Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
what have we really learned?
- Michael Tremblay (24 October 2008)
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Google Health as a disruptive technology
- Suparna Das, SE5 9RS (28 October 2008)
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Sleeping with the enemy - or riding the tensions?
- Trisha Greenhalgh, on behalf of the Summary Care Record evaluation team (31 October 2008)
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Simple SCR in everyday use in 2008?
- Nigel J Masters (1 November 2008)
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Socio-technical Pull for Electronic Records: Making it Happen
- Chris Clegg, Ken Eason and Malcolm Peltu (15 January 2009)
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Michael Tremblay, health technology and innovation policy advisor Brabourne Lees, Ashford, Kent TN25 6RJ
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The authors' point: "A case study approach and multi-level theoretical analysis can illuminate how contextual factors shape, enable, and constrain new, technology supported models of patient care." surely must be right as the research in both health (e.g. Lehoux, "The problem of health technology") and in other economic sectors leads us here anyway. I get the sense that the authors may be trapped within the NHS-framed context of the use of the SCR, and wedded to the underlying logic of the SCR. The eight key findings are impressive and any one of them enough for a meal and further research funding. But taken together, the authors see the SCR having to respond to existing ways of working and established practices, not the other way round. I can't help but being underwhelmed. My take is this: 1. there are powerful forces within established ways of working in the NHS that are hostile to technological changes that threaten established and possibly dysfunctional and wasteful practices; as a taxpayer, this is not acceptable, especially when we need to explore better ways of using tax revenues when times are likely to be hard. 2. overly complex, large-scale IT projects are overly political with their scale empowers dissident behaviour to feed political interest; better to think in terms of flexible, networked, distributed -- school of fish, not supertankers...; politicians would be better off responding to the public anyway. 3. if we wait for organisational readiness, pigs will fly and hell will freeze over; by their very nature, introduction of novel technologies must have some consequences and these are not necessarily helped by protecting incumbents and legacy systems from threat. The lack of a patient held smart card for health, for instance, maintains the control of information in the hands of the clinicians and the provider infrastructure. Giving patients complete and total ownership of their health record (all of it!) is a critical way of driving quality improvement and disrupting what these eight factors evidence. My fear is that the sunk costs are already so great that a rethink is unthinkable and that we are now in what is called a 'dollar auction' where people will actually pay more than a dollar for a dollar -- in effect pay more for something than it is worth, rather than cut their losses and start again. In politics it is a u-turn, something requiring another innovation called courage. Competing interests: None declared |
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Suparna Das, Locum consultant anaesthetist King's College Hospital, London, SE5 9RS
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Such is the pace of modern technology that this article is already out of date. It doesn't mention the launch of Google's web based personal health record on 20 May 2008 and nor does it refer to the following article in yesterday's Financial Times: NHS records project grinds to halt. By Nicholas Timmins, Public Policy Editor Published: October 27 2008 23:27 http://www.ft.com/cms/s/0/b54a2e1c-a46e-11dd-8104-000077b07658.html Web 2.0 technology will no doubt disrupt the grand aspirations of the NHS IT project. Techno-savvy patients using Google style applications might soon ask doctors to access their personal health records on the web. Like the music industry, the NHS appears to have become self- importantly complacent. We are deluding ourselves if we think that "the world is waiting to see" how the NHS IT programme unfolds. The world has already seen that, six years into the programme, NPfIT is already overbudget and behind schedule. The NHS isn't the global gold standard. Instead, it is a hugely wasteful, inefficient and bloated monopoly that needs some serious competition. Did record companies ever imagine that one day, music could be downloaded for free? Competing interests: None declared |
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Trisha Greenhalgh, Professor of Primary Health Care University College London, on behalf of the Summary Care Record evaluation team
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The above correspondence makes uncomfortable but important reading. Our study was funded by the Department of Health, whose staff helped establish its terms of reference. A senior Connecting for Health official emailed me recently to remind me that policy for the National Programme for IT has been set centrally, and that my team’s remit is to evaluate HOW certain technologies are being implemented, not WHETHER the funding was appropriately allocated. As reported in the paper, my team are formally answerable not to Connecting for Health but to an independent External Advisory Group chaired by a layperson and with representation from professional bodies, external academics, and patients, whose input has been crucial to achieving balance and perspective (1). But even with robust governance and a reflexive awareness of the potential ambiguity of our position, we buy into a particular system of thought. Health research policy arises from, and serves to perpetuate, dominant meta-discourses of power and knowledge (2). Research questions don’t just happen, nor do they become prioritised on the basis of a priori scientific merit. Rather, issues of ‘importance’, ‘quality’, ‘methodology’, ‘rigour’ and so on are constructed within particular frames of legitimacy and signification. Nowhere is this more evident than in the allocation of funding for research on big IT in healthcare, and a critical analysis of who funds what, and why, is overdue. The question of which body should sponsor such an analysis is important: I have some data on bodies which won’t. But as I have argued previously, it is time to move on from morally absolute dualisms – for example whether we are friends or enemies of Connecting for Health, or for or against making patient data universally accessible (3). Thus framed, the exercise is reduced to an inspection of the other side’s war-paint. My team recently proposed that the technical, organisational and ethical complexities of distributed electronic records should be considered in terms of a series of inherent and unresolvable tensions (4). Ironically, a technical editor from the BMJ sought (unsuccessfully) to edit out the word “tensions” and replace it with “problems” to make the article more accessible to BMJ readers. (1) Greenhalgh T. "We have your medical record on file": researching unpopular government policy. Opticon1826 2008; October:in press. (2) Shaw SE, Greenhalgh T. Best research - For what? Best health - For whom? A critical exploration of primary care research using discourse analysis. Soc Sci Med 2008; 66(12):2506-2519. (3) Greenhalgh T, Stramer K, Bratan T, Byrne E, Russell J, Mohammad Y et al. Summary Care Record Early Adopter programme: An independent evaluation by University College London. London: University College London. Full report can be downloaded from http://www.ucl.ac.uk/openlearning/research; 2008. (4) Greenhalgh T, Wood GW, Bratan T, Stramer K, Hinder S. Patients' attitudes to the summary care record and HealthSpace: qualitative study. BMJ 2008; 336(7656):1290-1295. Competing interests: Principal Investigator, Summary Care Record Independent Evaluation |
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Nigel J Masters, Full time general medical practitioner Highfield Surgery Highfield Way Hazlemere High Wycombe HP15 7UW
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At our general practice where I work we have been producing simple shared SCR records using existing technology in ways that benefit both practice and patients. The cost is low and is has been devised by one of Greenhalgh's newly described 'entrepreneur' researchers in primary care (1)! Our simplified SCR contains allergic and adverse drug reactions and a list of all repeat medications with their clinical indications .This is recorded on the patient drug request slips so that it can be carried and checked by patients. It is described in more detail at the website www.clinicalindications.com and look for the recently added 'shared adverse and allergic drug' article.Here you can find a repeat prescription computer screenshot and examples of a repeat prescription slip. Of course in a way this a real practice based pilot and further development is needed. I hope she can nurture this development when talking about the SCR! 1. T .Greenhalgh. Thirty years on from Alma-Mata :Where have we come from? Where are we going? R Coll Gen Pract 2008;58:798-804. Competing interests: None declared |
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Chris Clegg, Professor of Organisational Psychology Leeds University Business School, University of Leeds, Leeds, LS2 9JT, Ken Eason and Malcolm Peltu
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The report on the introduction of shared electronic records by Greenhalgh et al (BMJ 2008:337:a1786) offers a penetrating analysis of the problems encountered in four early adopter sites in England. One of the main conclusions is that the Summary Care Record programme has focused too much on ‘technology-push’, arguing instead that the national programme should be viewed as involving “10% technology, 90% business change”. The report makes a strong case for a socio-technical pull model of change which takes seriously the need for changes in the working practices and job roles of users, i.e., the wider social systems. The authors also suggest these lessons have wider applicability to the design and implementation of large scale information technology projects in health care more generally. Nor are these lone voices – the same case, albeit with slightly different emphases, has been argued by the BMA, the House of Commons Public Accounts Committee, the National Audit Office, and several independent research groups. Unfortunately however, no-one has yet articulated what such a new socio-technical pull approach would entail in practice. Members of the British Computer Society’s Socio-Technical Systems Group have been working with NHS Trusts on the implementation of applications in the National Programme (e.g., the full electronic care record and Choose and Book), developing an approach suitable for e-health applications. The fundamental approach is to focus on service improvements by planning and delivering local changes in working practices and job roles at the same time as the changes in technology. This involves helping local healthcare staff establish how new technical capabilities can best be exploited in their particular settings. The main socio-technical methods are summarized in the following key actions. • Treat NPfIT as a ‘service delivery’ project not as a ‘technical change’ project. • Focus on service improvement through changes to delivery processes and to working practices, supported and enabled by the new IT. • Ensure that senior users own and lead the projects, with the support of IT specialists. • Engage all stakeholders, extending to users a sense of ownership of the new ways of working. • Exploit the flexibility of technical systems to support local customisation. • Use evaluation metrics based on service delivery and user responses. • Phase implementation to provide time and space for learning lessons and to plan the most appropriate local working practices and technology. • Embed into routine processes independent reviews of key applications to understand why things have gone well or badly, and what adjustments are needed. • Develop capacity and capability by funding widespread development and training. • Create a local design plan to realise benefits and minimise costs and risks. • Experiment with new healthcare practices. • Evolve and sustain the new ways of working. These principles and their relevance to the wider introduction of IT to the NHS are explored in greater detail in: Peltu M., Eason K., Clegg C. W., How a Socio-Technical Approach can Help NPFIT to Deliver Better NHS Patient Care (see: http://www.bcs.org/upload/pdf/sociotechnical-approach- npfit.pdf) Competing interests: None declared |
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