Refereed Studies

From Nhs It Info


Privacy in clinical information systems in secondary care (15 May 1999)

BMJ 1999;318:1328-1331

". . . In the BMA consultation document Security in Clinical Information Systems Anderson identifies nine principles governing the design of a clinical information system meeting the requirements for patient privacy.2 Doubts have been raised about the feasibility of adopting the code for governing access to patients' electronic records in secondary care. Our experience is that the principles are achievable. This article is based on our experience of a large scale clinical information system in use in three British hospitals---Conquest Hospital, Hastings; Aintree Hospital, Liverpool; and Royal Devon and Exeter Hospital, Exeter. We describe the approach taken to ensuring control over access to confidential patient information on the basis of expected relationships between staff and patients. . . . This can be achieved by matching a patient's current clinical contacts with a user's rights; this has been shown to be workable in a hospital-wide clinical information system . . ." [Denley & Smith]

Issues in the multi-disciplinary assessment of healthcare information systems (Sep 1999)

Information Technology & People 12, 3

"Abstract: Considers the problems of a multi-disciplinary team working together to understand and evaluate a healthcare information system, which itself is situated in a complex organisational and political environment. Provides general discussion of problems faced by evaluators of such systems. Describes this specific evaluation project (Electronic Patient Records in the UK National Health Service), gives an account of the evaluation process as it occurred, highlights some of the problems encountered, and discusses attempts to overcome these. Suggests that social, organisational and political factors are inherent in all such research enterprises, and that in order to facilitate a rich understanding of complex systems, these factors must also be considered as part of the research data." [Heathfield et al]

Construction of a Virtual EPR and Automated Contextual Linkage to Multiple Sources of Support Information on the Oxford Clinical Intranet (1999)

Proc AMIA Symp

"Abstract: We have used internet-standard tools to provide access for clinicians to the components of the electronic patient record held on multiple remote disparate systems. Through the same interface we have provided access to multiple knowledgebases, some written locally and others published elsewhere. We have developed linkage between these two types of information which removes the need for the user to drill down into each knowledgebase to search for relevant information. This approach may help in the implementation of evidence-based practice. The major problems appear to be semantic rather than technological. The intranet was developed at low cost and is now in routine use. This approach appears to be transferable across systems and organisations." [Kay et al]

Evaluating computerised health information systems: hard lessons still to be learnt (Apr 2003)

BMJ 2003;326:860-863

"Enormous investment has gone into computerised hospital information systems worldwide. The estimated costs for each large hospital are about $50m (£33m), yet the overall benefits and costs of hospital information systems have rarely been assessed. When systems are evaluated, about three quarters are considered to have failed, and there is no evidence that they improve the productivity of health professionals. To generate information that is useful to decision makers, evaluations of hospital information systems need to be multidimensional, covering many aspects beyond technical functionality. A major new information and communication technology initiative in South Africa gave us the opportunity to evaluate the introduction of computerisation into a new environment. We describe how the project and its evaluation were set up and examine where the project went wrong. The lessons learnt are applicable to the installation of all hospital information systems." [Littlejohns, Wyatt and Garvican]

Integrating Child Health Information (11-12 Dec 2003)

Integrated Care Records: Problems and Solutions Workshop, Edinburgh

"Abstract: The Scottish Executive highlight that better sharing of children’s information is crucial to providing improved co-ordinated care, for all Scotland’s children, especially for those most in need. The “Shared Information Project” a £340,000, flagship 2 year programme, funded by the Changing Children Services fund was set-up to meet this goal. The project is clinically lead, by a Consultant Paediatrician, Primary Care Management and supported by a Clinical Specialist in Health Informatics, a Senior Social Worker and a Project Manager. Information Requirements have been defined using evidence based health informatics methodologies and the outcomes analysed using thematic-analysis. Importantly this work highlights the benefits of systematic evidence based informatics in defining actual requirement, their strength and variation across care providers. This project highlights that for successful integration of children’s information human systems and IT systems need to be developed in parallel." [Hammond et al]

dbMotion: Virtual Health Community (11-12 Dec 2003)

Integrated Care Records: Problems and Solutions Workshop, Edinburgh

"Clalit Health Services is the largest health organization in Israel and the second largest in the world. It is a decentralized organization that provides services to approximately 3.7 million clients through 14 hospitals, 1,300 clinics and medical centres. The organization employs approximately 20,000 care providers, each of which can create medical data and, more importantly, request up-to-date data about patients. The medical information systems in the organization differ from one another and lack unification between the systems. The dbMotion system is currently installed at all Clalit hospitals, and in some specialty hospitals. The system is also in use at in all the districts and clinics. Since the system is Intranet-based, it is accessible to any service or care provider for whom an account has been defined in the organizational network. The dbMotion solution, implemented at Clalit, was based on the requirement to collect data from the existing legacy systems without the need to replace them, change their function or the way they are utilized. dbMotion integrates data from clinical sources that are dispersed geographically all throughout the Clalit, and contain various types of information. For example, the solution integrates data from the hospital Emergency Room and wards, the local clinics, as well as the several Clalit laboratories. In addition, the solution needed to utilize existing infrastructures for communication and data transfer such as the LAN and WAN networks or the Internet, as well as a web-based viewer, where the physician can browse through his patient's history.The solution provides available, up-to-date medical information while maintaining the highest level of information security." [Gillon et al]

Trusting The Record (2003)

Methods inf. med. 42,4 (2003) pp. 345-352

". . . The setting for our study is the toxicology ward within a large Edinburgh hospital. The aim was to subject work within the ward, and in particular document work, to close empirical investigation. . . Paper-based records are criticised for being hard to access, poorly organised, incomplete, inaccurate, hard to read, lacking consistency in format and use of terminology. The electronic medical record (EMR) is consequently seen as providing the conditions for the imposition of greater discipline and structure on record-keeping practices and it has also become a major factor in the drive for the standardisation of medical record formats. This standardisation is, in turn, expected to lead to better treatment and the realisation of 'joined-up', 'seamless' healthcare. Our fieldwork data points to a number of trust issues - related to the way that record use is a fundamental aspect of the moral order of the working division of labour . . . Existing patient admission procedures involve the concurrent physical handover of the patient, and of information relating to the patient's admission in the form of the pink and blue sheets. This naturally provides the opportunity not only for the transfer of information about the patient, but also for the checking of its accuracy by the admitting nurse. . . With the deployment of the EMR, future admission procedures might reasonably be expected to dispense with the handover of paper: Ward nurses will be able to access the information recorded at A&E directly through the nurses' station EMR terminal. While this may seem to exemplify the ways in which the EMR can streamline and improve information-handling procedures, we suggest that, in as much as this will decouple the arrival of patient and patient information, it may undermine the robustness and reliability of the process. " [K. Clarke et al]

Making a Case in Medical Work: Implications for the Electronic Medical Record (2003)

Journal of Computer-Supported Cooperative Work, 12(3), p. 241-66

“… Numerous studies … have cast doubt on how effectively IT in general, and the EMR in particular, can deliver information – or service – integration as long as this is pursued using a narrowly technical approach, and without a proper understanding of the work being supported. As a contribution to this important debate, we present findings from a study of inter-organisational work in the context of the provision of UK psychiatric healthcare services. Briefly, these findings reveal important discrepancies between the assumptions of the role of the EMR and the ways that healthcare professionals actually use and communicate information within the particular work setting studied. As a result, the findings lead us to conclude that, contrary to presumptions, the EMR may have relatively little impact on issues related to inter-organisational working, at least as they are manifest within the context of current UK psychiatric healthcare service provision. Although it might be argued that this is a domain that is characterised by vagueness and negotiation -- and so is in some sense untypical of healthcare generally – our ongoing research suggests not only that many of the issues highlighted here have a more general relevance but also, and importantly, continues to stress our central point that the representation, storage and transmission of information, by whatever means, needs to take account of the lived reality of the work in which that information is used. However, our final point is not that better healthcare service integration is an impossible goal, nor that technologies like the EMR are irrelevant to its achievement. Rather, it is that technologies like the EMR will only deliver their promised benefits if the processes followed in their design, development and implementation are oriented to providing sufficient opportunity for user-led evolution of both work practices and technologies.” [Hartswood et al]

Supporting Informality: Team Working and Integrated Care Records (2004)

Proc. 2004 ACM Conf. on Computer Supported Cooperative Work (2004) pp.142 - 151

"This paper reports findings from an ethnographic study of the work of Adult and Care of the Elderly Community Mental Health Teams in the context of the deployment of an Electronic Medical Record. Our findings highlight the importance of informal discussions and provisional judgments as part of the process by which teams achieve consensual clinical management decisions over time. . . it would appear that lessons learned from CSCW studies have not, as yet, made a major impact on how large-scale IT systems are designed and implemented. Most work is collaborative, but large-scale IT systems are often poor at supporting the collaborative dimensions of work. . . It would seem that integrated care records systems are, in the main, modelled along the same lines as airline reservation systems - always online, and always up to date. While this model may have its advantages in that it increases organisational control and enables strict auditing (what information was recorded in the system at a particular time and who had access to it), it fails to acknowledge and support the kinds of professional practices we have described. The consequence of this in practice may well be that the system fails to achieve one of its main aims, namely to make more information accessible on time, as people develop practices around the system, committing information to it only once it is 'publication ready'. . ." [G. Hardstone et al]

Implementing an EPR Project: Everyday Features of NHS Project Work (2004)

Proc. 9th Int., Symp. for Health Information Management Research

"This paper considers some of the everyday practicalities of delivering an electronic health record project within an NHS Hospital Trust. Using ethnographic, observational, data we document how and in what ways the orderly character of project work is achieved against a background of battles and negotiations to deliver the project within and despite various organisational contingencies and constraints. . . System design in a large NHS Trust (and the associated processes of analysis, configuration, testing, integration, evolution etc) is a complex, messy business. Within our EPR project and our Trust it is proceeding in tandem with the implementation of a new network infrastructure. In these circumstances, issues such as hardware provision, data point placement, database configuration and population, interface design and training is inextricably linked to other projects and organisational working associated with modernisation and investment in IT. At the same time the NHS environment can be said to be characterised by upheaval and changing circumstances, policies, even governments. . . Information exchange practices and systems are rooted in local work processes as well as wider patterns of co-ordination and communication. Attempts to change practices, and redefine roles and relationships may lead to resistance, if those involved have different commitments and understandings of organisational processes and service provision. Current health and social care policy initiatives in the UK make significant claims about the desirability of integrated services for better health and social care, i.e., more patient-centred healthcare delivery, improved resource utilisation and management of information. Plans for implementing these initiatives appear to be largely predicated on information integration being a precondition for service integration. The EPR is an element of this strategy, yet as our research too readily documents, its implementation presents formidable challenges." [Mariane et al]

‘That’s How The Bastille Got Stormed’: Issues of Responsibility in User-Designer Relations (17 Mar 2005)

Proc. 5th DIRC Research Conference, Edinburgh

"This paper presents data and analyses from a long term ethnographic study of the development of an electronic patient records system in a UK hospital Trust – TA ‘Dependable Deployment’. The project is a public private partnership (PPP) between the Trust and a US based software house (USCo) contracted to supply, configure and support their customizable-off-the-shelf (COTS) healthcare information system in cooperation with an in-hospital project team. We use data drawn from our observational studies to highlight a range of responsibility issues in designer-user relationships." [Martin & Rouncefield]

Out with the old in with the new: What gets missed when deploying new technologies in A&E? (21 Mar 2005)

Medical Informatics and the Internet in Medicine 30(2) 34-40.

"Abstract: This paper presents a longitudinal study (over 4 months) of an A&E department where the existing whiteboards were replaced with PC based computer systems. The study was conducted in two parts; an observation of the physical whiteboard usage and in-depth interviews with all users of both the traditional whiteboard usage and the replacement technology. The research was conducted with systems manager and all whiteboard users (i.e. nursing management, nurses, doctors, porters, and agency staff) across a spread of time-frames. Although the technology supported simple information requirements complex co-ordination, collaboration and awareness issues were left unsupported. The important role of a ‘pen-holder’ (information co-ordinator) was poorly supported by the replacement technology as was the task of annotating information with changing situations and needs. Specific deployment issues are derived from these findings that should guide designers when implementing technology replacements for current physical information formats (e.g. whiteboards, notice boards, shared paper notes)." [Broome & Adams]

Implementing digital resources for clinicians' and patients' varying needs. (21 Mar 2005)

Medical Informatics and the Internet in Medicine 30(2) 107-122.

". . . Traditional design and implementation approaches, isolated from communities, produce users – both clinicians and patients – who are either unaware of the technology or perceived it as complex and inappropriate for their needs. Random deployment of technology within communities, with poor design and support, is perceived by many as complex, inappropriate for their needs and a threat to current roles and practices, including the maintenance of clinician–patient relationships. . ." [A. Adams et al]

Implementing the National Programme for IT: what can we learn from the Scottish experience? (2005)

Informatics in Primary Care 2005; 13:105-11

"The National Programme for IT (NPfIT) promises to revolutionise the delivery of health care by enabling seamless and secure electronic exchange of clinical information within the NHS. Challenges to NPfIT highlighted in the media and academic commentary are common to such initiatives worldwide. This paper offers key messages and recommendations derived from a comparable electronic clinical communications programme in Scotland, and elsewhere, as a means to aid the implementation process. . . Observations, recommendations and lessons learned:

  • Complex IT projects usually take longer than anticipated and cost more than initially estimated
  • Never underestimate the complexity of a multi-faceted programme
  • Target realistic and timely outcomes
  • Avoid raising stakeholder expectations unrealistically
  • Involve end-users early in the process of developing new systems and act on their feedback
  • Ensure communication and integration between related programmes
  • Clarify the conceptual nature of the programme
  • When commissioning evaluation research, recognise what can and cannot be demonstrated in the timescale and budget that you are considering
  • There should be openness about the processes of the programme and a willingness to accept and respond to feedback from objective observers
  • Human factors are as important as technological ones in getting systems into practice"

Reflexive Standardization: Side-Effects and Complexity in Standard-Making (Aug 2006)

Management Information Systems Quarterly, Vol 30.

". . . Based on a case study conducted over a period of three years in a Norwegian hospital on the standardization process of an Electronic Patient Record (EPR). . . The research presented in this paper explores the borders and limitations of modern standardization in the context of developing a pan Norwegian standard for electronic patient record systems (EPR). . . EPR systems can be used by individual doctors, as a common system in a clinical department, as a shared and common system in an entire hospital or even among a set of interconnected hospitals. EPRs can be an off-the-shelf product, a proprietary system, or (as in our case) a system co-developed between a group of hospitals and a vendor. An EPR system is used to specify, routinize, and uniform the type and format of clinical information to be collected. Moreover, it is meant to support coordination and cooperation between departments, professions and hospitals. A hospital wide EPR could reduce redundancy and inconsistency of patient information, as the information would be stored in one single location being accessible from any place at any time. Standardization activities have aimed at defining the appropriate design of EPR as an information system, e.g. with respect to fundamental architecture, access control and data storage. . . With regard to the external validity of our case, we can ask: is our case representative of a new class of standardization problems? We believe so, especially in the health care domain where plans for developing electronic health records grow continuously bigger and more ambitious. For example, in his 2004 State of the Union address, George W. Bush Jr. envisioned ‘an EHR for all Americans within the next decade’ (The White House, 2004). In addition, to building a national health information infrastructure, establishing data interoperability and comparability for patient safety data is seen as crucial. This is expected to be facilitated through adopting standards that allow medical information to be stored and shared electronically while assuring privacy and security. Similarly, the British ‘Connecting for Health’ initiative proposes to establish the NHS Care Record Service. For each individual patient the Patient Clinical Record will be used to deliver direct patient care, and in addition a centralized database (“The Spine”) will contain a National Summary Record in order to support urgent and emergency care (NHS, 2005). For both initiatives, huge challenges can be recognized and critical voices emanating from our analysis can predict significant obstacles. However, from official documents and presentations of these projects, the general perception of standards is the value of increased control: developing and adopting standards is definitely seen as part of the solution, rather than part of the problem. We do not claim that standardization of medical information systems is impossible or undesirable. Because our case study site is a specialized hospital, it represents a paradigmatic example of the socio-technical complexity arising from the close intertwining of technical standards with local and highly professional work practices (in terms of professional disciplines and geography). To some extent our case represents a general class of problems associated with the interactions between the complexity of information infrastructures, information processing, and local work practices. Thus, the common shared complexity in these classes is the immense heterogeneity and multiplicity of actors involved and the need to coordinate and standardize their behaviors. . . Through our analysis we argue that traditional standardization approaches can not deal with such complexity appropriately. Not only will such approaches fail to not deliver the intended outcome- order-; they can also lead to the opposite effects of greater dis-order, and instability. The need of future research on IS standardization, is therefore critical in approaches that help mitigate the increasing complexity IS standardization. . ." [Hanseth et al]

Who and what are electronic patient records for? (13 Sep 2006)

Proc. Symp, Current Development in Ethnographic Research in the Social and Management Sciences

"[We] report on a field study conducted between 2003 and 2005 at an NHS Trust in the North of England. The choice of case study is interesting because the Trust in question was an 'early adopter'. Before the current version of the NHS IT programme had been announced, the Trust had already signed a contract with an Anglo-American software firm - hereafter 'OurComp' - for them to implement and support a full blown EPR system. The NHS gave them the go-ahead, and so the study provided an opportunity to investigate what some of the issues might be when the larger scale deployment of such systems across England and Wales got underway. . . When the system eventually went live we were lucky enough to observe the first week in the hospital. Unfortunately our concerns were proved valid - the system proved to have multiple problems. Most notably it did not fit well with a number of existing work patterns but to compound this, due it its strict model of governance, when work did not fit with the system the system broke down. . . The unfortunate postscript to this is that after the first week our access was denied as the drama unfolded. It was not particularly unfortunate for us as our project has gone well. However, we do feel very sorry for the members of the project team as it appears that the blame fell as some of their doors even though it was clear from our fieldwork that the system had not failed through lack of skill or effort but rather it had been bound to fail because of the massive ambition for the 'EPR' in general and the way the NHS has conceived of the requirements for such systems. . ." [David Martin]

A Local Sociotechnical Design Approach to Exploiting the Potential of The National Healthcare IT Programme NPfIT (3 Nov 2006)

The Bayswater Institute

". . . In practice the use of a NPfIT system will depend on its match with local requirements. If the 'push approach' is limited to training the users in the operational detail of each IT system, it will be left to each specialty and each unit to find its own way of 're-constructing' the system to suit their needs. The users will decide what to use and what not to use and how to 'workaround' the obstacles or inadequacies. This will become a piecemeal approach, largely hidden and informal, and may well involve a lot of delay and stress. It is likely to be dysfunctional from the point of view of the staff and management of each Trust and also for those who have invested in the development of the systems. Is there a better way of implementing these systems? . . . A striking feature of the NPfIT programme is that many people in the NHS seem to agree with its overall goals. What they have trouble with is the way it is being implemented. There is a lot of work to be done in every Trust to implement the new systems. If we can mobilize the reservoir of expertise in healthcare matters that is available in every location it may be possible to find ways of 'pulling' these systems in the direction of significant local goals. If not, unintended consequences will be rife as we try to cope with systems that do not serve local needs. Under these circumstances neither national nor local goals will be met." [By Ken Eason]

Understanding and Improving the Design, Deployment and Use of Electronic Health Records: Final Report (2007)

Chameleon Project - EPSRC GR/R86751/01

". . . We used ethnographic studies of EHR projects, interviews with stakeholders and workshops to examine fundamental assumptions surrounding EHRs, and explore the fit with existing and emerging practices, technologies and regulatory requirements. The case study design enabled examination of factors such as project scale, clinical setting, professional and organisational boundaries, and the different integration strategies adopted by NHS England and NHS Scotland. . . Our findings raise a number of issues that must be seriously considered as NHS programmes continue:

  • The NHS has seriously underestimated the scale of the task involved in deploying EHRs. Constantly changing government and NHS policies has led to EHR procurement being very protracted: requirements have to be continually re-drawn and re-shaped and often leads to unsatisfactory compromises. Procurement is also made problematic because these systems will be used as instruments of significant organisational change. However, the Trusts (and the NHS itself) do not have a concrete idea of what the results of those changes will lead to, consequently it is very difficult to assess system suitability.
  • Although ‘supporting medical practice’ and ‘patient centred’ are twin mantras of EHR design in the NHS, an over-riding design emphasis is on implementing ‘proper’ process, and on coding medical and administrative procedures ‘correctly’ so they may be standardised, counted and reported on. These ‘other’ requirements that stem from the need to provide fully technically and organisationally integrated systems can actually disrupt current medical practices. Standardisation implies that some features of local practice will be re-configured around new models that may run contrary to the way staff organise and understand their work; technical constraints can reduce flexibility. Since these ‘other’ requirements must be met, support for tried and tested local work routines may be removed with serious consequences later down the line.
  • Currently, NHS hospitals have a poor understanding of exactly how they function in any kind of overall, comprehensive manner. Processes, if they are documented, are done so on a departmental or speciality basis, so particularly achieving ‘integrated, computer-supported’ working represents a massive organisational challenge that consideration might have been better paid to before the purchase of systems. Addressing this problem calls for better management of stakeholder – and local user – participation in EHR projects but this is very difficult to achieve. Identifying the ‘right’ stakeholders is problematic in such large and diverse organisations, they will likely have some competing versions of current practice and competing ideas about where they want the design to go. Managing this effectively is a big challenge. . ."

Interpretive Flexibility Along the Innovation Decision Process of the UK NHS Care Records Service (NCRS) (Apr-Jun 2007)

Int. J. of Technology and Human interaction 3(2), 1-12, April-June 2007

". . . In this paper, we look at how interpretive flexibility manifests through the diverse perceptions of stakeholders involved in the diffusion and adoption of the NHS Care Records Service (NCRS). Our analysis shows that while the policy makers acting upon the application of details related to the implementation of the system, the potential users are far behind the innovation decision process, namely at the knowledge or persuasion stages. We use data from a local heath authority from a county close to London. The research explores, compares, and evaluates contrasting views on the systems implementation at the local as well as national level. . . With medical errors becoming a cruel reality in the provision of healthcare worldwide, the role of information technology in preventing those errors becomes predominant. It is recognised that more people die every year due to medical errors than from vehicle accidents, breast cancer, or AIDS . . . One way to reduce medical errors is to make efficient, accurate, reliable medical decisions, based on reliable and up-to-date information or patient records. Integrated patient records can reduce medical errors by using information technology . . . NCRS is one of the National Program for Information Technology (NPFIT) targets and, as with many healthcare IT projects, its evaluation will be difficult, provided that government led IT projects in the NHS have a history of notable project failures. The complexity of such huge investments, currently £7.6 billion, calls for a clear understanding of the environments in which healthcare networks exist. The research focus here is the diffusion of the NCRS from the policy makers at a highest decision making level to the users of the system. We examine how diffusion receivers (users, such as doctors or nurses) perceive the NCRS implementation in comparison to policy makers. We argue that there is a gap between the demand and the supply side of the diffusion process, which reveals a broad barrier in the NCRS implementation. We use primary and secondary data to capture the perceptions of both diffusers and diffusion receivers in order to get a better understanding of the NCRS diffusion process. The primary data was collected through interviews with the managerial and technical staff as well as future users of the NCRS within a specific county in the United Kingdom. . ."

Managing integration work in an NHS electronic patient record (EPR) project (2007)

Health Informatics Journal, Vol. 13, No. 1, 47-56

"This article uses an ethnographic study of the design and deployment of an electronic patient record (EPR) system in the UK NHS to document some of the difficulties of integrating new IT systems with existing and developing practices, technologies and regulatory requirements. It highlights that `integration' in this situation produces a variety of different but connected and potentially competing requirements that create difficulties in achieving artful and successful system deployment." [Martin et al]

Implementing the NHS information technology programme: qualitative study of progress in acute trusts (17 May 2007)


"Objectives: To describe progress and perceived challenges in implementing the NHS information and technology (IT) programme in England. Results: Interviewees unreservedly supported the goals of the programme but had several serious concerns. As before, implementation is hampered by local financial deficits, delays in implementing patient administration systems that are compliant with the programme, and poor communication between Connecting for Health (the agency responsible for the programme) and local managers. New issues were raised. Local managers cannot prioritise implementing the programme because of competing financial priorities and uncertainties about the programme. They perceive a growing risk to patients' safety associated with delays and a loss of integration of components of the programme, and are discontented with Choose and Book (electronic booking for referrals from primary care). Conclusions: We recommend that the programme sets realistic timetables for individual trusts and advises managers about interim IT systems they have to purchase because of delays outside their control. Advice needs to be mindful of the need for trusts to ensure longer term compatibility with the programme and value for money. Trusts need assistance in prioritising modernisation of IT by, for example, including implementation of the programme in the performance management framework. Even with Connecting for Health adopting a different approach of setting central standards with local implementation, these issues will still need to be addressed. Lessons learnt in the NHS have wider relevance as healthcare systems, such as in France and Australia, look to realise the potential of large scale IT modernisation." [J. Hendy et al]

Time to rethink health care and ICT? (Jun 2007)

Comunications of the ACM 50,6

"The health care sector has explored how information and communication technology might improve patient service for the past 50 years, but there is evidence that many, even most, health care information systems are failures. Nonetheless, in the U.K., the National Health Service (NHS) has started to build a modern, dependable ICT infrastructure through an expenditure of £20 billion over the next several years. The unprecedented scale of the U.K. development, along with the scope and breadth of the NHS remit in providing universal cradle-to-grave health care for all U.K. subjects and the questions raised about the underlying models used in applying ICT to health care, suggests the U.K. experience has global applicability. We therefore explore the U.K. experience here as exemplar for our study of health care and ICT. . . There are many and varied reasons for the failure of health care IS, some relating to issues that are well understood in non-health care sectors of the economy. We recognize a common understanding of the role of IS in them in terms of an underpinning "enterprise-type" model. With the ongoing multi-billion-pound NPfIT deployment of information infrastructure in the U.K. it is important to explore this understanding in two areas: First, the "enterprise" is too small a building block for health care, and models that start with national context, scale, and complexity might serve health care better. This means that health service provision is different and should be looked at differently from any other industrial or government sector. Nevertheless, we recognize that lessons can still be learned from the business sector. Second, better person-to-person models are needed to understand how the collegiate and interpersonal elements of care delivery could be embodied better in the systems used for care delivery. We have not sought to prescribe solutions but to encourage the IS community to critically consider existing models when addressing health care. This may not stop altogether the history of IS failure in health care, but once the more obvious failure mechanisms are addressed, clinical communities may be more positive about IS generally, making them more likely to benefit from its potential to help deliver the kind of service patients need most and win the public's trust." [David Avison, Terry Young]

Changing Healthcare Institutions with Large Information Technology Projects (2007)

Journal of Information Technology Research 1, 1

Abstract: "This article reviews the development of institutional theory in direct relations to historical changes within the UK's National Health Service (NHS) with an eye to contributing to the theoretical specification of healthcare information processes. This is done partly by extending certain paradigms (see Meyer & Rowan, 1991; Powell & DiMaggio, 1991; Tolbert & Zucker, 1994) through a proposed model of causes and consequences of variations in levels of institutionalisation in the healthcare industry. It reports findings from a 5-year study on the NHS implementation of the largest civil ISs worldwide at an estimated cost of $10 billion over a 10-year period. The theoretical basis for analysis is developed, using concepts drawn from neo-institutionalism, realisation of business value, and organisational logic, as well as mixed empirical results about the lack of IT investments value in the NHS. The findings suggest that large scale, IT change imposed upon a highly institutionalised healthcare industry is fraught with difficulty mainly because culturally embedded norms, values, and behavioural patterns serve to impede centrally imposed initiatives to automate clinical working practices. It concludes with a discussion about the nature of evaluation procedures in relation to the process of institutionalising IS in healthcare." [Guah, Matthew W.]

Action on Immunisation. No data, no action (11 Nov 2008)

Archives of Disease in Childhood (ADC Online)

Abstract: Immunisation is one of most evidence-based activities of the NHS, and much of its success owes to the sensible use of information systems which both run the programme and at the same time evaluate its implementation. The recovery of the national programme from the whooping cough vaccine scare of the 1970's (when coverage fell to ~30%) owed a lot to improvements in co-ordination of the programme including the use of information technology which was rolled out nationally in the 1980's. The much smaller fall in coverage which occurred following the MMR and autism scare in the late 1990's is at least in part a tribute to these better systems. It is therefore a retrograde step that new software chosen by the local providers as part of Connecting for Health has had less functionality than the systems it is replacing. This has consequences for general practitioners, practice nurses, Primary Care Trusts, public health departments and for parents and children. The immunisation programme is something which everyone takes for granted until things go wrong. Lessons from two decades of good practice should be taking the Immunisation programme in London forwards; ignoring these lessons has taken it backwards. [Natasha Sarah Crowcroft]

Key NHS IT Programmes - UCL report (17 Jun 2010)

University College London

Press release: The Summary Care Record (SCR) and HealthSpace technologies, introduced in the NHS as part of the National Programme for IT (NPfIT), have so far demonstrated only modest benefits according to the final report of a three-year independent evaluation carried out by UCL researchers. The report's publication coincides with the publication of a research paper based on the findings in the British Medical Journal. The report authors found that while millions of people had received a letter informing them about the programmes, creation of SCRs and HealthSpace accounts was occurring much more slowly than originally planned. Progress in the programmes was delayed by a number of ‘wicked' (pervasive, seemingly insoluble) problems, including the difficulty of defining a ‘minimal dataset' of key medical data, the huge task of ensuring that GP records were complete and accurate, the need to gain informed consent from 50 million people (many of whom appeared to throw away the letter unread), and the numerous technical and operational challenges associated with uploading data onto the SCR database from local GP records. They also found that whilst many stakeholders shared a broad vision of an efficient, accurate and accessible national electronic record system, making this vision a reality required collaboration across a number of very different worlds - political, clinical, technical, commercial and personal. Differences in expectations, values and ways of working between these worlds accounted for many of the misunderstandings and frictions occurring at the operational level. They conclude that the future fortunes of the programmes will depend at least partly on efforts to bridge the deep cultural and institutional divides that have so far characterised the NPfIT and suggest that it may be time to revisit the logic behind the policy-level link between ‘empowerment' and a state-run online records service. . .

Full Report - The Devil's In The Detail: Final report of the independent evaluation of the Summary Care Record and HealthSpace programmes

Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study (16 Jun 2010)

BMJ 2010;340:c3111 (Trisha Greenhalgh et al)

Results: Creating individual SCRs and supporting their adoption and use was a complex, technically challenging, and labour intensive process that occurred more slowly than planned. By early 2010, 1.5 million such records had been created. In participating primary care out-of-hours and walk-in centres, an SCR was accessed in 4% of all encounters and in 21% of encounters where one was available; these figures were rising in some but not all sites. The main determinant of SCR access was the identity of the clinician: individual clinicians accessed available SCRs between 0 and 84% of the time. When accessed, an SCR seemed to support better quality care and increase clinician confidence in some encounters. There was no direct evidence of improved safety, but findings were consistent with a rare but important positive impact on preventing medication errors. SCRs sometimes contained incomplete or inaccurate data, but clinicians drew judiciously on these data along with other sources. SCR use was not associated with shorter consultations or reduction in onward referral. Successful introduction of SCRs depended on interaction between multiple stakeholders from different worlds (clinical, political, technical, commercial) with different values, priorities, and ways of working. The programme’s fortunes seemed to turn on the ability of change agents to bridge these different institutional worlds, align their conflicting logics, and mobilise implementation effort. Conclusions: Benefits of centrally stored electronic summary records seem more subtle and contingent than many stakeholders anticipated, and clinicians may not access them. Complex interdependencies, inherent tensions, and high implementation workload should be expected when they are introduced on a national scale.

Do summary care records have the potential to do more harm than good? Yes (16 Jun 2010)

BMJ 2010;340:c3020 (Ross Anderson)

A digital medical record system that shared information when appropriate between care providers, and was dependable and safe, would be of great value. However, the summary care record isn’t it. It must be abandoned—for reasons of safety, functionality, clinical autonomy, patient privacy, and human rights. The summary care record was marketed to the public as a way for accident and emergency staff to check up on unconscious patients. According to Tony Blair, if you ended up in hospital in Bradford, doctors could look up your records with your general practitioner in Guildford. But this is nonsense. Very few patients have conditions that must be made known to emergency staff; for those that do, the properly engineered solution is MedicAlert. Unconscious patients often can’t be reliably identified, so a database is less robust than a tag or card; the record doesn’t have everything accident and emergency staff might want to see; and it is not even available in Scotland (let alone on a beach in Turkey). The truth is that the summary care record was designed to accumulate large amounts of data about patients from multiple sources. Many patients’ records will start with a hospital discharge summary rather than a general practice summary, while plans are afoot to include medical images and even ambulance messages. . .

Do summary care records have the potential to do more harm than good? No (16 Jun 2010)

BMJ 2010;340:c3022 (Mark Wolpert)

. . . The primary purpose of electronic patient records is to improve patient care. As a patient I expect the following: that my records will be accurate and that I can work with my carers to improve their accuracy; that they will be treated confidentially; that they will be shared between the members of the healthcare team that collectively look after me in primary care and in hospital; and that they will provide a basis for accountability for the quality of my health care. In addition I would hope that my records could be linked to "expert systems" that would minimise the chance of treatment errors and maximise the chance of my being prescribed the best treatment. There is another huge potential benefit of a nationwide electronic patient record system, to improve treatment through research. Research provides the evidence that medical treatments work or, equally importantly, that they don’t. It is an integral part of the best health systems. . . The new coalition government, coupled with the economic crisis, means that the future is uncertain for Connecting for Health. I do not believe that Connecting for Health has been marketed well to either patients or the medical profession. There has been much too much about its use as a management tool and too little about its primary aim, which should be to improve care. It may be that it would be better implemented as a more federated programme, ensuring common standards to allow interoperability. A key aim must be integration of records and communication across primary and secondary care. But one thing is certain—the best care requires the best medical records. A world class NHS demands a world class infrastructure. The future for medical records is digital.

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