Introduction of shared electronic records: multi-site case study using diffusion of innovation theory
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1786 (Published 23 October 2008) Cite this as: BMJ 2008;337:a1786
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Socio-technical Pull for Electronic Records: Making it Happen
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
Competing interests: No competing interests