Feb 27, 2014
By Nicola Shaw, PhD, FBCS, CITP

The challenge to go paperless: Act 2

Evgeniya Uvarova/Shutterstock

In 2005, Richard Alvarez, Canada Health Infoway’s president and CEO, laid out the progress made toward accelerating Canadian electronic health record implementation. During this presentation, he lauded England’s National Programme for IT (NPfIT), which was to provide an electronic health record for the entire population by 2010. However, by 2011, and after an investment of more than 12 billion pounds (C$20 billion), the NPfIT had been scrapped.

Then early last year, Health Minister Jeremy Hunt issued a challenge to the National Health Service (NHS), England’s publicly funded health system, to go paperless by 2018. What lessons had been learned in the intervening two years that could lead to a recommitment to an initiative that had failed so spectacularly?

Numerous pundits have written about the many different causes for its demise. However, some consensus has formed in three areas:

  • The motivation to implement the NPfIT came from the top. The health ministers must have forgotten that such projects are more likely to flop than those initiated with a bottom-up approach.
  • Failure to engage the right stakeholders led to hostility from a workforce that was unwilling, if not actually unable, to accommodate the expectation that they would overcome the inherent accessibility and utility issues of the systems. These included technical difficulties that arose when different systems were forced to work together in environments in which they had rarely been fully tested. Additionally, too little attention was paid to the country’s geographical and cultural divide and to the diversity of practice in different communities.
  • IT contracts, which were weighted heavily in favour of the NHS, were awarded long before the scope of the project was fully understood. Vendors, who had assumed all the risk, withdrew even before the procurement process was completed; one walked away from a contract worth two billion pounds.

It appears to me that the NHS hasn’t learned from its earlier mistakes, to any great extent. To be fair, results of a November 2013 poll of NHS staff showed support for a paperless health system, particularly for its potential to improve patient care. This might be a sign that the right stakeholders are being engaged. Unfortunately, funding responsibilities and contractual issues have yet to be clarified, and there remains a lot of ambiguity about what paperless means, what the true benefits are and how it will be taken forward. A revamped NHS technology strategy is due to be delivered in March. Whether the NHS has a better chance of success this time will become clear once the content of that document is made public and it lays out how problematic issues will be addressed. Canada would be well advised to carefully watch what unfolds next. It’s a small world. Our own failures in going paperless have been noted by the international community, and we ought to be listening for any small voice in the crowd crying out “The emperor has no clothes!”

Nicola Shaw, PhD, FBCS, CITP, is the ESRI Canada Research Chair in Health Informatics and an Associate Professor with Algoma University and the Northern Ontario School of Medicine.
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