As an NHS consultant with two decades of experience, I have lived through what David Ingram aptly describes as the “anarchy of transition”. We have moved from paper notes which are fragmented but tangible, to digital systems that promise the world but often deliver disjointed, burdensome silos of data. Ingram’s two volume magnum opus is not merely a history; it is a diagnosis of why NHS IT has struggled and a prescription for a “programme for reform”. Ingram’s work should be mandatory reading for every stakeholder in our health service, from the Secretary of State for Health to my frontline colleagues.
Volume 1: The Adventure of Ideas. Ingram begins by grounding us in the “adventure of ideas” that preceded the computer taking inspiration from the great mathematician and philosopher Alfred North Whitehead. David takes us through the evolution of knowledge, measurement, and engineering (Chapters 2–5). For a surgeon, the discussion in Chapter 3 on “omnuscles” (data atoms) resonates; we generate vast amounts of data, yet struggle to retain its clinical meaning. Ingram illustrates how the “goldrush” of commercial IT often ignored the complex reality of clinical practice, leading to the “wicked problems” of policy failure we face today.
Volume 2: The Care Information Utility and openEHR. The heart of the review for my clinical colleagues lies in Volume 2. Ingram argues we must move away from industrial age models toward a “Care Information Utility”. A public utility akin to water or electricity, centred on the citizen. This is critical for the realisation of the Single Patient Record (SPR) for the NHS. Currently, our records are trapped in proprietary systems. Ingram proposes a radical shift: the separation of clinical data models from the software that runs them.
This brings us to openEHR, detailed in Chapter 8½. Born from the GEHR project, openEHR provides a vendor neutral platform where clinical content is defined by clinicians, not software developers. For the SPR to become a reality, we need this “common ground” where a patient’s fracture history in Leeds is semantically identical to that in London, regardless of the IT supplier. Ingram details how this approach is already working, citing the OpenEyes ophthalmology record and openOutcomes, an openEHR native digital Patient Reported Outcomes (PROMs) platform as a shining examples of clinician led, open source and open standards success.
Tim Berners-Lee and the Semantic Web. Reading this alongside Tim Berners-Lee’s This is for Everyone, the parallels are striking. Just as Berners-Lee championed the open web (as elegantly mentioned in Ingram’s book) standards to create a universal information space, Ingram champions openEHR to create a universal clinical information space. Berners-Lee’s vision of the “Semantic Web”, where data shares meaning across boundaries, is exactly what openEHR operationalises for healthcare. By adopting open platform specifications in the public domain, we prevent the “enclosure” of medical knowledge by private monopolies, ensuring that the health record, like the web, remains a public good.
Finally, we must address the incoming wave of Artificial Intelligence (AI). As discussed throughout the book, AI offers the potential for “Deep Medicine,” but it currently risks amplifying noise and bias because it feeds on fragmented, non-coherent data. Ingram rightly
warns that without a coherent information utility, AI cannot deliver its full societal benefits. We cannot safely deploy algorithms on “messy” legacy data. Standards like openEHR provide the rigorous, structured “phenotype” data required for AI to be safe and effective.
In summary, Ingram offers a path out of the digital wilderness. It is a plea for “implementation, implementation, implementation” of a shared, open health and care infrastructure. For the sake of our patients and the future of the NHS, we must listen.
Book Reviewer
Kanthan Theivendran
Kanthan is a full-time practicing Consultant Orthopaedic Surgeon in the NHS. His interests include Digital Health, Leadership, AI and Patient Reported Outcomes (PROMs/PROs) in value based healthcare.
Declaration of Interests