The following appeared in e-Health Insider a few days ago.
ASSIST says idea NHS like a bank 'fundamentally flawed'
08 Oct 2008
NHS informatics professional body ASSIST has published a paper saying the original NHS National Programme for IT plan of one size fits all approach “does not work”.
The paper says attempting to treat the NHS as if it were a bank when the NPfIT strategy were misguided, and failed to understand the NHS.
ASSIST says there has been too much focus on standardisation of system rather than standards, and stresses that both national and local systems have a role to play but cannot succeed if they are imposed.
It says a revised strategy must reflect the shift to a pluralistic, federated model of care delivery, in which information follows the patient.
The paper calls for changes to NPfIT to take account of the changed policy environment, for mistakes to be acknowledged and lessons learned.
ASSIST, which is affiliated to the British Computer Society, says the standardised systems approach of the original NPfIT strategy, emerged from a “misguided attempt” to see the health service as analogous to a big business.
“We reject the notion that the NHS is analogous to a bank (especially in the current 'credit crunch'!), a global telecommunications company or an airline, and this believe that focusing on their ICT models for a healthcare environment was fundamentally flawed.”
…..
ASSIST makes the following recommendations
• Focus on the basics before trying the ambitious
• Do not lose or threaten hard won successes
• Focus on standards not standardisation
• Achieve a balance between technology, systems, people, process and culture
• Ensure much earlier and more integrated policy planning at both national and local levels
• Invest in a systematic health informatics research and development programme
• Avoid structural change
• Avoid stand-alone data demands
• Avoid insular systems development
• Invest in developing informatics skills, leadership and the profession
Jon Hoeksma
The full long article, can comments are here:
The submission that prompted the article is found here:
Independent Review Commissioned by Conservative Party
ASSIST has made a formal submission to an Independent Review Group, commissioned by and reporting to Stephen O'Brien MP, the Conservative Shadow Health Minister.
The Review Group has been established to inform the future policy for the use of information technology in the NHS, health and social care in England.
ASSIST's submission was developed through a facilitated workshop for senior informaticians held on Wednesday 24th September 2008, with other ASSIST members contributing by correspondence. ASSIST is grateful to John Farenden and Tribal for leading the workshop, continuing Tribal's long-term support of ASSIST.
More here:
http://www.bcs.org/server.php?show=ConWebDoc.22027
The home page for ASSIST is here(and is worth a visit):
http://www.bcs.org/server.php?show=nav.7898
This is remarkably like the conclusion of the Environmental Scan done for the Victorian E-Health Strategy.
http://www.health.vic.gov.au/ictstrategy/environment-scan.pdf
(Note this is a new, much better version of the document in terms of accessibility and searchabilty from a week ago.)
See especially pages 25 - 27.
“The Environmental Scan has identified some common critical success factors which will greatly enhance the chances of eHealth initiatives succeeding. These are:
• High level sustained commitment over several years with levels of investment of at least around 3% of Gross Operating Revenue.
• Clearly stated simple goals that can be measured.
• Manageable scop and timeframes (2-3 year planning horizon)
• Involvement of clinicians at all stages of the process.
• Enforcement of standards with some local flexibility in implementation of common systems.
From this research the following broad conclusions have been drawn with detailed examples contained within the body of this document.
1. Have a Plan
It is important to actually have a plan! The plan must be clear, simply understood by all stakeholders and offer an attractive vision of the proposed future. Additionally the plan must have the various components discussed in the introductory section. More than that the plan needs, if unintended consequences are to be avoided, to have a broad scope covering both the private and public sectors, where relevant, and also ensuring coverage of the needs of both the ambulatory, service and hospital sectors.
The plan also needs to be actively managed and reviewed every three to four years to make sure planned objectives are being met and to ensure there is a clear and current way forward.
It is clear from the cases discussed in the scan that the approach of developing an agreed plan and regular re-visitation of that plan has a beneficial effect in terms of objective progress made compared with lack of a plan.
2. Get Commitment
It vital to have high level political / managerial commitment to the key aspects of the plan. This is best achieved by creating a ‘burning platform’ based on the impact Health IT has on patient (i.e. voter) safety and the quality of care that is received or on the argument of the current sustainability of the health system as a whole (or both).
3. Be Prepared to Invest
It is clear that not providing an realistic level of funding for eHealth initiatives has very negative consequences. This means that not only is it important to have a clear plan but also to have a compelling business and operational justification for the investment. In Australia planning was undertaken for the HealthConnect initiative in the absence of such a compelling case and when the time came for the (significant) investment to be made the then Government decided it was all too hard and five years work was essentially wasted.
4. Set Reasonable Time Frames
It is important to set reasonable time frames to achieve the various milestones in the implementation plan. Implementation of a National or Regional EHealth Strategy is a complex and quite difficult task and setting over ambitious milestones can lead to loss of confidence on the part of those on the ground if too many milestones are missed. It is important to have sensible milestones in place to ensure progress is being made at an acceptable pace.
5. Recognise Change Management Constraints
There are real constraints on the scale of change that can be applied uniformly before implementation becomes unwieldy. The apparent ease with which smaller countries (with comparable levels of development) seem to make progress compared with larger ones is hard to ignore. The lesson to be drawn from this is that it is important to structure any national initiative to recognise the degree of inertia and lack of strategic and implementation flexibility that can be found in larger countries and to work to mitigate this issue.
6. Develop Incentives to Participate
There is considerable evidence that the use of incentives can assist in reducing the ‘friction of change’. As an example, in virtually all countries where there has been widespread adoption of EHRs in ambulatory care those who pay for the health system have provided some form of (usually financial) incentive to obtain widespread adoption. Examples include the Practice Incentive Payments in Australia and the provision of systems without any physician expense in the Kaiser system.
7. Tailor Plan to Existing Health IT Capability
When planning it is vital that the plan be tailored to existing Health IT capability and that gaps in the capability (be it lack an adequate number of Health Informaticians, inadequate internet connectivity, lack of appropriate standards or whatever) be identified and addressed.
8. Balance Technical Risk with Proven Technology
It is clear that there needs to be a balance struck between technical risk and complexity and the possibility of the implementation of obsolete or out of date systems. While most suggest that in ordinary times IT systems should be refreshed very five to seven years many core systems in hospitals seem to have lives measured in decades. The importance of getting system and technology selection as close to the mark as possible is obvious in these circumstances.
The other issue that needs to be considered is that if very advanced technology is utilised there is an increased risk of project delays as technological obstacles are overcome. The key in all this is a balance between ‘bleeding edge’ and ‘early possible obsolescence’.
9. Make Technology the Servant of the Health System
It is important to make sure the technology is the servant of the health system and that the technology is responsive to the needs of those who have to use the system. Experience suggests that initiatives which are driven by responding to the needs of the particular health system are the most likely to succeed.
10. Planned Incremental Approach
The deliberate adoption of a planned incremental approach that builds on earlier successes has a better likelihood of success than a ‘big bang’ approach.
Understanding the lessons of these experiences will go a long way towards avoiding repeats – especially getting the balance of local versus central control of implementations right.
Lots of food for thought in working out how Australia should proceed nationally.
David.
The bloomin’ obvious is equally applicable in Australia. The two most notable examples of where no-one has wanted to know about the “bloomin’ obvious” have been Canberra (consider the HealthConnect - NeHTA 7 year saga) and Victoria (consider the rigidity of thinking and policy imposed around HealthSmart for the last 4 years or so). If only the politicians would read your “Stating the Bloomin Obvious on HealthIT”, if only the bureaucrats would do so too, and much more importantly - if only they had the capacity and political will too comprehend.
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