HealthManagement, Volume 3 / Issue 5 / 2008

One-Size-Fits-All?No,Not Always,in IT

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Catalina Ciolan

ASSIST, an association of 1,800 healthcare IT professionals in Britain, has published the results of a survey on the Big Bang modernization project of the England’s National Health Service. Its findings may underscore the need for some re-evaluation of the parameters and objectives of major healthcare IT projects, especially those seeking to make Europe e-Health ready.


The ASSIST survey, whose findings were released in September to an Independent Review Group, set up by Member of Parliament and Shadow Health Minister Stephen O’Brien, sought to determine how clinical, public and management needs could most effectively be addressed by IT.


The survey’s backdrop consists of growing concerns about NPfIT (the National Programme for Information Technology), the IT modernization mega-project underway in the National Health Service (NHS) which has been billed the world’s largest civilian IT project.


Stunning Successes But …

The ASSIST investigation was moored in agnostic foundations. It began by underlying an assumption about the intrinsic benefits of healthcare IT, especially from electronic patient records.


ASSIST also expressed particular concern about the sustained bouts of negative publicity over NpfIT, in spite of what it called “stunning” successes over the past decade.


It praised standards of IT in use at GP practices and emphasized Britain’s global leadership in developing health information and IT standards. Largely due to NPfIT, it noted, Britain had a “robust, secure IT network”.


… Small is Beautiful

Nevertheless, ASSIST concluded that “ITimposed solutions” have “always tended to failure and that a one-size-fits-all approach does not work in the real world.


Instead, the study advocates ‘simple’ systems which can be configured locally. More sophisticated systems, in its view, are a recipe for rigidity.


Return to Basics

ASSIST recommends that major healthcare IT projects focus first “on the basics”, and only then target more ambitious goals.


Crucially, it strongly calls for policy makers and managers to begin by making existing healthcare IT systems achieve their original objectives before aiming higher at more sweeping ones.


Standards or Standardization More Than Terminology at Stake

ASSIST also says calls for more focus on standards, rather than the standardisation of systems - which was one of NPfIT’s original goals.


In this context, it underlines that although IT plays a core role in delivering healthcare at both national and local levels, it is often an “afterthought” for planners and poli - cymakers – “at all levels.” In turn, such an abs ence of strategic vision leads to “lastminute, ad-hoc” demands and system changes.


More Than Performance at Stake

The problem lies in the increasing coupling of the above factors – between the integral role of core systems in front-line care and a Band-Aiding ad-hoc approach. This “increasingly put patients at risk”. The ASSIST report provides several examples of strategic planning and impact assessment lagging behind implementation.


It also calls for greater transparency in learning from what has gone wrong. To do otherwise, it asserts, “is not just a matter of seeking to avoid criticism; patients’ lives may be at risk if we do not heed them.”


No Hyperbole

The above observations were not hyperbole. On October 5, a ‘Sunday Times’ report (‘Patients at risk’ from flawed £12bn IT system) quoted an internal paper about a computer system at the Royal Free Hampstead NHS Trust in London. The system, which was “intended to revolutionize patient care”, had so many software flaws that seriously ill patients faced a risk of being inaccurately diagnosed. According to the document, the system (used in the accident and emergency department), had been routinely crashing, with patient information intermittently ‘lost’ forcing staff to revert to pen and paper. Sources have also pointed to a host of other issues with the Royal Free Hampstead NHS Trust system. Some of these were, in fact, discussed in HIT Issue 2, 2007 in an exclusive article by Dr. Jan K. Melichar, ‘The UK NHS IT Programme: The most expensive patient administration system ever?’.


The key ones:

Ó Problems expected to be sorted before the system went live were remained unfixed three months later.

Ó Regular system crashes posed a clinical risk as patients can be lost in the system.

Ó Long smartcard log-in times wasted valuable clinical time and/or discouraged physicians from using the system.

This also led in some cases to smartcard sharing (not only a breach of protocol but also carrying serious problems about liability).


Assist Recommendations


Focus on the Basics Before Trying the Ambitious:

The visibility of ICT in hospitals is high and successes will be noticed and build confidence.


Do Not Lose or Threaten the Hard Won Successes:

The national security and information governance models, the high levels of ownership and use in primary care,s the success of national systems and IT infrastructure –notably PACS and the national broadband network. Public and staff confidence is fundamental to exploiting the further potential of (healthcare IT).


Focus on Standards Not Standardisation: 
A key theme of the 2002 NpfIT implementation vision was ‘ruthless standardisation’. This emerged from an attempt to see the health services as analogous to a big business, where efficiencies and control was exercised through the deployment of common systems. We reject the notion that the NHS is analogous to a bank, … a global telecommunications company or an airline.


Achieve a Balance Between Technology, Systems, People, Process and Culture: 

Different health and social care organisations are at different stages of maturity, for each of these key dimensions. ‘Big bang’ implementations of highly sophisticated solutions will rarely succeed in organizations without structured and integrated operational processes, top–level commitment from care professionals and managers, and strong informatics skills and infrastructures.


Ensure Much Earlier and More Integrated Policy Planning at Both National and Local Levels:

It is important to recognise that informatics is now core business and needs to be included in mainstream planning. Information is a vital and costly asset and should be treated as such.


Invest in a Systematic Health Informatics Research and Development Programme: 

This should be used to develop an innovative and robust supplier market, with lower entry barriers into the NHS IT market.


Avoid Structural Change: 

This drains resources, diverts management attention, incurs cost, creates substantial disruption, and delays implementation of the consistent vision.


Avoid Stand-Alone Data Demands: 

Information should be derived as the product of operational systems. Ad hoc demands, often requiring inefficient and staff-intensive solutions, are wasteful, produce poor quality data and continually divert resources and attention from addressing the underlying information and systems gaps.


Avoid Insular Systems Development.

It is important to recognise the potential value that individual local systems can have but only if they are developed in line with standards and support the flow and integration of information along care pathways, and delivered where and when needed by care professionals.


Invest in Developing Informatics Skills, Leadership and the Profession.

The full benefits of investment in informatics depends critically on the NHS and Social Care workforce – care professionals, managers and administrative staff – having the necessary core skills to make effective use of information and IT.



Adapted from report to the independent review group for the use of information technology in the NHS, health and social care in England. ASSIST National Council, September 2008.


Author<br> Catalina Ciolan <br> ASSIST, an association of 1,800 healthcare IT professionals in Britain, has published the results of a survey on the Big

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