Patient Safety in Community Care: e-health systems and the Care of the Elderly at Home

Handbook of Research on Patient Safety and Quality Care through Health Informatics

This chapter reviews a number of technologies used for remote care: telecare, telehealth, telemedicine, electronic patient record systems, and technologies to support mobile working.

Abstract:

The increasing number of elderly people in need of health and social care is putting pressure on current services to develop better ways of providing integrated care in the community. It is a widely held belief that e-health technologies have great potential in enabling and achieving this goal. This chapter reviews a number of technologies used for this purpose: telecare, telehealth, telemedicine, electronic patient record systems, and technologies to support mobile working. In each case, technocentric-design approaches have led to problematic implementations and failures to achieve adoption into the routine of delivering healthcare. An examination of attempts to implement major changes in the service delivery of integrated care shows that e-health technologies can be successfully implemented when they are seen as an intrinsic part of the creation of a complete system. However, the design process required for successful delivery of these services is challenging; it requires sustained and integrated development work by clinical staff and technologists coordinating their work on process changes, organisational developments, and technology implementations.

Patient Safety in Community Care: e-health systems and the Care of the Elderly at Home Ken Eason

Link to IGI Global

Eason K. D. and Waterson P.E Patient Safety in Community Care: e-health systems and the care of the elderly at home In Michel V., Gulliver S., Rosenorn-Lang D. and Currie W. (eds) Patient Safety and Quality Dimensions of Health Informatics. IGI Global 198-213

The Sociotechnical Challenge of Integrating Telehealth and Telecare into Health and Social Care for the Elderly

Published in ‘Healthcare Administration: Concepts, Methodologies, Tools, and Applications’

Abstract:
Telehealth and telecare have been heralded as major mechanisms by which frail elderly people can continue to live at home but numerous pilot studies have not led to the adoption of these technologies as mainstream contributors to the health and social care of people in the community. This paper reviews why dissemination has proved difficult and concludes that one problem is that these technologies require considerable organisational changes if they are to be effective: successful implementation is not just a technical design issue but is a sociotechnical design challenge. The paper reviews the plans of 25 health communities in England to introduce integrated health and social care for the elderly. It concludes that these plans when implemented will produce organisational environments conducive to the mainstream deployment of telehealth and telecare. However, the plans focus on different kinds of integrated care and each makes different demands on telehealth and telecare. Progress on getting mainstream benefits from telehealth and telecare will therefore depend on building a number of different sociotechnical systems geared to different forms of integrated care and incorporating different forms of telehealth and telecare.

The Promise and Disappointment of Telehealth and Telecare

There is widespread belief that telehealth and telecare applications can be used to help people live independent lives at home even when they are suffering from multiple conditions that are severely disabling. In England the Department of Health has launched the 3 million lives programme to encourage their widespread deployment in community care. There are a variety of names given to technologies that support the health and social care of people in their own homes and in care homes. Telecare applications, often associated with social care, typically provide monitors and alarms in the home or on the person that can alert external agencies, e.g. in a call centre, when the person has a fall or another kind of emergency so that help can be sent. Telehealth and telemedicine are tools for health practitioners to deploy which, for example, enable test results to be collected at home and monitored by healthcare agencies or, in the case of telemedicine, enable remote real-time conversations between a patient and a medical specialist.

The Sociotechnical Challenge of Integrating Telehealth and Telecare into Health and Social Care for the Elderly Ken Eason

IGI Chapter Link

Eason K. D., Waterson P. and Davda P. (2013) The Sociotechnical Challenge of Integrating Telehealth and Telecare into Health and Social Care for the Elderly International Journal of Sociotechnology and Knowledge Development 5(4) 14-26

Bottom up & Middle Out Approaches to Electronic Patient Information Systems: A Focus on Healthcare Pathways

Published in ‘Journal Of Innovation in Health Informatics’

Background
A study is reported that examines the use of electronic health record (EHR) systems in two UK local health communities.

Objective
These systems were developed locally and the aim of the study was to explore how well they were supporting the coordination of care along healthcare pathways that cross the organisational boundaries between the agencies delivering health care.

Results
The paper presents the findings for two healthcare pathways; the Stroke Pathway and a pathway for the care of the frail elderly in their own homes. All the pathways examined involved multiple agencies and many locally tailored EHR systems are in use to aid the coordination of care. However, the ability to share electronic patient information along the pathways was patchy. The development of systems that enabled effective sharing of information was characterised by sociotechnical system development, i.e. associating the technical development with process changes and organisational changes, with local development teams that drew on all the relevant agencies in the local health community and on evolutionary development, as experience grew of the benefits that EHR systems could deliver.

Conclusions
The study concludes that whilst there may be a role for a national IT strategy, for example, to set standards for systems procurement that facilitate data interchange, most systems development work needs to be done at a ‘middle-out’ level in the local health community, where joint planning between healthcare agencies can occur, and at the local healthcare pathway level where systems can be matched to specific needs for information sharing.

BCS Journal Link

2012 EASON K. D., DENT M., WATERSON P., TUTT D., AND THORNETT A. Bottom up and middle out approaches to electronic patient information systems: A focus on healthcare pathways Informatics in Primary Care 20:1 51-56

Getting the Benefit from Electronic Patient Information that Crosses Organisational Boundaries – Final Report NIHR Service Delivery and Organisation Programme

Final Report National Institute for Health Research Service Delivery and Organisation Programme

Executive Summary Conclusions

Within the two LHCs studied, there are areas in which substantial progress has been made in creating working forms of integrated care in healthcare pathways. These islands of progress have produced solutions that are quite different from one another and they are the result of evolutionary processes over several years in the face of many difficulties. As a result, there are parts of the systems development process that are mature in the ways in which the challenge of integrated design is tackled. We would single out, for example, the long tradition that has now built up for engaging ‘hybrids’ as the go-betweens in the endless dialogue between informatics specialists and the healthcare user community. However, current electronic support for integrated care can only be described as patchy and, to build on what is already in place, there is a need to create more mature systems development processes that can cope with the many challenges of bringing together a diverse set of stakeholder interests across a number of different healthcare agencies to create the sociotechnical systems necessary to serve the specific needs of healthcare pathways.

Link to PDF

Eason K. D., Dent M., Waterson P., Tutt D., Hurd P. and Thornett A. Getting the benefit from electronic patient information that crosses organisational boundaries – Final Report NIHR Service Delivery and Organisation Programme, November 2012

The Implications of e-health System Delivery Strategies for Integrated Healthcare: Lessons from the UK & Elsewhere

Abstract:

Purpose
This paper explores the implications that different technical strategies for sharing patient information have for healthcare workers and, as a consequence, for the extent to which these systems provide support for integrated care.

Methods
Four technical strategies were identified and the forms of coupling they made with healthcare agencies were classified. A study was conducted in England to examine the human and organizational implications of systems implemented by these four strategies. Results were used from evaluation reports of two systems delivered as part of the NPfIT (National Programme for Information Technology) and from user responses to systems delivered in two local health communities in England. In the latter study 40 clinical respondents reported the use of systems to support integrated care in six healthcare pathways.

Results
The implementation of a detailed care record system (DCRS) in the NPfIT was problematic because it could not meet the diverse needs of all healthcare agencies and it required considerable local customization. The programme evolved to allow different systems to be delivered for each local health community. A national Summary Care Record (SCR) was implemented but many concerns were raised about wide access to confidential patient information. The two technical strategies that required looser forms of coupling and were under local control led to wide user adoption. The systems that enabled data to be transferred between local systems were successfully used to support integrated care in specific healthcare pathways. The portal approach gave many users an opportunity to view patient data held on a number of databases and this system evolved over a number of years as a result of requests from the user community.

Conclusions
The UK national strategy to deliver single shared database systems requires tight coupling between many users and has led to poor adoption because of the diverse needs of healthcare agencies. Sharing patient information has been more successful when local systems have been developed to serve particular healthcare pathways or when separate databases are viewable through a portal. On the basis of this evidence technical strategies that permit the local design of tight coupling are necessary if information systems are to support integrated care in healthcare pathways.

Highlights

  • Links between electronic patient databases and healthcare agencies are defined in terms of tightness of coupling, range and scale.
  • The English Detailed Care Record System was unable to serve the diverse needs of healthcare agencies and was not successfully deployed.
  • Tight coupling was successfully deployed at a local level between agencies engaged in integrated care in healthcare pathways.
  • Widespread uptake was also found when portal systems were deployed that permitted viewing of a range of patient databases.
  • Adoption of patient databases was greater when there was middle-out design and technical strategies delivered looser forms of coupling.

Link to PDF

Science Direct Link

Eason K.D. and Waterson P.E. (2013) The Implications of e-health system delivery strategies for integrated healthcare: lessons from the UK and elsewhere. International Journal of Medical Informatics. 85(5) 96-106 Doi:10.1016/j.ijmedinf.2012.11.004

Fitness For Purpose When There Are Many Different Purposes: Who Are Electronic Patient Records For?

The use of the electronic patient record in supporting e-health care pathways

Abstract:
Electronic patient record systems serve many purposes for many different kinds of users. Four case studies are reported of the use made by healthcare staff of electronic patient record systems that supported healthcare pathways. The results demonstrate that the systems fit the purposes of strategic and managerial users of the record, but they are problematic as tools for use by the frontline staff delivering care. As a result, these staff frequently resort to workarounds to accomplish their work goals. An analysis of the design processes that created these systems shows that the specification of the systems was based on strategic and managerial requirements and there was no formal assessment of the needs of frontline users. Efforts to address the needs of frontline staff in the provisions of electronic systems were most often made after the main system was implemented.

Sage Journal Link

Eason K.D. and Waterson P.E. Fitness for purpose when there are many different purposes: who are electronic patient records for? Health Informatics Journal 20 (3) 189-198 1460458213501096

How to Fail When Introducing Electronic Technologies into Organisations

The challenges of large scale IT projects viewed through the National Programme for IT – NPfIT

Abstract:
The history of computer applications is littered with examples of large and expensive IT systems failing when they were implemented in organisations. This paper illustrates how this happens by describing the case of the NPfIT, the National Programme for IT, in the UK National Health Service. It was introduced with a great fanfare in 2004 to standardize electronic patient records across the NHS and was ‘dismantled’ in 2011 having cost somewhere between £12 and £20 billion.

The paper concludes this programme encountered major problems because it adopted a top down, technocentric approach that led to a ‘one size does not fit all’ response from health agencies of widely different types. A major lesson is that these developments have to be treated not just as technical developments but as sociotechnical developments, i.e. the organisational and technical changes have to be treated in parallel and as interdependent entities. The paper offers six principles for the implementation of new technology into organisations that may improve the chances of users being able to harness the potential of new technology.

IEEE Explore Link

Eason K.D. How to fail when introducing electronic technologies into organisations. Proceedings of DESE 2016 (Developments in eSystems Engineering’, Liverpool September

 

Local Sociotechnical System Development in the NHS National Programme for Information Technology

National Programme for IT Electronic Health Records – User Perspectives

Abstract:
The National Programme for IT is implementing standard electronic healthcare systems across the National Health Service Trusts in England. This paper reports the responses of the Trusts and their healthcare teams to the applications in the programme as they are being implemented. It concludes that, on the basis of the data available, it is likely that the emergent behaviour of healthcare staff will serve to minimise the impact of the systems. The paper looks at the opportunities within the programme to undertake local sociotechnical system design to help staff exploit the opportunities of the new electronic systems. It concludes that there are opportunities and offers one case study example in a Mental Health Trust. However, it concludes that there are many aspects of the technical systems themselves and also of the approach to implementation, that limit the opportunities for local sociotechnical systems design work.

Local Sociotechnical System Development in the NHS National Programme for IT Ken Eason

Springer Link

EASON K.D. Local sociotechnical system development in the NHS National Programme for Information Technology, Journal of Information Technology 22 (3) 257-264

Action Learning across the Decades: Case Studies in Health and Social Care Settings 1966 & 2016

Comparison of the Hospital Internal Communications (HIC) project of the 1960s with the Better Outcomes for People with Learning Disabilities (BOLDTC) project in 2016 and their use of action learning approaches

Purpose – The purpose of this paper is to explore how action learning concepts were used in two healthcare projects undertaken many decades apart. The specific purpose in both cases was to examine how action learning can contribute to shared learning across key stakeholders in a complex socio-technical system. In each case study, action learning supported joint design programmes and the sharing of perspectives about the complex system under investigation.

Design/methodology/approach – Two action learning projects are described: first, the Hospital Internal Communications (HIC) project led by Reg Revans in the 1960s. Senior staff in ten London hospitals formed action learning teams to address communication issues. Second, in the Better Outcomes for People with Learning Disabilities: Transforming Care (BOLDTC) project, videoconferencing equipment enabled people with learning disabilities to increase their opportunities to communicate. A mutual learning process was established to enable stakeholders to explore the potential of the technical system to improve individual care.

Findings – The HIC project demonstrated the importance of evidence being shared between team members and that action had to engage the larger healthcare system outside the hospital. The BOLDTC project concerned the continuing relevance of action learning to healthcare today. Mutual learning was achieved between health and social care specialists and technologists.

Originality/value – This work draws together the socio-technical systems tradition (considering both social and technical issues in organisations) and action learning to demonstrate that complex systems development needs to be undertaken as a learning process in which action provides the fuel for learning and design.

Action Learning across the Decades: Case Studies in Health and Social Care Settings 1966 & 2016 HIC BOLDTC Ken Eason

Emerald Insight Link

Eason K. D. Action learning across the decades: case studies in health and social care settings 1966 and 2016 Leadership in the Health Services, 30(2) 118-128
https://doi.org/10.1108/LHS-11-2016-0057

Productivity? – Don’t Just Fund the Technology Phil! A response to the budget of the 22nd November 2017.

By Dr. Adam Hoare

The Organisation for Economic Co-operation and Development has downgraded its 2017 growth forecast for the UK to 1.5% from a 1.6% estimate made in September, making Britain the weakest economy in the G7. The office for budget responsibility had taken the rosy view that after 2008 UK productivity growth would return to previous levels of around 2% It has now admitted, after years of getting it wrong, that it is likely to sit around 1.3-1.5% until 2020. Last week’s budget reverberated with the recurring issue of low productivity growth. The solution presented was an industrial strategy. Something that had fallen out of favour as Government interference.

The announcements based on borrowing came thick and fast:

  • Digital skills and startup funding to reinvigorate the UK’s waning productivity.
  • £3 billion to cushion the landing of a potential hard Brexit, the chancellor said: “This Budget is about much more than Brexit. For the first time in decades Britain is genuinely at the forefront of this technological revolution. Not just in our universities and research institutes, but this time in the commercial development labs of our great companies, and on factory floors and business parks across this land. But we must invest to secure that bright future for Britain.”
  • Last year’s £23 billion National Productivity Investment Fund was to provide £31 billion in funding over six years, compared to the originally planned five. R&D to receive another £2.3 billion investment, under the government’s Industrial Strategy aim to ramp up R&D spending to 2.4% of GDP.
  • To double the number of tech startups founded in Britain with the goal to see one created every half an hour.
  • A £10 million Regulators’ Pioneers Fund to help regulators find new ways to bring emerging tech – AI and 5G – to market.
  • Tech City UK, to be rebranded as Tech Nation, a body with a remit to spend £21 million on developing the UK’s various startup hubs.
  • In a bid to tackle the UK’s stark digital skills gap, the chancellor also outlined fresh cash to retrain people and provide a greater focus on maths and computing for children and teenagers.

The idea of a strategy and a long list of funding opportunities for new technology seems to overlook some very important evidence. Figures for various IT projects (some of the figures originating from the National Audit Office no less) demonstrate a persistent gap between the projected benefits and the reality:

  • Child Support Agency – £500m estimated loss;
  • DEFRA Rural Repayments Agency – £130m estimated loss;
  • Inland Revenue NIHS – £3-4 billion estimated loss;
  • Magistrates Court LIBRA – £232 million estimated loss;
  • HM Prison Service C-NOMIS – £690 million estimated loss;
  • Fire and Rescue FiReControl – £469 million estimated loss;
  • NHS NPfIT – £20 billion estimated loss.

As we borrow money to fuel a technological “hail Mary pass,” it would seem a good time to think about why we fail to convert so many such passes to a touchdown. The Bayswater Institute has been extensively involved in embedding and evaluating digital technologies in health and social care over several decades. Over the last decade alone there have been hundreds of initiatives to improve productivity in care provision by elevating the use of technology to 21st century standards. Although there has not been an overall assessment of the impact of these initiatives the experience of care provision points to low impact from these initiatives. From seeing these projects from the inside, we have developed a level of understanding of why they struggle – and it is not the technology. Two things work against the use of technology in many of these scenarios:

  1. The technology does not exist in isolation it is part of a system that involves the people using it and the people receiving services. If it does not work for them it is not productive.
  2. Where there is an increase in productivity it usually means a single person can handle more work or the workforce can be reduced. This inevitably generates resistance.

Both of these challenges are rooted in social science and the interface between people and technology. Understanding these sociotechnical systems is essential in successfully capturing the benefits the technology can bring. Looking back over the announcements we cannot see where this is mentioned. Throwing money at the technology and expecting social transformation is an interesting approach but the evidence is – it has been done before and it will fail.

A third issue that recurs in productivity considerations. To know a system is more productive than it was before it must be measured in a meaningful way. This links back to point 1 above. If it works for the professional but not the citizen – it does not work. Hence, the outcomes of productivity must include social value and social impact otherwise public money is spent on making the system happy and the service recipient unhappy.

We spend much of our time providing summative evaluations of where the barriers and challenges are in technology projects that are trying to embed into practice. We have a special interest in formative evaluations of interventions where we can draw on our experience and anticipate some of the problems ahead of the development and have the opportunity to have an impact on the NAO estimated loss. If the focus remains on the technology and not the combined scoiotechnical system the return on investment is likely to be negative. The last thing that Phil wants.