We first offer a brief critique of the main ideas of the framework, based around the questions.
Two central assertions of the framework for health and social care in England are that:
What evidence supports this claim?
Under the heading: ‘There is good evidence that better use of data and technology improves patient outcomes and the value of services’, the document refers to:
an unpublished management consultancy report - about potential benefits, according to its reported title;
anecdotal data from a US hospital; and
the National Voices evidence summaries.
The latter sources cite systematic review evidence of reduced service consumption (in surgery) from improved pre-operative and pre-discharge information, conflicting results about telemonitoring and some evidence of the cost-effectiveness of home-based self-management (but with questions about its economic sustainability).2
Against this must be weighed other findings. For example the European Commission funded a study of the economic impact of interoperable electronic health records (EHRs) and electronic prescriptions (the ‘EHR IMPACT’ study). This 2010 report evaluated the costs and socio-economic benefits of EHRs in nine implementations in various European countries (including local, regional and national project of different kinds) and concluded that:
‘EHRs and ePrescribing are beneficial socio-economic investments in better healthcare, but, except in very specific circumstances, need net cash injections’.2
So simply put, information technology makes things better but not cheaper.
Another obvious example is the large scale trial of telehealth in England, known as the whole system demonstrator (WSD).2 The WSD examined effects on mortality and secondary care utilisation,2 organisational issues,2 cost-effectiveness2, 2 and the perceptions of healthcare professionals.2 The flagrant political spin on the findings of the WSD, as selectively exploited by the Department of Health, is well known.2 However, the plain fact is that the studies showed that telehealth was not cost effective, based on a realistic estimate of acceptable cost per qualityadjusted life year. Again, perhaps better but not cheaper.
In addition, there are sometimes new inefficiencies introduced by EHRs. The 2013 RAND Corporation report on physician satisfaction2,2 found that clinicians in thirty US practices agreed that EHRs improved communications, data access and some aspects of care quality. However, they mostly reported worsened satisfaction arising from time-consuming data entry, poorly designed user interfaces that did not match clinical workflow, interference with direct patient care, insufficient interoperability, information overload, cost, document templates and increased administrative tasks. These various inefficiencies (in some cases requiring work re-design to introduce a ‘scribe’ to support physician use of the EHR) are all tractable issues, but perhaps suggest that the current generation of off-the-shelf products may not pose a ready-made solution to health service transformation.
In another example, the effect of patient portals to promote self-management on service utilisation and efficiency is unclear; systematic reviews have reported mixed findings, whilst noting that a pronounced social and ethnic digital divide exists.2
There is no doubt that information technology has the potential to reduce transactional operating costs in many areas of health and social care, as in other industries, but the important questions are what will work in what circumstances and how well the transitional costs and operational changes will be managed. In many cases, the financial benefits are not likely to arise in the same organisational budget as the costs, so judicious whole-system management will be required.
Feasibility by 2020
The framework’s second basic proposition is that an ‘information revolution’ by 2020 is feasible for health and social care in England. To support this, the framework uses the time-honoured analogies with simple transactional services like flight booking and online banking. While there are certainly ‘customer transaction’ elements in the administration of care (predominantly when it is elective), the long slog to make progress with even the easiest ‘service channel’ like hospital outpatient booking2,2 surely shows that even changing administrative transaction processes in the NHS is far from a trivial piece of business change – however, tantalisingly simple the technology may seem to be.
There are serious flaws in the banking and airline analogies. First, the inherent richness and density of patient information in all its forms is orders of magnitude more complex2 than the simple data used in financial transactions or the instrumentation and logistics data used in aviation. Second, the finance and aviation companies have straightforward hierarchical management structures, unlike the fairly loose ‘system’ of autonomous professions and organisations that deliver health and social care in England. Third, both of the cited industries have had decades of sustained and substantial investment in their information technology capabilities.2,2
Of course, Wanless2 identified back in 2002 the very low proportionate spending on information technology in health as compared to other sectors of the UK economy. The most recent update2 on NHS spending on information technology (not reported since 2009) did not show a significant improvement in revenue expenditure. It is unknown whether the selective capital financing provided through the NHS England technology funds2 has stimulated sustained increases in revenue expenditure. The successes of general practice computing in comparison to hospital EHRs had much to do with the incentives provided.2
No doubt many of the ambitions of the framework are eminently achievable. However, the briefly stated 2020 ambitions (‘all care records digital, real-time, interoperable and using SNOMED CT’) seem rather far-fetched. By way of comparison, using a relatively straightforward information requirement, the ‘new’ NHS number was introduced in 19954 yet is still not universally used after nearly 2 years (as acknowledged by the latest attempt to make it mandatory in the current planning guidance2). Of course, ‘stretch goals’ are sometimes useful and no one would suggest an unnecessarily pessimistic or unambitious target. Perhaps the forthcoming ‘roadmaps’ will build confidence that the five year vision is achievable.
What is planned for evaluation?
With the notable exception of the experimental patient-controlled mobile care record (page 25),2 there is a lack of any evaluative framework that might identify either beneficial or harmful unintended consequences of this plan. Evaluation and prospective outcome measurement is only mentioned with reference to care data (page 34)2 and in a passing reference to producing evidence of impact ‘using experimental and quasiexperimental methods’ (page 54).2 The digital maturity index (page 30),2 a ‘census of digital progress’, seems to be the principal measure of adoption and benefit. The planning guidance indicates that NHS England proposes to establish ‘a new operational research and evaluation capability’ (page 8,3.6),2 but this is for the new models of care not for the revolutionary information changes.
Policy makers and commissioners should want to ensure that national experiments of this scale and importance are properly evaluated so that each iteration of ‘information revolution’ produces an evidence base to inform subsequent generations of care provision models and technology innovation. Evaluation should be planned from the very start rather than added in as an afterthought. Like any good business plan there should be defined critical success factors for health and social care, and a declaration of how they might be measured. Unintended consequences should be qualitatively explored. Evaluation should consider critical-interpretive social perspectives2 to understand the human factors in technology deployment and should seek a theoretically informed insight into the mechanisms of change.2