Worldwide, healthcare systems are facing up to an uncertain future as populations age and demand for treatments rise. One universally agreed strategy for ensuring their sustainability has been the implementation of IT-enabled care designed to automate processes and deliver more personalised care.
But, globally, there has been a history of professional resistance to using IT. For example, back in October 2007, US management magazine Modern Healthcare polled its readers to find out how successfully they had handled the installation of electronic medical records systems. Of those that had an EMR, one-third said that some healthcare professionals refused to use it.
Sadly, such refusals remain an issue in health industries worldwide and not without cause. As Matt Swindells, chair of the British Computer Society’s health section, points out: "I think there is a certain amount of cynicism – in the NHS, for example – about IT being part of the solution. And there is a reason for that: not enough has been delivered and it’s not been delivered fast enough."
In the UK, this assessment was confirmed in the recent National Audit Office (NAO) report on the delays in rolling out electronic health records to NHS hospitals.1 Amyas Morse, head of the NAO and author of the report, highlighted the ongoing dilemma: "The NHS is now getting far fewer systems than planned despite the department paying contractors almost the same amount of money. This is yet another example of a department fundamentally underestimating the scale and complexity of a major IT-enabled change programme."
In February 2012, the Queen’s Nursing Institute released a report, “Smart New World: using technology to help patients in the home”2 , that raised additional concerns. The report details how some community nurses are actively resisting the use of mobile healthcare IT and came to the conclusion: "There are practitioners who refuse to use information technology; and decline to offer their patients home monitoring equipment on the assumption that they won’t be able to manage it."
Rosemary Cook, director of the QNI, says: "This is not just about whether we can afford the kit or whether the kit exists – it does. It is not happening because of professional and human issues." Nursing, she says, has a very oral tradition: "Some nurses say that it is not nursing if you are not in the same room as the patient."
Cook disagrees and illustrates her point with a story about one nurse working in telephone triage: "Colleagues told her that she was not nursing. Yet she was using the same knowledge and professional judgement to do the same work with the patient. Yes, technology pushes at the boundaries of nursing and how it’s done and what nursing means, but it’s still nursing."
Similar cultural issues are emerging in medicine. At a recent conference, Dr Paul Altman, chief clinical information officer at the Oxford Radcliffe Hospitals NHS Trust, outlined how IT can become a barrier between clinicians and patients – something that doctors may resist.
"We have to be very careful about the doctor-patient interaction when we digitise healthcare," he said. "There is a tendency for people to gather round computers looking at the numbers and not talk to the patient."
This can have serious consequences, he warned, as illustrated by this anecdote from a US hospital he had visited.
"The hospital had very poor patient outcomes," he said. "They had put computers at the end of each bed and they discovered that clinicians were visiting the computers, not the patients."
Healing old wounds
Breaking down professional resistance to technology is not an easy task. At one level, there is enforcement. In February 2009, the US enacted HITECH – the Health Information and Technology for Economic and Clinical Health Act – a federal law that promises financial compensation for hospitals and doctors using an electronic medical record in a “meaningful way”. From 2015, the government will start to impose financial penalties on hospitals that do not comply.
Some European countries, notably Belgium, have tried to force the issue by making it illegal to gather information more than once in public information systems – a measure designed to force the use of shared records.
The UK is not likely to follow the same route but policy levers have been put in place that will require the use of IT-enabled care. In the last two months of 2011, the NHS Future Forum called for universal access for patients to their own health records; the prime minister launched the “3 Million Lives” campaign with an ambition to see telehealth extended to three million people with long term conditions who could benefit; and the NHS chief executive called for the NHS to be “digital by default”, pointing out that every one per cent reduction in face-to-face contacts saves £200m3 ( €240m). NHS organisations will receive incentive payments to make the shift to technologies such as Skype or email.
Enforcement is going hand in hand with persuasion, also known as clinical engagement. One innovation tested in the US and now being imported to the UK is the appointment of a “chief clinical information officer”. Essentially, this is a senior clinician (often a doctor) who has a lead role in implementing IT-enabled care in a healthcare organisation.
In 2010, the College of Healthcare Information Management Executives pointed out that the largest and best-rated hospitals universally employ chief medical information officers. They had a clear role in the successful implementation of EMRs. It also pinpointed the emergence of the chief nursing information officer, noting that “CNIOs help organisations achieve success in outcomes reporting, quality reporting, workflow improvements and data assessment, and generally allowing the nurses’ voice to be heard in the implementation process.”
The healthcare IT website E Health Insider has been running a campaign since 2011 for all UK hospitals to appoint CCIOs. This has won the backing not just of the NHS medical director Sir Bruce Keogh and the health secretary Andrew Lansley, but also of 11 medical royal colleges. There are now at least 10 CCIOs in UK hospitals.
Healthcare IT companies large and small have also recognised a role for clinicians in the bid to overcome clinical resistance and improve clinical engagement. Most global healthcare IT companies now employ clinicians in senior roles; Dell boasts that 10 per cent of the staff in its healthcare division are clinicians.
Nicola Thomas, head of health sector for Vodafone in the UK, says the issues of professional resistance to adopting IT-enabled care are very real.
“In my experience, it breaks down into three main areas,” she says. “There is a fear of the unknown, there is concern around reliability, coverage and security, and there are people who have had their fingers burned in the past with poorly implemented projects.”
“But some organisations are just asking the wrong question: how can I save money without transforming the way we work? They need to look at the bigger picture. By changing the way they work, they can rationalise priorities, improve patient experience and make huge savings.”
The approach now adopted by Vodafone is to start by working with nurses.
“Our strategic approach is to spend time with the nurses to see what their working day looks like and to determine where we could help them save time. We understand what is being done at the moment and make recommendations about how to improve it.”
Where this approach has been taken, it has reaped dividends. The development of clinically-meaningful, patient-centred, mobile systems such as Vodafone’s award winning mHealth professional4 are starting to make an impact by showing clinicians that IT really can deliver more efficient care and release time for face-to-face consultations.
“We have seen nurses delivering more patient facing time, reducing duplication and improving decision making by providing information at the point of care,” says Thomas.
This is replicated in the QNI report in which, alongside the dire warnings about resistant nurses, are also stories from nurses who have found that mobile technology solutions have given them more time to spend with patients, not less, and enriched their consultations.
As the report concludes: “Technology will never replace the expert nurse; both are needed to deliver high quality care to patients. Neither will the nurse, however expert, be able to substitute entirely for the use of technology in modern healthcare. That would be as unfair as denying a patient modern medicines. Now is the time for the intelligent, comprehensive and creative use of every possible technological aid to deliver nursing in the community. It is no longer a fictional long-term vision; we are already in the Smart New World.”
This Vodafone mHealth Solutions Insights Guide focuses on one of the fundamental barriers to the adoption of mHealth: human behaviour. With input from a number of industry specialists, the guide delivers insights into the role that patients and healthcare professionals play in the acceptance of new mHealth services in the developed world.
1 “The National Programme for IT in the NHS: an update on the delivery of detailed care records systems”. National Audit Office. 18 May 2011. http://www.nao.org.uk/publications/1012/npfit.aspx
2 “Smart New World: using technology to help patients in the home”. The Queen’s Nursing Institute. February 2012. http://www.qni.org.uk/docs/smart_new_world_final_web.pdf
3 Innovation Health and Wealth, Department of Health, December 2011.