Lack of research, risk management and long-term commitment:
Information Systems implementation are getting more complex and immense in terms of their costs and required functions. It is no longer sufficient to assume that one can competently manage the project without prior research, formal training or the necessary expertise.
This would apply equally to the management, the Information Technology staff and the leadership as well.
Project risks, including budget over runs and delays, must be fully researched and equally distributed and managed prior to the initiation of the project.
To facilitate the above, the management and their political masters must be prepared for a more realistic time-frame for the delivery of the Information Systems and willing to be part of long-term commitment to the project.
Lack of user buy-in and ownership:
In addition to making a case for change, users must also be convinced that the new system would lead to better work practices and better patient care in the unique environment of the NHS.
Clinicians are on the whole very pragmatic people, and the above factors would be much more valued than the inherent “convenience” of using an Information Technology system.
Too often, assumptions are made on behalf of the end users without consulting them. To quote Ash et al, “we often blame the users for not embracing new systems; yet a system may embody perspectives that may not be meaningful to or appropriate for their intended users” .
An example in the real world would be the implementation of Computerised Physician Order Entry Systems.
Although these systems benefit the management by providing them with a rich source of coded data and enable the close scrutiny of physician prescribing patterns, the extra work required, with its unintended frustrations from systems slowdowns and crashes, does not add any extra benefit to the physician’s daily practise.
The much publicise reduction of adverse drugs reactions does not hold much water in reality on close study as there already exist ward pharmacists, pharmacy-based pharmacists and discharge nurses, who will check each and every prescription along the patient care pathway in the current system.
Although this may seem like an inefficient process at first glance, it has an inherent flexibility in prescribing for special circumstances and has the advantage of multiple layers of inspection by clinical staff involved in the direct care of the specific patient (The “Swiss-cheese” safety model). The staff in this chain of care are able to say:
“We know who this patient is”
To-date, there are no head-to-head randomised comparative trials in this area so the comparative benefits are only presumed, not tested.
However, in a poorly staffed ward or hospital, it would not be inconceivable that any additional support from the Computerised Physician Order Entry System may reduce errors.
Whether this is cost-effective in the context of good overall clinical care is unclear, as “good clinical care” is more qualitative than quantitative and thus, difficult to define and study.
Work satisfaction derived from human interactions must also be taken into account in any analysis of “good clinical care”, as this would be necessary for sustained high performance among clinical staff.
Inappropriate use of technology:
Technology is a tool and nothing more. Information Technology cannot exist and solve problems on its own, nor can it increase productivity or profit without the right work processes already in place and with adequately trained staff whom are ready and able to use it appropriately.
Worst still, if a tool is “hijacked” and manipulated to achieve a secondary goal, it would be very likely then that it would fail to achieve its original aims.
The “Choose and Book” initiative is a good example. The original project was designed to facilitate patient referral and booking into local outpatients clinics by General Practitioners.
However, once the pilots started showing promise, the focus was changed to meet the political agenda of “Patient’s Choice” and “Payment by Result”.
Most NHS patient surveyed have not preferred choice over a good local service, where they can be visited by their friends and family, and General Practitioners do not see additional benefit in patient care nor the logic in referring patients to Consultants whom they have not established a professional relationship with.
There is also the additional time-consuming work to explain the benefits of each option over the others, when one may not have all the necessary information to do so in the first place, especially when the hospital is hundreds of miles away or is a private entity.