An advisory group chaired by Robert Wachter, M.D., a professor and interim chairman of the Department of Medicine at the University of California, San Francisco, has made 10 recommendations to the National Health Service (NHS) in England on how to move forward implementing digital health technology. One recommendation is setting an ambitious goal of 2023 for having robust clinical information systems implemented across NHS with a high degree of interoperability. Another is the development of a workforce of trained clinician-informaticists with appropriate resources and authority.
Robert Wachter, M.D.
An ambitious British program to digitize healthcare – the National Programme for Information Technology (NPfIT), launched in 2002 – was shut down in 2011 after having mostly failed to achieve its goals, the advisory group’s report notes. In late 2015, the National Advisory Group on Health Information Technology in England was formed to advise the Department of Health and NHS England on its efforts to digitize the “secondary care system.” The advisory group led by Dr. Wachter had strong representation from the United States, including:
• Julia Adler-Milstein, Ph.D. – Associate Professor, Schools of Information and of Public Health, University of Michigan;
• David Brailer, M.D., Ph.D. – CEO, Health Evolution Partners (current); First U.S. National Coordinator for Health IT (2004-6);
• Dave deBronkart – Patient Advocate, known as “e-Patient Dave”;
• Rollin (Terry) Fairbanks, M.D., M.S. – Director, National Center for Human Factors in Healthcare; Emergency Physician, MedStar Health;
• John Halamka, M.D., M.S. – Chief Information Officer, Beth Israel Deaconess Medical Center; Professor, Harvard Medical School; and
• Christine Sinsky, M.D. – Vice-President of Professional Satisfaction, AMA; Primary Care Doctor, Dubuque, Iowa,
Lessons drawn from the U.S. implementation of health IT
It is interesting to read in their report how the advisory group’s interpretation of the U.S. experience with health IT offers some possible lessons for the NHS.
The group’s report notes that while the early stages of Meaningful Use, designed to ensure that organizations that accepted HITECH subsidies were actually using their EHRs in “meaningful” ways, were popular and widely accepted, later stages “involved marked increases in regulation, creating a major burden on both suppliers and delivery systems, stifling innovation, and contributing to the consolidation.”
So while MU created a tipping point for digitization of the healthcare sector, they see the major downside of HITECH is that it “opened the door to the overregulation of Meaningful Use Stages 2 and 3.” They also say that in terms of its impact on clinical care, the U.S. experience with health IT has been disappointing. “While the literature points to modest improvements in safety and quality, the promised efficiency gains have not yet materialized, and unhappiness among health professionals is a dominant theme of the current era. While there are many reasons for this, there is little question that health IT has, to a surprising degree, added to the woes.”
They also note the failure of MU to achieve widespread interoperability.
In their recommendations, the group said the new effort to digitize the NHS should guarantee widespread interoperability. “The goals of interoperability are to enable seamless care delivery across traditional organizational boundaries, and to ensure that patients can access all parts of their clinical record and, over time, import information into it. Widespread interoperability will require the development and enforcement of standards, along with penalties for suppliers, trusts, GPs, and others who stand in the way of appropriate data sharing. The system, standards, and interfaces should enable a mixed ecosystem of IT system providers to flourish, with the goal of promoting innovation and avoiding having any one vendor dominate the market.”
Which lessons from the U.S. experience might be relevant to England? Here is a brief summary of some of the advisory group’s thoughts and recommendations:
• Great attention needs to be paid to issues of adaptive change from the start. "In particular, the predicament of clinicians, especially doctors and nurses, must be deeply appreciated. The tendency simply to digitize ineffective and inefficient analog processes needs to be resisted. Digitization offers an opportunity to rethink the work and workflow."
• Invest in clinical informatics workforce. "The U.S. was well served by several decades of research into information technology and a strong cadre of clinician-leaders in IT, many of whom became chief medical/nursing/pharmacy information officers (the equivalent of UK CCIOs and CNIOs). These individuals serve as crucial bridges between the technology and front-line clinicians. The UK lacks a large cadre of such individuals; early efforts to build such a workforce will need to be supported and expanded."
• IT implementation is expensive. In the U.S., large hospitals often spend more than $100 million (£76 million) implementing an advanced, full-featured EHR, the report noted. "While few trusts will be able to afford such systems, it will be important to allocate appropriate resources for purchase, upkeep, and workforce training, and to provide the funds needed to support innovation and the integration of IT into improvement work."
• The risk of ‘vendor lock’ is real. For example, in the U.S., it will be very difficult to displace Epic from its near-monopoly position in large healthcare systems, the group wrote. However, it seems unrealistic to believe that homegrown systems or those built by small companies can meet the needs of large trusts (although they may be able to deliver some key components of systems).
• Patience is required. "The history of the productivity paradox points to a lag of 10 years or more before the full benefits of health IT are realized. An effective communication strategy should aim to balance enthusiasm for digitization with appropriate expectations amongst various stakeholder groups."
• Appoint and give appropriate authority to a national chief clinical information officer. The advisory group recommends that a national chief clinical information officer (CCIO) should be appointed to oversee and coordinate NHS clinical digitization efforts.
It will be interesting to see how many of the advisory group’s recommendations are adopted by NHS and how much funding is provided. One has already been acted upon: In July, Prof. Keith McNeil, the former head of Cambridge University Hospitals NHS Foundation Trust, was appointed as England’s first national chief clinical information officer.