This blog is totally independent, unpaid and has only three major objectives.
The first is to inform readers of news and happenings in the e-Health domain, both here in Australia and world-wide.
The second is to provide commentary on e-Health in Australia and to foster improvement where I can.
The third is to encourage discussion of the matters raised in the blog so hopefully readers can get a balanced view of what is really happening and what successes are being achieved.
Monday, March 04, 2013
Professor Enrico Coiera Explores Why Health IT Is So Hard. A Very Good Read.
This appeared in the Medical Journal of Australia today.
Why e-health is so hard
Med J Aust 2013; 198 (4): 178-179.
We need to respect the basic rules of informatics and invest in e-health expertise
Medicine holds dominion in the microcosm of molecules and genes. It is in the macrocosm of people and organisations where things seem to fall apart. Modern health care appears unsustainable in its current form,1 and information technology is increasingly seen as a major intervention that can drive “reform”.
Evidence for e-health’s potential to improve the safety and quality of care grows,2 but remains patchy.3 The long list of disappointments and failures,4,5 locally and internationally, is also hard to ignore. There is a real dissonance in the discourse between what research evidence tells us is possible and what often happens with large-scale e-health projects in practice.6
The literature repeatedly describes basic “rules of informatics” for implementation success: the need for stakeholder engagement, culture change, user training, slow and considered implementation, and user-friendly systems that fit into clinical workflow.7 The very first rule of informatics tells us to start with the clinical problem we want solved rather than the technology we want to build.8 Yet, too often, large-scale e-health projects break this most basic rule, focusing on technology rather than compelling clinical problems.5 We are often told that national e-health projects must first lay down basic technical infrastructure and that high-value clinical systems will naturally follow, in the same way that laying railway lines is a precursor to delivering transport services.9 But railways can be too expensive, over-engineered, or not take us anywhere particularly useful — unless there is a destination on which we can all agree.
Why so many projects repeatedly fail to observe these basic rules of informatics remains a mystery, but it probably reflects that there are still very few people with deep expertise in e-health.10 Despite the crucial role of the informatics workforce in e-health success, and the billions spent on e-health over the past decade by government, barely a dollar has been in direct support of informatics workforce training.
E-health is hard because it is a complex intervention in a complex system.11 Indeed, e-health projects are probably among the most complex interventions we can undertake, especially at a national scale. The rules for designing e-health at the level of clinical practice are not the same as those at large scale, and the gap is as wide as that between in-vitro and in-vivo clinical studies. This explains why success at individual sites is no guarantee of success elsewhere.
Just because e-health is hard does not mean we can ignore it and do something else instead. The goal is worthy, and alternatives are thin on the ground. We do, however, need to urgently invest in the informatics workforce, as this is no game for amateurs. We must also respect the basic rules of informatics. Like the laws of physics, they exist, whether you like them or not.