But, against its primary goal of digitising the secondary care sector, NPfIT failed to deliver – largely because it was too centralised, failed to engage properly with trusts and their healthcare professionals, and tried to accomplish too much too quickly. In the short- to medium-term, digitisation of England’s hospital sector is likely to be accomplished with commercial systems, many built by non-UK companies. While it is natural to seek a short-term financial return on investment (ROI) from health IT, experience has shown that the short-term ROI is more likely to come in the form of improvements in safety and quality than in raw financial terms. Which lessons from the US experience might be relevant to England? Of particular concern is the need for a cadre of CCIOs and others with both clinical and informatics training. Heifetz R, Laurie DL. But the larger issues of how the increasingly dynamic world of patient-facing health data and the more corporate world of enterprise health IT can fuse into one stream, and how this vast data stream will be managed and protected, remain largely unresolved. The media and the US Congress have criticised EHR suppliers and some healthcare systems for willful ‘information blocking’; there is even talk of prosecution of individuals or organisations that participate in such alleged blocking (39). The work of leadership. As Professor Trish Greenhalgh told our group, ‘“Clinical engagement” is more about being listened to than being written to’. This framework should bring together a mixture of system levers, incentives, and technical solutions in order to meet the key goals. These indicators are reviewed annually and are mostly extracted from GP EHRs (21). Jones SS, Heaton PS, Rudin RS, Schneider EC. To support purchasing, implementation, and ongoing improvements by trusts, digital learning networks should be created or supported. Holroyd-Leduc JM, Lorenzetti D, Straus SE, et al. App Clin Inform 2010; 1:197-212. Technical change is straightforward: simply follow a recipe or a checklist and the problem will be solved. Health IT systems need to evolve and mature, and the workforce and leadership must be appropriate for this task. In 2012, the National Information Board (NIB) was established to create such a plan by bringing together organisations from across the NHS, public health, clinical science, social care, local governments, and the public. Moreover, Americans were unwilling to accept the rationing and gate-keeping that are generally accepted in the UK. Friedman CP, et al. Our recommendations fall into 2 broad categories: 10 overall findings and principles, followed by 10 implementation recommendations. In the US the adoption of health IT has resulted in growing rates of clinician (particularly physician) dissatisfaction and burnout, in part because of increasing administrative burdens and challenges to efficiency. The combination of a cradle-to-grave patient record (mostly digitised) collected for clinical (not billing) purposes, the NHS number, and a secure NHS network (the Spine) is unique and should be much better exploited for patient, population, and societal gains. The issue of regulatory requirements for digitisation merits some discussion. Drew BJ, Harris P, Zègre-Hemsey JK, et al. The National Programme for Information Technology (NPfIT) was an ambitious £12.4 billion investment designed to reform how the NHS in England used information to improve service and patient care. In the current NHS effort, the centres would be orientated to helping trusts with their digitisation.) £1.0 billion for infrastructure, including networks, £250 million for data to support audit, planning and research, Transformation of care delivery through new care models, most notably the development of multispecialty community providers and primary and acute care systems, similar to the Accountable Care Organisation (, A radical upgrade in prevention and public health, Greater investment in the health and well being of employees, Exploitation of the information revolution, including greater transparency of data and acceleration of health innovation, create and publicise a name and appropriate branding for the new effort to digitise the, create and begin to enact a national campaign to engage clinicians and trust leaders in the new effort to digitise the, create a job description for, and then hire, a prominent physician-executive with broad experience in information technology, leadership, and change management to become the, trusts seeking Phase 1 (2016-2019) national funding for digital implementation/improvement (Groups A and B; defined under, confirm allocation of approximately £42 million (1% of the £4.2 billion to be spent on digitising the, establish and launch a programme designed to rapidly train, the Faculty of Clinical Informatics, working closely with the British Computer Society and the Royal Colleges, should launch an accreditation and professionalisation agenda designed, ultimately, to certify and professionalise the. In 1993, Massachusetts Institute of Technology (MIT) researcher Eric Brynjolfsson coined the term ‘productivity paradox’ to describe a phenomenon witnessed in a cross-section of industries – financial services, retail, entertainment, and others – as they computerised (1). Rather, interoperability needs to enable integrated workflow, service redesign, and clinical decision support. While this point can be debated, many observers believe that HITECH was a wise intervention, in that US healthcare represented an IT business failure (that is, typical business incentives did not drive healthcare delivery systems to implement IT, as happens in most other industries), and the programme created a tipping point for digitisation of the health care sector (33). 62000. In fact, the first year or so after implementation is more likely to see efficiency losses than gains. Safety risks associated with the lack of integration and interfacing of hospital health information systems. Harvard political scientist Ronald Heifetz has popularised the paradigm of technical versus adaptive change. ↩, The NIB’s ‘Work Stream 6 Roadmap’, published in June 2015, focuses on this area. At the outset, a long-term engagement strategy should be enacted to promote the need for healthcare information technology, identify the likely challenges during implementation, educate stakeholders about the opportunities afforded by a digital NHS, and set the stage for long-term engagement of end users and co-creation of systems and strategies. While welcome, this level of funding is likely not enough to enable digital implementation and optimisation in all NHS trusts. This sensibility is also important as we bring patients in as active partners in seeing and contributing to their digital data. Moreover, the National Information Board report highlighted, in a general way, the need for a more robust CCIO workforce, and some of this effort has already begun under the NIB’s Domain G (1)[footnote 22]. This led to a loss of corporate knowledge and leadership, and a diffusion of accountability and responsibility. ↩, While efforts are being made to align the activities, today the structural elements of digitisation and transformation are more than a little confusing. First, it makes clear that digitisation is not the end-goal – it is a means to an end. The goals of interoperability are not merely to create the technical capability to exchange digital data. Our Advisory Group was charged, in part, because the leaders of the NIB, DH, and the NHS acknowledged the challenges in adoption and clinician engagement, areas that were underemphasised in the NIB report. We have to get the hearts and minds of physicians back. Given the upfront costs of switching from analog to digital (tens of millions of pounds for a mid-sized trust, still more for a large one), new investments are required to promote digitisation across the secondary care sector. Patient information, collected through GP EHRs, has been used in public-private collaborations for research, epidemiological surveillance and quality improvement. There must be a major effort to place well-qualified clinicians with advanced informatics training in every trust. Lead for social care information and technology at Department of Health, North West Care and Health Improvement Advisor (social care adviser) at Local Government Association, Information and Technology lead (for social care) at Local Government Association, Professor of Primary Care Health Science and practising, Health and Social Care Information Centre, NIHR clinical lecturer in surgery, Imperial College, London, with particular interest in digital health, Social Care Account Manager at the Health and Social Care Information Centre (now, Clinical Director of Pharmacy and Medicines Optimisation, Newcastle upon Tyne, Professor of Human-Computer Interaction & Director of UCL Institute of Digital Health, Director General of Innovation, Growth and Technology, Department of Health, Chief Executive Officer, Health Education England, Director of Informatics Delivery, Department of Health. Turning on a new information system in a large hospital or trust (so-called ‘Go-Live’) is always a difficult period, but is nonetheless just the start. Our recommendations are designed to change that dynamic, because such attitudes harm the NHS and its ultimate ability to meet the vision of the Five Year Forward View (4). By using national incentives strategically, balancing limited centralisation with an emphasis on local and regional control, building and empowering the appropriate workforce, creating a timeline that stages implementation based on organisational readiness, and learning from past successes and failures as well as from real-time experience, this effort will create the infrastructure and culture to allow the NHS to provide healthcare that is of high quality, safe, satisfying, accessible, and affordable. This history has also meant that systems have evolved over long periods, utilising technologies that may no longer be state of the art. Poorly designed and implemented systems also result in frustrated healthcare professionals, by adding to their already substantial workloads and diverting them from meaningful work. In came the computers and then… nothing happened. Moreover, we believe that the adaptive-change aspects of health IT cannot be managed effectively without such individuals embedded within trusts. “To get there you do need to be willing to take every opportunity, because if you will not be doing it, somebody else will. In considering whether to offer government money to a trust to subsidise digital implementation, close attention should be paid to the adequacy of its plan to hire and support this workforce. Throughout their development, these systems have been steered by strong user groups. That is, nothing except disrupted workflows, unhappy front-line staff, and a confused finance department. Faced with growing demands from an ageing population, over the past 2 decades the NHS has attempted to improve service and efficiency through a series of reorganisations, cost-cutting manoeuvers, and changes in incentives and targets. In The Digital Doctor, a case is described in which the lack of user-centered design, along with alert fatigue and overreliance on technology, resulted in a 39-fold overdose of a common antibiotic (33). “I was fortunate to meet [the] people myself recently, and I can say that Haas with their work ethic and the amount of hours they're putting in, they really do deserve a better result than they have gotten in the past. NPfIT did enjoy some successes, including the development of a national infrastructure to provide core services (the Spine); a single national patient identifier (the NHS number); and national electronic prescription and radiology programmes. Several individuals provided important input into specific chapters. In healthcare, while there are a number of best practices for designing user interfaces, there are also enormous opportunities to improve Bin 2 design, and this work, in particular, has been underemphasised to date (18,19). The new digital strategy for the NHS should involve a thoughtful blend of funding to help defray the costs of IT purchases and implementation, resources for infrastructure (hardware such as monitors and keyboards, network modernisation, wifi), support for leadership and informatics training, as well as support for education of leaders, front-line providers, trainees and, as above, chief clinical information officers (CCIOs) and other clinician- and non-clinician informaticians.
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