New Zealand’s shared learning model offers lessons on implementing the electronic patient record system
Between 1997 and 2010, the Labour government sought to modernise public services with the help of “state of the art information technology”, meaning very large, centrally procured systems developed by commercial software suppliers working under contract to detailed advanced specification and the highest technical security standards.
The national programme for IT is a paradigm case. Depending on who you ask, it is world leading in scope, vision and sophistication or monolithic, inflexible, resource hungry and over governed. Some say both.
What is not disputed is that the national IT programme came at an estimated cost approaching £13bn, many of its projects are now years behind schedule, clinical engagement is lukewarm in some quarters and the civil liberties lobby is asking uncomfortable questions about the “database state”.
Announcements that a further £700m would be sliced off the central budget and offered to NHS organisations to develop locally appropriate solutions and that the country’s largest supplier of general practice systems (EMIS) has been given full roll-out approval for what some are calling a rival product to the national IT programme, have created a sense that a line is being drawn under the old regime.
So where next? We should look to countries that have successfully introduced nationally shared electronic records. In New Zealand, a GP is automatically sent all laboratory results, hospital discharge summaries and specialist letters electronically. Healthcare providers may seek remote access to laboratory reports, discharge summaries and other document based data from any public sector hospital. The amount of information exchanged electronically between general practices and other healthcare providers has increased by 33 per cent every year since 2000. Patients access information from a personal health record attached to their GP’s electronic system.
All this was achieved at an estimated cost of NZ$30m (£15m) between 1994 and 2008 for a population of 4.5 million.
The New Zealand experience suggests that, contracts aside, four aspects of the UK’s programme need reviewing.
The first is the central role of government. The New Zealand government has avoided any attempt to manage the changes it seeks to support.
Second, we should revisit the change model. The national IT programme’s approach has been to “deploy” particular centrally mandated technologies to particular levels of saturation by particular dates, using PRINCE2 methodology (in which project managers work methodically towards tightly defined goals and milestones set largely by high level committees).
In contrast, New Zealand’s socio-technical change model is characterised by clearly defined service objectives with a high degree of flexibility in how those are achieved. Key change tools are a minimum set of hard and fast rules and boundaries, effective incentives and disincentives, and constant feedback from all stakeholders.
Third, we should stop equating organisational learning with codified knowledge (for example, “lessons learned” spreadsheets signed off by committee chairs and circulated to closed recipient lists) and consider the powerful concept of the learning environment.
In New Zealand, people and organisations involved in the national electronic records programme work on the challenge simultaneously by agreeing in broad terms what needs to happen, setting ground rules (such as communications standards and ethical business processes), moving forwards with possible approaches, learning (both positive and negative), and moving forwards again. At each review point, a general direction is agreed but not a specific end point or completion date - this uncertainty does not discourage stakeholders from working with one another and modifying their views as the work progresses.
Fourth, the IT programme needs to find ways of allowing small scale, low risk, incremental change in parallel with the large scale, high risk efforts. It is almost impossible to get a complex technology with a range of unknown socio-technical implications right first time. After a technology is released, confidence may build as users view its impact as positive and make small scale efforts to improve it and embed it locally.
New Zealand’s successful and popular e-referral system went through four iterations as clinicians, hospital IT staff and commercial organisations worked together, aided by early agreement on the use of key data communications standards. This system is now becoming business as usual at a fraction of the cost of choose and book.
New Zealand’s organic and locally adaptive approach has not reduced interoperability, nor has it lowered standards.
Indeed, active and ongoing debate has produced leading edge innovations in both these areas. As the UK government considers how to make ends meet in the new age of austerity, a hard look at the New Zealand model would be a good place to start.
Professor Trisha Greenhalgh led the independent evaluation of the summary care record and HealthSpace programmes in England. Tom Bowden is involved in developing New Zealand’s successful national shared electronic record scheme.