Frectally speaking

Healthcare: needs better Information Technology

In our initial analysis of healthcare under pressure, we have identified the particularly information intensive nature of modern medicine.
We have seen that information is a critical element of clinical care at the frontline, improving the quality of care via clinical audit, improving the research and evidence base of healthcare and delivering better value for money.

You may then naturally conclude that healthcare reform needs important support from information technology. However you may also be aware that the evidence of successes in healthcare IT is decidedly mixed.

What is clear is that there is some evidence of the significant value of healthcare IT (e.g. within primary care medicine and across a number of hospital institutions) in ;
-improving the quality of care e.g.  with adherence to guidelines
-reducing the risks of care e.g. by reducing medication errors
..though there is much less evidence of related savings of time or money.
Certainly the evidence of widespread benefit across healthcare systems is limited and points to the challenges of scaling and maintaining information technologies amidst the complexity of healthcare.

Yet while there has been a myriad of stories of suboptimal health IT deployments, the appetite and drive towards greater and wider use of healthcare information technologies continue apace. What can explain this puzzle and gap between aspiration and reality?

Firstly, healthcare is complex.
As we have explained already, healthcare is a good example of a complex system. As a system of many parts and many interactions between those parts healthcare is more of an ecosystem than a machine and should be treated as such.
So while there may be umpteen stories of IT success at a local level, it is when one tries to scale up and then maintain larger and larger systems across healthcare systems that it can quickly become unmanageable.

Secondly as with change in an complex systems, success or failure usually relates to some of the key patterns that we have identified within.

The failures usually come down to one or more of 3 key factors-
People-  lack of clinical leadership, clash of cultures
Process-  poor fit with clinical process and
Technology – inflexible technology that struggles at scale .

Equally the successes are usually linked to ;
People – strong clinical leadership,
Process-  a concerted and combined effort to improve processes and
Technology – that is flexible technology that can handle change..

Let us look further at these key points with a brief exploration of some work I have done in the past..

As part of my MSc and the start of my work within NHS Connecting for Health (which ran between 2004 and 2010 to deliver the NHS National Programme for IT), I was involved in the setup of a “Model Community”.
In healthcare terms this was a novel idea, attempting to support good practice in clinical engagement, process improvement and information testing by setting up an alpha test site as a Model Community..
Located within an NHS clinical setting, we invited NHS clinical and administrative staff to attend and explore and trial process changes with health IT software, in advance of it going live in any live clinical setting.

The clinical staff who attended enjoyed the experience for the most part, while highlighting common process and software issues that were then fed back to ensure further process improvements and software fixes.
If was fascinating at times and as expected familiar common patterns began to emerge from amidst the complexity..

People;
NHS Staff from differing parts of the service often/usually came with their own culture and view of the health service. While the NHS is one very large organisation, cultural variances within the NHS were/are common place.

Process:
As diverse groups exist within the NHS, each had their own view of their own processes. So alongside significant variation in existing processes, we also noted that the language used to describe similar processes differed significantly between groups. For example, the clinical terms “assessment”, “care plan”, care pathway” while widely known, meant differing things to different groups.
Without a consistent healthcare process vocabulary and widespread process variation, one of the common findings we made was a clash between good process/practice and the related information technology solution that was expected to add value.
This finding of a mismatch between business process and information technology is not a new finding by any means, rather a common pattern that is exposed when exploring business change with technology amidst complex environments.

Technology
Without a common process language and framework, the natural result was/is that clinical teams, by articulating their processes in varied ways have defined varying information technology requirements that produce information systems with significant variation in their design and build.
Therefore the current health IT landscape has a multitude of technical solutions (with significantly overlapping functionality) yet they do not interconnect and interoperate, which is an acknowledged barrier to future healthcare reform.

The most common approach to interoperability to date has been to agree on and standardise the messages between disparate systems. There are numerous international standards available for “interoperability”, primarily for messaging… within healthcare the standards body Health Level 7 has long been the pioneer in this field.

To date the approach to interoperability between systems via messaging alone, while yielding significant benefits, continues to assume that clinical facing frontline systems can be treated as “black boxes”, without any pressure to standardise component parts within the clinical systems.
While that fits with the current health IT markets’ approach to each vendor maintaining their own proprietary information systems architecture, this does nothing to attempt to standardise the important fit between best practice or process and supporting information systems across healthcare that is needed for healthcare reform.

Naturally these issues are not confined to the NHS in the UK, but are rather universal issues found across the world of healthcare.

Simply put, Healthcare needs better IT.

Further to my work within the NHS CfH Model Community exploring common challenges in people, process and technology, we then began to explore common patterns in healthcare processes as a means to identifying common information technology requirements and related standards towards interoperable solutions. For more on that I will move on….

• Healthcare: chasing the right fit between Process and IT..
• Healthcare: openEHR’s potential to handle Complexity & Diversity
• Healthcare change: why “Open Source” is part of the recipe..

References

http://www.connectingforhealth.nhs.uk/

Barretto, Sistine (2005) Guideline Based Workflow Integrated Electronic Health Records Barretto_PhD_Thesis_2005

Chaudhry B, Wang J, et al (2006)  “Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care” Annals of Internal Medicine, May 2006, vol. 144, no. 10, p 742-752
http://www.annals.org/content/144/10/742.full

http://junkfoodscience.blogspot.com/2008/12/separating-myth-and-evidence-about.html

Kerr, E A, Fleming, B “Measuring quality through performance: Making performance indicators work: experiences of US Veterans Health Administration” BMJ 2007;335:971 doi:10.1136/bmj.39358.498889.94

Majeed, A, Helen Lester, H, Bindman, A “Improving the quality of care with performance indicators” BMJ 2007; 335 : 916

doi: 10.1136/bmj.39337.539120.AD

Shannon T, (2004) “Evaluating business processes with information technology in user acceptance testing,” MSc IT Management project Dissertation

https://frectal.files.wordpress.com/2009/10/tonyshannon_mscitmprojectdissertation_comm1l.pdf