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Digital Change in Health and Social Care

Digital change in health and social care – a report by the King’s Fund

Reviewed By: Dr Adam Hoare

Digital change in health and social care King's Fund Bayswater Institute
Digital change in health and social care

This report by the King’s Fund, presented at the Digital Health and Care Congress 2018, usefully draws out some of the challenges in adopting and scaling digital health and care interventions through consideration of five significant case studies. It begins by recognising some of the unique challenges of digital change and goes on to identify some key themes. The report is a practical and timely contribution to the practical understanding of digital change and not only references some of the work that The Bayswater Institute (BI) members have been involved in for many years but raises many of the issues that the BI come into contact with on a daily basis.

The report recognises several challenges around large-scale digital change. The negative memories around the National Programme for IT (The Implications of e-health System Delivery Strategies for Integrated Healthcare) and the inability to undertake such change whilst under pressures of current demand on resources being key issues.

The Evidence About Managing Digital Change

The report references the Wachter review (Making IT Work) which identifies the need for change processes using digital technology to be ‘adaptive’ and ‘technical.’ That “Adaptive change is change that relies on human behaviour for its success.” At the heart of this challenge lies approaches that are central to the BI way – action research and sociotechnical systems. Action research involves iterating towards a solution and sociotechnical systems thinking recognises that the solution is a collaboration of people working with technology. This recognition represents a significant departure from the “big-bang” approach to system change where it is assumed everything is known up-front. It signifies a shift to more “test and learn” thinking that underpins so much successful innovation in other industries and endeavours.

The report goes on to recognise the productivity paradox identified by Brynjolfsson (Beyond the Productivity Paradox.) That efficiency gains accompanying widespread digitisation is often absent in the traditional indicators. Our work indicates that it is often necessary to expand the range of indicators and evidence to understand how new practice is being enabled and what that means. This means that the evaluation approach must evolve with the intervention.

The work of Prof. Eason (a member of the BI) is discussed with regard to the tensions between top-down and bottom-up approaches in digital innovation (Bottom-up & Middle-out Approaches to Electronic Patient Information Systems.) The benefits of a middle-out approach are recognised in trying to link front-line change to national standards and frameworks. The work of Eason goes on to recognise that large-scale digital change is challenging and frequently fails (Getting the Benefit from Electronic Patient Information that Crosses Organisational Boundaries – Final report NIHR service delivery organisation programme)

In considering the barriers to successful digital change the work of Greenhalgh is cited (Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies ) which distinguishes between complicated and complex interventions. Complexity in this sense arises from systems that are interconnected and dynamic and produce emergent behaviour. Too often solutions are assumed to be complicated and fail because they do not address the complexity. In discussing the use of telephone triage in primary care the report refers to the absence of clear evidence of benefits but that some practices improved their ability to cope with demand. The same intervention in a different sociotechnical implementation could yield completely different results. Further, the originally identified benefit may not always be the useful benefit found in practice. This complexity again goes back to the need for a “test and learn” approach. This situational complexity and lack of a one-size-fits all approach underlies the challenges of the Whole System Demonstrator which saw the intervention as fixed and tried to generate an economic value (or QALY) for the intervention. Although the value of telehealth in reducing emergency admissions and better managing patients is generally recognised (Reduced Cost and Mortality Using Home Telehealth to Promote Self-Management of Complex Chronic Conditions: A Retrospective Matched Cohort Study of 4,999 Veteran Patients) it is highly situationally dependent and cannot be implemented as a black box approach as it is a sociotechnical intervention. The report reiterates that digital change is adaptive and does not lead to static states for testing – it evolves.

The report goes on to explore five different digital interventions across very different sites and applications. It identifies five key themes that are highly correlated to themes we see recurring in our BI work.

Leadership and Management

A key theme here was that personalities count. Often, selecting the right person to lead on a particular aspect was central to success. This is reinforced by the observation in the report that technology implementations should not be seen as IT projects but as a cultural change that is highly dependent upon good leadership. This leadership is most effective when clinically driven. At the BI our experience shows that many digital projects are approached as linear implementations that do not seek to learn or understand what is working and what is not. The need to build collaborations, often across organisational boundaries, is underestimated. In our work we regularly see digital projects pigeonholed as IT and lacking in the attention to culture change and leadership identified in the report.

User Engagement

The report recognised that a common approach across the case study sites was to recognise user engagement not as a single event but as a continual collaborative process involving users of the technology. The work we did at the BI in the BOLD-TC (Better Outcomes for People with Learning Disabilities – Transforming Care) project was based on just such an ethos involving not just the front-line practitioners across health and social care but also people with learning disabilities and their families. The move to a more collaborative, ongoing engagement with users is essential if services are going to evolve.

Information Governance

The case study sites focused on cultural rather than the technical aspects of information governance. By creating the right environment for partners to come together and solve the problems of sharing data it was found that collaboration, in general, was increased. Leadership and approaching information governance as a framework rather than trying to solve each problem as it occurred led to sustainable approaches.

Partnerships

It was identified that the right supplier could act as a facilitator for change by coordinating actors and change processes. Our experience at the BI is very similar. The ability of a supplier to see all of the challenges being addressed by the organisations coming together in pursuit of a common digital solution puts them in a key coordinating role. By providing each of the stakeholders in the intervention with valuable reporting and evidence specific to their needs they can act as the glue that binds the intervention. However, this requires an open supplier that sees the long-term benefits in building trust and collaboration. As the report points out choosing suppliers is a significant contribution to the success of the approach.

Resourcing and Skills

For the project to succeed the resources and skills need to be there, over and above what is required to keep the engine of delivery going. For large-scale digital interventions this is challenging in the current environment. Recognition was given to starting small and evolving solutions in a phased way. This was particularly important when crossing organisational boundaries. Trying to do too much at once absorbed resources and slowed progress. Our experience reflects this. Developing solutions that can have an impact on day-one but evolve over time to cross boundaries is essential and, again, part of the ongoing “test and learn” approach.

Evaluation

Although not a separate heading the importance of evaluation was noted. Significantly, the importance of evaluating success and failure was recognised. One of the quotes equated randomised control trials with a lack of rigour recognising that iterating understanding and learning was essential. At the BI we are committed to evaluation that engages with complexity and evolves with the intervention to develop learning and understanding. This requires formative evaluation and an understanding of the challenges the collaboration partners are facing.

Conclusion

The report is a significant contribution to understanding the challenges of implementing digital change. The use of case studies that demonstrate both the barriers and how they were overcome is the most useful way to share learning and understanding. At the BI we hope to see more of this kind of sharing and a move to learning “what works for who and under what circumstances.”

In my work with Airedale NHS Foundation Trust we addressed the issues of one-size-fits-all, the black box view of technology and the need to embrace complexity. Beginning in 2008 as part of the Assisted Living Innovation Platform (ALIP) we worked with Airedale NHS Foundation Trust and partners to use video in the home to address a range of care scenarios. Over a period of eight years Red Embedded Systems Ltd. developed the v-connect service. We developed a communication platform that could facilitate a range of care scenarios including video calls through the TV and delivery of educational content. We implemented interventions for long-term conditions, social care interventions such as virtual visiting, support for people with renal failure and remote support for people with learning disabilities. We integrated ambient monitoring, remote physical measurements, evidence collection and reporting (A Socio-technical Approach to Evidence Generation in the use of Video-conferencing in Care Delivery and Factors Affecting the Move to an eSystems Approach to remote Care delivery.) Many of the challenges discussed here were addressed in working with a broad range of partners in care delivery. We overcame barriers in all of the key themes identified but failed to make the commissioning case in every situation. Digital interventions have the potential to prevent and reduce current activity in the care system. Better educated and managed patients are more independent, and this reduces the need for care. For people with learning disabilities, remote support enables them to live more independent and confident lives. Prevention reduces need for care, independence and confidence all reduce the amount that the current providers are paid. This raises significant issues for leaders and for culture change. Often the right thing to do for the patient or client is the wrong thing for the financial standing of the organisations involved. This requires leadership at the policy and Governmental level. The focus of this report is on how successful digital interventions can be against the resource and skills challenges in the current climate. Imagine how successful they could be if there was a strategy and funding to facilitate a market in solutions.

We can only hope that future initiatives such as the Industrial Strategy Challenge Fund on Healthy Ageing (Industrial Strategy Challenge Fund: for research and innovation) and the recently announced £487m Transformation Fund for Healthcare will begin by taking notice of what we know and not try to reinvent the wheel.

 

 

Putting Social Science to Work

Social Science Theory and Use Case Studies Organisations Britain Germany

Book: Putting Social Science to Work

The Ground between Theory and Use Explored through Case Studies in Organisations

In this book, Lisl Klein and Ken Eason look at the various issues involved when attempts are made to make use of the theories, methods and findings of the social sciences in practical affairs. They consider how human and social considerations may be successfully integrated with technical and economic ones in the design and development of organisations at work.

Their study is both empirical and theoretical. Its core is the examination of fourteen case studies from manufacturing and service organisations in Britain and Germany. The various projects were carried out by units within the organisations themselves, by university departments, commercial consultants and an independent research institute. Outside the field of organisations the the authors consider the background and strategies of a number of individual practitioners, and also an attempt at national level (in Germany) to make systematic use of research. Their study is informed by their own extensive experience as researchers and practitioners of social science.

The book concludes with a discussion of what contributes to successful practice. Its findings will be invaluable to all social scientists interested in the application of their disciplines as well as to potential clients in the world of business and industry.

Published in 1991 the book remains relevant to contemporary issues of social science utilisation in organisations. It recognises the challenges of the social science practitioner in engaging with varied and complex dynamics within organisations. Further, that the goal of behaviour change is not well served by “packaged” approaches but must begin with the current situation in action. The case studies resonate with current attempts to introduce technology into the workplace and the recognition that the social context of behaviour change plays a key role.

KLEIN, L. & EASON, K.D. (1991) Putting Social Science to Work. Cambridge University Press, Cambridge.

Representing Socio-Technical Systems Options in the Development of New Forms of Work Organization

Abstract:

It is widely accepted that effective implementation of new technology into work organizations needs an integrative approach in which developments in both technical and social systems are considered. Furthermore, success depends upon the effective participation of significant stakeholders in this process. This article reviews the methods available for this purpose and concludes that a particular weakness is the methods that can be used to generate and review socio-technical system opportunities early in the development process. Whilst methods exist to support stakeholder participation at this stage, they need to represent future socio-technical opportunities if they are to make an effective contribution. This article presents the ORDIT (Organizational Requirements Definition for Information Technology Systems) methodology, which uses responsibility modelling as a basis for constructing socio-technical systems opportunities. The application of telemedicine in health care is presented as a case study to demonstrate how this method can be used to construct and evaluate socio-technical scenarios.

Socio-technical Systems Work Organisational Development Information Technology

Publication at Taylor and Francis Online

Eason K.D. Harker S.D.P. and Olphert C.W. (1996) Representing Socio-Technical Systems Options in the Development of New Forms of Work Organization. European Journal of Work and Organizational Psychology 5(3) 399-420

DOI Link

Before the Internet: The Relevance of Socio-technical Systems Theory to Emerging Forms of Virtual Organisation

Abstract:

Virtual organisations, in which the technology mediates the interactions in the social system, are an emergent form of socio-technical system. This chapter reviews the concepts and techniques of the 50 years of socio-technical systems theory development that preceded the internet to examine their relevance for the study of the virtual organisation. It first examines the socio-technical system concept of work organisation in relation to the quality of working life and relates these issues to contemporary forms of virtual organisation. It then examines work organisations as open systems and explores the implications of task interdependencies for the delivery of operational work. It questions whether socio-technical concepts are appropriate for emergent forms of virtual social community and concludes that many socio-technical characteristics are also likely to be found in these forms of organisation. The chapter then examines the implications of a technology that mediates communications between people in the social system. It concludes with a plea that we go beyond the design of technical systems to support virtual organisations and, in the tradition of socio-technical systems research, concern ourselves with the joint design of the social and technical components of virtual organisations.

The Emergence Of Virtual Organisations

We may define virtual organisations as enterprises in which people engage in a collective mission remotely from one another through the medium of information and communication technologies. Some enterprises started as virtual organisations in order to exploit the capabilities offered by the internet, i.e. they have never existed as ‘bricks and mortar’ organisations where staff worked and customers visited. In the commercial world, Amazon and eBay are examples of such organisations and in the social networking world, FaceBook and Twitter have developed in a similar way. The majority of organisations, however, originally operated and offered their services from physical premises and may be on a journey to becoming progressively more virtual. Several authors have used maturity models to define the stages through which organisations tend to pass as they become more virtual.

 

Knowledge Development and Social Change through Technology

IGI Global Publication Link

EASON K.D. Before the Internet: The Relevance of Socio-technical Systems Theory to Emerging Forms of Virtual Organisation, International Journal of Sociotechnology and Knowledge Development, April-June 1, 2 23-32

 

The National Health Service National Programme for Information Technology (NPfIT): A Socio-technical Systems Perspective

From the book ‘Integrating Healthcare with Information and Communication Technology’ addressing the National Programme for Information Technology in the NHS

The book ‘Integrating healthcare with information and communication technology’ presents a collection of essays that discusses a set of challenges that arise when attempts are made to integrate Information and Communication Technology (ICT) into health care services. By exploring the outcomes of the National Programme for Information Technology (NPfIT) in the NHS in England the book attempts to learn from experience. It recognises that interoperable information systems are paramount for efficient integrated care, and contributions to explore ICT in the ongoing transformation processes towards seamless care should be of importance for the integrated care community.

The book consists of eleven chapters and the book is organised into three parts: Transforming Health Care Services using ICT, Electronic Health Records (EHR) and Global ICT Adoption and Implementation in Health Care. This national programme offered a wealth of learning about user-centred design, action research, understanding the intent of technology development and the impact of technology interoperability. The value of such learning is that by understanding where the approach was successful and not so successful future programmes could be better designed.

Information and Communications Technology National Programme for Information Technology NPfIT

Review in the International Journal of Integrated Care

Link to Amazon Listing

EASON K.D. The National Health Service National Programme for Information Technology (NPfIT): A Socio-technical Systems Perspective. In Currie W. and Finnegan D. (eds) ‘Integrating healthcare with information and communications technology’ Radcliffe, Oxford 183-204

Socio-Technical Theory and Work Systems in the Information Age

Book chapter entitled ‘Socio-technical theory and work systems in the information age’

This chapter of the book set the traditional focus of socio-technical systems theory on primary work systems in modern context where information and communication technology (ICT) has a major influence in the way work is undertaken. The chapter begins with a summary of the original work of the Tavistock Institute of Human Relations and critically reviews the major concepts to emerge from these studies. This is followed by a review of recent studies of the impact of ICT on work systems and how socio-technical systems are used to interpret these findings. Finally, concepts and methods of designing and implementing customisable and generic ICT systems in organisations. The authors call for a recognition and evaluation of socio-techcial systems as never completed but evolving over time; placing an emphasis on the emergent behaviour resulting from the use of new technical systems.

“Technology presumes there’s just one right way to do things and there never is.”

– Robert M. Pirsig

Socio-technical theory design networking systems

Google Books Link

EASON K. AND ABDELNOUR-NOCERA J. Socio-technical theory and work systems in the information age. In Whitworth B. and de Moor A. (eds) ‘Handbook of research on socio-technical design and social networking systems’ Information Science Reference, Hershey New York 65-77

Information Technology and Organisational Change

A book addressing the need to consider technical and organisational change as a system in the implementation of information technology

The Preface for this book published in 1988 was contemporary and on reflection, nearly thirty years later, still applicable in many ways today to implementation of information technology. It opens:

It is widely acknowledged that information technology will revolutionise organisational life. And yet if you look at most organisations you will find that the pace of change is slow and that there is not much sign of a revolution. In many organisations expensive equipment seems to be making very little contribution to the goals of the enterprise. It seems that suppliers are always in the midst of editing new technological breakthroughs whilst potential user organisations are still trying to assimilate yesterday’s technology. The pace of technological development poses the end user with the perpetual headache of trying to decide what is worth using and how to use it.

Ken wrote – of nearly twenty years as one of the founders of the HUSAT research centre, I have been working with my colleagues to understand the difficulties people encounter when trying to harness information technology and then to build tools and techniques which will help them in the process. As information has advanced the methodologies and tools for technical systems design have become progressively more sophisticated and efficient. By contrast the techniques by which uses can specify their needs, evaluate alternatives, implement systems, make complementary organisational changes etc. have hardly progressed at all. Most design methodologies pay scant attention to these issues. It is almost a truism to say that we need socio-technical systems design; the joint design of the technical and social sub-systems in the organisation. However, many forces keep the two processes apart. Technical design is the province of technologists who know little of social system design. Technical tools do not address this issue.Organisational change is the province of management but is seen as separate from technical change and ether are few tools to help the fusion of the two kinds of change.

Information Technology and Organisational Change Ken Eason

 

EASON, K.D. Information Technology and Organisational Change, (1988) Taylor & Francis, London.

Google Books Link

Amazon Link to Book

Other Publications in this Area:

Understanding Organisational Ramifications of Implementing Information Technology Systems

1966 and All That: Trends and Developments 1956-1974 within UK Ergonomics

Development of ergonomics in the UK between 1956 and 1974

Abstract:
The 1960s represents a key decade in the expansion of ergonomics within the UK. This paper reviews trends and developments that emerged out of the 1960s and compares these with ergonomics research and practice today. The focus in particular is on the expansion of ergonomics as a discipline within industry, as well as more specific topics, such as the emergence of areas of interest, for example, computers and technology, automation and systems ergonomics and consumer ergonomics. The account is illustrated with a detailed timeline of developments, a set of industrial case studies and the contents of important publications during the decade. A key aim of the paper is to provide the opportunity to reflect on the past and the implications this may have for future directions for ergonomics within the UK.

The paper provides practitioners with an insight into the development of ergonomics in the UK during one of the most important decades of its history. This is especially relevant given the fact that in 2009 the Ergonomics Society celebrates its 60th anniversary.

Introduction:

The quote from the Italian writer Italo Calvino was made during a debate held on ‘industry and literature’ at the beginning of the 1960s. Calvino sums up what were to become dominant themes in later accounts of the period, namely, the growth of automation and the increasing role played by technology within society. Both of these themes are important within ergonomics and continue today as sources of debate in research and practical applications of the subject. Similarly, many issues have declined in interest or relevance as compared to 40 years ago. Much has been written about the origins of ergonomics, alongside other discussions centred around pioneers within ergonomics and the future of the discipline (e.g. Frederic Bartlett). By comparison, little detailed information is available covering specific periods within the development of ergonomics. This paper focuses on the 1960s within UK ergonomics for a number of reasons. First, the 1960s can be seen as a mid-point between the immediate post-war roots and birth of ergonomics and its subsequent development into a fully fledged discipline. Second, during the 1960s, ergonomics became firmly established within industry and made firm steps towards closer engagement with civil, government and industrial users and practitioners. The late Brian Shackel (1927–2007), in a paper written to celebrate the 50th anniversary of ergonomics within EMI, viewed the period as a bridge between earlier work on military ergonomics and a later focus on consumer ergonomics in the 1970s.

In 2009 the UK Ergonomics Society celebrates its 60th anniversary. It seems timely and appropriate to stand back and review trends and developments over the period and compare these with present day ergonomics.

Taylor and Francis Ergonomics Ken Eason developments 1956 1974 within uk ergonomics

Taylor and Francis Publication Link

WATERSON P. AND EASON K.D. 1966 and All That: Trends and Developments 1956-1974 within UK Ergonomics. Ergonomics 52(11) 1323-1341

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