Dr John Lambert - Chief Clinical Information Officer

In this episode of the One Health Podcast, Dorian Broomhall from People and Culture gets to know Dr John Lambert, the Chief Clinical Information Officer (CCIO) for the Department of Health.

During our conversation, John spoke about his passions for technology and medicine and how they have led him to his current CCIO role. He explains how that role varies across jurisdictions and describes acting as a universal translator between clinicians, technicians and executives.

John speaks about dealing with uncertainty and the importance of being capable of making decisions even when we don’t possess all the information we’d like.

He also explains how the Bluegum Health Transformation will revolutionise the future of Tasmanian healthcare by delivering statewide change supported by key digital solutions. He describes his consultative approach to this program and how this will ensure both human-centred design and effective change management.

Transcript

Dorian Broomhall:
Welcome to the One Health Podcast. This episode was recorded on the land of the palawa people. I acknowledge and pay respect to all Tasmanian Aboriginal people and to their deep history of storytelling. My name's Dorian Broomhall, and I'm from People and Culture at the Department of Health here in lutruwita, Tasmania. For this episode, I had the pleasure of speaking with Dr. John Lambert, our Chief Clinical Information Officer. During our conversation, we spoke about his long-held parallel passions for technology and for medicine. He speaks about dealing with uncertainty and the importance of making decisions even when we might not possess all the information that we'd like.
John explains how the role of the CCIO varies across jurisdictions and describes being a universal translator between clinicians, technicians, and executives. He describes the Bluegum Health Transformation Programme, which will evolve healthcare in Tasmania through digital solutions over the next 10 years. He also speaks with us about his consultative approach, which ensures both human-centred design and effective change management. I start every one of these conversations with the same question, so let's get into it. What did you want to be when you were in kindergarten?

Dr John Lambert:
I think quite probably a fireman. The only thing I remember from kindergarten was chasing some poor girl that I had a crush on around a bench and tripping over the bench and falling, and that's why I have a scar on my forehead. It's lasted me all my life, so I get a constant reminder of that idiocy, but maybe I hit my head and I've forgotten what I was thinking of being at that age because I hit my head on the ground that day.

Dorian Broomhall:
Probably tells you enough of a story to start painting a picture. Where were you in the world when you were running around this bench?

Dr John Lambert:
I was at Dover Heights Primary school in Sydney, so just north of Bondi Beach. My dad and I used to run down to Bondi Beach even in winter, and dad would go swimming and I'd be shivering on the beach under a towel. I remember that distinctly, and then I'd run back home with him as I got older, of course, I started surfing and body surfing and swimming with him. But yeah, Dover Heights, Eastern suburbs.

Dorian Broomhall:
Great. And you say then you grew up your whole childhood in Sydney?

Dr John Lambert:
No. Dad used to work in Silverwater and at one point he worked out that there were 100 traffic lights between where we lived in Dover Heights and Silverwater, and he said, "This is ridiculous. I'm spending too much time in traffic." So we moved to the northwest, we moved to Beecroft, which is where I spent from... It'd been fourth grade primary school actually through uni until I left home at a very late age.

Dorian Broomhall:
So you were at Beecroft, you mentioned by the time you got to high school, you started to develop some ideas about what it is that you might want to do?

Dr John Lambert:
So when I was in primary school, actually, believe it or not, in fourth grade, my primary school teacher was very inspirational and had an interest in electronics. So I started learning electronics and I was building and designing circuits in primary school. So then when I went to high school, I continued that interest and in year nine that was when Apple IIs were pretty popular and dad was doing a lot of import export work in Taiwan and he brought back as you did an Apple II clone from Taiwan. I don't know how he got it on the plane. It was this massive metal case thing. Not sexy like the genuine Apple IIs were.
And he said to me, "Well, if you want to play any games on this, John, that's totally fine. You just have to write them yourself." So he plonked an assembler language and a basic language manual on top of it and he said, "Go for it." So I had to learn how to programme. I then discovered I was absolutely atrocious at writing games, and I ended up heading more into machinery control, hybrid analogue and digital circuitry where there's a computer sitting in a circuit board with circuits that do other things. I love it when what you work with creates an impact on the real world, not just run software in some backend server somewhere. And that started my journey in digital.
And then when I got to university in second year med school, I ran into the son of a doctor who was selling a practise management solution that was, believe it or not, written in the macro language of a Word processor. It's got taken me back thinking about that. And by that stage, I'd been working part-time in a computer store and the owner realised I could write software and he was farming me out as a database developer. So I met a gentleman by the name of Ray Healy, who was a retired, had a biliary surgeon of all things. And that's when I started writing practise management solutions in second year uni. And then I kept doing that until it got a bit busy when I graduated as a specialist in 2002. So I gave up that at that point.

Dorian Broomhall:
Interesting. You've had the parallel ICT and medical for a really long time then. So why did you decide you wanted to go to medical school?

Dr John Lambert:
That was my dad. My dad was an engineer and when he gave me this computer and I started a learning programming, of course, that was why I said to you in high school I wanted to grow up to be a programmer, and dad was the one who said, "John," and no offence to all the people who are programmers out there, he said, but "John, if you learn to be a programmer, you'll forever be writing software for other people's needs. If you learn to do something else, you'll be able to tell people how to write software to meet your needs." And that stuck with me forever. So I was originally going to be a vet and I went to James Bruce Ag High School. So the agriculture really stuck. I wanted to work in an agricultural environment and I wanted to work with large animals.
So I actually worked for a vet in high school and the vet convinced me to not be a vet. So dad convinced me as an engineer not to be a computer science engineer. And the vet convinced me not to be a vet and he said, "John, you need to operate in an environment that's bigger than a vet practise and all the rest of it." I was very malleable at that age and believed them both. So I ended up doing medicine. And the reason I did medicine was actually not because I wanted to be a doctor, but because I looked at medicine and I thought at the end of the medical degree, I have as many if not more options as I had at the beginning.
So most degrees tend to narrow your focus and get you into a specialist area, but at the end of a medical degree, I could do biomedical engineering, I could invent robots that replace arms. I could be a laboratory scientist, I could be a coalface clinician, I could be, there's so many avenues that you can use medical training. So that was really my logic in doing that. And of course I got the marks, so I thought, why not, as you do when you're 18.

Dorian Broomhall:
Yeah. Correct. When you did graduate medical school then, what did you choose to do?

Dr John Lambert:
So that was interesting as well, because while I was in med school, I was the book skiing director for the Medical Society of Sydney University. I didn't run the shop. We had a manager do that, but I was actually like the chief executive officer for the bookshop. And this is at student level. So of course I digitised the whole place and we implemented the first digital point of sale system. It was my first point of sale system at the Medsoc Bookshop. And because of that role, they put in a request for me to do my medical training because there were five hospital training sites at the time, and you didn't automatically get one just because you wanted it, but they put in a special request so that I could get Royal Prince Alfred because the bookshop was literally in the basement of a building that sits on the boundary between Royal Prince Alfred Hospital and Sydney University.
So I got preferential treatment to go to RPA. And then in that job, a funny letter came in and I mean letter, piece of paper in an envelope, asking for volunteers to help with the liver transplant unit that was running out of Royal Prince Alfred, only liver transplant unit in Australia, I think, or certainly at that time. And they needed a blood runner, and this was a body who could literally run the blood samples. We took every 15 minutes at some phases of liver transplant up to the laboratory, wait for the results, run them back down, chart them and do all of this. So I became part of the anaesthetics team because I volunteered to do it and we didn't find anybody else who wanted to do it. And it was funny because they paid in training.
So I was a med student in second year med school of a six year course, and I was putting in some of the most advanced monitoring devices that you've ever heard of. Most doctors have never touched a swan gains catheter, let alone put in 10 by the time they're an intern. I was putting in arterial lines. I was putting in large bore infusion devices. I loved it. It was just fantastic experience. And I had an anaesthetist teaching me the physiology of the liver and the lungs. I learned more about physiology as a med student than I had any right to because I had all these experience. These are top notch anaesthetist, working with top-notch surgeons in the most difficult and challenging operation known to mankind at that time. And I was in the middle of it all and it was all happening in the dark hours of the night. So I'd be getting up at 1 in the morning to do these because the procedure took like 12, 14 hours back then and learning all about transfusion medicine.
So to me, anaesthetics, that was the gods. It was fantastic. It was so exciting. So real time experiments really in a sense because every patient's different and you give them the same treatment, but they react differently, so you've got to modify it. So that was all very exciting. So I was going to be an anaesthetist by the time I finished med school, and then I went out and started my anaesthetics training and discovered that actually most anaesthetists, and again, no offence to anaesthetists, but most anaesthetists do something that I consider quite boring, which is there's a lot of repetition.
So 99% sleeping, 1% total panic, and I felt that wasn't as good a fit, but as part of anaesthetics training, you spend time in intensive care and I went to intensive care and that's where I found my home. I found my people. So I thought the way we conduct medicine, it's got the acuity and the risk and the edge of 10% of people who come to intensive care die. So that's how sick they are. So the sickest of the sick, it's all multiorgan, multidisciplinary, but there's all the people. It's a team sport. You've got nursing, allied health, other staff that all have to work as a team to make it happen. So there's all that team coordination, people skills.
People say, "In intensive care you never talk to the patients," but if the patients are asleep, there's always the family. So there's all that complex family dynamics. So it just was very exciting. So I switched courses. Actually, I didn't switch. Back then you could do both together. So I decided to finish with both tickets. So I became an intensivist anaesthetist by the end of that. But after getting the ticket, I went rurally, there was my agricultural background back again, and I went to Orange in Midwest, New South Wales and ran the intensive care out there for 12 years before I moved into the CCIO space.

Dorian Broomhall:
There's a pattern that runs through all of that that you-

Dr John Lambert:
Find something I love and do it.

Dorian Broomhall:
I mean, it is that, but it's also being aware of your preference to experiment is probably the word that you use, that you want to go, "Let's go in and have a go at something, see what happens. Does it improve things? Does it not? Let's try something different." As opposed to working in an environment that perhaps might be more structured and repetitive, which of course as I acknowledge with you, that's crucial. We need that work.

Dr John Lambert:
You need both.

Dorian Broomhall:
And we need people who have got preferences for both. One's not better than the other, but it strikes me that you identified somewhat early that you might enjoy working what I'll call a complex environment as opposed to a complicated environment.

Dr John Lambert:
Remember I said in the book scheme, there was a general manager of the store and I was like the CEO, not the manager. She wrote me this lovely reference once, I guess it was... I'm reacting like this because she was probably the first person who recognised my true comfort zone, which was to be able to make a decision in the absence of sufficient information to make a decision. I was always comfortable. She said, "It was great because anytime we had a challenging discussion, there just was no way of knowing the right thing to do, John was always comfortable making the decision." And you need that in intensive care because however much people talk about all the things doctors know, we know nothing about so much.
So if you aren't comfortable making a decision that could actually shorten somebody's life, knowing that you don't have enough information to know if it's the right decision or not, you can't really be a good intensivist. But it applies to everything. Like everything we do, we don't know what the outcome is. And in this role, it's exactly the same. I can't be sure every decision I make is going to be the right decision for the organisation. I know I'll do my best, but so many decisions we make have to be made in an area of uncertainty. And yeah, I think I'm getting emotional because she was one of the first people to really recognise that and document it. And she was a classic long form cursive writing, and I remember the shape of her writing and it was literally a beautiful letter as well as a lovely reference, and she really nailed who I am. Yeah.

Dorian Broomhall:
Isn't it amazing those relationships that we have that might only be for a small amount of time, but end up shaping so much of what we end up being or who we are. And at the time, we might not even realise it.

Dr John Lambert:
100%.

Dorian Broomhall:
And usually the person that we have that relationship with, they may never know.

Dr John Lambert:
She may not have... Yeah. And we worked together for three years, four years actually. I started doing that quite young, and I ended up being the book scheme director and then the senior undergraduate vice president, then the president of the Medsoc in that journey. So it was many years we worked together. Yeah, no, she was an amazing character and-

Dorian Broomhall:
Remarkable.

Dr John Lambert:
Actually, remarkable is the right word for her, and I guess that's why it has more power on me because I knew how good a person she was. So to have that from her was really high praise but yeah.

Dorian Broomhall:
I really love this idea that we sometimes, and not always, but certainly sometimes we need to make a decision in the absence of a really clear path. I'm really interested in your decision making process. When you make a decision and you know don't know, but I'm quite comfortable to say, "Yeah. This is what we're going to do." What happens next?

Dr John Lambert:
It's actually really interesting because when you're a doctor, you have a very different way of working to an executive. And I actually, when I first... I've been an executive now for 10 years and I was terrible when I started. The crazy thing was I had the right skills, but I turned them off when I stopped being a doctor, like the skills I used to have empathy with my patients and the team and all the rest of it, for some reason I thought you didn't use them as an executive. So I consciously turned them off, which was the most stupid thing in the world to do.
One of the things as a doctor you do of course, is you're the leader of the team and generally in medicine, you are the sole authority and the buck stops with you, which is different to an organisation where executives, yes, there's a degree of that, but it's really much more of a team decision, effort, governance, good governance is a lot of minds on the decision. So you're very used to making a decision, not being sure of it, but putting on a face that's calm. And some of that's conscious, some of it's actually unconscious. The last thing you need in an emergency when everybody's running around with chooks with heads cut off, the last thing you need is a leader that's doing the same. So interestingly, the more scary and exciting everything gets. I have a funny physiologic response where I get quieter and calmer and slower, and I know my team here are probably laughing because they've never seen that version of me, but when the proverbial really hits the fan, that's when I turn into this, I feel like I'm actually in slow motion in mud.
So interestingly, the same thing happens in these roles where I'll make a decision and my uncertainty, I will expose to a few people just to show them that especially that they can speak up and give me a different view and I'll be open to it. But generally speaking, nobody sees it because because I'm leading the team, I have to give them the confidence that they're doing the right thing. I don't want them getting anxious about the decisions or second guessing themselves. I second guess myself constantly. So every day I'm questioning whether the decision I made yesterday was right or not, within the bandwidth available. The good thing is problems keep turning up so fast you don't get much time to think about the ones you've already made. But where I get that opportunity and for the really big decisions, so I'm constantly thinking, "Am I really doing the right thing here? Am I pushing for the right thing? Am I trying to be too innovative or new?" Just treading on the edge of what's safe. Yeah. So I'm constantly questioning that, but a lot of people probably don't see that.

Dorian Broomhall:
The idea that it's okay not to know is good, but to be able to be a calm and strong leader and to know that you don't necessarily know and still make a call because indecision isn't necessarily helpful. Not knowing is actually okay, noting that as your point, you might think about it and go, "Actually, I've reflected on that. We might do something different. That's not going to be great." On all decisions that we ever make, but certainly for a lot of the things that you find yourself working on that's actually okay and useful when there's then an operational follow through from the decision that you've made. Okay, maybe not so strong.

Dr John Lambert:
I feel that that constant internal critique also protects me from becoming the stereotypical arrogant doctor type, because there are certainly a lot of people who spend so much time being in charge that they really have this self-belief that exceeds the honest assessment of our understanding of whatever the topic matter is. And I get uncomfortable when I see that because sometimes it's in a field that I'm well aware of and I'm thinking, you don't really have the right to be that confident about what you just said. You can tell that they genuinely believe that they have a right given to them from God to be the source of answer for that issue. I mean, life isn't quite that way. So maybe that has helped me in that respect that I've seen the danger of that centrist arrogance. So I always remain open to it.
But I have to say I fight a battle because once you get the C in front of your name chief, and when you're a senior, as I am in an organisation, I would never use this term, but the term was used to me recently, Messiah complex, where you're the one who has the knowledge, you're the one we've recruited to do this, and so your view is the right view. I do everything I can to try and disavow them of that because the best way to make great decisions is cognitive diversity, and you want lots of people with different backgrounds and different ideas expressing those ideas without fear of repercussion and then you get good decisions.

Dorian Broomhall:
I want to start with a question that might seem obvious, the CCIO, what is it?

Dr John Lambert:
Yeah. Good question. One thing I can tell you is this is my third jurisdiction, and I do feel very privileged that I've been able to be the CCIO of three separate jurisdictions in Australia. And I can tell you that none of those jobs are remotely like each other. So what a CCIO does is very context dependent, and there's a lot of people out there that are called CCIOs in different countries, in different regions, and they're vastly different again. The common thread is mostly a universal translator. As you can probably imagine from my background, I have a deep understanding of the language of clinicians. I have a deep understanding of the language of technicians, technical people, ICT people, digital. And in the last 10 years, I've learned the language of executives.
When I first walked in the door as the CCIO of New South Wales, I had no idea what it was to be an executive, and I was probably pretty average in retrospect. So those three language sets are really interesting because they all use English. I do tell this story a few times, but I've literally been in a meeting room with three teams of people all speaking English, all using exactly the same words and being the only person in the room who realises they're all talking about different things. And in this meeting, I had to test it. I said, "When you said that you mean this?" And I'd paraphrase in their language, "Yes. That's what I meant. When you said that you meant this, didn't you?" And I'd paraphrase in their language, and then I'd do that to the third cohort. Then I played each of them back what the other team was talking about in their language for the other two teams, six responses, they were just blown away. They had no idea they were talking about such different concepts.
So that's actually the greatest value I add because I deeply understand what an IT person means when they use this word versus a clinician using the same word. I can help break down the mistakes that are made when everybody thinks they're talking about the same thing. The translation piece is actually my, I think, greatest value add. And then if you're in a leadership position, you can be in the right decision-making groups where you can say, "Tune the decisions to the betterment of the organisation." So making sure that the clinician needs are met, the IT needs are met, the executive needs are met, and everything synchronised and aligned is probably the key to being a successful CCIO. But that's just my view.
And look, I just would also point out that chief clinical information officer, there's a couple of mistakes people made when they hear that. Firstly, they think clinical means clinician, and I used to actually say that to my own mistake. So clinical means the delivery of clinical services. So it's not just clinicians, it's ward clerks, admin staff, back room people, hotel services, et cetera. So it's the chief information officer for the delivery of healthcare. And then when we do talk about clinicians who are a big part of that, the other problem is that many people hear the word clinician and think doctor. And I've always been very vocal about the fact that this role is for all clinicians, doctors, nurses, allied health staff, and there are many other types of clinical work that we forget.
And of course, the reason I emphasise that it's clinical, not clinician, is because of the ward clerks, the admin staff, the finance, the revenue people, the admin staff, the executive, the executive officers, the office of the minister, all that. They're all part of the health system. And if you design systems and forget the audience is that broad, you tend to make mistakes.

Dorian Broomhall:
You put out on social media that we're going to be building an army here in Tasmania because we've got a bit of work to do to roll our sleeves up. What would it mean then to work within the team of a chief clinical information officer?

Dr John Lambert:
So this is where the difference is most stark. My role here is very different to the roles I've had in the other two jurisdictions. So it's caused a lot of pain and suffering in my stakeholder engagement team because even what I thought I was here to do has changed dramatically in the last 12 weeks, even as much as 2 weeks ago. So I've been brought down here to be accountable for the digital health transformation strategy and the programme of work that is to deliver against that strategy.
Now a programme of work, most lay people, people who don't work in this space, think a programme is something you click on a desktop to open a piece of software on your computer. So in the space I live in, and this is the translation thing, most people, clinicians would all think a programme is a piece of software. I thought it was a piece of software until I walked into New South Wales offices and I learned that a programme is basically a funded activity that's got a budget, a scope, and a schedule a timeframe, and that's it. I mean, there are actually three other elements to it, but those are the three important ones.
So this government decided to spend nearly half a billion dollars, there's the budget, on transforming healthcare with digital solutions. There's the scope over 10 years, there's the schedule. So that's all the programme is. So the digital health transformation strategy said, "This is the outcome we want." The programme is the funded body that delivers that outcome, and I'm accountable for that. So that's my job here. So my office is actually an office that is the programme. They're one and the same. So most people in Tasmania would realise that we have a CIO, Brett Farley, he's the CIO and he has an office called the office of the CIO, but he runs a team called Health ICT. I'm the CIO, I have an office of the CIO, but I run the Bluegum Health Transformation programme.
So my team is a very complex team that includes people who are responsible for stakeholder engagement, design support, capability development. We have a huge amount of training to do to train our teams how to do this work. And I mean clinicians out on the floor, not just the teams inside the programme. We have a whole lot of external and internal relationships to manage. So I've got a team focusing on that. And then we have what to a classic programme, digital programme type person would recognise as a portfolio of programmes and projects.
So we have many simultaneous streams of work happening. One of them is the EMR. It's probably about 60% of our work, but only 60% of our work and there are lots of others. So that's in a portfolio team in my office. So those, I think it's six teams are... And of course I have the team, we're going to call them the gum nuts, who are the teams that are the nuts and bolts to keep everything working or the eucalyptus oil that keeps everything moving inside the Bluegum programme.

Dorian Broomhall:
I really like how you describe what you're accountable for there. And in some of the work that we do through our leadership development programmes, when we talk about delegation, we talk about the distinction between delegating activities that are tasks, specific bits that you need to do and delegating activities at the level of intent. And what you've got described there is a beautiful overall example of an activity at the level of intent, which then your job is to translate and delegate within that accordingly.

Dr John Lambert:
Yeah. And that's interesting. Look, I have to say it's also an area of translation difficulty between executives, programme people, in this case, not so much ICT people, it's all programmes and clinicians or general workers on the floor. And I have to say, I tend to use the RACI language, the responsibility, accountability, consultant informed type language, readily understood by clinicians as well. Because once you say them in that set, they get the difference. If you just say, "I'm accountable, what's the difference between accountability and responsibility?" But they don't think to ask that unless you say there's responsibility. There's accountability.
So responsibility, I'm going to do the work. Accountable is I'm accountable for making sure that the work happens. Consultant, I'm going to make sure that I listen to your opinion and change what we do as a result of that. Inform, I don't care what you think, but I'm telling you what I'm doing. And you can bring people on board on that language. So I find that really useful language that tends to cross boundaries pretty well. So that's the language I use and say, yes, accountability is the right word for what I'm doing. I'm not personally going to be touching code or designing anything. I'll be accountable for making sure the right team and the right methods and processes are in place to do it well.

Dorian Broomhall:
So it also strikes me that this whole programme, this whole body of work is largely around, well obviously is around system improvement, but therefore it's about change.

Dr John Lambert:
It is.

Dorian Broomhall:
So we've got change that will happen because our systems will change. The bit that might not surprise you that I'll be interested in is how are we considering bringing people along for that change, noting that the system change will drive behaviour change because it simply has to. And that's great, and I love that to an extent because it's get on board because you have to. How do you approach thinking about that other component of change that want to come to?

Dr John Lambert:
What do you mean by system?

Dorian Broomhall:
It could be any way of doing things.

Dr John Lambert:
All right. So you mean a system or process, not a piece of software?

Dorian Broomhall:
Correct. Yes.

Dr John Lambert:
Some people talk about the system as the health system. Others are a system of thinking, system thinking. In my context, system always means the piece of software that you're using, which we sometimes call a solution, but a solution is generally that system being used by somebody. So we use a slightly variation and then you say, well, solution. But that's the answer to a problem. So see how the same words can mean so many different things for people. Now, in most digital projects, people would say, "You mean we're changing the piece of software we're using from IPM to a new EMR or whatever?"

Dorian Broomhall:
We might be introducing a piece of software that never existed before.

Dr John Lambert:
Exactly. So we're starting to use a new system which is digital rather than paper. I agree. That's one way of using that word. And like I would say, if you take that word to mean the entire people process and technology combination that delivers a health service, then yes, we're changing that system. And then you say to me, "Well, how do you bring the people along, or how can I not bring the people along?" If I'm changing that definition of system, the people and the process are actually the biggest part of the transformation. And that's actually my answer to you.
Historically, this programme of work, the half a billion dollars spent over 10 years was called the Digital Health Transformation Programme. And that is still the correct name for the team responsible for making this change. And we're just adding the word Bluegum to it to make it a little bit easier because we can just say Bluegum and everybody knows what we mean. But that's the programme, that's the team that we spend the money on, the licencing, all of the machinery of change. But the outcome of that, the objective of that programme is to transform healthcare in Tasmania. And that's in Tasmania, not in Tasmanian Health, not in the Department of Health. We're transforming the way healthcare is delivered across Tasmania, which includes patients, healthcare providers outside of Tas Health, private providers, everybody. So the outcome is health transformation, which is why we're calling this for everybody outside the programme team, it's just going to be called the Bluegum Health Transformation.
So how are we transforming health? By enabling and assisting and supporting the humans who deliver healthcare to do their healthcare in a different way. And yeah, we're going to assist them with a lot of digital tools, but that's the language. So it starts with the language. It starts with the way we engage with people. No, I'm not giving you an IT system. I'm helping you change the way you work. And yes, whilst doing that, we're going to support you with some cool digital tools that are going to help you, I hope.
So the design architecture for the programme team has shifted significantly. We are really focusing on delegating design decisions right out to the people who actually use the systems. And that includes patients, it includes people outside of Tas Health. It includes every type of clinician inside the organisation, but also all the administrative staff and everybody. So I say this is a health transformation that affects every person in Tasmania. Clearly it's going to have a much bigger impact on the 16,000 people employed by the Department of Health, but it is basically everybody. So all of our design is about creating an ecosystem where those people can be involved in changing the way they behave in the future.
And if you talk to Dale, it was quite interesting because Dale and I haven't talked about this in that much detail, but when he welcomed the new digital health transformation executive committee, which is the committee that is in charge of the programme, he never mentioned digital or if he did, it was very, very secondary. He said, "This health transformation is how we are going to survive the incredible upsurge in need for healthcare with a limited budget and a limited workforce. And if we can't transform the way we deliver healthcare to support our future expectations, we just won't survive." So he views it as a health transformation, not as a digital project, and that's what I'm doing as well.

Dorian Broomhall:
Yeah. I mean, the way he described it makes an incredible amount of sense to me. We'll be enabled by the digital tools.

Dr John Lambert:
Digitally enabled care, I'm okay with. On LinkedIn, somebody came up with the term digitally assisted healthcare. I like that one too. I like it more because it enabled sounds a bit, I don't know, fancy, but yeah. These are digital systems. That's where I use the word system to mean the software. Digital systems that will support clinicians and everybody else to deliver better healthcare more efficiently, faster, whatever.

Dorian Broomhall:
How do we support the people in adopting that change, noting that they will simply have to change as the system changes?

Dr John Lambert:
So if you think about just one of the things we're rolling out, which is the EMR. To design an EMR, most EMRs are what we call COTS systems, which are configurable off the shelf. So they're a system that somebody else has designed that you have a whole lot of buttons and knobs that you can turn to change how it works. A typical EMR has somewhere between 10 and 100,000 different knobs. So some of the vendors have tried to measure that and think it's around 25,000 knobs that we have to adjust. Now, one decision-making group's not going to do that. So we have to create a whole set of decision-making groups. We're calling them design working groups, and we think we're going to need somewhere between 50 and 80 of them, and each of them will have 10 to 12 people on them. So you can do the math. There's almost 1,000 people, and they're not our people. They're people out there who do their jobs today. So that's the first step. The people who do the work are going to be on the decision-making groups to design how this system works.
But the other key thing to realise is that the design working group is not just designing the system, the solution, the software. They're designing themselves. They're making decisions about how they want to work with this tool in the future, and then that's going to be supported by what we're calling a design community. Now, the design community, if it actually includes every single person in Tasmania, I'd be delighted. That's okay. The design community can scale that large.
Now, what I expect is that we'll probably get about a quarter of the population of Tas Health involved. So 4,000 people would be a good number and they will be on the journey, and they'll be involved in a lot of different ways because not everybody can be in the decision-making room. We've already talked about the 50 to 80 groups of 10 to 12 people. They make the decisions, but the design community will see everything they're doing. It's all fully transparent. So they'll be able to look at the designs. And then you get the guy in row 50 in the aeroplane who can say to the pilot, "Hang on, you're about to hit a mountain." That design isn't going to work with my unique workflow. Maybe you should think about this. And then they tell the design group and then they incorporate that. So we've got that type of level of engagement.
And of course from that group, we will also pull what we call representative users. So if you're an aficionado of human-centred design, we design things with, and the science backs this, a number of around five to eight representative users. Where do we get them from? They're not the design working groups, they're from the design community. So people who are interested in thinking about how they will operate in the future, provide the bodies that we will use to design tests. We're going to do huge amounts of usability testing on the solutions to make sure they work in the real-world environment. So all those people, are the people who deliver healthcare, not me, not the programme team. They're all those bodies. So in that process, they will see the reality of their future, help design the reality of their future, and then live and breathe it when we go live with a bit of luck in mid 2028

Dorian Broomhall:
In all of that, what's the bit that you know you need to pay closest attention to?

Dr John Lambert:
There are so many things that can go wrong. Because it's impossible to have everything in your brain at once, I do tend to focus on principles. One of the first principles that I've evolved over the 10 years in this type of role is that when you're making design decisions, there are 6 knowledge domains that have to be present every time you make a design decision. You have to be thinking about six things. And unfortunately, I made it six because my brain has a short-term memory slot capability of five things. I always forget the sixth thing, but I'll try to remember them all.
So the first knowledge domain is safety and quality and accessibility. Is the thing we're building going to be safe and of high quality? Is it going to promote safe and high quality healthcare? And is it accessible to all the people who use it? Safety, quality, accessibility, that's domain one. If you build anything that doesn't comply with that requirement, you shouldn't be building it. You should turn it off, get rid of it.
The second domain is usefulness, usability. Is it useful? Is it usable? And will it be used? And we will have team members who assist in that, but the best way to do that is to get the people who are going to use it part of the design process. So that's domain two. Domain three is about the rules. We're in healthcare in a government organisation, there are lots of regulations, policies, procedures, standards that apply, and you must not build something that is in breach of those. So somebody who understands those rules that pertain to the thing you're designing have to be in the room when you're making those decisions.
Number four is sustainability. We don't have an infinite budget. Sometimes the sexist, the most wonderful thing in the world is too expensive for us to afford. We have to accept that sometimes we design systems that are so hard to use, we can't keep up with the training required. We can't train the people before they hit the floor, and we wonder why everything falls apart. So there's sustainability, focus, HR, finance, there's a whole lot of facet training is all part of sustainability.
The fifth domain is whether the solution is informative. Does it generate the information we require to do what we need to do with that information? That could be revenue, billing, research, performance analytics, feedback to improve models of care. You've got to have that in the room when you design the tool because otherwise the users put data into the screens that is rubbish because they don't understand the label on that field. And then two years later, some analytics person who's never been at the front coalface uses that data field because it looks like the right field. And suddenly you get people saying, "Well, that doesn't represent our reality." So informatics with the solution stores and accepts and works with the right information is a critical domain.
And then the final domain is feasibility. Can we actually build it? Like you can design things that are amazing that you can't build because the EMR doesn't support it or the technology doesn't support it. So those six knowledge domains, if you make sure all six of those are in the room present when you're making design decisions, you tend to get better success. And that I can say that from all my years of experience because what I've looked at is why did this disaster happen? That's interesting. They didn't have anybody in the room that knew that, and that's why we broke the rules.
So one of the things I focus on is in every design making group, do we have the right people in that group so that we can trust them to make the right decisions? Because delegation only works if you trust the decision makers. You can only trust people if you have a clear understanding of what you're expecting of them, and you give them good methodologies and processes. So that's the second thing I focus on. Are we using the best methodologies and processes?
Above those two things, I would put culture and transparency. So you've got to have a culture where people can speak up and that you can trust people to be open and try things and be open-minded to new ideas and have cognitive diversity in the team and all the rest of it. And transparency, and I mentioned that earlier where the design community sees everything the design working groups do. If everything's secret grill business and happening behind closed doors, it's a complete waste of time because the product of those decisions can never be hidden from.
The solution, talking about the technical solution, is going to be what it is. Everybody will use it. So why would you hide the decisions that create it? Because they're going to find out. What you really want to do is find out if there's a problem before you go live. There's this saying in usability circles, in human-centred design that you can never skip usability testing. It's impossible. The only question is, do you want to do usability testing before or after you go live? And I've been present for many lives where the usability testing happened after go live, and it was horrible. So I don't want to let that happen.

Dorian Broomhall:
I that love you think about scalable decision making. What you've described is a beautiful set of principles that you, as the person who's accountable for this, can employ to track across all of this scalable decision making to note that if we're following along on these sorts of things only that they won't always be perfect. And sometimes there might be reason for them to be broken, maybe but that's your way of approaching that. That's a really lovely toolkit for-

Dr John Lambert:
Two key things I might want to just add as a suffix is escalation elevation. With these design groups, they're all going to have a scope of what they're responsible for, and they need to be allowed to say, "We need to make this decision, but it's outside our scope, so we'll elevate it so that that decision can be given to the right group." And escalation is we can't get consensus over this decision. There's too many people in the room that are still worried about this solution, so we're going to escalate it. And anybody can escalate. So even somebody in the design community can say, "Look, I've told the design working group that this isn't going to work. They've listened to me and they've considered it, and I still don't think their solution's going to work. And we've got to open that door to allow them to send the red alert right up the tree." So that's part of the way I keep an eye because I can't know everything that's going on, but I trust that the people in the know will tell me.
And that's actually one thing I've found in every job, in every role like this, it's the disasters have always been discovered. Sometimes the problem is that the people who discover them have just never felt empowered or had a clear path to let somebody know about the disaster. Because the number of times I've seen it go live and it goes live and there's this doesn't work and blah, blah, and people say, "Yeah. We told them about that two years ago. Look at the minutes. We said this wasn't going to work." How did that happen? No clear escalation path.

Dorian Broomhall:
It's a really good lens for governance.

Dr John Lambert:
Well, I like to think so. I mean, I'm quite confident that if everything goes perfectly and I think we've developed the best governance on the planet, things will still go wrong. We'll still have disasters. I just hope they're small.

Dorian Broomhall:
To an extent, that's why we do all of that though, isn't it? So that when the thing does go wrong, but we've got the capacity and the resilience to be able to deal with it.

Dr John Lambert:
Yeah.

Dorian Broomhall:
My final question then is in the last 12 weeks or so since you've joined us down here in Tassie, what have you enjoyed the most?

Dr John Lambert:
Gosh, that list is another hour's long interview. I love the weather. I love the food. I love the people. I was surprised by the diversity, the historical view of Tasmania hangs around long after it's relevant, the old, the two heads, the lots of grey old retirees, all that stuff. It's just a very different Tasmania to that that I'm seeing. I think it's wonderful. I walk down Elizabeth Street and I can be in 20 different countries just by walking through 20 doors into the restaurants, and they're all staffed by people from the country that they're selling the food of, which is just amazing. I love the weather. The cool climate really suits me.
And the people, the open-mindedness, the enthusiasm, the positivity, the can-do attitude like I've given people, even in my own team, ideas that are radically different to the way they've worked before, and they all think about it and look at it and think, "Actually, this is not the way we're used to doing things, but I reckon we should give this a go. This could work." I can tell you that is not universal behaviour. It's very, very special. The support I've had from Dale, Brent, who is the whole reason I'm here. He's been a fabulous partner in crime, and Lisa Headstrong. The team inside level 150 Elizabeth Street that I work with, not a bad egg amongst them. It's just so lovely. Just no toxicity. There's no toxic people, not that I've discovered yet anyway, and I've been all over Tasmania. I've been up to Lonnie. I've been out to Bernie. I've seen the people out there and in the Mersey Community Hospital. It's consistent everywhere. It's really nice.
And look, I hear about politics and regional differences and all the rest. I've been to so many organisations with that. It's not funny, but I actually think it's less of an issue here than in most other jurisdictions I've been in. I really do. If anything, the only negative I'd say is that you guys don't rate yourself as highly as you should. There's a lot of, "Tasmania, we're a bit backward. We know this." No, you're actually pretty good where it matters. And that's why I love doing this because it's in an environment we can be successful and nobody else can be because we've got a better culture, better people, better capabilities. We're small, but we can do things.

Dorian Broomhall:
John, thanks so much. It's been great.

Dr John Lambert:
No problem.

Dorian Broomhall:
Thanks to Dr. John Lambert, our Chief Clinical Information Officer, for taking the time to speak with us, and to you for listening. I hope you found something in our conversation that you can take away and apply into your own life.