Monday, September 13, 2010

More Evidence About How Hard Mega Projects Are and How There Are Probably Better Ways.

A few days ago an important paper was published in the British Medical Journal.

BMJ 2010; 341:c4564 doi: 10.1136/bmj.c4564 (Published 2 September 2010)

Cite this as: BMJ 2010; 341:c4564

Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation

  1. Ann Robertson1,
  2. Kathrin Cresswell1,
  3. Amirhossein Takian2,

For full list see the paper - there are about 20!

  1. Correspondence to: A Sheikh, professor of primary care research and development,
  • Accepted 5 August 2010


Objectives To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide early feedback for the ongoing local and national rollout of the NHS Care Records Service.

Design A mixed methods, longitudinal, multisite, socio-technical case study.

Setting Five NHS acute hospital and mental health trusts that have been the focus of early implementation efforts and at which interim data collection and analysis are complete.

Data sources and analysis Dataset for the evaluation consists of semi-structured interviews, documents and field notes, observations, and quantitative data. Qualitative data were analysed thematically with a socio-technical coding matrix, combined with additional themes that emerged from the data.

Main results Hospital electronic health record applications are being developed and implemented far more slowly than was originally envisioned; the top-down, standardised approach has needed to evolve to admit more variation and greater local choice, which hospital trusts want in order to support local activity. Despite considerable delays and frustrations, support for electronic health records remains strong, including from NHS clinicians. Political and financial factors are now perceived to threaten nationwide implementation of electronic health records. Interviewees identified a range of consequences of long term, centrally negotiated contracts to deliver the NHS Care Records Service in secondary care, particularly as NHS trusts themselves are not party to these contracts. These include convoluted communication channels between different stakeholders, unrealistic deployment timelines, delays, and applications that could not quickly respond to changing national and local NHS priorities. Our data suggest support for a “middle-out” approach to implementing hospital electronic health records, combining government direction with increased local autonomy, and for restricting detailed electronic health record sharing to local health communities.

Conclusions Experiences from the early implementation sites, which have received considerable attention, financial investment and support, indicate that delivering improved healthcare through nationwide electronic health records will be a long, complex, and iterative process requiring flexibility and local adaptability both with respect to the systems and the implementation strategy. The more tailored, responsive approach that is emerging is becoming better aligned with NHS organisations’ perceived needs and is, if pursued, likely to deliver clinically useful electronic health record systems.

The full paper is accessible from here (free) along with some additional web-only material.

What I found most interesting in this were the voices of the individual clinicians who clearly seemed to recognise the value in a working system but who were frustrated about the inflexibilities, slowness and inefficiencies that seemed to be associated with reaching a practical end-point.

It is also clear that and complex system implementation needs to be addressed at a coherent organisation that can work well internally to solve problems. This means there needs to be, in my view, implementation flexibility at the level of the area health service or region. The approach of state-wide implementations and equally the approach of giving every tiny organisation too much choice in how they proceed both seem to be problematic - as we have seen here in Australia.

The key to success I believe is to be clear just what aspect of any initiative need to be locally driven, what needs to be state driven and what should be nationally consistent. Getting this right can save a lot of money and angst!

This work and the papers that follow will become regarded as classics of the Health IT literature and those who worked on it are to be congratulated.

The lessons are pretty clear. I hope the relevant authorities are listening.



Anonymous said...

One other thing, stop allowing clinicians to direct business initiatives, they are NOT the experts here and are the cause of a good majority of failures within health IT projects.

They should stick to their area of expertise.

Anonymous said...

Actually, I find that clinicians are pretty good, because they understand the business processes and the business. Of course they need to be working with their IT staff, or to be getting good advice from their IT staff. Let's not forget that putting in a new system includes a whole range of components - people, processes, policies, and oh yes a bit of technology. Good IT people can communicate, listen and build the technology components to fit the business requirements, which as stated in the article above need to be 'clinically useful'! What does DOCTOR More think about this?

Dr David More MB, PhD, FACHI said...

My view,

If both clinicians and technologists are not properly involved and are dead meat on these projects.

This is not easy..but it is crucial!