The Inadvertent Pioneer of Kidney Care Software

How it all started… 

Conrad Venn was a Computer Science undergraduate at Imperial College, London, when he was introduced to Mike Gordon by Peter Throsby, Assistant Director of the Department of Computing & Control. This was to be a pivotal introduction that shaped the trajectory of Conrad’s career. 

Mike had joined the Department of Medicine as Lecturer in Computing at Charing Cross Medical School in 1973 and was tasked with developing a computerized record system for the hospital’s renal unit. The research project was under the esteemed Professor Hugh de Wardener, a pioneer of kidney dialysis in Britain and the founder of what is now Kidney Research UK. 

The complexity of renal care meant that the sheer volume of paper records in the renal unit was becoming a challenge. Not only from a storage perspective, but also for clinicians to review and interpret in order to make informed decisions about patient care. 

This was in 1977, and technology looked quite different.  

The challenge was not just to computerize the records; the records needed to be easy to access and interpret too. The project and the technology involved sparked the interest of Conrad Venn, and in 1978 he joined the team as the core programmer. 

At the time, which was way before the PC, it was the opportunity to work with exciting new technology that grabbed my attention and distracted me from my studies!

In June 1979, Conrad travelled with the team to Amsterdam to showcase the system at the European Dialysis and Transplant Association (EDTA) conference, as it was then known. The nephrologists were impressed and 65 consultants registered their interest. This was an exciting development as the consultants were very influential at their facilities. 

Based on the positive feedback at the conference, Conrad, Mike and Prof. de Wardener could see the demand and recognized the commercial opportunity. And so, they established Clinical Computing Ltd.  

Dr Martin Knapp from Nottingham City Hospital Renal Unit reviewed the project and knew that it would be game-changing for his facility. But, much like today, budgets were tight and didn’t stretch to investing in new technology. Not to be deterred, Knapp launched a fundraising campaign, including drumming up donations from local working men’s clubs, and the system was installed the following year. 

CCL was the first UK company to develop a computer system to support clinical care in renal units, with Nottingham City Hospital being the first client. 

Transforming challenges into an advantage 

Tackling a problem for the first time is never easy, especially with the added pressure of the impact on people’s health. Conrad was focused on overcoming the technical challenges, of which there were many: 

The Barriers  

• It was the age of ’dumb terminals’ and the central PDP-11 server had only 56KB of RAM. To put that into context, a modern-day PC has about 300,000 times more. The system needed to access and return data quickly for several concurrent users, despite these restrictions. 
• The data returned to the user needed to be in an easy-to-interpret format that would help support clinical decision-making.  
• The system needed to be flexible to meet the changing needs of clinics and configurable without the involvement of dedicated programmers.  
• Navigating between data views and different patients was a necessity. Today we have the trackpad, the mouse and even touchscreens, but before those advancements, a different approach was needed. 

The Solutions 

To work within the server memory constraints, and support up to five concurrent users, the system had to be designed using extremely economical programming techniques, including an in-house-written multi-tasking operating system, shared code and programming at machine-code level. 

Data could be presented in different ways, allowing users to select the appropriate view for their requirements. These options allowed users to quickly interrogate the details through tables or easily spot trends with charts. The visuals have moved on from the early Proton displays seen below, but the fundamental views still exist in Clinical Vision. This is a testament to the work that went into understanding the requirements needed in renal care. 

As demand increased, it became obvious that flexibility needed to be built in to ensure the scalability of the solution. As requirements changed, clinics were able to reconfigure the software without calling in specialist programmers.  

A novel navigation method was invented, using the nine-button numeric keypad and a dynamically updated set of nine menu options at the lower right of the screen. Navigation was simply a case of choosing one of the menu options and tapping the key at the corresponding position. This was the inspiration behind the company’s logo as seen on this original branded mug (the creative pottery work of Conrad’s brother). 

The keypad allowed users to flip between patient records and quickly navigate to the information they needed. Think of it like a keyboard shortcut, which despite modern enhancements, was far quicker than navigating menus using a mouse. It was noted that new users, after a short time, would develop ‘muscle memory’, which enabled them to navigate rapidly, without looking at the menu options or the keypad. 

Working within the technical constraints, although challenging, helped to create the strong framework that sits at the heart of CKG’s Clinical Vision today.  

• An intuitive user interface
• Surfacing information in a format suited to the data
• Flexibility to cater to different workflows and requirements
• High-quality code for fast, stable and scalable solutions 

I’m pleased that the structure and frameworks we created in the early Clinical Computing days have stood the test of time, despite the advancements in technology that have occurred.

CCL Growth 

In 1981, two systems were installed, one at Liverpool Royal Infirmary, the other at St James’s Hospital, Leeds. The next year, three more UK installations followed, and then further expansion was seen with the first installation in the US at the Henry Ford Hospital, Detroit. The year after, saw even more sites added to the portfolio in the UK and the US, including five systems at the prestigious Mayo Clinic.  

By the late 1980’s, the majority of UK Renal Units used the system. As technology developed, the system did too. In 1988, it was re-developed for the popular IBM PCs, and ‘Proton’ was born, one of the earliest electronic patient records in the world. A product still in use today, albeit with a few enhancements. 

The largest customer for Proton was National Medical Care (NMC) in Boston. At the time, they owned and operated over 500 dialysis centres throughout North America. Due to the scale of the operation, Conrad visited them many times in the 1990’s, sometimes up to 3 weeks at a time, helping them to develop their own standard renal application. Over time, they opened further centres that required additional licences, culminating with Proton in over 2,000 centres. 

Between 1996-2000, the system was further redeveloped for Windows, and the first version of Clinical Vision was established. By this point CCL had clients in Europe, North America, Saudi Arabia, Australia and New Zealand. Conrad travelled the world to support individual client installations. 

I still remember in the early days, the many nights spent in a small dark machine room with no windows at Charing Cross Hospital, to produce the machine code for the first prototype system. It made studying at college the next day a little more challenging!

In the UK, Proton data was used on a broader scale to compare the performance of different units, looking at metrics such as death rates, transplantation and other health markers. Today, this is known as the UK Renal Registry (UKRR), which Clinical Vision integrates with directly. The data collected is used to support research into improved care and better patient outcomes. 

In 2017, CCL was acquired by Constellation Software, Inc., but Conrad’s contribution to kidney care software didn’t end there. Conrad’s expertise has continued to shape CKG’s market-leading solutions to this day. 

A Lasting Legacy 

The ethos behind the computerization of renal data is highlighted in this excerpt from an early commercial document for Proton. The goal of improving access to data to facilitate better patient outcomes is reflected in CKG’s mission today.

The system improves utilisation of two major resources in dialysis and transplantation clinical data and staff. Data is expensive to acquire, but in conventional records systems becomes obscured by necessary accumulations of new data, and cannot be seen in context. Staff must spend much time searching notes, or remain inadequately informed. In either case quality of care falls, especially with growing numbers of patients and changes of staff. The computer improves access to data and permits better care for more patients. 

Conrad’s input has provided CKG with unmatched nephrology software expertise, and his work laid the foundations for our best-in-class renal care solutions. Conrad’s contribution has been instrumental in the positive impact software has on improving care for patients with kidney disease around the world. 

Thank you, Conrad. The CKG team wishes you all the best for your retirement. 

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