Health Connection Research Articles

A Call to Reconsider a Nationwide Electronic Health Record System: Correcting the Failures of the National Program for IT.

Abstract The National Programme for IT (NPfIT) was launched in 2005 to implement 7 nationwide IT services across the National Health Service (NHS). Despite the success of many of these designated “deliverables,” the establishment of a single nationwide electronic health record (EHR) system never fully materialized. As a result, NHS medical records are now stored using a diverse array of alternate EHR systems, which frequently restricts health care practitioners from accessing extensive portions of their patients’ notes. This not only limits their ability to make well-informed clinical decisions but also impacts the quality of care they are able to provide. This article assesses the medical, economic, and bureaucratic implications of an NHS-wide EHR system. Additionally, it explores how the shortcomings of the NPfIT should be addressed when attempting to introduce such a system in the future.

Challenge for the National Health Service Information System in England- Dismantling the NHS National Programme for IT.

Challenge for the National Health Service Information System in England- Dismantling the NHS National Programme for IT.

Accelerating health information technology capabilities across England's National Health Service

The National Health Service (NHS) England Global Digital Exemplar (GDE) Programme has, by contrast to earlier failed programmes such as the National Programme for IT, made considerable progress in developing digital transformation capability in select hospitals. These GDE provider organisations are now among the most digitally advanced sites worldwide and have successfully exploited these capabilities during the COVID-19 pandemic.1 Digital transformation, such as implementing and optimising electronic health records and electronic prescribing, has been achieved through organisation-wide engagement and alignment of efforts around a future-oriented vision, while still allowing space for more organic development supported by nationally orchestrated knowledge sharing initiatives.

Avoiding Project Failure and Achieving Project Success in NHS IT System Projects in the United Kingdom

Although project success varies from business to business depending on different internally agreed success criteria, most organisations measure project success by analysing if the project delivered the planned project objectives within the set budget, schedule (project timelines), and quality. However, for some projects especially, development projects success goes beyond just meeting time frames and budget goals. In such projects and programmes, success refers to delivering the benefits coupled with the required expectations by stakeholders, beneficiaries, and funding bodies. This paper re-examines why the National Programme for IT (NPfIT), the largest public-sector IT programme that was ever undertaken in the UK, failed and how any future NHS National IT System implementations can be completed successfully.

Self-management support for chronic disease in primary care: frequency of patient self-management problems and patient reported priorities, and alignment with ultimate behavior goal selection

BackgroundTo enable delivery of high quality patient-centered care, as well as to allow primary care health systems to allocate appropriate resources that align with patients’ identified self-management problems (SM-Problems) and priorities (SM-Priorities), a practical, systematic method for assessing self-management needs and priorities is needed. In the current report, we present patient reported data generated from Connection to Health (CTH), to identify the frequency of patients’ reported SM-Problems and SM-Priorities; and examine the degree of alignment between patient SM-Priorities and the ultimate Patient-Healthcare team member selected Behavioral Goal.MethodsCTH, an electronic self-management support system, was embedded into the flow of existing primary care visits in 25 primary care clinics and was used to assess patient-reported SM-Problems across 12 areas, patient identified SM-Priorities, and guide the selection of a Patient-Healthcare team member selected Behavioral Goal. SM-Problems included: BMI, diet (fruits and vegetables, salt, fat, sugar sweetened beverages), physical activity, missed medications, tobacco and alcohol use, health-related distress, general life stress, and depression symptoms. Descriptive analyses documented SM-Problems and SM-Priorities, and alignment between SM-Priorities and Goal Selection, followed by mixed models adjusting for clinic.Results446 participants with ≥ one chronic diseases (mean age 55.4 ± 12.6; 58.5% female) participated. On average, participants reported experiencing challenges in 7 out of the 12 SM-Problems areas; with the most frequent problems including: BMI, aspects of diet, and physical activity. Patient SM-Priorities were variable across the self-management areas. Patient- Healthcare team member Goal selection aligned well with patient SM-Priorities when patients prioritized weight loss or physical activity, but not in other self-management areas.ConclusionParticipants reported experiencing multiple SM-Problems. While patients show great variability in their SM-Priorities, the resulting action plan goals that patients create with their healthcare team member show a lack of diversity, with a disproportionate focus on weight loss and physical activity with missed opportunities for using goal setting to create targeted patient-centered plans focused in other SM-Priority areas. Aggregated results can assist with the identification of high frequency patient SM-Problems and SM-Priority areas, and in turn inform resource allocation to meet patient needs.Trial registrationClinicalTrials.gov ID: NCT01945918.

712-P: Lessons from a Pragmatic Trial to Implement a Patient Self-Management Support Program in Primary Care

Advanced primary care models emphasize patient-centered care, including self-management support (SMS). Connection to Health (CTH) is a comprehensive, evidence-based SMS program that enhances interactions between primary care clinicians and patients. Uptake and maintenance of programs such as CTH in primary care have been limited by the inability of practices to adapt and implement program components into their culture, patient flow, and work processes. Thirty-six primary care practices participated in a three-arm, cluster-randomized trial to determine the incremental benefit of brief, targeted practice facilitation on the implementation of CTH. Practices receiving the CTH program, compared to those receiving only standard SMS education, showed significantly greater improvement in SMS activities (e.g., goal setting, action planning, patient follow-up, behavioral health discussions), as assessed by chart audit (p<0.022). Yet, there was variable practice-level use of the CTH tools during the 9-month intervention. Practices receiving practice facilitation used CTH more with patients with higher hemoglobin A1c levels and more comorbidity. Qualitative analysis of interviews and field notes point to barriers impeding uptake and maintenance of SMS: lack of visible champions, lack of shared vision, low interest in CTH/SMS, emergent higher priorities, clinician/staff turnover, and perceived redundancy of CTH. Facilitating factors included alignment with system priorities, role and time dedicated to SMS delivery, functional practice teams, and adapting CTH to fit with existing workflows. The overall effect of introducing the SMS program and facilitation support suggests primary care practices can improve their delivery of SMS to patients with T2DM with a brief targeted intervention. However, broadly implementing and sustaining SMS programs in primary care will require attention to overcoming barriers and building on individual practice’s facilitating factors. Disclosure D. Fernald: None. D.M. Hessler: Consultant; Self; Eli Lilly and Company. V. Bowyer: None. B. Jortberg: None. R. Wearner: None. L. Fisher: Consultant; Self; Abbott, Eli Lilly and Company. P. Dickinson: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (1R18DK096387-01)

A protocol for a cluster randomized trial comparing strategies for translating self-management support into primary care practices

BackgroundAdvanced primary care models emphasize patient-centered care, including self-management support (SMS), but the effective use of SMS for patients with type 2 diabetes (T2DM) remains a challenge. Interactive behavior-change technology (IBCT) can facilitate the adoption of SMS interventions. To meet the need for effective SMS intervention, we have developed Connection to Health (CTH), a comprehensive, evidence-based SMS program that enhances interactions between primary care clinicians and patients to resolve self-management problems and improve outcomes. Uptake and maintenance of programs such as CTH in primary care have been limited by the inability of practices to adapt and implement program components into their culture, patient flow, and work processes. Practice facilitation has been shown to be effective in helping practices make the changes required for optimal program implementation. The proposed research is designed to promote the translation of SMS into primary care practices for patients with T2DM by combining two promising lines of research, specifically, (a) testing the effectiveness of CTH in diverse primary-care practices, and (b) evaluating the impact of practice facilitation to enhance implementation of the intervention.MethodsA three-arm, cluster-randomized trial will evaluate three discrete strategies for implementing SMS for patients with T2DM in diverse primary care practices. Practices will be randomly assigned to receive and implement the CTH program, the CTH program plus practice facilitation, or a SMS academic detailing educational intervention. Through this design, we will compare the effectiveness, adoption and implementation of these three SMS practice implementation strategies. Primary effectiveness outcomes including lab values and evidence of SMS will be abstracted from medical records covering baseline through 18 months post-baseline. Data from CTH assessments and action plans completed by patients enrolled in CTH will be used to evaluate practice implementation of CTH and the impact of CTH participation. Qualitative data including field notes from encounters with the practices and interviews of practice personnel will be analyzed to assess practice implementation of SMS.DiscussionThis study will provide important information on the implementation of SMS in primary care, the effectiveness of an IBCT tool such as CTH, and the use of practice facilitation to assist implementation.Trial registrationRegistered with ClinicalTrials.gov – ClinicalTrials.gov ID: NCT01945918, date 08/27/2013. Modifications have been updated.

Persecution complex: I am getting one over electronic patient records!

The electronic patient record (EPR) is a core organisational document in which integrated health and social care records and secondary care processes can be stored. EPR was the brain child of the NHS’ National Programme for Information Technology, under the Blair government. 1 Since then, attempts have been made to install EPR in secondary care – a typical example being the installation of specialist imaging systems in hospital trusts. 2 The primary aim of EPR was to make the NHS services efficient via digitised patient records that could be viewed, discussed and transferred electronically between clinicians and/or trusts. 1 , 3 Other anticipated uses of EPR were to provide easy patient access to services such as e-referrals and e-prescriptions, as well as appointment systems. 3 , 4 Here, we discuss EPR and information technology in plain language, and assess the impact of EPR on NHS secondary care orthodontic services.

National Health Information Network: Lessons Learned From the USA and the UK

National Health Information Network (NHIN) is a network in which all health care organizations, government agencies and other health-related organizations are connected to each other to exchange information about health. Due to the necessity of a framework for NHIN development, in this paper, according to the literature review, a definition for NHIN framework was provided, and then the NHIN related projects were reviewed in the United States of America (USA) and the United Kingdom (UK), NHIN and National Programme for Information Technology in the NHS (NPfIT), respectively. The Review of NHIN framework in the countries studied show some similarities and differences in each dimension that are discussed in this framework. NHIN guiding principles in the NHS NPfIT were not regarded or were considered incomplete, compared to the US. NHIN architecture in the US is decentralized while it is centralized in the UK. Based on the review of NHIN framework, these two countries represent important points that can be used in many other countries. However, it can be said that the development of NHIN does not only mean the implementation of national system or systems, or the binding of local health information systems, but It also needs to build on a framework in which many of the issues related to the formation of NHIN would be considered; including the cooperation between government, private sector and stakeholders with regard to local, national and international needs.

The UK's National Programme for IT: Why was it dismantled?

This paper discusses the UK's National Programme for IT (NPfIT), which was an ambitious programme launched in 2002 with an initial budget of some £6.2 billion. It attempted to implement a top-down digitization of healthcare in England's National Health Service (NHS). The core aim of the NPfIT was to bring the NHS' use of information technology into the 21st century, through the introduction of an integrated electronic patient record systems, and reforming the way that the NHS uses information, and hence to improve services and the quality of patient care. The initiative was not trusted by doctors and appeared to have no impact on patient safety. The project was marred by resistance due to the inappropriateness of a centralized authority making top-down decisions on behalf of local organizations. The NPfIT was officially dismantled in September 2011. Deemed the world's largest civil IT programme, its failure and ultimate demise sparked a lot of interest as to the reasons why. This paper summarises the underlying causes that lead to dismantling the NPfIT. At the forefront of those circumstances were the lack of adequate end user engagement, the absence of a phased change management approach, and underestimating the scale of the project.

How does joint procurement affect the design, customisation and usability of a hospital ePrescribing system?

The aim of this article is to explore the effect of the joint procurement model adopted during the English National Programme for Information Technology (NPfIT) on the customisation, design and usability of a hospital ePrescribing system. Drawing on qualitative data collected at two case study sites deploying an ePrescribing system jointly procured within one of the NPfIT's geographical clusters, we explain how procurement decisions, difficult relationships with the supplier and strict contractual arrangements contributed to usability issues and difficulties in the customisation process. While some limited change requests made by users were taken up by the developers, these were seen by users as insufficient to meet local clinical needs and practices. A joint procurement approach, such as the NPfIT, thus limited the opportunity and scope of the changes to the ePrescribing system, which impinged not only on the perceived success of the implementation but also on the system's usability.

Investigating healthcare IT innovations: a "conceptual blending" approach.

The purpose of this paper is to better understand how and why adoption and implementation of healthcare IT innovations occur. The authors examine two IT applications, computerised physician order entry (CPOE) and picture archiving and communication systems (PACS) at the meso and micro levels, within the context of the National Programme for IT in the English National Health Service (NHS). To analyse these multi-level dynamics, the authors blend Rogers' diffusion of innovations theory (DoIT) with Webster's sociological critique of technological innovation in medicine and healthcare systems to illuminate a wider range of interacting factors. Qualitative data collected between 2004 and 2006 uses semi-structured, in-depth interviews with 72 stakeholders across four English NHS hospital trusts. Overall, PACS was more successfully implemented (fully or partially in three out of four trusts) than CPOE (implemented in one trust only). Factors such as perceived benefit to users and attributes of the application - in particular speed, ease of use, reliability and flexibility and levels of readiness - were highly relevant but their influence was modulated through interaction with complex structural and relational issues. Results reveal that combining contextual system level theories with DoIT increases understanding of real-life processes underpinning implementation of IT innovations within healthcare. They also highlight important drivers affecting success of implementation, including socio-political factors, the social body of practice and degree of "co-construction" between designers and end-users. The originality of the study partly rests on its methodological innovativeness and its value on critical insights afforded into understanding complex IT implementation programmes.

Exploiting the information revolution: call for independent evaluation of the latest English national experiment

BackgroundThe English National Health Service (NHS) has a long history of national experiments with information technology; some successful, others less so. The NHS England Five Year Forward View aspires to...

Clinical safety of England's national programme for IT: A retrospective analysis of all reported safety events 2005 to 2011

ObjectiveTo analyse patient safety events associated with England's national programme for IT (NPfIT). MethodsRetrospective analysis of all safety events managed by a dedicated IT safety team between September 2005 and November 2011 was undertaken. Events were reviewed against an existing classification for problems associated with IT. The proportion of reported events per problem type, consequences, source of report, resolution within 24h, time of day and day of week were examined. Sub-group analyses were undertaken for events involving patient harm and those that occurred on a large scale. ResultsOf the 850 events analysed, 68% (n=574) described potentially hazardous circumstances, 24% (n=205) had an observable impact on care delivery, 4% (n=36) were a near miss, and 3% (n=22) were associated with patient harm, including three deaths (0·35%). Eleven events did not have a noticeable consequence (1%) and two were complaints (<1%). Amongst the events 1606 separate contributing problems were identified. Of these 92% were predominately associated with technical rather than human factors. Problems involving human factors were four times as likely to result in patient harm than technical problems (25% versus 8%; OR 3·98, 95%CI 1·90–8.34). Large-scale events affecting 10 or more individuals or multiple IT systems accounted for 23% (n=191) of the sample and were significantly more likely to result in a near miss (6% versus 4%) or impact the delivery of care (39% versus 20%; p<0·001). ConclusionEvents associated with NPfIT reinforce that the use of IT does create hazardous circumstances and can lead to patient harm or death. Large-scale patient safety events have the potential to affect many patients and clinicians, and this suggests that addressing them should be a priority for all major IT implementations.

Factors Affecting the Implementation of the National Programme for Information Technology in the National Health Services: The Case of Lorenzo in the North, Midlands and East of England Region

This study is concerned with the aspect of revealing the factors that affect the adoption of IT programs in the health sector in the NHS in UK. It focuses on the identification of the factors that influence significantly the adoption of LORENZO, the Electronic Health Record system that is being implemented in the Strategic Health Authorities (SHAs) in the North, Midlands and East of England (NME) region as part of the National Program for Information Technology (NPfIT) in the NHS. This study is based on the Technology Acceptance Model (TAM). A qualitative research methodology was used to approach this area unlike the quantitative approach usually associated with the TAM. The data was obtained by conducting face-to-face semi-structured interviews with people who represented the end users in the NHS and the designing company (the LSP). By contrast with most academic studies, the research, therefore, studied the NPfIT from the bottom up (i.e., the end user perspective). The main tool used to aid the analysis of the interview data is NVivo. This analysis was used to develop an extended TAM model and to suggest a theoretical model of the relationship between LORENZO development methodology and users’ acceptance. The study suggests some factors, apart from usefulness, which LORENZO’s designers, the NHS should take into account when it comes to enhance users’ usage of IT adoption. These factors are clinical safety, security, integration and information sharing.

Hybridity as a process of technology's ‘translation’: Customizing a national Electronic Patient Record

This paper explores how national Electronic Patient Record (EPR) systems are customized in local settings and, in particular, how the context of their origin plays out with the context of their use. It shows how representations of healthcare organizations and of local clinical practice are built into EPR systems within a complex context whereby different stakeholder groups negotiate to produce an EPR package that aims to meet both local and generic needs. The paper draws from research into the implementation of the National Care Record Service, a part of the National Programme for Information Technology (NPfIT), in the English National Health Service (NHS). The paper makes two arguments. First, customization of national EPR is a distributed process that involves cycles of ‘translation’, which span across geographical, cultural and professional boundaries. Second, ‘translation’ is an inherently political process during which hybrid technology gets consolidated. The paper concludes, that hybrid technology opens up possibilities for standardization of healthcare.

Organizational learning in the implementation and adoption of national electronic health records: case studies of two hospitals participating in the National Programme for Information Technology in England.

To explore the role of organizational learning in enabling implementation and supporting adoption of electronic health record systems into two English hospitals. In the course of conducting our prospective and sociotechnical evaluation of the implementation and adoption of electronic health record into 12 "early adopter" hospitals across England, we identified two hospitals implementing virtually identical versions of the same "off-the-shelf" software (Millennium) within a comparable timeframe. We undertook a longitudinal qualitative case study-based analysis of these two hospitals (referred to hereafter as Alpha and Omega) and their implementation experiences. Data included the following: 63 in-depth interviews with various groups of internal and external stakeholders; 41-h on-site observation; and content analysis of 218 documents of various types. Analysis was both inductive and deductive, the latter being informed by the "sociotechnical changing" theoretical perspective. Although Alpha and Omega shared a number of contextual similarities, our evaluation revealed fundamental differences in visions of electronic health record and the implementation strategy between the hospitals, which resulted in distinct local consequences of electronic health record implementation and impacted adoption. Both hospitals did not, during our evaluation, see the hoped-for benefits to the organization as a result of the introduction of electronic health record, such as speeding-up tasks. Nonetheless, the Millennium software worked out to be easier to use at Omega. Interorganizational learning was at the heart of this difference. Despite the turbulent overall national "roll out" of electronic health record systems into the English hospitals, considerable opportunities for organizational learning were offered by sequential delivery of the electronic health record software into "early adopter" hospitals. We argue that understanding the process of organizational learning and its enabling factors has the potential to support efforts at implementing national electronic health record implementation endeavors.

Evaluation as a Multi-Ontological Endeavour: A Case from the English National Program for IT in Healthcare

This paper analyzes how researchers’ different ontological and epistemological assumptions shape the process and outcomes of evaluation research. Focusing on the critical realism (CR) and social constructionism (SC) philosophical approaches, it outlines the rationale for multi-ontological evaluation and develops principles for conducting it. The paper draws from experience of evaluating a national implementation program of electronic health records in hospitals, one of the projects of the English National Programme for IT. It argues that an evaluation based on SC and one based on CR are significantly different in how they use knowledge gained in the field, and in the kind of evidence and recommendations that they can offer policy makers. The CR philosophy applied to evaluation research provides foundations from which judgments and abstractions can be presented in the form expected by the policy makers and managers who commission evaluations. In line with its ontological standing, social constructionism cannot simply or directly abstract and generalize across contexts, though it can offer other types of valuable evaluative insight. We show that, despite their differences, these two philosophical positions can, when taken together, produce jointly useful knowledge. This paper argues for the use of multi-ontological evaluation approaches and provides guidelines for undertaking such endeavors by emphasizing the need for mutual respect, dialogue, negotiation, and reflection.

‘Choose and Book’: are patients ill informed?

‘Choose and Book’ (CaB), part of the government's National Programme for IT, was rolled out in the NHS in 2006. It aims to empower patients by offering them unrestricted referral to health service providers. Patient choice has been a key element in successive governments; yet little research exists into what motivates patient choice. This audit looked at referral pathways over a four-week period in 2010 to establish how patients had been referred; and if referred via CaB, what factors motivated their choice. Only 50% of patients were referred via CaB. Of those given a choice of providers, 46% chose the closest hospital and 18% chose the shortest waiting time. The results show that the patient makes choices based on everyday practicalities rather than quality of healthcare provider as they are potentially ill informed and disempowered to decide on the basis of any other factors.

A toolkit to support the implementation of electronic prescribing systems into UK hospitals: preliminary recommendations

Hospital electronic prescribing (or ePrescribing) systems have the potential to reduce drug-related morbidity and mortality. However, their implementation and adoption has been slow to date, despite the considerable service interest in implementing systems and the long-standing policy drive towards computerization. The underlying reasons may include the demise of the National Programme for Information Technology; a lack of change management expertise and capacity in the National Health Service (NHS); the relatively immature and fragmented market; limited standards guiding procurement, functional specifications and expected benefits; and lack of resources.