Overview

In January 2019, Aire Logic was engaged by The Christie NHS Foundation Trust to do a review of the primary hospital EHR system - Clinical Web Portal (CWP). CWP had been developed in-house over many years, primarily by a skilled clinician who had also learned to code. The review found that — whilst CWP had rich functionality ideally suited the trust’s needs, and was generally liked by the hospital clinicians — it contained a large amount of complex legacy code and technical debt, was built on unsupported technologies (e.g. classic ASP), and also carried some security and IG risks. Overall the trust recognised that further expansion of features and capability on the monolithic, legacy technology stack would compound the technical debt, expose the trust to risks around key individuals and would ultimately not scale from a resilience, maintenance, security, clinical risk and flexibility perspective.

Solution

In the initial phase Aire Logic used its broad healthcare domain knowledge and technology expertise to assess the technology and architecture of the legacy CWP application.

Using the Architectural Trade-off Assessment Method (ATAM) Aire Logic established the main features and non-functional requirements the trust was focussed on and assessed that against the legacy application and options for the future state architecture. In particular Aire Logic recommended adopting the strangler pattern to gradually replace capability in CWP with a modern (cloud ready) web technology stack whilst maintaining high availability of CWP and minimising clinical
risks.

The proposed approach for modernisation also supported the delivery of roadmap features not present in the legacy CWP application (e.g. workflow) alongside the code modernisation for existing CWP features.

Following the delivery of the ATAM report, Aire Logic were further engaged in summer 2019 to support Christie with the technical delivery of the project with a suitably skilled team — comprising of business analysts, scrum masters and full stack developers with skills in SQL Server, C#, Angular.js, Docker, Azure Devops as well as engineers with integration skills such as HL7 and HL7 FHIR.

Over the course of the engagement we have been able to adjust the composition and scale of this team to meet the needs of the trust and CWP modernisation project, as well as provide expert healthcare consultants to deliver the discovery phase for future strands of work such as ePMA, Patient Comms & Triage & Referrals.

Results

To date the modernisation project is well underway and making good progress. Although some of the ambitions of making the application cloud ready have had to be scaled back, significant aspects of the legacy system have now been strangled. These include:
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• Replacing the legacy (vulnerable) authentication solution with a modern, industry standard aligned authentication solution that nonetheless still allowed clinicians to use their pre-existing credentials.
• Wrapping the legacy session state management solution to allow the new parts of the application to stay in-sync with the old.
• Deploying a significant user interface update that now acts as the primary application, hosting aspects of the legacy application in an iFrame (and maintaining session state as above).
• Currently on the path-to-live is the first clinical use-case (PROMS) for a low-code, OpenEHR aligned forms engine backed by the new OpenEHR clinical persistence - the first such use-case that will eventually see the retirement of the existing, bespoke CWP forms engine.

Alongside the modernisation workstream significant new capability has been added to CWP including:

• A flexible workflow engine that has initially been configured to support the Pathway follow-up assessments clinical use-case.
• Development of the architecture and initial versions of a new Order Comms component including lab system integration.
• A simplified role based access control system with capabilities primarily for feature toggling.
• Load balancing capability for the legacy application, securing its operation while the extensive replacement work is undertaken.

Finally, Aire Logic has worked with Christie to develop and improve its agile delivery practices. This includes:

• Running a tailored agile (scrumban-like) process that can rapidly deliver changes (and adapt to change), but also contains enough controls appropriate to a clinical system.
• Building an overall, transparent one-team delivery approach working alongside the trust’s team including architects, product owners, developers and testers.
• Utilising Azure DevOps to maintain accurate and relevant documentation to support knowledge sharing and handover.
• Building a CI/CD pipeline on Azure DevOps including automated tests, build and deployment artefact generation including database schema migrations.
• Infrastructure as code approach that both allows developers to work on the full stack locally, but also allows new team members to “spin-up” their environment with the minimal amount of effort.
• Ability to rapidly deliver changes to the production environment - with daily live releases now possible, and in some cases making multiple live releases in a day, with little or no impact to availability.
• Broadening the understanding, buy-in and adoption of agile delivery thinking with wider (e.g. clinical) stakeholders within the trust, including running show & tell sessions. Engagement has also been strengthened with a community of Clinicians to request their help to test as Early Adopters.
• Regular reviews of working practices take place ensuring lessons are identified and improvements are implemented.
• Input into backlog/ roadmap prioritisation sessions resulting in work being estimated and scheduled appropriately with the input and agreement of key Stakeholders.

Overall the replacement of CWP has now gained significant momentum, the major technical barriers have been removed, and the project is primed for an accelerated roadmap of modernisation and expansion of CWP’s capability.