plenary 3 ministerial address
DESCRIPTION
TRANSCRIPT
DRIVING QUALITY THROUGH INNOVATIONAndrew Morris Chief Scientist
Scottish Government Health Department
NHS Conference, 22nd June, 2012
Options and Opportunities for Health Science Innovation in
Scotland
The next 30 minutes
Current challenges Gearing an entire
country for quality health care and research
Information science as the catalyst for change
The role of academic health science networks
Case studies
Visit of Mark Walport and James Rothman, 15th November, 2007
The birth of the NHS
Aneurin Bevan, Lancet, July 3rd 1948
“…quite the most
ambitiousadventure in the care of national health that any country has seen”
Visit of Mark Walport and James Rothman, 15th November, 2007
Visit of Mark Walport and James Rothman, 15th November, 2007
Framingham1948All 5,200 town residentsAged 30-62 yearsRegular “health checks”Three generations of
participants Iconic epidemiological
study
Visit of Mark Walport and James Rothman, 15th November, 2007
What did it tell us? “Risk factors”
– High blood pressure– Smoking– Cholesterol– Diabetes
Links to heart attacks and stroke
“Has resulted in an average of four extra
years of life”C Lenfant, Shattuck Lecture, 2003
Visit of Mark Walport and James Rothman, 15th November, 2007
“The Town That Changed America's Heart”
Visit of Mark Walport and James Rothman, 15th November, 2007
The new horizon - The Human Genome Project
• Map of the three billion letters that make up the code of life
“It is rather like reaching the top of a mountain pass and seeing in front of you a fertile plain, rich with new ideas, new methods, new techniques and new concepts for understanding the complexity of human biology in health and disease”
M Bobrow....and informatics is fundamental to the success of this revolution in science” A Morris, NHS Conference, June 2012
THE CHRONIC DISEASE CHALLENGE
Up to three quarters of people over 75 years of age currently suffer from a chronic disease
It is estimated that the incidence of chronic disease in the over 65s will double by 2030
Approximately 44% of all chronic disease deaths occur before the age of 70
WHO data show that 75% of the population has one chronic disease…
...and 50% have two or more conditions
Mortality will increase by 17% in next decade and by 25% in Africa and Middle East
Up to three quarters of people over 75 years of age currently suffer from a chronic disease
It is estimated that the incidence of chronic disease in the over 65s will double by 2030
Approximately 44% of all chronic disease deaths occur before the age of 70
WHO data show that 75% of the population has one chronic disease…
...and 50% have two or more conditions
Mortality will increase by 17% in next decade and by 25% in Africa and Middle East
DEATHS from chronic disease
in 2008:
DEATHS from chronic disease
in 2008:
CAUSED by:CAUSED by:
DIABETESDIABETES
•Affects 366 million people (6.4% of world population)
•4 million deaths attributable to diabetes annually
•Number affected will increase to 552 million by 2030
•80% of current cases occur in low and middle income countries
•Largest age group affected in 2010 was 40-59 years. This will move to 60-79 year age group by 2030
•Type 2 diabetes accounts for 85-95% of all diabetes in high income countries
•Affects 366 million people (6.4% of world population)
•4 million deaths attributable to diabetes annually
•Number affected will increase to 552 million by 2030
•80% of current cases occur in low and middle income countries
•Largest age group affected in 2010 was 40-59 years. This will move to 60-79 year age group by 2030
•Type 2 diabetes accounts for 85-95% of all diabetes in high income countries
COMPLICATIONS OF HEART DISEASE, AMPUTATIONS, BLINDNESS…..
IMPACT ON HEALTHCARE SERVICESIMPACT ON HEALTHCARE SERVICES
•Patients with a chronic disease use > 60% of hospital bed days
•Three quarters of patients admitted as medical emergencies have an exacerbation of a chronic condition
•Patients with three or more chronic conditions (15%) account for 30% of total inpatient days
•A small number of patients (10%) account for 55% of total inpatient days
•Patients with a chronic disease use > 60% of hospital bed days
•Three quarters of patients admitted as medical emergencies have an exacerbation of a chronic condition
•Patients with three or more chronic conditions (15%) account for 30% of total inpatient days
•A small number of patients (10%) account for 55% of total inpatient days
ECONOMIC IMPACT ECONOMIC IMPACT
•UN summit 2011 declared chronic diseases to be a global threat to future sustainability and affordability of healthcare delivery
•World Economic Forum placed chronic diseases amongst the most important and severe threats to economic growth and development
• Institute of Medicine study found that chronic diseases currently costs developed countries 0.02-6.77% of GDP
•World Economic Forum estimates that chronic diseases will cost world economy $47 trillion over next 20 years
•Chronic disease management estimated to cost 75% of GDP by 2030
•UN summit 2011 declared chronic diseases to be a global threat to future sustainability and affordability of healthcare delivery
•World Economic Forum placed chronic diseases amongst the most important and severe threats to economic growth and development
• Institute of Medicine study found that chronic diseases currently costs developed countries 0.02-6.77% of GDP
•World Economic Forum estimates that chronic diseases will cost world economy $47 trillion over next 20 years
•Chronic disease management estimated to cost 75% of GDP by 2030
Population-based study1.75M people in Scotland42.2% one or more CDs
“Management of patients with several chronic diseases
is now the most important task facing health services in developed countries, which
presents a fundamental challenge to the single-
disease focus that pervades medicine”
Lancet May 15th 2012
DOUBLE JEOPARDY
How are we responding to this challenge?
World ClassPatient care
Translation, Trials and Innovation
NHS Research ScotlandHealth Science Scotland
Our Thesis Quality Health Care and Research: From Cell to
Community
Excellence In Life Sciences
Community Cell
Informatics to support patient care
Layered accessLinks to CHI / NHS records
Prescription records
Population 5M
Single health care provider
Stability of health structures
High rates of morbidity of common complex disease
Collaboration – Aberdeen, Edinburgh, Dundee, Glasgow, St Andrews
Unique patient identifier
Community Health Number
Date of Birth Sex Check
07 10 64 02 5 0
Linking Data
GP Hospital
Eye Van
Pharmacy
Lab Data CHI
InvestigationsScreening
AHPs
- the key to seamless care
A National Diabetes System for Scotland
Total Scottish Population 5.2M
People with diabetes : 251,004 (4.6%)
People with Type 1 DM : ~27,000 (0.5%)
All patients nationally are cared for with a single clinical information system SCI-DC
SCI-DC used in all hospitals
Nightly secure sharing of data from all 1043 primary care practices across Scotland
National Data Standards and Quality Assurance
Quality
Team on the job!
Miracles
• Life after Death = range 1- 4 years
• Resurrection Rate = 0.092
• 10 patients found - according to NHS Sources - dead!
DARTSSCI-DC
NETWORK
Visit of Mark Walport and James Rothman, 15th November, 2007 24th September, 2010
SCI-DC is a fantastic clinical tool!
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Data recoded within the previous 15 months Source: Scottish Diabetes Survey
Scottish Diabetes Survey 2002-2007 Recording of Key Biomedical Markers
Evidence of improved clinicaloutcomes
Diabetes Care 2008Diabetic Medicine 2009
Latest Scotland wide data
Kennon et al; Diabetes Care; 2012; in press
“If you live in Dundee and suffer from diabetes, you have recently been taking part in
a medical revolution.”
Sir Mark Walport, The Times, 30th May, 2011
“If you cannot measure it, you cannot improve it”
Is this new?When you can
measure what you are speaking about,
and express it in numbers, you know something about it;
but when you cannot express it in
numbers, your knowledge is of a
meagre and unsatisfactory kind;
Lord Kelvin, 1824-1907
Institute of Engineers, 3rd May 1883
Can changes to organisation and
delivery of care improve quality of care and outcomes?
Cleveland Clinic
Kaise Permanante
Puget Sound
Henry Ford MC
Marshfield Clinic
Lovelace Clinic
Inter Mountain Health
Mayo Clinic
Park Nicollet Clinic
Chronic care management in nine
leading US physician organisations
BMJ 2002; 325; 958-61
Factors determining success
Barriers Lack of financial and staff
resources LACK OF CLINICAL
INFORMATION SYSTEM Doctors are busy No financial incentive for
quality care Doctors resist change
Facilitators ORGANISATIONAL CULTURE
SUPPORTS QUALITY IMPROVEMENT
ELECTRONIC MEDICAL RECORD
Supportive managerial and medical leadership
Support from external organisations (Health Plans)
Organisation’s strategic plan
Levels of Information
Board
ET
EMT
Directorate / CHP
Ward / Team Level
Patient / Practitioner Level
ASSURANCE
Validated Data for 6 domains: Access, Efficiency, Infection & Prevention, Quality & Patient Experience, Patient Safety and Data Quality
PERFORMANCE
Validated and un-validated data across 6 domains:Clinical Excellence, Finance & Activity, Valuing Staff, Capacity & Activity Planning, Patient Experience and
Patient Safety
Imp
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Patient to Board
“focusing on information and data to provide assurance on improvement and quality to deliver better, safer care”.
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IMPROVEMENT
Un-validated data provided in real time through Unified Patient Tracking, Clinical Portal and operational
dashboard with metrics covering Patient Flow, Inpatient Activity, Out Patients, Waiting Times, Patient Safety,
Infection Control, Clinical Outcomes
Strategic Dashboard Report
Cancer Performance
Run Chart showing July 2011 – January 2012
July 2011 compliance with the 62 day cancer target
Compliance 94.6%
Site Number treated
Number within Target
% Complianc
e
Breast 25 25 100%
Colorectal 14 11 78.6%
Head & Neck 1 0 0%
Cancer 62 days capability
Lung 16 16 100%
Gynaecology - Ovarian 4 4 100%
UGI - Hepatopancreastobiliary 2 2 100%
UGI - Oesophagogastric 3 3 100%
Urology - Bladder 1 1 100%
Urology – Prostate 8 8 100%
Urology – Other 4 4 0%
Gynaecology – Cervical 0 0 -
TOTAL 75 71 94.6%
CommentaryThe figures for July indicate that performance for the 62 day (patients referred urgently with
suspected cancer target was 94.7% overall. Performance across all sites was below the 95% HEAT target.
95% Target
62-day Standard % Compliance
0
20
40
60
80
100
July
'11
Au
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Sep
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Oct
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Jan
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Co
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95% HEAT Target
95% HEAT Target
Data Information for Improvement
Contains extensive datasets including appropriate dates such as referral, appointment, waiting list, waiting times between stages.
Operational real-time dashboardsExploiting existing information sources
– record information once, use many times
– deliver information as near to real time as possible
Focusing on intuitive, user friendly presentation.
World ClassPatient care
TranslationTrials and Innovation
Excellence In Life Sciences
Community Cell
The Innovation Pathway
http://www.healthsciencescotland.com/
Health Science Scotland
• “NHS Scotland’s new platform to support research for patient benefit and foster related
economic development”• Initially four Health Boards,
four University, SE PartnershipLaunched June 2009; Health Minister and Finance Minister
The best clinical research and innovation laboratory
in the world
NHS Boards Universities
• a strong science infrastructure with vibrant PhD and post doctorate communities
• Academic Health Science Networks with a tripartite mission and significant infrastructure investment
• a commitment to linking information from medical and non-medical sources using electronic patient records to support better
treatment, safety and research
• a new pathway for the regulation and governance of health research
• collaborative arrangements with the biotechnology pharmaceutical and medical devices industries
• positioning Scotland as a single research site
Key ingredients for change
Health Science Scotland
Health Science Scotland Oversight BoardChair - Chief Medical Officer
Health Science Scotland ExecutiveConvenor – Chief Scientist
Health Science Scotland Central Portal
Scottish Government, CEO Health Boards, Vice Chancellors
Chief Scientist Office, Medical Deans, NHS R&D Directors
Programme management, Communications
Recognising the need for critical mass in academic excellence and healthcare systems to compete as a global destination for medical research the Collaboration was formed in 2005.
Health Science ScotlandExecutive structure
Key Delivery UnitsNHS Research Scotland
Clinical Research Facilities
‘Safe Havens’Health informatics
research
Project managementQuality & Facilitation
Tissue acquisition service
Biorepositories
Research imaging platform
2009/10£4.5m
2010/11 2011/12£10m
188 WTE staff
NRS Infrastructure investmentCore research dedicated staff in NHS
CRF nurses/adminBiorepositoryResearch ImagingInformatics Research
63
26
29
16
WTE
Quality/ Governance 22
Clinical trials support 33
Central functions 6.5 WTE manager + admin staffNRS PCC, databases, contracts, research passport
86 WTE staff
Clinical Research Centres
• State of the art clinical research facilities• Part of a managed network across Scotland• All have generic research nurse teams• All have specialised staff with specific clinical and technical skills
NRS W
NRS NE
NRS SE
NRS E
Biorepository network
Strategic national collections• Rheumatoid arthritis• Renal cancer• Type 1 diabetes• Generation Scotland/ SHHS
National/ local planned collections• Generic consent• Strategy driven• Future focus
Bespoke collections• Specific consent• Project based• Investigator ‘owned’
Infrastructure development• Inventory management system• Patient record linkage• Enhanced storage capacity• Facilitated rapid accessPathology archive
~200,000 consented for genomic studies
Informatics Information from cradle to
grave...• Mothers ante-natal records• Maternity• Neonatal record• Register birth - NHS number• Register with GP - CHI• GP systems• Dental Appointments• Outpatients• A&E attendance• General hospital admission
(ICD10/OPCS4)• Prescribing – community pharmacies• Cancer registration• Cancer treatment• Community care• Death
Imagingphenotype(PACS)
laboratoryphenotype(SCI store)
Storage Area Network
Mortality(GROS)
Hospital episodes(SMR: ISD)
Identification(CHI)
Prescribing
NHS Data stores
Primary Care?Dumb terminals
SAFE HAVEN
Secure storagepower protectioncamera surveillance
NHS staff
Integrated datasets
Accredited academic staff
Health Informatics Centres
320-MDCT 3T MRI 128-mCT/PET Cyclotron
SINAPSE “calibrain” The scanner harmonisation problem• Each scanner presents a unique bias• Harmonising pre-processing approach
Reducing Regulatory BurdenSingle sign off across Scotland
NRS W
NRS NE
NRS SE
NRS E
NRS CC
Regional working – 4 hubs- ethics- R&D management
NRS Permissions CC - Approvals
- Costing- Contracting
- Reciprocity with NIHR CSP
Targets- Ethics approval in 30 days (Scottish average)- R&D 95% approved in 30days
Universities umbrella agreement of single contracting
NRS Permissions Co-ordinating Centre Performance
Time to permission for all Scottish sites
CommercialNon-commercial
Table 1 Time (working days) to approval for multi-site studies
Notes :Time to permission is the number of working days elapsed between the receipt of a ‘full document set’ by the Permissions Centre and management approval by all Scottish sites. It includes the time taken for generic review of principal governance issues by the lead review site (once for Scotland) and for local review of resource availability.
Case Studies
Trials Evaluation of policy
GeneticsNational programmesExporting the Model
Informatics Driving Efficiency in Clinical Trials
• Scottish Diabetes Research Network• National collaboration for clinical
trials • Research register of patients
– On personal approach, 70% of patients agree to join the register.
– By invitation letter from GP, 50% of patients agree to join.
• Major programmes from EU (SUMMIT €24M), Innovative Medicines Initiative (DIRECT €22M), JDRF (£3,5M)
• www.sdrn.org.uk
Welcome: Emma Riches
Please Select Diabetes Type Drop down options;
Type 1 Type2 Both Type 1 & 2
Please Select Drop down for BP/ BMI/ Cholesterol/ Creatinine/ HbA1c;
Between Greater Than Less Than Equal to
Please Select Drop down for values recorded within;
Last Month Last 6 Months Last 12 Months Last 15 Months Last 18 Months Ever
Research Criteria
Patient Specific Criteria
People with Diabetes Type = Age Criteria: Biochemistry Criteria
The above values need to be recorded within the;
Submit Reset
Please complete the form below in order to generate a list of people with diabetes who meet the specified criteria of the study;
BMI:
Blood Pressure:
Cholesterol:
Creatinine:
HbA1c:
Case Study
• Phase III NCE cardiovascular outcomes trial.
• target recruitment 10 patients in 18 months.
• 10 patients contacted from research register, all 10 screened and randomised.
• Site hit target in < 2 weeks and was global top recruiter for 3 months.
2007 2008 2009 2010 2011
Academic 57 80 95 97 73
Commercial 26 37 44 61 58
Total(s) 83 117 139 158 131
Number of Studies & Participants
2007 2008 2009 2010 2011
No. of Participants 2655 4860 6171 6434 8830
Log-rank p=<0.0001
Placebo
Pravastatin
Efficient trial follow up West of Scotland Coronary Prevention
Study
Original trial
Ford et al, N Eng J Med (2007) 357 1477-86
CH
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Case Studies
Trials Evaluation of policy
GeneticsNational programmesExporting the Model
Admissions fell by 17% - 67% of reduction was in non-smokers
Fall in England 4% (no legislation); long term trend 3%
Non-experimental evaluation (policy)Effect of smoking legislation in Scotland
Pell et al, N Eng J Med (2008) 359; 482-491
Acute Coronary syndrome Childhood asthma Pell et al New Engl J M 201o, 363 . pp. 1139-1145
Before ban 5.2% increase per annumAfter ban 18.2% decrease per annum
Case Studies
Trials Evaluation of policy
GeneticsNational programmesExporting the Model
The population modelThe population model
Scotland Phenotyped cohorts Genetic Epidemiology
Translational Programmes
Epidemiology & Trials
“The outstanding longitudinal tracking you have in place will add
considerable information …….there is no doubt that a resource like this is
desperately needed.”
David Altshuler
Department of Genetics, Harvard Medical School;Department of Medicine, Massachusetts General Hospital
GENETICS - ADDING VALUE TO RESEARCH: BIOBANKING PROGRAMMES • Generation Scotland
• Scotland wide• >30,000
• UK Biobank• 50,000 Scots recruited• Exemplar of informatics linkage
• Colon cancer • Cardiovascular disease • Type 2 Diabetes
• >20,000• DNA distributed nationally
• Type 1 Diabetes• Scotland wide• 10,000
The UK Type 2 Diabetes Genetics Consortium
Illustration of the power of genetics Studies in twins separated at birth
Dizygotic Twins
Borjeson,Acta Paed.1976
Monozygotic Twins
Is it worth studying genetics of chronic diseases?
Diabetes life time risk
0 Parent 10%1 Parent 30%Brother/sister 40%Both parents 70%Identical twin 80-100 %
Can molecular genetics define pathophysiology?
Glazier et al, Science, 2002
Slow progress….
single variant (100 SNPs; 103 genotypes)
detailed study of individual genes(102 SNPs; 105+ genotypes)
regional studies (104 SNPs; 108 genotypes )
genome-wide association (106 SNPs; 1010 genotypes)
complete resequencing (108 SNPs / 1012 genotypes)
Until.....the march of technology!!
Map of diabetes susceptibility June 2012
Allele frequency
Effect size
Not in my Lifetime!
PPARG
KCNJ11
HNF4A
CAPN10
HNF1APNDM
TNDM
Other rare syndromes
mt3243
LMNA
few if any genesup here
ACDC
LARS2
otherMODY
Rare CommonSmall
Large
LMNAINS
TCF7L2
WFS1
IGF2BP2 CDKAL1
CDKN2A
FTO
SLC30A8
HHEX
Now we have some genes…
Confirmedvariants
Genetics:Which are the aetiological variants
PhysiologyWhat are the physiological correlates
of these variants?
PharmacogeneticsDo these variants also influence
complication risk, or response to available treatments?
Clinical medicineDo these variants allow us
to predict disease progression (eg from prediabetes) and the effect of
lifestyle interventions?
Cell biologyWhat are the molecular
mechanisms?
Genetic epidemiologyHow does variation here
interact with variation at other sites?
EpidemiologyWhat is the population risk
and are there importantinteractions with exposures?
WILL IT HELP PRESCRIBING?THERE IS CONSIDERABLE VARIATION IN
RESPONSE TO MOST DRUGS
Data from DARTS, Tayside, Scotland
Absolute HbA1c reduction
-3.00 -2.00 -1.00 0.00 1.00 2.00 3.00 4.00
0
10
20
30
40
50
60
Frequency
Mean reduction = 1.315
Std. Dev. = 1.05189
N = 290
Baseline Hba1c 8-9%
PHARMACOGENETICS:
• In use for over 50 years
• We still don’t understand how it works
• 25% of patients get GI intolerance;
• 5% cannot continue it
• Can we use genetics to help us?
• Ability to link genetics with drug exposure and therapeutic response
GWAS Metformin ResponseQ-Q plot
The gene links cancer pathways, metformin pathways and type 2 diabetes
Case Studies
Trials Evaluation of policy
GeneticsNational programmesExporting the Model
National Collaborations
Wyeth 2006-2011
Grand Challenges 2011-2014
Preferred Site
Preferred Site
National Informatics Programme
Scottish Stem Cell Network
Generation Scotland
Case Studies
Trials Evaluation of policy
GeneticsNational programmesExporting the Model
Internationalisation Kuwait Scotland eHealth
Innovation Network
“The Scottish Health Science Package”•Scientific Research•Education •Clinical Skills•Informatics
Education• PG Certificate/Diploma/MSc Diabetes Care &
Education– training the multi-disciplinary health care team – 120 students enrolled
• Two ‘Discovery Courses’ have exposed 400 HCPs in Kuwait to latest diabetes knowledge (March & May 2011)
• “OSCE” assessments and workshops for Nurse Educators, Nutritionists, Call centre team
• National Clinical Skills Facility– 1st of its kind within GCC, modelled on world-
class facility at University of Dundee – Provides novel and safe training environment
for all HCPs in Kuwait
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KHN Designs: Home page
ServiceImprovement
Find patient quickly
Community tools
IntegratedLearning
Scotland as a Single Research Site Challenges for Delivery
“However, access to clinical data ……is
currently hampered by a fragmented legal framework, inconsistency in
interpretation of the regulations, variable guidance and a lack
of clarity amonginvestigators,
regulators, patients and the public”
It’s true in Scotland!Linkage of SCI-DC to SMR 01• R&D approval from 14 Boards
– 8 page form, covering letter, CV, proposal, sponsor letter, funder letter
• Ethics approval 23 page form • PAC approval 11 pages• 14 Caldicott guardian approvals
– Initially difficult to identify– Took 4 months to get all replies– Multiple contacts - 5 requested further information– “end to end” 16 months
www.scot-ship.ac.uk
Recommendations • Governance
Infrastructure• Research Infrastructure• National Safe Haven
– located in NSS• Model to be mirrored at
Health Science Scotland nodes
Stage 1Benchmarks
Stage 2Privacy Risk Assessment
Proportionate Governance
Category 1: Low impactNo further review: standard terms and conditions
Category 2: Medium impactFast track review – possible further conditions
Category 3: High impact full review possible further conditions
Category 0: Public domain
No further conditions
Scotland : A World Leading Global Hub
10 “C’s for Success”Clinical quality
Collaboration
Centres of Scientific Excellence
Connectivity across NHS/Universities
Commercial engagement - encouraged
Clinical Trial Permissions/Regulation
Clinical Informatics using the CHI
Clinical Research Facilities
Collections of tissues/DNA
Clinical Research Imaging
The Final “C”
Complacency - Competition is
Fierce
Beware!
Commissioning DevelopmentProgramme
Building choice of high quality support for commissioners
Academic Health Science Networks
May 2012
US is doing it!
http://catalyst.harvard.edu/home.html
It is a shared enterprise of Harvard University, its ten schools and its eighteen Academic Healthcare Centers (AHC), as well as the Boston College School of
Nursing, MIT, the Cambridge Health Alliance, Harvard Pilgrim Health Care and numerous community partners. Harvard Catalyst was founded in May 2008 with a five year, $117.5 million grant from the National Institutes of Health (Clinical and
Translational Science Center, CTSC) and $75 million dollars from the Harvard University Science and Engineering Committee, Harvard Medical School, Harvard
School of Public Health, Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Children's Hospital Boston, Dana-Farber Cancer Institute and
Massachusetts General Hospital. The resources of the Harvard Catalyst are available to all faculties at Harvard regardless of their institutional affiliation or
academic degree.
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D O B L I N
Mayo Clinic Centre for innovation Platform Collaborators
PLA
TFO
RM
S
Mayo Clinic
Connection
Prediction &
Prevention Experienc
e
Wellness Experienc
e
Destination Mayo Clinic
Experience
Culture & Competency
of Innovation
Summary • Opportunities for Scotland to be world leading despite the current challenges and economic climate
• Open innovation, embedded within NHS Boards a founding principle
• Bring information science into the Board room
• Could a more collaborative model between NHS and HEI partners add value?
• Support Scotland’s first National Outcome
We live in a Scotland that is the most attractive place for doing business in Europe
The road ahead for the next few years
“The only place where success comes before work is in a dictionary”
V Sassoon, 1928-2012
“If we do not succeed, then we run the risk of failure”
D Quayle, 1947- US Vice President
"In the middle of difficulty
lies opportunit
y."
Thank you for listening!