Over the last decade, several healthcare systems around the world have invested in information technology (IT) in order to improve efficiency and effectiveness. Although the intention has been right, many healthcare IT projects haven’t delivered fully on their promise to make patient care more joined-up and safe. A prime example is the National Programme for IT (NPfIT) – the flagship programme of the National Health Service (NHS) in England run by NHS Connecting for Health. Costed initially at £2.4 billion, this 10-year programme has been described as the largest civilian IT project in the world [1]. And like many such large-scale, complex IT projects, it is now over-budget and behind schedule – the initial cost of £2.4 billion has risen to £12.4 billion and the 10-year schedule has now been extended to 12 years, with an estimated completion date in 2014-15 [2]. Little surprise then that the National Audit Office reported in May 2011 that ‘the original vision for NPfIT in the NHS will not be realised’ [NAO 2011].
So the question is: Why do large-scale IT projects often fail to deliver? And how does this apply to healthcare IT?
Information systems are socio-technical systems [3]. Therefore, engaging the ‘social’ or human aspect i.e. the end-user is vitally important right from the design and development phase of the system. Only about 20% of large-scale IT projects are successful and ignoring the human interface of socio-technical change is usually the principal reason for failure [4]. Similarly, in healthcare, ‘bring in the IT and the change will follow’ doesn’t work. As end-users, if clinicians are involved only at roll-out and implementation of IT systems, they will find it hard to engage with and influence the product and most likely abandon it [1].
So should clinicians lead and drive healthcare IT strategy, in order for it to be successful? There are reasons both for and against such an initiative.
As engaging and involving end-users right from the beginning of the design stage is a critical success factor for an information system, allowing clinicians to drive the strategy would appear to be the obvious choice. After all, they understand the needs of the patient and clinical systems best. And they also understand the implications of poor data quality, patient confidentiality and security. Evaluation of a clinical IT system is also, perhaps, best done by clinicians themselves. If clinicians don’t perceive the systems as ‘useful’ and ‘user-friendly’ they are unlikely to engage with it [5]. Hence, as anecdotal evidence suggests, they are rapidly adopting smartphones, tablets, apps and social media and ditching clunky, outdated legacy systems. A significant proportion of UK doctors are carrying powerful smartphones in their pockets and iPads in their bags but have little or no means of integrating these with legacy systems to make healthcare delivery more efficient.
In addition to the above, there is another reason for clinicians to be at the forefront of healthcare IT strategy. The system change needs to be ‘IT-enabled’ and not ‘IT-driven’ i.e. the business processes ought to be optimised before the new IT system is designed. Trying to retro fit the business processes to an off-the-shelf IT system defeats the purpose. And clinicians are best placed to advise on these business processes. To be an IT-enabled change, the end-user needs to be in the driving seat with the technologists as able, supportive passengers.
However, despite these arguments in favour of clinicians leading healthcare IT strategy, there may be some downsides to such an initiative. First of all, clinicians have varying degrees of IT literacy and competence. Being born into technology, generation Y may be different, of course. However, even this tech-savvy generation needs training in health informatics which isn’t yet a mainstream subject in the clinical curriculum. It isn’t just about the technology – the concept of information orientation has three strands: information technology, information management and information behaviours [6]. Most technical-minded clinicians are self-taught enthusiasts while informatics professionals have formal training in all three areas. Moreover, clinicians may have little knowledge about open source systems unless formally trained.
Successful clinical leadership in healthcare IT requires both business as well as informatics skills in order to influence procurement decisions effectively. But while a combination of clinical knowledge, business nous and informatics abilities is a powerful one, individuals with such capabilities are few and far between in the current system. The US has long had a well-developed system of appointing Chief Medical Information Officers but finding the right candidate for the job is often a challenge. In UK, E-Health Insider has recently launched a timely and high-profile campaign to appoint Chief Clinical Information Officers along these same lines. However, as powerful professional groups, historical allegiances and complicated organisational dynamics at different levels of the healthcare system can distort and distract attention from the task; such Officers will need to be armed with significant political skills as well.
Let’s hope the campaign is successful and that appropriate candidates for such jobs are soon available.
References:
- Hendy, J., Reeves, B.C., Fulop, N., et al. 2005. Challenges to implementing the national programme for information technology (NPfIT): a qualitative study. British Medical Journal, 331; pp. 331-6.
- House of Commons Committee of Public Accounts. Department of Health: The National Programme for IT in the NHS – Twentieth Report of Session 2006–07.
- Laudon, K.C. and Laudon J.P. 2001. Essentials of Management Information Systems: Organization and technology in the networked enterprise. New Jersey: Prentice Hall.
- Clegg, C.S. and Shepherd, C. 2007. ‘The biggest computer programme in the world …ever!’: time for a change in mindset? Journal of Information Technology, 22, pp. 212-221.
- Bhattacharjee, A. and Hikmet, N. 2007. Physicians’ resistance towards healthcare information technology: a theoretical model and empirical test. European Journal of Information Systems,16, pp. 725-37.
- Davenport, T. H. 1994. Saving IT’s soul – Human centred information management. Harvard Business Review, March-April, pp. 119 -131.
About Suparna @ e3
Suparna is a hospital doctor and director/co-founder of e3 intelligence Ltd, providing clinical oversight and a frontline perspective - more info here
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One of the fascinating things about this debate is the way that “clinicians” changes apparently without thought into “doctors”: quite often it is the senior nurses and pharmacists who are key in defining needs, tailoring systems both organisational and IT to satisfy those needs – and ensuring that the staff using them are enthused with the possibilities and actually use the systems.
From a GP viewpoint, it seems that senior doctors in secondary care lack information about other departments (GPs don’t exist in the minds of secondary care! ;-<) so may not always be aware of the needs of those outside their speciality.
Hi Mary – thanks for stopping by and posting your comments. You are right in pointing out that the term ‘clinicians’ morphs into ‘doctors’ in my blog on two occasions. That’s because I was referring to anecdotal evidence that many doctors carry smartphones and iPads these days – I’m not sure if the same applies to nurses, therapists and pharmacists. Also, I had to refer to the role of Chief Medical Information Officers in the US – that’s a job title I cannot change but, interestingly, a campaign for similar roles in the NHS refers to them as Chief CLINICAL Information Officers.
I agree with you that senior hospital doctors may not always be aware of needs outside their specialty and often, there’s no incentive to do so. I’m not saying this is right or wrong but that’s just the reality. And GPs do exist in the minds of many senior hospital doctors, myself included, and will become more so with the NHS Reforms and CCGs.
Broadly agree with what you say above and you are right try and put both sides of the case.
Too often in this area politician and senior managers are looking for “White Knights” and “Silver Bullets” – Simply answers to complex problems, great if they exist but they rarely do.
Clinical engagement is necessary but not sufficient. I’d go broader than Mary and say we need front-line engagement. Not just doctors, other clinicians and HCPs, but also front-line management, technical and administrative staff, but still this is not sufficient.
While front-line staff with self-taught informatics skills are likely to do a better job that informatics professional who now little about health relying on such gifted amateurs alone is not optimal and occasionally disastrous
We need to ensure that all health and care professional are eHealth literate and that those with a particular role in relation to information and informatics, like CCIOs, have the formal training needed to give the skills to have a deep and meaningful discourse with informatics professionals. Similarly, informatics professional need to know more that a little about clinical medicine, health and care processes to effectively play their role and have a meaningful discourse with their HCP colleagues and customers.
One of the failings of the NPfIT was that the two parties didn’t understand or respect each other a situation made worth by the imposition of the LSP and local PfITS between front-line staff and the specialist health IT suppliers whose systems the LSP were deploying.
We need HCPs with a good knowledge of informatics working with Informatics professionals who understand medicine and healthcare working together and jointly leading the appropriate application to the IT and Informatics to support and transform the process of care.
Hi Ewan – thanks for stopping by and posting your comments. You have eloquently made some very good points that add to the thrust of my piece. Appreciate it.