UK a company is defined as being an SME if it meets two out of three criteria: it has a turnover of less than £25m, it has fewer than 250 employees, it has gross assets of less than £12.5m)
  • UK Public Sector bodies (NHS Bodies, Government agencies and local authorities etc.) irrespective of size.
  • 7.4) Match funding obligations

    We suggest that applicants will be required to match fund any award from the fund as follows

  • Social or commercial micro-enterprises 1
    No match funding obligation
  • Social or commercial SMEs 2
    Match funding equal to 50% of the award
  • Public sector bodies and large commercial entities – Match funding equal to 100% of the award

    _ 1 A business with less than 10 employees and (a turnover < £2 million euro or a balance sheet total of less than £2 million euro)  _ 2 A business with less than 250 employees and (a turnover < £50 million euro or a balance sheet total of less than £43 million euro)  
    These are the current official definitions applying in the UK  

    8) Criteria

    We suggest that an Open Platform fund is open to projects that stimulate and support both the creation and adoption of an open digital ecosystem which meet the definition in section 5 of What is an Open Platform.

    While the main aim of all projects will be to improve NHS services towards personalised health and care 2020, the criteria by which the funding from this fund will be allocated will depend on the concurrent creation of value add in the form of;

  • Collaborative – all projects must establish open channels of communication and means of engagement with other parties in the bid at the time of their application (e.g. INTEROPen Ryver etc).
  • Transparent – all projects must be willing and evidence how they will partake in regular clinical and technical reviews. We suggest these should be in the form of bi-annual CCIO Network led review along with INTEROPen led Connectathons with a minimum of 3 out of 6 Connectathons undertaken.
  • Share Ideas, Knowledge, Experience – i.e. willing and able to openly collaborate with others in this initiative (e.g via online community building via tools such as the Open Health Hub, Ryver etc) and  partake in Open Data connectathon against INTEROPen FHIR APIs
  • 9) Judging process

    Initial Bid and Review Point Principles

    We suggest the related submissions into this fund will need to evidence the following as part of their bids and progress at agreed review points:

  • Clinical merit  – against the Personalised Health and Care 2020 Vision
  • Technical merit – against the open platform principles outlined
  • Clinical gap / need / demand
  • Clinical Leadership – all projects need nominated clinical lead
  • User Centred Design – include/demonstrate a commitment to open publish UX design
  • Alignment with Agile Development methodologies
  • Business readiness (preparatory work, governance etc in place)
  • Collaboration with other parties in the open platform bid
  • Open Source track record
  • 10) Conclusion

    If public monies are for one purpose, they should be for the common good. Our proposal aims to ensure the efficient and effective allocation of public monies to projects that can impact the health and care of millions of citizens in England, supporting local NHS & Social Care organisations in their hour of need, while leveraging Britain’s long held reputation for industry and innovation to enable a new global open platform fit for the 21st Century.

    Our proposal for an open platform technology fund aims to offer a means towards the integrated care vision of Personalised Care 2020 that is in the best interests of the NHS. In aligning patient, clinical and care needs with the investment potential offered by open platforms in healthcare, we believe there is a clear win-win on offer here.

    At times of challenge and change the natural instinct may be to withdraw from risk or novel action, yet all our instinct is telling us that now is very time to embrace this challenge and seek the opportunity – which is why we are taking a public lead in getting this Open Digital Platform for Healthcare into action and welcome your interest and support in this effort.

    Dr Tony Shannon,  Ewan Davis 14th January 2017

    Questions or Comments?
    Email us at or tweet @rippleosi with #1percentfund

    11) Declarations of Interest

    Both of the authors are unashamedly proponents of an open platform in healthcare for some time. One might argue that this constituents a conflict of interest with the proposed approach. Rather we would suggest that our track record in leading the effort to disrupt the market towards an open platform, equates to a confluence of interest with the approach now required.

    Dr Tony Shannon,  Director – Ripple Foundation C.I.C
    Director – Frectal Ltd

    Ewan Davis, Director – Synapta C.I.C
    Director – Handi Health C.I.C
    Director – Open Health Hub C.I.C
    Director – Operon Ltd
    Director – Woodcote Consulting Ltd

    12)  Related Links

    Ripple Foundation Community Interest Company http://ripple.local
    HANDI Health Community Interest Company
    Synapta Community Interest Company
    Endeavour Health Charitable Trust
    Apperta Foundation Community Interest Company
    INTEROPen Collaborative
    openEHR Foundation
    HL7 FHIR

    Appendix 1 – Open Platform Infrastructural Component Candidates

    The aim here is to initially outline examples/suggestions of a “top 10” set of federated service components in a Service Oriented Architectural world that would be useful to in healthcare. In doing so we welcome further suggestions and related expressions of interest that would aim to provide open source solutions to plug gaps / provide enhancements towards the open digital platform movement. The fund may support the open sourcing of existing components or their development.

    Identification & Authorisation
    Master Patient Index
    User Interface framework
    Integration technologies
    Clinical Data Repository
    Terminology services
    Workflow services
    Rules engine
    Business intelligence
    Clinical content collaboration/authoring tools (i.e. openEHR/FHIR etc)

    Applications for these open source infrastructure projects are encouraged to state their preferred OS license (weighting towards non copyleft (Apache 2/MIT/BSD) or  AGPL licensing)



    How to turn the Universal Capabilities within the Local Digital Roadmap – in the financial reality of the NHS.

    Local Digital Roadmaps set out how to achieve the ambition of paper free at the point of care by 2020 for the NHS.  77 areas across the nation have submitted documents and assessed themselves against ten universal capabilities.  This has left many areas wondering how they can achieve this with tightened budgets, limited resource and tight deadlines.

    Building towards an open source platform underpinned with open standards can help achieve the following universal capabilities.  

    • Professionals across care settings can access GP-held information on GP-prescribed medications, patient allergies and adverse reactions
    • Clinicians in U&EC settings can access key GP-held information for those patients previously identified by GPs as most likely to present (in U&EC)
    • Patients can access their GP record
    • GPs can refer electronically to secondary care
    • GPs receive timely electronic discharge summaries from secondary care
    • Social care receive timely electronic Assessment, Discharge and Withdrawal Notices from acute care
    • Clinicians in unscheduled care settings can access child protection information with social care professionals notified accordingly
    • Professionals across care settings made aware of end-of-life preference information


    By contacting Ripple we can help you access the following to help build your open integrated platform to deliver your Local Digital Roadmap Universal Capabilities:  

    • tailor the open platform solution to your own individual requirements
    • clinically led technology – built with clinicians for clinicians
    • focused on user experience – helps to drive usage
    • adaptable technology – use UI/middleware/backend in combination or separately
    • future proof – built on openAPIs that are positively promoted by NHS England and NHS Digital with robust records architecture underpinning (openEHR)
    • flexible – small or large scale



    What next?

    If you are interested/committed to collaborating, simplifying, standardising and sharing with others in an open manner, please get in touch.

    Get involved in the latest web enabled real time communication (webRTC) which is being developed within the Ripple showcase stack.  

    This open source video consultation software has endless opportunities for use across the health system from GPs communicating directly with patients at home, to multi-disciplinary teams from around a city meeting to discuss patient’s needs.  Currently the clinically led open source webRTC offers voice, video and text functionality.

    Ripple want to work with the community to ensure it meets the needs so please get involved.  Ripple is building an open integrated care platform that meets the needs of 21st Century care and telehealth is a big step on this journey.

    Attached are some screenshots of the work progressed to date.  If you want to know more please do contact  

    Clinician view

    Patient view

    Appointments and chat history




    Building Back Better Update: 2020

    We have been contacted from far and wide in 2020 asking for open solutions that may help remote/tele care possible.

    We have a been a very small team, but we believe in open source for the greater good, so check out the results of our efforts, openly and freely available to all.



    We hope this work may be useful to you, wherever you are – as part of a global team working to Build Back Better..!

    See related article here

    Building Back Better: Open Source TeleHealth


    The letters IDCR are currently used in the NHS in England as an abbreviation for Integrated Digital Care Records, part of the latest push to transform health and care in England in the 21st Century towards more holistic, integrated, patient-centred care,  supported by the right healthcare IT.

    The abbreviation IDCR is the latest in a line of health IT abbreviations or keywords to symbolise the information technology that healthcare needs/wants/requires. Those include EPR (Electronic Patient Record), EHR (Electronic Health Record), portal, SCR (Summary Care Record), CDR (Clinical Data Repository), patient registries, etc, etc. Though such terms and abbreviations might suggest that the health IT “buyer” has a range of technical products from which to choose, it is increasingly understood that any of these tools are simply technical artefacts amidst a sea of change.

    That 21st century healthcare change that is upon us is a “complex change challenge” made up of people, process, information and technology. We also know that to make such complex change happen we need a mix of clinicians, managers and technical team to work together, for the greater good, for the patient.

    Involved in such change over the last years, I’ve seen many related change efforts and am aware of the significant challenge in aligning clinical, managerial and technical language and purpose effectively towards these noble goals. There is often an inherent tension between the clinical/business change desired and the technical tools on offer. Ideally a well informed clinically led team will have a deep understanding of the process they want to improve and access to/control of a technical tool that meets that clinical/business need.  More often these multidisciplinary teams are convened towards a common health improvement goal, yet a little/lot unclear on how the IT will get them there. In many cases this desire for change ends up as a clinical and business push ends up tied to a likely technical product. The current push in the NHS around Integration Pioneers and Vanguards and Integrated Digital Care Records is a case in point.

    Clinicians who join these explorations and discussions often struggle initially for a reference point. They may cite the health IT system that they themselves know and/or love/hate, it may be a clinical guideline (or related proforma) that they have a particular interest in having supported in this new world, or a particular clinical report that they want/need to support here and now. They use these as reference points as these are the healthcare information and knowledge artefacts that they know.

    In bringing clinicians together around a healthcare improvement/IT project (e.g. EPR, IDCR, Registry etc etc) to gauge their “clinical requirements”,  then analysing those requirements to generate a related system design etc, significant clinical time and real intellectual effort is required by all those involved.  If the aim of these efforts is about patient centred healthcare improvement, the focus of these efforts could/should involve a look at clinical guidelines, forms, reports etc to inform the approach. Yet if one teases apart just one clinical guideline, one discovers the rich tapestry of information and knowledge embedded within. Splitting a single guideline apart in technical terms into the clinical content, workflow and clinical/business rules involved helps explain how and why traditional approaches to programme and project management struggle at scale in this field. The lengthy, detailed documentation that can result from such efforts to elicit “requirements” does little to contain the challenge here. Indeed such an approach to procurement and the related documentation can become a key part of the change challenge… and so a key gap between clinical need and technical direction can begin to emerge..

    Is there an alternative approach to this “complex change challenge”? We think so.

    Firstly we emphasise the word complex, to reinforce that this change challenge is about managing complexity, more akin to curating an ecosystem than crafting a machine. We offer the following tips based on our experience of these challenges at scale and with some reference to the helpful Government Digital Service standard.

    Tip #1

    Q: How to quickly scope a clinical change project with health IT? A: Put the user in charge of these (clinically led) proceedings, with the support of an agile design team. Follow the principles of User Centred Design and Agile Development with early “wireframes”/”mock-ups”/prototypes.   The tools involved might be as simple as a sketch on paper, a PowerPoint slide or an online mockup tool (e.g. Either way this allows the clinical teams to express their needs and wants in terms of usability.. perhaps the most critical factor in health IT adoption. If their ambitions are big and dreamy, so be it, it’s a vision to aim towards. Of equal value, these visual designs help management and technical colleagues discuss and establish what is “do-able” within the time and budget available. Such prototypes are perhaps the simplest and most effective way for clinicians, managers and technical folk to communicate the scope of the change involved. A picture tells a thousand words.

    Tip #2

    Q: Where to focus the early effort in a major healthcare improvement project with health IT? A: Focus the diversity of the clinical community involved around its common interest in core/generic clinical content. One of the main challenges in bringing a multidisciplinary team together is the difference in culture, language and agendas in the room. Such discussions are full of rabbit holes for the unwary. (Try agreeing a consensus definition in such a room on terms like “Care Plan” or “Care Pathway” if you want to while away some time). Aim your focus on getting the clinicians in the room to find their common ground.. the needs they both/all share. These common needs are invariably linked to the core generic processes in health and care, although this is often poorly understood by those in the room. On a related note, focus firstly on the shared clinical content that is required, but not the workflow or rules involved.  While consensus on clinical content can be gathered more easily (via openEHR archetyping for example), clinical workflow and clinical rules are generally less amenable to early consensus.

    Tip #3

    Q: Who should own this requirements & design process? The healthcare customer or IT supplier? A: The healthcare customer, aka the clinical lead and core clinical team involved, supported by “in house” project management and technical architecture expertise. In our experience there is a compelling case that the process of requirements analysis and the related design authority should be overseen/owned by the healthcare “customer”. This should ensure that these key aspects are guided by the clinical need, not by the supplier want.
    We would go further to suggest that you aim to ensure the key clinical requirements captured in this process are opened up and widely shared. That could/should include both the visual mock-ups (e.g. JPGs etc) and clinical content specifications (e.g. openEHR archetyping helps again here) –  so that you have captured and kept these in a vendor neutral format for supplier engagement purposes, while other clinical colleagues can learn from, reuse and recycle this same material.
    The natural extension of this thinking is to suggest an Alpha “Discovery” phase to bring early health IT requirements to life in an open source reference implementation. The potential benefits here are at least three fold, its serves as (1) method of engaging the healthcare change project team with proof of what can/cannot be easily done (2) a means of bridging the significant gap between local frontline health change agents and national health IT standards setters (3) a means towards a “bi-modal” health IT strategy – keeping your future options open/avoiding vendor lock in

    Experience in Leeds has highlighted these 3 key tips in a real life setting while illustrating the nature of such change. What began life as the Leeds Clinical Portal project morphed over time into the Leeds Teaching Hospitals EPR platform (named Patient Pathway Manager +). That in time became the platform that has served/is serving the Leeds Care Record, an Electronic Health Record for the people of Leeds. That journey from portal to EPR to EHR was not about swapping technical artefacts in and out, it was about change in a complex environment. Change that was clinically led, user centred in design, agile and evolutionary in development. That journey continues today in the ethos.

    So if you think you are in the market for an IDCR… think again.

    Image Copyright Immediate Connect

    Starting with the Public

    Below is a news article from Joined Up Leeds, something we are very proud to be collaborating on. For anyone considering undertaking Person Held Record (PHR), whether developing or looking to implement, this should be of real use.

    Joined Up Leeds


    Leeds has a vision to be the best city for health and wellbeing and to be a global leader for health innovation. Using and sharing information about citizens underpins this ambition yet there is often hesitancy around sharing information, even when this may lead to improved health outcomes and reduced health inequalities. Involving citizens in the discussion from the beginning is crucial.

    Joined Up Leeds was developed as a two week period of conversations taking place across the city. Citizens discussed how their health and wellbeing data could and should be shared, the benefits of sharing, the concerns they have, and how information could be used for the benefit of people in Leeds. This report summarises the initial main findings.

    Joined Up Leeds researches the desires for a Person Held Record

    Leeds is also a leading city for data, with many different initiatives driving the way health and care information can be used for the benefits of people. The development of Person Held Record forms part of the city’s strategic direction, enabling people to better manage and plan their health and wellbeing.

    The leaders in the city were keen to find out whether Leeds residents want a Person Held Record.  Leeds Informatics Board, in conjunction with Ripple, commissioned Brainbox Research, an independent research agency based in Leeds, to encourage people in the city to talk about having a Personal Health Record.  Questions were asked around how they would use it and how it might affect their health. Four themes evolved from the engagement with the eight focus groups:

    • Making it work for me – how a Person Held Record could encourage individuals to actively engage with it.
    • I control my information – individuals want to decide what to share and who to share it with.
    • How to reassure me – discussed concerns and extent to which the record would provide unique value or replicate services that are already in existence.
    • Potential impact – to increase the amount of control individuals feel over their own health and wellbeing.

    The full report is available here to DOWNLOAD


    What NextRipple_landscape_lo_14B4EB5

    The results will be shared nationally and will be used by Ripple, a clinically led technical team hosted by Leeds City Council, to build an open source Person Held Record demonstrator that will be further tested by a small group of people in the city.  The Person Held Record demonstrator will initially be designed to include the “core information” that people highlighted, for example, NHS number, allergies, blood group.

    Ripple Foundation

    Ripple Foundation is also helping the adoption of an open integrated digital care record platform that is built for the future.  Open source refers to something that can be modified and shared because its design is publicly accessible, therefore the work done in Leeds can be adopted and then adapted for other areas across the country and beyond.  An integrated digital care platform allows health and social care workers involved in a person’s care access to the most up to date care information about that individual, no matter which digital system their organisation uses. The flexible nature of the open approach and technology can meet a wide range of other related needs, from small health and care departments up to regional care records.

    Ripple Foundation is committed to working with others and wants to want to change health and social care for the better with the inclusive approach to learning, sharing outcomes and experience with a blend of open source technologies.   If you would like to learn more about Joined Up Leeds and the work that Ripple Foundation is undertaking, please email on or tweet on @RippleOSI

    Much has been written about the impact that open source approaches to information and technology are having across the whole of society.  A new chapter, some of which is still being written, is emerging and challenging the way that individuals, communities, organisations and governments interact with each other.

    Open data is enabling us to see the world in new ways as untapped patterns and systems emerge and these can be extremely powerful. In healthcare, the recent creation of Open Prescribing by Ben Goldacre and Anna Powell-Smith at the EBM Data Lab is a superb example of how using open data, anonymised GP prescribing data routinely published by NHS England, can be used to create a tool which could have a huge impact on prescribing patterns and spend.

    Primary care prescribing spend totaled over £8 billion in 2013/2014.  Open Prescribing cost £50,000 to develop and yet, just a quick look round the site uncovers the huge potential for efficiency savings and better decision making.  The telling thing is that this data has been published for years, but it just took an innovative vision to collating, rendering and presenting the information to provide a real insight into prescribing decisions across England (this makes it sound easy but it was clearly somewhat more complex). Those behind Open Prescribing are hoping that the site will be used not only by commissioners and providers but also by individual patients, wishing to understand their own practice prescribing patterns in comparison with others.  Open data is enabling a change of the prescribing dynamic.

    Here at the Ripple Programme we too want to change the dynamic of health and social care through the adoption of open source principles and methodologies.  These are allowing us to develop a range of templates, standards, APIs and user interfaces which are deliberately adaptable for use across any health and social care ecosystem.  And open source means that, unlike closed vendor dependent systems, there are no licence cost implications, no vendor tie in through lengthy contracts.

    Ripple was initially established to support NHS Integration Pioneers in the development of their integrated digital care record programmes and we have deliberately taken a community approach, encouraging other pioneers to contribute to and shape our offers.

    Open source is dependent upon sharing, it only flourishes because people are wanting to share their ideas and can see the value that expanding learning and ideas brings and for Ripple this is very important.  The programme is reliant on like minded developers, organisations and individuals who are able to see the mutual benefit of disrupting the healthcare IT market.  Iteration and improvement of the Ripple offers will not happen without this reciprocity.  The aim is for the organisations and localities who adopt the Ripple offer to be able to contribute to a mutually improved product – for their learning gained during implementation to feed straight back into the development so that future adoptees can also benefit.

    Therefore, in a similar way to Open Prescribing, we are anticipating that a relatively small outlay to develop and invest in an integrated digital care record will unlock huge efficiency and resource savings across whole communities.

    The above image is owned by [Trainer Academy]

    As clinicians, we share a common purpose: to heal, to alleviate suffering and to comfort. In the 21st century, the explosion of knowledge has increased our armoury to achieve our aims. We share our discoveries freely and subject them to peer review, publish them in journals, print and online. We acknowledge one another’s contribution, build on it and share it back to the wider community. We rarely license or commercialise the way we work. That is the community and values that I grew up in as a doctor.

    Then Health IT happened. I discovered a whole new world of license fees, non-disclosure agreements, patents and intellectual property. As a clinician in the NHS, this was all foreign to me. Something didn’t feel quite right about not being able to easily and freely share my new digital way of working with my colleagues.

    I recognise that there is intellectual property in the development of software. Everyone who has ever used a well crafted smartphone app can attest to that. However, the issue that I have with software related to Health IT is that any software really has no value unless it is properly configured and designed alongside clinicians and frontline healthcare workers.

    For example, clinical input is required for defining and designing data models, data sets, outcome indicators, clinical decision support logic, user interface elements and patient pathways. I want to be able to share this with my colleagues regardless of the IT system that they use. Currently, this is technically very difficult even if the vendor does not actively prevent us from doing so.

    So at the moment, sharing of IT best practice is limited to organisations using the same system. Indeed many large vendors use this as a selling point. ‘Buy our system and become more like these internationally famous hospitals.’, they say. ‘You can use the things they built, see how they work! Join the club!’.

    The clinical community does not work that way. We collaborate across organisations, across international borders and definitely across IT systems! We need a technological approach that supports this. This is why I’m so excited about Ripple. In using openEHR, Ripple supports a vendor and technology neutral way of defining health IT information models, the DNA of any electronic health record.

    This is the same approach that we want to take with OpenCancer. We want to define the data models required to support cancer care and research in openEHR. Based on this, we also want to provide decision support based on openEHR. Continuing the theme of using open standards, we will also like to support exchange of patient pathways using open notation languages such as BPMN.

    Clinicians and the community in which we work in immediately relate to the values of sharing and collaboration. It is time we used Health IT approaches that align with our values. Ripple, together with similarly minded organisations like the openEHR foundation, openEyes foundation, open mHealth are showing us the way. OpenCancer will inevitably join the fold.

    These are exciting times!


    Dr Wai Keong Wong, UCLH, London, November 2015

    The article below was published on the Local Digital website on 23 September 2015

    The article below was published by on 18 September 2015.

    We want to encourage debate and discussion about Open Source and will repost and attribute articles whenever we can.  We would also like to encourage guest bloggers and commentators.   The article below has been co written by Source Code Control Limited and Protecode.

    Our thanks go to Martin Callinan for bringing it to our attention.


    From relieving people of repetitive tasks, to building everything around us that shapes our lifestyle, and on to transformation of volumes of data into new insights and perspectives, software has become the new feedstock for the human evolution. All facets of life are touched by software, and healthcarei s no exemption.

    The Complex Web of Health Industry

    The health and social care industry is a highly fragmented and complex industry with medical practitioners, nurses, health professionals, hospitals, clinics, government and non-government agencies all providing health services. The spectrum of health care providers range from individual clinicians such as General Practitioners (also known as GP or doctor) to large monolithic entities such as the National Health Service in the UK which is the third largest employer in the world today.

    Health and social care providers offer a complex and diverse range of facilities and services. By the nature of these services the healthcare industry is driven by large and varied amounts of data which in turn require varied and complex IT systems to manage this data. Generally, these systems come under the umbrella term of eHealth. While there is no consensus on the exact definition of eHealth two example definitions are:

    “…the cost-effective and secure use of information and communication technologies in support of the health and health-related fields including healthcare, health surveillance and health education, knowledge and research.” The World Health Organization (WHO)

    “…the use of modern information and communication technologies to meet needs of citizens, patients, healthcare professionals, healthcare providers, as well as policy makers.” The European Commission

    Whatever way people choose to define eHealth it generally encompasses:


    • Electronic Health Records (EHR)
    • Electronic Medical Records (EMR)
    • Telehealth and telemedicine
    • Health IT systems
    • Consumer health IT data
    • Virtual healthcare
    • Mobile Health (mHealth)
    • Big data systems used in digital health

    eHealth Software Complexity

    Software complexity is increasing with no end in sight as today’s code becomes the foundation for tomorrow’s more complex functionality. Historically, healthcare organisations have created platforms to manage these solutions fairly autonomously, both within individual organisations and industry wide. Quite often these systems were procured at significant expense from software vendors who lock them into solutions that restrict innovation, stifle diversity and have little ability to be re-used.

    In the past, developing all software internally was a point of pride for many organizations. Today, the complexity of modern software, coupled with the pressures to release applications and products on tight deadlines, has made delivering projects that rely exclusively on internal code development almost impossible. Increasingly, organizations are turning to commercial third party code, code brought in from outsourcers and contractors, and open source software (OSS) to accelerate development and reduce costs.

    If this approach is compared to other industries such as the automotive industry where in the early days of car manufacturing car models were largely custom made. In more recent times, automotive manufacturers have developed “platforms”, commonly re-used across companies and continents. This gives them the ability to re-use existing components and enables greater flexibility – a new model is no longer a completely new design and as a result costs are significantly reduced.

    The same approach is now being applied to eHealth systems and with the emergence of Open Source Software there is a shift to adopt Open Systems, Open Platforms and Open Data. These solutions are developed efficiently without licence restriction where the code can be shared and re-used across the public and private healthcare industry.


    A great example of this repurposing is an initiative launched recently by NHS England called Code4Health.

    Code4Health is a resource used by healthcare professionals and providers of services to deliver better patient outcomes. It provides a platform for clinicians to come together with IT suppliers to identify and experiment with the systems in their Trusts and develop new functionality and products or solutions that they can potentially deploy.

    “Our ambition for Code4Health is to educate clinical and administrative staff to develop their interest in digital technology and stimulate a desire to engage more closely in the design, development and delivery of systems and apps”.

    Code4Health are currently piloting ‘App In a Day’ where individual clinicians are being trained and encouraged to play an active role in the development of apps or even develop their own apps using LiveCode.

    Over time, the goal of the NHS is to:

    • Create a market of viable Open Source solutions
    • Provide evidence of the value of Open Source software to the wider Health and Social Care Community
    • Ensure by default all code created in the NHS is shared as part of a library of assets for re-use
    • Ensure a level playing field for Open Source commodity and infrastructure services
    • Achieve a self-sustaining eco-system of communities

    Managing Open Source and Other Third Party Content

    Clearly there are huge benefits to be gained from this approach but it is not without its risks. Along with the advantages realized by using third party code, there are a few challenges that can arise. Governing the quality, security, licensing and intellectual property (IP) ownership attributes are imperative in avoiding risks and potential downstream costs of using third party software. Last year Community Health Systems Inc. lost data related to 5.4 million patients which could end up costing the health system between $75 and $150 million. This data breach leveraged the bug Heartbleed to access VPH log-in credentials.

    The process of managing third party content in a code base can be time-consuming and resource intensive, and an understanding of the effort associated with this exercise is the first step in optimizing the process and mitigating the costs. This highlights a need for a governance program to underpin Open Source initiatives. Indeed the NHS have created a custodian model for Code4Health and will have “code custodians” to manage the risks of OSS and make the adoption of OSS based solutions easier for less technically proficient trusts.

    A study of common practices deployed at software organizations, concerning adoption of open source and other third party software components, has revealed a pattern consisting of a number of necessary as well as some discretionary steps. Originally coined as Open Source Software Adoption Process (OSSAP), this process is equally applicable to any third party software that is deployed and used in a project within any organization. Eight steps are identified in a structured open source adoption process.

    1. Establishing a software policy, identifying acceptable attributes of a third party software, and highlighting remedial actions that should be taken in case of a violation of the policy. Typically, an “open source committee” consisting of legal, technology, security and business stakeholders are responsible for establishing and communicating the policy.
    2. An optional software package pre-approval workflow process that allows technology teams to request open source and other external packages to be approved for use on a certain project under certain use-case scenarios. The package-preapproval process would allow the “software clearing house” in an organization to open and assess the requests and grant or deny permission depending on how well the requested package aligns with the policies established in step 1.
    3. Establishing a baseline, or taking stock of the existing code in the organization. This is a necessary step in all but the simplest cases and is performed using automated tools creating a detailed view of the code that is already present in the software organization. This will produce a resulting map of proprietary, commercial or open source components and their licensing, security, quality and supplier attributes. Furthermore, the results obtained at the conclusion of this step are compared against the established policies and components and can be blacklisted/whitelisted as a result for future projects.
    4. Assessment of all code delivered to the project by contractors and outsourcing suppliers against the policies using automated tools, and extending the software inventory map that was established during the baselining process of step 3.
    5. Regular scanning and examination of the project code library. This can be done by scripting an automated policy-based scanner to review the complete library for any changes at regular intervals, for example, every weekend, and highlighting content that violates a policy component.
    6. Optional real-time assessment of code as it is checked into the organization’s Source Control Management (SCM) system against the policies, and taking appropriate action if a violation is detected. This step ensures that the project repository contains only acceptable code.
    7. An optional real-time automated scanner residing on the developer’s workstation. Similar to a virus checker, the content that is downloaded from the web, brought in through, for example from a USB memory card or simply assembled on the developer’s workstation is continually scanned against the project policies. Any violations against the policy can be highlighted to the developer (and the developer only), allowing for either quick remedy at the source or a comment to be inserted against the offending code (e.g. “will be used for testing only”).
    8. Final build assessment, usually through an automated process tied into the build (for example Jenkins) process.

    The purpose of steps 2-7 is that all the code that could potentially end up in a project is logged and approved in that it satisfies the project IP, security and exportability policies. By the time the final application is built at step 8, there will be no surprises if steps 2-7 are diligently followed.


    There is a significant opportunity to advance the caliber of healthcare by applying intelligent software solutions to electronic health records, delivery of consumer health information, and the provision of mobile and virtual health services. Leveraging open source software and drawing on the associated groups accelerates the identification and development of healthcare applications, creates a level playing field for all ecosystem communities, and allows the sharing and re-use of efforts across a wide range of healthcare domains and geographies. The distributed and crowd-based nature of the open source development can be managed by applying a structured open source software adoption process that will ensure quality, security and legal compliance to the re-use obligations inherent in any open source code.

    Download this article as a PDF


    List Of Additional Resources

    Open Source Software Adoption Process (OSSAP) | Best practices that enable organizations to effectively leverage open source software in their projects. Infographic, Measuring Open Source Management ROI | As open source adoption becomes mainstream, open source compliance management is maturing. Organizations are moving away from manual code audits to real time, automated open source scanning tools. Ensuring Responsible Open Source Use with Software Audits | This paper explains how organizations can responsibly adopt and manage open source software in order to remain innovative and competitive.


    The word ‘opportunity’ is defined as ‘a time or set of circumstances that makes it possible to do something’ which help to introduce our story of now.

    As one of 25 Integration Pioneers, we have been given the opportunity to blaze the trail for change and new ways of working to support Health and Social care. With our successful bid to NHS England’s Integrated Digital Care Fund (IDCF), as mentioned in  our earlier story (the story of us), we have been given the opportunity to work with and support Integration Pioneers and the wider community on their own journeys towards integrated digital care records.

    Across health and social care organisations, the top priority is to provide the very best care for people, to improve their care outcomes and ultimately to improve the lives people lead. We recognise that to do so we need to support the practitioners working across health and social care by giving them better information and better tools in order for them to provide the very best care.

    Integrated digital care records therefore play an important role in the drive towards improving care. They bring together information from various care settings to provide a more joined up view of a person’s care. Without, there is a disconnect in care journeys as the information doesn’t flow between care settings, causing delays, inefficiencies and potentially impacting the care provided. With this technology change begins as people and process evolve to truly deliver integrated and thereby improved care.

    The 25 Integration Pioneers on this journey recognise the need for integrated digital care records, as an important part in this change equation, allowing staff to work smarter to provide improved sustainable care in their respective cities and regions.  Each are at different stages on this road, some just starting out and some well on their way.

    There are two common patterns appearing in the early work we have undertaken with Integration Pioneers in this area;

    1. the disconnect between the pressing need for change and the maturity and capability of care systems to meet these demands
    2. as pioneers, we are each doing our own thing, ploughing our own unique path and potentially encountering the same problems, when actually we all have the same core need – we need to work together

    An open, collaborative and joined up approach is needed in the journey towards integrated digital care records. As Integration Pioneers an open approach allows us to act together, tackling the problems and learning once and sharing with all so everyone can benefit.

    We have begun the Ripple community effort to support this approach. Key to that community effort, our experience has shown that there are six core components needed to support the delivery of an integrated digital care record system, explained here along two key themes outlined below:


    Open Requirements – Working with Integration Pioneers, we will identify the common requirements and capabilities needed for an integrated care record, along with their associated benefits. The identified aspects will be shared with all Integration Pioneers to save time and effort and to provide a consistent strategic direction to the community.

    Open Governance – we will work with Integration Pioneers to standardise the governance arrangements for the sharing of information across care settings. At the moment this is seen as a real barrier to progress. Working with Integration Pioneers and with the support of NHS England we will provide standard governance templates and guidance to ensure the right arrangements are available and shared across the Pioneers and this emerging community across England.

    Open Citizen – we will work with other Integration Pioneers on citizen engagement in sharing care information. It is essential to build trust as well as talking about care records openly, communicating widely and clearly. Working with Integration Pioneers and their respective communities, we will provide the common information and core tools  needed to support engagement in and communication of care record initiatives. In addition to this we will undertaken citizen engagement with the Integration Pioneers around the needs and requirements of a personal health record (citizen access to an integrated care record) and other key healthcare apps as a demonstration of this community effort in action.

    Open source platform

    Open Viewer – based on the Open Requirements identified by pioneers we will develop and deliver regular enhancements for an open source viewer for the community to use. As ease of use is critical at the front line of care, we will be working towards an Open Source care record viewer that makes the navigation around care records intuitive.

    Open Integration –  In between the viewing and the storage aspects of any platform is an important element of bringing information together from the various systems Pioneers currently work with. To meet this need, we will be providing an Open Source Integration Engine which will be connected to those core systems that emerge from the Integration Pioneer analysis delivered by a series of related Open Application Programme Interfaces (Open APIs) to the community.

    Open Architecture – Our learning to date has shown that many clinical groups require similar elements of clinical content, although they use them in slightly different ways to meet their own local need.  The current market offers a huge number of applications to accommodate this however these are very difficult to integrate. To move away from this approach and into the 21st century we need a more adaptive, modular, building block approach that allows the community to collaborate. Working with the pioneers we will provide a collaborative forum to develop these key building blocks, in line with international best practice, known as openEHR. With this in mind, we are working towards an open source storage mechanism to support this approach.


    Why open source?

    We believe Open Source and Open Standards are key to innovation and an alternative to traditional ways of purchasing systems from software suppliers.  Open source is owned by the Integration Pioneers and related community, though it can be reused by others across the health and care community.

    We see the key features of an open source approach to Healthcare IT as;

    • Unconstrained Innovation – Ideas and ambitions can be shared by collaborators who work in different ways, in different organisations, different communities and different skills and experiences, including those not directly employed in healthcare IT
    • Transparent credibility – Allowing immediate detailed scrutiny immediately boosts credibility within the community
    • Decentralized control – amendments and improvement come from the community, bottom up

    Based upon the findings from the initial survey issued we are now formulating programme plan around these six strands, aiming to deliver a release to the community every two months for the first 12 months of the programme. All the deliverables will be made available in the public domain under a recognised open licence.

    Now is the opportunity to deliver a real change to care in the 21st century, to remove the barriers to progressing and to give the practitioners the tools they need to deliver more joined up care.

    Ripple has begun, the community effort has started.

    Hands up if you’re in!


    Integration Pioneers in the 21st Century

    There is a widely held view that 21st century care is under pressure, in a state of near-crisis in many places (ref #NHSwinter) where the burden of disease and the limitations of current health and social care systems are becoming ever more apparent.  We know that at the frontline, staff are already working under immense pressure, in unsustainable ways and that change is needed. We must find ways to “work smarter, not harder”.  So we must also find ways to improve the quality, safety, timeliness and cost effectiveness of 21st century care.

    Of course,  the change that 21st century care needs will require strong leadership and changes in the way staff work at the coalface, and one question that presents itself is around the role of technology and specifically information technology.

    Health and care commentators are, for the most part, all agreed that Information Technology is a key driver for change, while many are also aware that its great potential remains untapped. The gap between the hope and the reality of the promise of improving care via effective IT remains one of the key challenges facing us today.

    In exploring this challenge, there is a view that the health and care IT market is not as good as it could be, lacking leadership and a mixed bag of technologies on offer with vendor lock-in a real issue.

    Quite often it is still too hard to;

    • share citizen and patient information between providers and across city and district boundaries
    • adapt care pathways in a way that combines Lean thinking with a flexible information system
    • support the audit of care and research which for the most part is done by duplicating effort with cumbersome “back-room” processes.

    It would be hard to contest the fact that the current state of the health IT market is holding us all back from the advances that 21st Century health and social care demands.

    So is there an alternative path?

    Leeds is one of 25 integration pioneers chosen to lead the way on the integration of health and social care through; new ways of working for staff, process redesign and integrated digital care records. Many are at early stages for this work but all with the same focus to improve care and work smarter.

    Leeds, as part of an effort to positively disrupt the market, has ploughed its own pioneering path in this field via a mix of open source and open standards to underpin the Leeds PPM+ platform which now powers the Leeds Care Record. Great progress continues to be made on both fronts and positive feedback from both users and citizens alike is emerging, but Leeds believes it would benefit by contributing to and working with a broader community.

    Recognising this need for change, to collaborate and to support integration pioneers, Leeds City Council on behalf of the city and with the support of the integration pioneers submitted a successful bid for the second phase of NHS England’s Integrated Digital Care Technology Fund. With the clinical leadership of Dr Tony Shannon, we are now reaching out to work with those 24 other integration pioneers who want to be part of Ripple community which is focussed along 6 open strands:

    1. Open Requirements
    2. Open Governance
    3. Open Citizen
    4. Open Viewer
    5. Open Integration
    6. Open Architecture

    We hope that in sharing our challenges, our learning and our efforts, we can kickstart a real health and social care community effort. We are keen to collaborate with all others who recognise this story and share this vision, who choose to take this path together.

    [Photo of Tony Shannon](wp-content/uploads/2015/03/Tony_Shannon_M20140305_005.jpg)
    Tony Shannon

    Repost from Tony Shannon’s Frectally speaking blog at


    My first blog of 2015 mentioned a word that is key to all change – culture.

    Cultural change is a challenging thing and yet if we examine history, there is a noticeable pattern across all human culture over countless generations, from tribes to chiefdoms to city states to modern nations; the power of a story.

    Often, scientific training teaches us that facts come first and therefore ones initial reaction may be to dismiss the power of stories. They can’t be scientific; there may be few specifics, no hard numbers or evidence base involved. I have many years of scientific training yet I realised as important as a scientific discipline is, any medical doctor will be able to recount a “good clinical case” – an individual patient story – that had a very important influence on their medical training and education. Certainly in the early part of my medical career I could not quite reconcile the power of these stories with the factual evidence base that we were trained to focus on and refer to. However as time progressed, I began to appreciate the real power in stories and what is also called “narrative” as an important element of the art and science of fields such as medicine or management. Clearly, there must be something about stories that we need to better understand.

    So when I heard of a recent webinar by the Faculty of Medical Leadership and Management on “Stories of Us: …. using public narrative to …. inspire change” I was keen to tune in. The series of webinars run by a medical colleague Dr Claire Marie Thomas (who did a great job) brought an approach to my attention which immediately resonated. Exploring the “Story of Self, Story of Us, Story of Now” it was quickly clear that, as a means of leading change and particularly cultural change, such an approach to stories and narrative offers invaluable help..

    The principle, as I understand it, is that all real change starts with one person, who leads and takes on that change. To do this they need to tell their own story, a Story of Self. For that person to work with others to achieve real change, that story of self needs to become a Story of Us, and for that change to begin to gain momentum the story needs to become a Story of Now.

    So if you’re sitting comfortably, then I’ll begin … my own short story, my Story of Self.

    My own background is from a deeply medical family in Ireland, my great-grandfather on my mother’s side was a doctor, both my grandfathers were doctors, both my parents were doctors, all of my uncles are doctors, my only brother is a doctor. Within that environment I did consider taking other paths, including a look at engineering in my last year in school, yet in the end I also wanted to become a doctor and graduated in 1993 from medical school, University College Dublin.

    Once qualified, my first job was in emergency medicine and although I considered a variety of other options I quickly realised that in terms of clinical practice, emergency medicine was the most challenging, diverse, stimulating and rewarding of all clinical environments – nothing else came close to holding my interest and attention and so I chose it as my own medical field.

    While doctors are understood as a privileged profession who work hard, most enjoy the push and the pressure that goes with the work, especially as it so readily offers a way to “give back”, in looking after your fellow man, your patients’, as a real means to make the world a better place. Certainly there are few places on the planet quite like an Emergency Department/Emergency Room, where “all of life is here”, literally from cradle to grave, where rich and poor are equal and care is provided based to whoever has the greatest need. The most moving moments in this intense setting.. are not those dramatic moments of the life or limb saved, but those moments after the event when patients and partners or family come together, quietly aware of what could have been, they are special moments to witness and stories not to be forgotten.

    Over 20 years practising in Emergency Departments I can explain them as perfect examples of “complex adaptive systems” where you are constantly juggling patients from major resuscitation to minor injuries and everything in between, never sure what will come in next, always working to balance issues of the quality, safety and timeliness of a patients care.

    Within that complexity and over time, I noted patterns emerge. Every emergency physician on the planet will know what I mean by the A/B/C approach to resuscitation, a simple yet vital tool to guide a team involved in the complex care of a patient by looking after: A – Airway, B – Breathing, C – Circulation. This process is essential to bring order from the edge of chaos. Another pattern I found involved asking a few key questions with every patient encounter: Was there anything I hadn’t covered? Had they any questions? Were they happy with their care plan?

    One key pattern that leapt out from my early days as a doctor was the information intensive nature of work at the frontline. Every shift I have done has reinforced the point that to bring emergency medicine into the 21st century, we need much better information tools to allow staff to work smarter, not harder. My interest in this challenge meant that I slowly and steadily moved into medical leadership roles in Informatics and I have worked between emergency medicine and Informatics for most of the last 10 years.

    So over the last ten years I have worked to lead and represent my clinical colleagues in the changes many of us believe are now required across healthcare in this 21st Century. I have listened to their stories whilst aware of my own and it has become increasingly clear to me that we are being hindered from making major progress in this field by the state of the health IT industry. Those who know me, who have heard my story before, will have heard me say that I believe the industry has much to offer and I know there are many good people working in health IT, but that the health IT market is way behind the rest of the software industry and holding us back. Simply put, we need better Health IT.

    Today, in 2015… many patients journeys through our health systems are too cumbersome and time consuming. Today in 2015, clinical staff often find it difficult to work effectively with current health IT solutions, it remains hard for disparate clinical groups to deliver integrated patient centred care and it is too hard for clinicians to keep up with the latest evidence based practice without better information and better tools. In essence the Health IT market needs major change to deliver and develop those systems which are required to support 21st Century high quality, safe clinical care and self-care.

    In recent years I have moved to lead on some of the change required by promoting the role of open source and open standards in work that has underpinned the development of the Leeds Teaching Hospitals PPM+ platform and the related Leeds Care Record. I think that this work has gone well and thankfully in recent times we have seen the market starting to change.

    Yet there is much more work to do and it has become increasingly clear that my journey needs to take this mission further and wider, to support the development of an enabling “open platform” that I believe will transform 21st century healthcare via the Ripple Open Source Initiative. So it was with that mission in mind that I completed my last shifts in Leeds ED last weekend, a new journey is in store, a new chapter in the story of self.

    Dr. Tony Shannon February 28th 2015

    Link to the original post The Story of Self at here