Layers Tools Enhancing Commercial Software
The situation before Layers
Learning Layers identified that one of the key management software packages used by General Practices in the UK was Intradoc247.
Intradoc247 provided a document management system but with limited functionality and in particular limited support for collaboration.
There was the potential for Intradoc247 to be enhanced so that healthcare professionals (working in teams to develop new policies or procedures) could collaborate on documents within Intradoc247, rather than limiting their knowledge development activities to face-to-face meetings and email exchanges.
Such an enhancement of commercial software (based on Open Source research developments) would allow Learning Layers developments to reach a much larger audience and to be tested in real work environments, as well as providing one sustainability route.
In General Practices in the UK, doctors, nurses, and administrative staff need to work together and manage their work schedule, processes, procedures and policies in delivering a professional medical service to their patients.
Intradoc247 provides a solution to the healthcare professionals with a system combining functionality for document management, diarising and managing tasks and work and providing compliance and assurance controls. The document management functionality was comparatively limited and comprised a container and sub folders within which documents could be uploaded. From here, the document could be downloaded and viewed locally on the user’s computer. The functionality was focussed around Healthcare compliance and the ability to demonstrate (in broad terms) document review dates, who had read which version of the document including when they read it, and to which compliance measures that the document related.
A basic search facility enabled users to search on document titles only.
When creating a new policy or procedure, normally a number of different people would work together. The exchange of knowledge needed and the negotiations about how and what to write in these documents is usually done via face-to-face meetings, or conference calls, which have to be planned and require attendance of ideally all persons involved at the same time. The full process is conducted by emailing files, often leading to multiple, possibly conflicting, versions of documents and resulting in version control issues that must be resolved. The larger the working group, the more negotiations are needed to reach an agreed document and the greater potential for confusion.
Furthermore, as staff are under pressure primarily to deliver patient care, they aren’t always readily available to answer questions. This leads to delays in the process as well as in exchanging updated versions of a document (which might also be changed in the meantime by someone else, so the potential for conflicting versions increases). Additionally these people frequently report themselves to be overwhelmed by emails - a situation familiar to many.
Empirical work in year 1 of the Learning Layers project had identified these issues around negotiating and documenting knowledge; and this was one of the motives for the project to design the collaboration and knowledge maturing support provided by LivingDocuments. The project team were keen to explore the synergies between LivingDocuments and Intradoc247 to see if a collaboration could help ensure that newly developed functionalities could reach a wide user group and have a sustained impact.
What Layers did
PinBellCom (the SME company that developed Intradoc247) joined the Learning Layers consortium in year 2.
A split development approach was used with an experimental branch (to allow the researchers to co-design, develop and field-test experimental functionality with a select group of healthcare professionals) and a stable branch (in which the commercial developers could embed selected, tested functionality within the stable product).
Commercial and research partners worked collaboratively (in the co-design teams) allowing each to learn from the other.
PinBellCom (the SME who developed Intradoc247) joined Learning Layers as a partner in year 2, and worked alongside other Learning Layers partners and healthcare professionals to explore how the collaboration and knowledge maturing functionality within LivingDocuments could enhance current working practices within the General Practices. This work took the form of a series of co-design activities and field-tests, as well as joint development work.
The challenge was to introduce new features, needed by healthcare professionals for knowledge exchange and negotiation, into existing commercial software (Intradoc247) whilst adhering to the processes required to deliver software in the healthcare sector.
The particular interest of PinBellCom and the Learning Layers project in partnering up for this project work was primarily due to the special requirements given in the General Practices environment. This is because using the features of LivingDocuments in a commercial software, learning from it’s usage and feeding the experience into the further improvement are aspects that are in a potential conflict as their focus is on different maturity phases: while integration into practice is phase IV of the knowledge maturing model, developing innovative approaches together with users is more located in phases I and II. This implies that we have different priorities, different ways of working etc. (flexibility vs. stability, openness to change vs. stabilization).
To solve these conflicting priorities, we adopted a split approach with two branches:
an experimental branch that focuses on exploring new ideas and showcases them, partly as fully functional prototypes, partly as simple mockups. For this purpose the standard LivingDocuments platform and infrastructure is used with the ultimate goal in mind to seamlessly integrate and merge it with the commercial software platform.
a stable branch that focuses on stability and usability while integrating the new concepts resulting out of the experimental branch into practice. As part of that the Learning Layers developers and technical teams recognised the necessity for commercial software to be ‘frozen’ and tested in a separate environment. Hence the project uses Intradoc247 for the stable branch as a vehicle for integrating these proven LivingDocuments concepts and solution approaches. By extending Intradoc247, the effort to finally install new systems into GP practices could be reduced to deploying a new version of Intradoc247.
During the Layers project, many features and capabilities were adopted in trials with the GP Practices. On top there have been a number of findings from this work, particularly that there is a continued reliance upon Microsoft Office products within day to day operations in General Practice. Additionally, the ability to ‘develop’ a document within the platform as opposed to merely present it has been well received, particularly with the ability to comment and associate other materials.
To drive the experimental branch further the LivingDocuments standalone version has been used to gather feedback in co-design activities such as workshops and test pilots as well as by the research team and institute colleagues of the University. Additionally PinBellCom also used the standalone LivingDocuments platform internally to get a common understanding and feel for the tool and how those features can benefit end users.
The situation after Layers
Collaboration and knowledge maturing functionality has been added to the Intradoc247 software, which is in use by tens of thousands of healthcare professionals.
This functionality was first developed and tested in the experimental LivingDocuments tool, before being picked up and embedded in the stable Intradoc247 system.
PinBellCom have plans for adding further functional enhancements to the Intradoc247 software based on the work of Learning Layers.
Commercial and research partners have learned from each others’ experiences and processes and found effective ways to work together on innovation developments.
The present, production version of Intradoc247 has tens of thousands of users across more than 900 organisations. ‘Core’ functionality adopted is:
Document management including threaded discussion and commentary and associated ‘likes’
More advanced review dates tracking
Association of related documents
Search tools including searching tagging nomenclature
Streamlined user experience by number of iterations of the user interface
These have been warmly received, are non-optional, core components and are in business-as-usual operation in every practice with the platform. All of these features are deployed in both a single organisational and multi-organisational structure.
Healthcare professionals have the flexibility to work and edit their contribution to documents at a time that suits them without the need to inform others about changes made as this is achieved through the system itself.
Using the collaborative and parallel working approach the documentation process is much faster, hence documents are available earlier for review by a wider audience. A core team can distribute documents and/or reports much quicker for soliciting feedback, consequently the review cycle time is reduced.
Conflict resolution is quicker because the document content is always visible and current for all, thus avoiding synchronisation issues. This encourages more and wider feedback all of which is integrated in less time.
Having separate stable and experimental branches enabled the project to meet the diverse needs of the different parties involved. Further integration and adoption of LivingDocuments features is ongoing at the time of writing and further changes are planned like MS Office compatible real-time collaborative editing of documents including change tracking, discussion and commentary for a document.
By using Intradoc247 as a trusted, known system already used by healthcare professionals, and through careful integration of features in a seamless UI from the stable branch solution, healthcare professionals adopted the new functionality very quickly. Their acceptance is further demonstrated by the fact that staff in the project partner General Practice continue to use the new functionality, within their Intradoc247 installation, to refine and revise previously created documents without any specific project intervention to stimulate these processes.
As a result of the Learning Layers project work Living Documents is now used by PinBellCom in two ways:
Enhanced functionality as part of Intradoc247 is and will be rolled out further to multiple medical practices to an agreed delivery schedule.
Internal usage by PinBellCom for creating software training documentation as well as evaluation of LivingDocuments as a tool for broader internal rollout.
An area of growth that PinBellCom have identified has been the desire for cross-organisational development of documents (particularly policies and patient pathways). This drive has been in part due to the increase in collaboration across General Practices, both through the new CCGs and the less formal Federations. To support such cross-organisational collaborative working demonstrated within LivingDocuments, Intradoc247 requires rethinking the current ‘enterprise deployed’ model for Intradoc247 and this is being explored.
Impact that Layers created
Improved take-up of Innovation
Throughout the process, the PinBellCom team found great benefit, not just in being able to utilise the research-led work in innovating, but importantly as a validation of existing process and forward decision making. This has both immediately tangibly identifiable benefits (including the documents area) and also intangible benefits in that it helps to inform the future decision making processes with greater insight. It is expected that this means that innovation will continue to be more focussed.
Changed Development Practices
In working through the project, the collaboration between commercial developers and research developers meant that agreement had to be reached on licensing and version control. The types of licenses that could be used weren’t merely limited to the choice in license that the University and Commercial Legal teams were satisfied with, but also with the adoption of derivative works with GPL. This is not usable in a commercial context, but perfectly adoptable in an academic context. The resolution to this was for the work completed by the academic partners to be aligned to the Apache 2.0 license and for PinBellCom to not adopt any GPL license derived works when integrating or developing.
Furthermore, stability is of paramount importance in a commercial setting, so the ability to adopt a codebase depends on techniques like adopting production versus development branches and code-written database migrations that transit upgrades and downgrades. These were pre-requisites for any PinBellCom technology adoption.
Ease of Integration
Working with the Layers research developers, a much higher emphasis was placed upon the use of mature, RESTful APIs that have in-line documentation. This has led to time savings and improvements in ease of integration.
- Martin Bachl (HsKA)
- Edward Bellamy (PinBellCom)
- Paul Hamill (PinBellCom)
- Andreas Schmidt (HsKA)
- Tamsin Treasure-Jones (LIME)