Friday, July 22, 2016

Talk About A Long Goodbye! The UK NPfIT Finally Wraps it Up.

Digital Health.net (http://www.digitalhealth.net/) has written two articles which somehow seem to be a long obituary for one of the largest Health IT initiatives ever!
First we have the reporting:

National Programme for IT ends, but not for everyone

Ben Heather
11 July 2016
The National Programme for IT has finally come to an end, although the bill for the enormously expensive and controversial project will continue to be paid for years to come.
The deadline to exit NPfIT national contracts in the North, Midlands and East passed on 7 July, marking the end of the final chapter of the £12.7 billion attempt to bring the NHS into the digital age.
Trusts in these regions should have now signed new local contracts but most have opted to simply stick with those services that were deployed under the national contracts with United States-based company CSC.
In a final move before the July deadline, four additional trusts have also applied, and will likely receive, extra Department of Health funding to deploy Lorenzo, the electronic record CSC planned to roll-out across the NME before running into development and deployment troubles.
That means 15 trusts will now receive additional central funding to deploy Lorenzo for years to come, with some of these contracts stretching out until 2022.
Health and Social Care Health Information Centre figures show that of the 782 systems deployed across 223 organisations under the NPfIT in the NME, 64 % were being retained under new local contracts.
In acute trusts this was mostly mix of older iSoft systems originally deployed as “interim” measures, such as the i.PM patient administration system, the i.CM clinical suite and related products such as the Ormis theatre system.
Lots more here:
Then we have the obit.

Lorenzo: the end of the beginning

The National Programme for IT in the NHS came to an end in the North, Midlands and East last week. Its flagship electronic patient record was Lorenzo. After ten years trying, and millions of pounds of investment, how are recent deployments going, and what legacy will it leave? Ben Heather reports.
Peruse the board papers of Norfolk and Suffolk NHS Foundation Trust and it soon becomes clear that it’s been a rough year on the IT front.
The trust deployed CSC’s Lorenzo as its electronic patient record on 20 May last year. It was hoped the new system would turbocharge Norfolk and Suffolk into the digital age, replacing paper and ageing, clunky software with a slick, adaptive platform. It hasn’t quite worked out that way, at least not yet.
In October last year, the Care Quality Commission warned the trust it needed to get Lorenzo in order, but as recently as June the trust’s board was still being told “performance issues” with the EPR were an “outstanding risk”.
Board papers reveal that 554 incidents relating to Lorenzo were reported on Datix between go-live and May 2016. Many of these issues were local; but others related to national “outages” that affected all trusts using Lorenzo.
Between November last year and April there were 11 such outages, and CSC, at least initially, struggled to get to the bottom of them. “Although reliability has improved, system outages have not been eliminated,” the board papers note. “Key actions are outside the control of NSFT [the trust] and so [there is] no timescale for remedy.”
It all started with the National Programme for IT
After Accenture quit the National Programme for IT in the NHS back in 2006, CSC became the sole local service provider for the North, Midlands and East of England – three fifths of the NHS.
It was due to roll-out Lorenzo to healthcare communities across these regions, but ran into repeated development delays and deployment issues. Eventually, CSC bought iSoft, which had developed Lorenzo, and with it a suite of older patient administration and clinical systems.
CSC offered these systems – primarily iPM, iCM, and the theatre system Ormis – to trusts as ‘interim’ solutions.  And, despite their age, they have proved popular. Offered a chance to tender for alternatives as their national contracts ran out, most trusts chose to stick with them.
Figures released to Digital Health News last week showed that of the 782 systems deployed across 223 organisations under the NPfIT in the NME, 64 % were being retained under new local contracts.
However, the number of trusts deploying Lorenzo remained small and mostly confined to ‘exemplars’ like University Hospitals of Morecambe Bay NHS Foundation Trust, which exerted a huge effort to make Lorenzo work.
In response, the Department of Health and CSC negotiated a contract reset in 2012 that removed the company’s right to be the sole supplier of systems to the NME, while making central money available to trusts that still wanted to adopt Lorenzo.
The Health and Social Care Information Centre confirmed last week that 11 trusts took up the offer; with a further four still in the pipeline.
Vastly more here:
This is a story well worth reading all the way through. I find it amusing that the older iSoft products seem to have been so successful in use – showing once again how sad it was that we lost the company from Australia – much more for commercial rather than technical reasons in my view.
Overall the program ran for close to 20 years and cost billions. It will be interesting to read the book when it is finally written.
David.

12 comments:

Bernard Robertson-Dunn said...

As long as people read and believe reports like this, the same old mistakes seen in NPfIT and MyHR will get made.
http://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/healthcares-digital-future

They talk about three waves and then say this:

"Many institutions in the private and public sector have already moved to the third wave of IT adoption—full digitization of their entire enterprise, including digital products, channels, and processes, as well as advanced analytics that enable entirely new operating models. No longer limited to helping organizations do a certain task better or more efficiently, digital technology has the potential to affect every aspect of business and private life, enabling smarter choices, allowing people to spend more time on tasks they deem valuable, and often fundamentally transforming the way value is created. What will this third wave of IT adoption look like for healthcare?

Players in the healthcare industry were relatively successful at—and benefited from—the first and second waves of IT adoption. But they struggled to successfully manage the myriad stakeholders, regulations, and privacy concerns required to build a fully integrated healthcare IT system. This is partly because the first and second wave of IT adoption focused more on processes and less on patient needs. Still, programs like the N3 communication network in the United Kingdom and the secure telematics platform in Germany have created powerful infrastructures that have the potential to support the third wave of digital services in healthcare—but only if stakeholders take the appropriate next steps."

So far so good.

It's when you get through the "myths" to the last sentence that the whole house of cards comes tumbling down:

"Understanding what patients want—and what is purely myth—can help pave the way."

They just don't get it.

Patients (and funding organisations) are the beneficiaries of better health care, however they are not the main users of "digital technology". The main users are health care professionals who need the technology and health information in order to make better decisions.

The Mckinsey report never mentions health care decisions.

Yet another consultant's report, based upon a survey; looking backwards, learning nothing giving the impression of insight.

Dr Ian Colclough said...

Thank you for that Bernard - I agree with you "They just don't get it.".

As you say - "Patients (and funding organisations) are the beneficiaries of better health care, however they are not the main users of "digital technology"."

Yet it is the funding organisations (or in other words the bureaucracy) with huge amounts of money at their disposal which dictate how and where the money will be spent; absent clear strategic thinking, grossly inadequate project management and overview, and a disconcerting lack of transparency and accountability, underpinned by a great sense of urgency, a big bang approach and very little involvement with the targeted end users, other than "we have developed this for you - use it".


Bernard Robertson-Dunn said...

Thank you Ian.

My one word summary is:
Hubris

or, in three words:
Ignorance and arrogance.

Anonymous said...

Bad project management and oversight? Perhaps it is amateur hour in procurement and lack of penalties and exit strategies in contracts that results in frustrated project management.

john scott said...

Bernard, I agree entirely with your comments.
The focus must be on the doctors and associated clinical teams--within and across professional domains, organisations and jurisdictions.

In my view, the bottom line is:
1. Doctors are required to make decisions about life and death and are held to account for those decisions;

2. Accordingly, they should be demanding control over the IT-related decisions directly affecting care, particularly including how they communicate with other health professionals. For safety and quality reasons they should not taking instructions from others about how they go about their work.

Having said that, When analyzing the habits of communication in the health sector with a view to enhancing productivity, doctors suffer from the "fish in water problem": a fish does not know it is in water. Doctors are not required to analyse these things and so they do not.

If we are to make e-health contribute successfully to care delivery we need to purposefully separate the physical human sphere of health from the electronic sphere. We need to do this in order to focus purposeful attention on the quality of cooperation among clinicians to improve the exchange of clinical information.

As a corollary, this purposeful separation would enable a re-think, re-design of our electronic health records strategy to more accurately portray where and under what circumstances we create such repositories.

Bernard Robertson-Dunn said...

John,
Adding to your insights:

1. Automating manual health record keeping systems will lead nowhere, other than increased costs, poorer quality health care (GPs end up as data entry clerks)

2. GPs don't know what they need in order to deliver better decisions (more static data is not the answer)

Therefore, any approach that focuses on building a dumb central health record database is the wrong answer.

What is the right answer? We just don't know yet.

What should be created? An evolutionary, experimental, low risk ecosystem that closely defines what is absolutely necessary and leaves other parts less well defined to support innovation, flexibility and feedback as to what works.

This requires a conceptual and logical architecture framework within which specific solutions can be implemented and co-exist. This is actually relatively easy, if you know what you are doing.

This approach supports John's proposition that we should "purposefully separate the physical human sphere of health from the electronic sphere"

Unfortunately, the NEHTA architects didn't know what they were doing. I base this observation on the NEHTA document:
"High-Level System Architecture, PCEHR System Version 1.35 — 11 November 2011"
where the definitions of conceptual and logical architectures are totally different from those that have been used by more experienced and enlightened architects for many years.

I'll repeat one of my favourite quotes:
“We fail more often because we solve the wrong problem than because we get the wrong solution to the right problem”
Russell Ackoff

In the case of NEHTA, they came up with the wrong solution to the wrong problem.

Which means we are now left with two, not one, questions:

1. What is the right solution to the right problem?
2. How do we persuade those who don't understand just what a big mess they are in that they need to answer the first question?

Unfortunately we may be in the same situation that scientific pioneers of the past faced - how do you get acceptance of new ideas?

History and experience shows that often the only way is for the old guard to die.

New ideas get taken up by the young; unlike the old guard, who resist change and have a lot to lose, the young don't have to change the way they think, they just adopt the new ideas because they are so obviously better.

Bernard Robertson-Dunn said...

Expanding on the uselessness of the NEHTA/PCEHR "architecture"...

When I was learning about Information System architectures and development, they used a library lending system as an example.

The conceptual information architecture included the concept of a book. This was central to the system as it was what the whole application was about.

Looking at the the supposed PCEHR "conceptual architecture", the one thing missing is "person". The only thing that comes anywhere near "person" is an identifier for "individual" in the HI service.

In other words, they have built a system where the whole purpose is to manage documents, where the contents of the documents (health information on an individual) are largely irrelevant.

As has been said before on this blog, the PCEHR/MyHR system is modeled on a filing cabinet.

If anyone thinks that the PCEHR/MyHR can be developed and/or modified into something useful medically, IMHO they just don't understand the depth of the hole that has been dug.

Anonymous said...

There is a collection of common post modern problems that will defy reason.

We have classic cognitive dissonance where the stronger the evidence against to correctness of what they believe becomes the harder they dig in. We now have a good going cargo cult.

We have generic management that don't feel that they need to have any real understanding of what they are managing and this allows inexperienced "architects" to go off into the weeds. The weeds are well over their heads at the moment but they trundle on. There will be a cliff somewhere.

Other professional bodies such as the AMA make the assumption the DOHA and NEHTA know what they are doing, but the bureaucracy distrusts anyone with experience as they feel they can't be controlled - by generic management. Anyone will a passion for doing something useful will soon be shown the door. Bodies like the AMA assume there must be some good in whats done and don't have the knowledge to know otherwise.

I suspect we have an element of crony capitalism with to many executives swapping sides and feathering nests.

We have easy borrowed money that supports all this, and politicians refuse to contemplate that it has all been wasted and join in the cognitive dissonance. They now use PIP payments to force use of a woeful system and make it opt out in a last ditch attempt to avert another big IT failure on their watch. If they can spin it out long enough maybe it quietly fade away???

No one in any position of power has the combination of IT and medical knowledge to actually see what a solution might look like and the dangerous bit is that the bureaucracy would try hard to kill any solutions that looked like they might work as it would be an embarrassment. They have ruined the Standards Australia process that used to work, as they wanted to be the only game in town.

I know Tony Abbott as health minister smelt a rat and tried to help, but the solution was probably a more malignant tumor than the original disease.

As I see it the only solution is likely to be a real budget emergency, where every non essential expenditure is canned. That process of cleansing is long overdue but is been held off around the world by increasing, but cheap debt that cannot continue forever and somewhere out there is the solution.... The great Reckoning to come.

Bernard Robertson-Dunn said...

Anonymous said "We have classic cognitive dissonance where the stronger the evidence against the correctness of what they believe becomes the harder they dig in. We now have a good going cargo cult."

It's a known phenomena - Backfire.

How facts backfire
http://www.boston.com/bostonglobe/ideas/articles/2010/07/11/how_facts_backfire?mode=PF

Researchers discover a surprising threat to democracy: our brains
By Joe Keohane | July 11, 2010

Here's a few apposite quotes:

"Recently, a few political scientists have begun to discover a human tendency deeply discouraging to anyone with faith in the power of information. It’s this: Facts don’t necessarily have the power to change our minds. In fact, quite the opposite. In a series of studies in 2005 and 2006, researchers at the University of Michigan found that when misinformed people, particularly political partisans, were exposed to corrected facts in news stories, they rarely changed their minds. In fact, they often became even more strongly set in their beliefs. Facts, they found, were not curing misinformation. Like an underpowered antibiotic, facts could actually make misinformation even stronger."

“The general idea is that it’s absolutely threatening to admit you’re wrong,” says political scientist Brendan Nyhan, the lead researcher on the Michigan study. The phenomenon — known as “backfire” — is “a natural defense mechanism to avoid that cognitive dissonance.”

"Studies by other researchers have observed similar phenomena when addressing education, health care reform, immigration, affirmative action, gun control, and other issues that tend to attract strong partisan opinion. Kuklinski calls this sort of response the “I know I’m right” syndrome, and considers it a “potentially formidable problem” in a democratic system. “It implies not only that most people will resist correcting their factual beliefs,” he wrote, “but also that the very people who most need to correct them will be least likely to do so.” "

"A 2006 study by Charles Taber and Milton Lodge at Stony Brook University showed that politically sophisticated thinkers were even less open to new information than less sophisticated types. These people may be factually right about 90 percent of things, but their confidence makes it nearly impossible to correct the 10 percent on which they’re totally wrong."

The report is mostly about voters, but, IMHO it applies to many players in the health care arena.

Read the report. And weep.

And when you are totally depressed have a go at this, it's called the Dunning Kruger effect:

Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments
Justin Kruger and David Dunning
Department of Psychology Cornell University
http://drbrd.com/docs/DunningKruger.pdf

"People tend to hold overly favorable views of their abilities in many social and intellectual domains. The authors suggest that this overestimation occurs, in part, because people who are unskilled in these domains suffer a dual burden: Not only do these people reach erroneous conclusions and make unfortunate choices, but their incompetence robs them of the metacognitive ability to realize it."

Anonymous said...

What an exquisite summary (July 24, 2016 4:01 PM) the truth of the matter. Turnbull, Morrison and Ley are oblivious to it all.

1. "generic management (that) don't feel that they need to have any real understanding of what they are managing and this allows inexperienced "architects" to go off into the weeds."

2. "Other professional bodies such as the AMA make the assumption the DOHA and NEHTA know what they are doing"

3. " .... politicians refuse to contemplate that it has all been wasted and join in the cognitive dissonance."

4. ".. easy borrowed money (that) supports all this,"

5. "No one in any position of power has the combination of IT and medical knowledge to actually see what a solution might look like "

6. " ... the dangerous bit is that the bureaucracy would try hard to kill any solutions that looked like they might work as it would be an embarrassment."

A canny investor could make a motza out of the golden opportunity now created, provided they knew how.

Anonymous said...

A canny investor could make a motza out of the golden opportunity now created, provided they knew how.

They need to be more than just canny. They also need access to a couple of pragmatic individuals with "a combination of IT and medical knowledge" and experience in complex strategic thinking.

Anonymous said...

Well, ironically, the DUnning-Kruger effect is quite visible with some of the comments here too.