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EDITOR'S CHOICE: Jane Smith The NHS's sewers? BMJ 2005; 331: 0-f [Full text]

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Evidence Based IT

Anthony E Davis   (8 August 2005)

London's sewers

Gavin Jamie   (8 August 2005)

Evidence Based IT 8 August 2005
Anthony E Davis, Director, addACUMEN Paddock House, Netheravon, Wilts, UK, SP4 9QP Send response to journal: Re: Evidence Based IT	As one fortunate enough to have worked in Health Care IT(HCIT) both as a clinician and as a technician for nearly four decades I am rather surprised by the current position of NPfIT. While the body of evidence in support of good IT practice is not organised in the same way as the evidence base for medicine it nonetheless exists. Good IT and good medicine share the goal of clearly improving their user’s world while not adding obtrusive side effects. Please excuse the Victorian use of anecdotes[1]. In response to discussion of the article by Jane Hendy and colleagues[2] a clinical representative of NPfIT reported that development was nearly complete and it was simply a matter of ‘roll out’[3]. As the article suggest this is a basis for failure. However, the choice they offer is not apt – it is not simply a choice between locally developed and centrally mandated system. Rather it may help to look at how successful IT systems have achieved their success. Consult users widely is wise advice. BA[4] have recently improved their check in procedures. This was not centrally mandated change. Business considerations determined that change was needed. Technical considerations required that investigation was needed to determine how to best meet the business goals. Time was spent doing experiments with different technical solutions. The result from the perspective of passengers, staff and management is an effective, efficient and easy to use system with several different ways of making contact with it. It is unlikely that the approach described by McKenzie[5] was born fully formed – it will have been the result of informal experiment. This is not roll out – it is finding acceptable technology solutions to meet the client’s needs. Integrate with business processes. One of the more ambitious goals of the initial NPfIT brief[6] was to use IT to drive process change throughout the NHS. Bernstein AG, an engineering firm, is small relative to the NHS but they are some way along this path. Their results[7] emphasise that while all businesses and business units have processes the complexity – or simplicity – of those processes is never the same. They would advise that organisations first address the processes which hurt and involve everyone in the project to improve those processes. In this £40m firm they manage this with an overall design team of 5 and separate, smaller teams for each process. When they began in 2002 the IT department was the driving force behind the project. Their aims were to make the business and the IT department more cost effective and more responsive to a changing world. Much like the current NHS. A major difference was that they devolved design decisions rapidly to operating units. And now, 2005, they see the benefits to be improvements in the organisations processes with many key employees beginning to think in process terms more widely than their own area of responsibility. This is not roll out – it is pick and mix to show the organisation’s operational units that technology can directly help them in their daily work. It may be that to achieve the NPfIT goal of driving process change requires a dislocation of the implementation of HCIT from the command control culture of central NHS. This is not to say that the IT will not be standardised and use a common infrastructure but it is to say that local requirements will be met by the implementation of local initiatives and that existing effective systems will not be discarded. Even matters like IT security - often thought of as purely technical topics to be left to technical managers - only make sense when considered from an overall management perspective[8]. Everyone seems to assume that the NPfIT project is feasible. Large HCIT projects seem to be more likely to fail than others, although IT projects do fail frequently[9]. Problems in HCIT may reflect hidden barriers in language and thought between the two professional camps, medicine and IT. Cooper – tongue in cheek - described ‘Homo Logicus’ [10] the species from which programmers are drawn. Briefly they trade simplicity for control, exchange success for understanding, focus on the possible to the exclusion of what is probable and act like ‘jocks’. Their enthusiasm for and focus on their subject to the exclusion of the outside world reminds me of some medical colleagues during the 60’s and 70’s. The collision between ‘Homo Logicus’ and ‘Homo Medicus’ may add to the difficulties which NPfIT has to face. Cooper advocates design as a first step to effective IT implementation. He defines design as understanding the motives of those who use the system and ensuring that those motives are met by the designed system. Getting design right is always a matter of iteration. Doing the iteration during the design phase is quicker and cheaper than doing it with the final product. Getting the right product early has huge benefits for user morale. Jane Hendy and her colleagues report little evidence that this goal is being met. The NPfIT initiative has been a brilliant start. It is a necessary but not sufficient condition for successful HCIT in the NHS. The roll it out approach is not a recipe for success. Flexibility is more appropriate[11]. And increasingly it is what can be achieved as illustrated by the examples cited. This problem is not new. Wildstrom[12] broached the topic of frustrated computer users and the answers he received are illuminating. After he had read the responses his conclusion is worth repeating. ‘There’s one thing missing from this outpouring. I’ve heard from engineers, programmers and usability gurus. But the product planners and marketers who make the key hardware and software design decisions have been conspicuously silent. You folks have lots of angry customers out there. How are you going to respond?’ Indeed, how will NPfIT respond to the charge that it is not following the well evidenced paths that lead to successful IT? The NHS cannot wait to enquire into its failure. Tony Davis (ad@addacumen.com) References 1. Editorial “The NHS’s sewers?” BMJ 2005;331 (6 August) accessed 7 August 2005 at http://bmj.bmjjournals.com/cgi/content/full/331/7512/0-f 2. BBC1 Breakfast Friday 5 August 2005 3. Jane Hendy et al, “Challenges to implementing the national programme for information technology” BMJ 2005; 331:331-336 (6 August), accessed 7 August 2005 at http://bmj.bmjjournals.com/cgi/content/full/bmj;331/7512/331 4. Tim Le Blond, Manager of Technology Services, British Airways at Mobility Summit, London 11 July 2005 www.mobilitysummit.co.uk 5. GM McKenzie “Where next with revalidation?” BMJ 2005;331:352 (6 August), accessed 7 August 2005 at http://bmj.bmjjournals.com/cgi/content/full/bmj;331/7512/352-b 6. “Making IT happen” NHSIA brochure 1501 and other NPfIT documents. 7. Bob McIntosh (bob@mcintosh.de) Private Communication 2005 8. J Babiak, J Butters and Mark W Doll, “Defending the digital frontier :: Practical security for management” 2nd edition Wiley 2005 9. “Harnessing the Power of Web Services and Middleware: Building and Deploying Integrated Applications for the Agile Enterprise” Gartner 2003 10. Alan Cooper “The inmates are running the asylum.” Sams Publishing 2004 ISBN 0 672 32614 0 11. JS Brown and J Hagel III, “Flexible IT, better strategy” The McKinsey Quarterly 2003 No 4 12. Stephen H Wildstrom “They’re mad as hell out there.” Business Week October 19, 1998 Competing interests: Director of addACUMEN, an IT consultancy
London's sewers 8 August 2005
Gavin Jamie, GP Whalebridge Practice, Swindon SN1 1ED Send response to journal: Re: London's sewers	The sewers of London were built to take the smells away from the city, as it was considered that these smells carried disease. It was pure serendipity that they also carried away the real micoscopic culprits. In the absence of a clear evaluation of the risks and benefits of the projects NPfIT may have to simply hope it is so lucky. Competing interests: None declared