Editorials
Why e-health is so hard We need to respect the basic rules of informatics and invest in e-health expertise
Enrico Coiera
MB BS, PHD, FACHI, Professor and Director
Centre for Health Informatics, Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW.
[email protected]
doi: 10.5694/mja13.10101
Research p 201 Commentary p 205
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edicine holds dominion in the microcosm of molecules and genes. It is in the macrocosm of people and organisations where things seem to fall apart. Modern health care appears unsustainable in its current form,1 and information technology is increasingly seen as a major intervention that can drive “reform”. Evidence for e-health’s potential to improve the safety and quality of care grows,2 but remains patchy.3 The long list of disappointments and failures,4,5 locally and internationally, is also hard to ignore. There is a real dissonance in the discourse between what research evidence tells us is possible and what often happens with large-scale e-health projects in practice.6 The literature repeatedly describes basic “rules of informatics” for implementation success: the need for stakeholder engagement, culture change, user training, slow and considered implementation, and user-friendly systems that fit into clinical workflow.7 The very first rule of informatics tells us to start with the clinical problem we want solved rather than the technology we want to build. 8 Yet, too often, large-scale e-health projects break this most basic rule, focusing on technology rather than compelling clinical problems.5 We are often told that national e-health projects must first lay down basic technical infrastructure and that high-value clinical systems will naturally follow, in the same way that laying railway lines is a precursor to delivering transport services.9 But railways can be too expensive, over-engineered, or not take us anywhere particularly useful — unless there is a destination on which we can all agree. Why so many projects repeatedly fail to observe these basic rules of informatics remains a mystery, but it probably reflects that there are still very few people with deep
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expertise in e-health.10 Despite the crucial role of the informatics workforce in e-health success, and the billions spent on e-health over the past decade by government, barely a dollar has been in direct support of informatics workforce training. E-health is hard because it is a complex intervention in a complex system.11 Indeed, e-health projects are probably among the most complex interventions we can undertake, especially at a national scale. The rules for designing e-health at the level of clinical practice are not the same as those at large scale, and the gap is as wide as that between in-vitro and in-vivo clinical studies. This explains why success at individual sites is no guarantee of success elsewhere. In this issue of the Journal, a study by Mohan and colleagues shows that introducing a new clinical system into the emergency department of a single hospital was associated with decreased performance, as measured by the time patients spent in the department.12 Although it is a truly valuable contribution, we should be careful in extrapolating this result. It measured one system cost — time — at unit not hospital level, so we do not know if there were time gains elsewhere in the hospital. The study did not measure benefits of the new system, such as improved quality or safety of care, and for any intervention it is the balance of cost and benefit that makes the case. As the authors acknowledge, there were so many confounding variables with their study design that it is hard to be sure of the causes of what they found. It seems to be the rule rather than the exception that outcomes will be different in different settings, so directly extrapolating to other sites without further study risks ecological fallacy.
Editorials This is the context within which we must understand ehealth: trying to re-engineer a system that was never consciously engineered in the first place, with a knowledge base that is sometimes loose praxis at best and not yet fully a science. More profoundly, while the cries to re-engineer the health “system” are near universal, we do not even know what kind of a system it is. Are we dealing with a linear or a complex adaptive ecosystem? Does it exhibit chaos or inertia?13 Where are its boundaries and control points? How can we re-engineer our health system when there is no discipline of health systems engineering, no health systems science? How can we change the “system” when people use the term so loosely, no one ever asking what the other means?14 Yet use it we do; re-engineer it we try; and nowhere is mostly where we get. Static solutions decay in a dynamic world, and if you live in a complex adaptive system, you had better adapt as fast as those around you. While computers are among the most adaptive of technologies ever conceived, big e-health systems are often among the least. As consumers, we see monthly changes in the technologies available to us, yet many of today’s clinical e-health products seem stuck in the pre-internet 1980s.15 Indeed, by the time a large ehealth system is in operation, it can be obsolete. In the years between modelling user needs and implementation, those needs can change. This also explains why national programs should leverage technical standards but not become sclerotic because of them, and why top-down approaches to e-health seem to struggle everywhere.6 Just because e-health is hard does not mean we can ignore it and do something else instead. The goal is worthy, and alternatives are thin on the ground. We do, however, need to urgently invest in the informatics workforce, as this is no game for amateurs. We must also respect
the basic rules of informatics. Like the laws of physics, they exist, whether you like them or not. Acknowledgements: This work is supported by the National Health and Medical Research Council Centre for Research Excellence in E-Health. Competing interests: No relevant disclosures. Provenance: Commissioned; externally peer reviewed. 1 Coiera E, Hovenga EJ. Building a sustainable health system. Methods Inf Med
2007; 46 Suppl 1: 11-18.
2 Bates DW, Gawande AA. Improving safety with information technology. N Engl
J Med 2003; 348: 2526-2534.
3 Black AD, Car J, Pagliari C, et al. The impact of eHealth on the quality and
safety of health care: a systematic overview. PLoS Med 2011; 8 (1): e1000387.
4 Magrabi F, Ong MS, Runciman W, Coiera E. An analysis of computer-related
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patient safety incidents to inform the development of a classification. J Am Med Inform Assoc 2010; 17: 663-670. doi: 10.1136/jamia.2009.002444. Greenhalgh T, Hinder S, Stramer K, et al. Adoption, non-adoption, and abandonment of a personal electronic health record: case study of HealthSpace. BMJ 2010; 341: c5814. Coiera E. Building a national health IT system from the middle out. J Am Med Inform Assoc 2009; 16: 271-273. doi: 10.1197/jamia.M3183. Gagnon MP, Desmartis M, Labrecque M, et al. Systematic review of factors influencing the adoption of information and communication technologies by healthcare professionals. J Med Syst 2012; 36: 241-277. Coiera E. Medical informatics. BMJ 1995; 310: 1381-1387. Jolly R. The e health revolution — easier said than done. Parliamentary Library Research Paper No. 3 2011-12. Canberra: Parliament of Australia, 2011. Smith SE, Drake LE, Harris JGB, et al. Clinical informatics: a workforce priority for 21st century healthcare. Aust Health Rev 2011; 35: 130-135. doi: 10.1071/ AH10935. Shiell A, Hawe P, Gold L. Complex interventions or complex systems? Implications for health economic evaluation. BMJ 2008; 336: 1281-1283. doi: 10.1136/bmj.39569.510521.AD. Mohan MK, Bishop RO, Mallows JL. Effect of an electronic medical record information system on emergency department performance. Med J Aust 2013; 198: 201-204. Coiera E. Why system inertia makes health reform so difficult. BMJ 2011; 342: d3693. Greenhalgh T, Russell J, Ashcroft RE, Parsons W. Why national eHealth programs need dead philosophers: Wittgensteinian reflections on policymakers’ reluctance to learn from history. Milbank Q 2011; 89: 533-563. Mandl KD, Kohane IS. Escaping the EHR trap — the future of health IT. N Engl J Med 2012; 366: 2240-2242. doi: 10.1056/NEJMp1203102. ❏
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