From This We Can Really Grasp Just How Hard A National E-Health Program Can Turn Out To Be! Way Beyond NEHTA / DoHA Can I Suggest!

The following paper appeared recently. The Abstract follows and the link below provides access to the full paper and a .pdf file.

Why National eHealth Programs Need Dead Philosophers: Wittgensteinian Reflections on Policymakers’ Reluctance to Learn from History

Trisha Greenhalgh, Jill Russell, Richard E. Ashcroft, and Wayne Parsons

Queen Mary University of London

Context: Policymakers seeking to introduce expensive national eHealth programs would be advised to study lessons from elsewhere. But these lessons are unclear, partly because a paradigm war (controlled experiment versus interpretive case study) is raging. England’s $20.6 billion National Programme for Information Technology (NPfIT) ran from 2003 to 2010, but its overall success was limited. Although case study evaluations were published, policymakers appeared to overlook many of their recommendations and persisted with some of the NPfIT’s most criticized components and implementation methods.

Methods: In this reflective analysis, illustrated by a case fragment from the NPfIT, we apply ideas from Ludwig Wittgenstein’s postanalytic philosophy to justify the place of the “n of 1” case study and consider why those in charge of national eHealth programs appear reluctant to learn from such studies.

Findings: National eHealth programs unfold as they do partly because no one fully understands what is going on. They fail when this lack of understanding becomes critical to the programs’ mission. Detailed analyses of the fortunes of individual programs, articulated in such a way as to illuminate the contextualized talk and action (“language games”) of multiple stakeholders, offer unique and important insights. Such accounts, portrayals rather than models, deliver neither statistical generalization (as with experiments) nor theoretical generalization (as with multisite case comparisons or realist evaluations). But they do provide the facility for heuristic generalization (i.e., to achieve a clearer understanding of what is going on), thereby enabling more productive debate about eHealth programs’ complex, interdependent social practices. A national eHealth program is best conceptualized not as a blueprint and implementation plan for a state-of-the-art technical system but as a series of overlapping, conflicting, and mutually misunderstood language games that combine to produce a situation of ambiguity, paradox, incompleteness, and confusion. But going beyond technical “solutions” and engaging with these language games would clash with the bounded rationality that policymakers typically employ to make their eHealth programs manageable. This may explain their limited and contained response to the nuanced messages of in-depth case study reports.

Conclusion: The complexity of contemporary health care, combined with the multiple stakeholders in large technology initiatives, means that national eHealth programs require considerably more thinking through than has sometimes occurred. We need fewer grand plans and more learning communities. The onus, therefore, is on academics to develop ways of drawing judiciously on the richness of case studies to inform and influence eHealth policy, which necessarily occurs in a simplified decision environment.

Keywords: eHealth, policymaking, case study, ethnography, evaluation, Wittgenstein, sensemaking, learning community.

Here is the link to the full (free) paper.

http://www.milbank.org/quarterly/8904feat.html

The paper needs to be carefully read two or three times as there is a huge amount of information in it, and it is by no means an easy read.

These two sentences from the abstract seem to say it all!

“National e-Health programs unfold as they do partly because no one fully understands what is going on. They fail when this lack of understanding becomes critical to the programs’ mission.”

It seems to me that having most of us not understanding just what is going on has actually been a managerial strategy for NEHTA and DoHA and that it is now really coming back to bite them!

I must say that I find a great deal of what is said very compelling. As I read it, the authors clearly recognise the complexity of healthcare and also recognise that deployment of technology within such an incredibly complex beast is not something that can be planned in a fully rational mechanistic way without recognising that the health ecosystem (and the breadth of stakeholders) defies simple rationally driven imposition of technology.

The section discussing “A Case within a Case: The Newtown Integrated Records Pilot” in the paper seems to me to be utterly typical of how apparently simple interventions can wind up in frustration, mis - communication and ultimately a sense bordering on despair. It is just too painful to read!

Seldom was the following more apt:

Those who ignore history are doomed to repeat it. —George Santayana (1863–1952)

To me part of the problem in all this is both the usual lack of leadership and governance but also a failure to remember just why the effort is being attempted.

There is only one reason for e-Health implementations to be undertaken and that is to improve the quality, safety and efficiency of the care each of us receives from the health system. Until NEHTA and DoHA get back to focussing on that simple proposition we are all in deep dodo.

All we see is a focus on systems, standards and technology and no clear exposition of the why we are doing this and what the evidence is that this is the right thing to be doing.

Until we step back from the mad helter skelter rush to have operational an ill-conceived and overly complex system those running the PCEHR program will be guilty of simply not bothering to learn from elsewhere.

That the Secretary of the Federal Department of Health can claim essentially we need to do it this way because we are different - as she did at a recent Senate Estimates Hearing - displays the sort of hubris that guarantees failure.

It has always been a source of amazement to me that the analysis of overseas National E-Health programs in the recently released ConOps ran to 2-3 pages. It should have been 20 times that - so anyone could have any confidence any lessons have been learnt!

David.