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How to avoid an e-headache

BMJ 2007; 334 doi: (Published 28 June 2007) Cite this as: BMJ 2007;334:1373
  1. Joan S Ash, associate professor
  1. Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health and Science University, Portland, OR 97239-3098, USA
  1. ash{at}

    The scope and boldness of the National Health Service's Connecting for Health initiative are unprecedented. While nations worldwide have set health information technology as a high priority to combat medical errors and increase efficiency, England has outlined the most courageous goal of this kind, aiming towards a national electronic health record service. Implementing systems nationwide, or even regionally, is extremely difficult, yet England is making admirable progress and essential iterative adjustments. Ongoing evaluation efforts, such as those described in Hendy and colleagues' study in this week's BMJ,1 are necessary to guide such adjustments. Temporary setbacks are inevitable and we must learn from them.

    Why is implementation of health information technology such a universally difficult process? It is because we are transforming health care through information technology rather than simply automating old processes. Workflow and work life must change, which means people must adapt. Such change is deeply disruptive. The related personal and organisational challenges are enormous, yet efforts to manage change receive inadequate attention and funding.2

    How can we succeed in such implementations of information technology? Firstly, we must define success explicitly and understand that our goal is long term, and that we will inevitably stumble along the way. Many, perhaps most, successful implementations of clinical systems have been preceded by suboptimal ones,3 yet these are too often concealed. We must begin to share these experiences openly and cherish these opportunities to learn how to improve implementation efforts. Boldness breeds occasional blunders, which can teach us much about what is required for eventual success.

    Secondly, we must expand knowledge about best practices for implementation in different settings. Informatics is the discipline that considers the effective organisation, analysis, management, and use of information in health care.4 Educational programmes in informatics aim to produce people who understand both the clinical and the information technology worlds,5 so that they are especially well prepared to implement systems sensitively. There is now a body of evidence about success factors for implementing clinical systems (see, for example,, and several major categories of success factors have been verified repeatedly.6

    The use of skilled project management techniques is one of the most important and perhaps the most applicable factor in implementing the NHS efforts. Defining the scope of any project is a first step, and any expansion of scope, such as delivery of an email system not originally planned,7 must be carefully considered and funded. When politics enter the picture, the tenets of good project management can become threatened. The foundations of project management—resources, schedules, and performance outcomes—are like the legs of a three legged stool: if one leg is weak, the stool might collapse. Cuts in resources must result in adjustments to schedules and performance expectations. Another relevant aspect of project management is that the leadership attribute of steadfastness is paramount.8 Stable, brave, bold leadership is needed to overcome the stumbles and seek the long term goals, even if the political environment at times interferes. Finally, ongoing evaluation and monitoring of the impact of new systems are necessary for project success.9 10

    Impatience is risky, and there is even greater danger in judging a large complicated project before it has had time to evolve and mature. In the United States, we are envious of the NHS's performance in implementing electronic records in primary care, and we are watching development of “the spine,” the centralised care record, with great interest. There is no doubt that implementing state of the art health information technology is the right thing to do. Wisdom, perseverance, and fortitude are all needed to overcome inevitable problems. Connecting for Health is making progress, but we must be mindful of the words of Winston Churchill in 1942, after the British victory at El Alamein: “Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”


    • Competing interests: None declared.

    • Provenance and peer review: Commissioned; not externally peer reviewed.