Challenges for Implementing the National Programme for Information Technology - Assignment Example

Introduction to case study The National Health Service (NHS) is the UK's flagship public health care system and also, the largest organisation in Europe from the vantage point of budget and employment (NHS official website, 2006). According to independent sources (Wikipedia, 2006), it employs over 1 million people and its expenditures are more than $140 billion. Funded entirely from taxpayer sources, it has become an institution in itself in Britain. Having done its deed in the most serviceful manner to the public ever since its humble beginnings in 1948, the NHS has recently undergone a massive modernisation drive to enable IT-based sophistication of healthcare systems, a process which is slated to continue well until 2010 (Igbokwe, 2006). The National Programme for IT (NPfIT) thus ambitiously laid out involve costs in the range of $11-55 billion ("Costs and privacy concerns erode doctors' confidence in NHS plan", 10 Jan 2006) and therefore, comes under the careful scrutiny of public opinion. The aim of this case study is to understand the issues that arise in the implementation of the "world's largest civil IT project" (Tony Collins, 25 Apr 2006), its tangible and intangible benefits, costs involved, scopes and limitations, problem areas and to finally, suggest, as well as recommend, acceptable and cost-feasible solutions to the aforementioned problems. A brief overview of the NPfIT programme NPfIT is an ambitious agenda. In keeping with the NHS's recent mission to "put patients at the centre of NHS" (NHS official website, 2006), it seeks to achieve superior healthcare services employing the best that latest technology in computer sciences have to offer in providing affordable, and quality health care to one and all. At its full steam by 2010, the NHS will have delivered the following (Igbokwe, 2006): An Information and Communication Technology (ICT) structure that provides secure and high-speed communications between NHS users and medical experts, to provide telemedicine services. Online booking and appointments The National Prescription Service for electronic prescriptions with full clinical and patient support. The NHS Care Records Service (NHS CRS) to maintain a database of patient records of all UK nationals, accessible at the click of a mouse to concerned medical teams. (As discussed later, this is among the most controversial elements of the programme, with many in the medical fraternity tooth-and-nail opposing it on privacy and security grounds). Reasons for change in technology NHS is in a crunch situation today where it concerns meeting the growing needs of a large patient body. As of today, Britain is capable of spending only $1700 per head on medical services, a figure much less compared to $4500 for the US, $2800 for Germany and $2500 for France ("Is the NHS falling apart", 2003). This means tighter constraints on existing resources such as beds in hospitals, and availability of medical care and surgical treatment. In its pursuit of a lean framework for the organisation, chancellor Gordon Brown has recommended an efficiency proposal to cut costs by $36 billion come 2008. A full-scale IT management of the present system will alleviate many problems that accrue out of an overstretched infrastructure. Information, if available at the right sources at the right time, can not only save vital time and expenditure, it can actually save many lives and improve the state of present health care services being provided. According to a survey made by market research firm, Medix, more than 50% of 1329 doctors polled across the UK, concur that the programme would improve clinical care in the "longer term" ("Costs and privacy concerns erode doctors' confidence in NHS plan", 10 Jan 2006). From a futuristic point-of-view, an IT-based infrastructure is the only viable solution to the burgeoning medical needs of a large nation. This vision is shared across the USA, Canada, the EU and Scandinavian countries, which are notches ahead of the UK in advancing latest technology measures. A medical expert sums up the positive side of NHS from a patient's perspective: "[The NPfIT] will significantly improve health care in patients with multiple diagnoses and help in my specialty of rheumatology, where diseases are chronic and changes may be made through out a patient lifetime." -Sonya Abraham, Kennedy Institute of Rheumatology, Imperial College, London (Tony Collins, 10 Jan 2006) Changes on course of NPfIT implementation In its countdown to computerise large chunks of data and data transfer activities, the information structure within NHS will undergo a rapid makeover from present manual systems to an automated affair. Here we highlight a few technical features of this new, disciplined mechanism and simultaneously discuss its implementation measures. Primary Care Information Services (PCIS) is the unit developed within the framework of NHS to initiate automation of existing structure and rationalise key procedures. It advocates tools and techniques for intelligent data manipulation through highly flexible and automated features. According to information posted on the website of Connecting for Health (CfH), a tailor-made service of NHS, the range of automation measures followed in the health care improvement exercises are (CfH official website, 2006): A client-server interface in which front-end data is kept separate from backup operations leading to redundancy of duplicate information. Storage is minimised. Various front-end systems are able to use the same data. All systems are kept in loop of each other. Data is regularly fed from PCIS to nhs.uk making the vast pool of information, much easier to manage. Data files are stored as SQL files on an SQL server, providing an easy glimpse into table definitions, when needed by the user. PCIS, thus, provides an open, and cost-effective solution to the transfer of data. The next key step would be to rationalise the entire implementation plan of these automation features. The main legacy of such a transistion would be to allow a structure that guarantees easy unlocking and maximising of available data, allowing reporting freedom, flexibile analysis and detailed profiling (PCIS webpage, 2006). Critical data is present at various systems within the organisation. PCIS has the ability to integrate and optimise the data sets, while ensuring that the entire system is endowed with the capacity to house a very user-friendly web browser technology that minimises duplication of both effort and data. For such a rationalisation, it is ensured that: All information is held and updated at one place only. Where possible, a single person is responsible for any updates. All updates take place on the source operational system where possible. Instituting a change in such a massive scale across organisational levels of NHS is no mean task; it calls for an all-out BPR initiative. Business Process Outsourcing (BPR) is a management approach that "examines aspects of a business, and its interactions, and attempts to improve the efficiency of underlying processes" (Wikipedia, 2006). A series of recommendations made by the School of Health and Related Research (ScHARR), Sheffield citing the example of Leicester Royal Infirmary mention lessons to be followed by NHS in its drive to incorporate modernisation of services, as applies to its present environment and culture (ScHARR webpage, 2000): Some reengineering techniques, such as "process thinking" (the analysis and redesign of patient care processes) can be used to improve patient care processes. External management consultants must be brought in, but their understanding of the NHS environment is crucial to deliver any turn-key solutions. It should be borne in mind that there are several notes of differences lying between different patient groups, so process reengineering is going to be a complex affair in the health care sector. Change is context-sensitive Effective redesign of patient care processes require sustained leaderships of change and massive support from clinicians. Limits to justifying intangible costs for NPfIT Delivering advanced medical care using IT systems bears one pivotal element: costs. Tangible costs include purchase and installation of sophisticated computer terminals across all medical care units of the nation, hiring and recruitment of staff to implement the exercise, purchase of security-enabled and reliable software packages. These costs are directly accountable to, in terms of rundown expenditure, as part of the $11-55 billion budget earmarked for the NPfIT mission, as mentioned earlier. But, there are certain intangible costs also, that merit consideration in decision-making. For example, a DoH (Department of Health) report on change management puts a conservative estimate of over $4 billion in instituting critical business roadmaps for the IT programme (Tony Collins, 12 Sep 2003). As if it were not enough, the British Computer Society's Health Informatics Committee, raises the tally to a staggering four times the previous figure (same report). Elaborating on the intricacies of any such impending scenario, we would have to consider allocating funds to deliver sufficient training tools and equipment to all of NHS staff, and considering the sheer magnitude of this very concept, it is relevant to appreciate such concerns. Moreover, money has to be diverted to routine operations like monitoring change management goals through process and technical reviews. A closer examination would bring everyday hassles, and the invisible costs to be mapped, to the fore of budgetary discussions. For example, Andrew Volans, a North Yorkshire based medical consultant, in a quote with ComputerWeekly.com, highlights a problem that arises due to poor software testing prior to installation (Tony Collins, 10 Jan 2006). Introspect closely, and we can find more skeletons in the closet. Software testing and debugging on such a pilot scale requires the expertise of a huge manpower, and that too would ultimately, pile up costs. Since there is no clear-cut strategy on exorcising the demons of intangible costs, many doctors and medical practitioners are less sympathetic to the cause of IT implemetation, according to the recent Medix survey (17% in 2006, down from 47% 3 years ago [("Costs and privacy concerns erode doctors' confidence in NHS plan", 10 Jan 2006]). So far we have presented arguments on the infinite range of possibilities concerning NPfIT, and we also clarified the need to address the spiralling costs' concern. While modernisation cannot be and should not be ruled out, a full-fledged investment should not be made in haste. Any plan-of-action has to be a trade-off between costs and technical advancement. The British government is wise enough to launch the mammoth programme in three phases (Igbokwe, 2006) extending well until 2010. Drawing a parallel to NASA's space endeavours, it is worth mentioning that they didn't straightaway launch a man to Moon: every action however desirable, mustn't throw your financial plans, completely out of gear. This is a case in point for NHS. A discussion on limitations of NPfIT and corresponding opposition viewpoints There are various conflicting voices of dissent and scepticism undermining the acceptability of NPfIT from different quarters, most significantly, physicians and other medical practitioners without whose support this initiative cannot succeed. Here is a detailed synopsis of main areas of contention, issues that need to be urgently addressed. Wherever possible, solutions have been suggested for the same. Poor design: According to a case study submitted in the British Medical Journal, some shocking examples of NPfIT's inadequacies have been brought to the fore. The architecture is beset with practical problems, and requires quick and efficient fixing. Enumerating the hazards, one doctor goes on record to evince that he isn't able to use a feature of the programme, called "Choose and Book", and his patients wouldn't care any less (Tony Collins, 10 Jan 2006). The other design flaws seamlessly intertwined with the structure relate to its functionality and implementation delays ("BMJ", 2006). The problem with the centralisation of large chunks of data is that it takes away the physician's autonomy in dealing with his subject; a mammoth programme undertaken on a national-scale, often fails at a level of customisation to local needs, and thus doesn't deliver the goods. Installing the framework of CfH has been a rough ride in many city hospitals. According to the experience of such an initiative at Nuffield Orthopaedic Centre in Oxford, installing the large frameworks led to mismanagement in the hospital. Some operations had to be cancelled and treatments for patients were delayed (Tony Collins, 25 Apr 2006). These are unacceptable side-effects, and must be paid attention to before implementation. It must be borne in mind that features to be designed, must be extremely user-friendly, and no patient or doctor must suffer during installation periods. Inaccurate data: As an example, according to an E-health insider report, some hospitals linked to the national Choose and Book module, are grossly overwriting local patient records everytime they receive an electronic referral from the NHS spine ("E-Health Media", 2005). Can't imagine the repercussions such incidents may have on serious medical issues concerning the affected patients, and must be duly addressed. Excessive expenditure: For such a massive outlay of a Project, it is pertinent that costs have to be brought down, by all means possible, and at all places possible. A case in point being made by Ewan Davis, the Chair of British Computer Society, in an article published where he writes that practioners are being made to upgrade from their own systems to host-based systems, which is an unnecessary, wasteful exercise ("E-Health Media", 8 Nov 2005). Breakdown in operations: Delays accruing out of installation of this project have already been mentioned. Role of users: Many doctors like David Wrigley feel that there is a lack of consensus in pioneering this behemoth undertaking called NPfIT (Tony Collins, 10 Jan 2006). The report in the British Medical Journal describes various instances where users needs have been ignored, leading to chaotic situations. There is a great deal of "persuasion" required to counteract disruption and change in implementing and installing sophisticated computer systems. Maintaining "goodwill" with patients is diffcult during the start phases of installation ("BMJ", 2006). Degree of Management support: In order to effect desired implementation plan, it is critical to derive support from management teams. According to an article published in the website of Carelink concerning NPfIT, a snapshot of management proceedings has been given. The NHS in England has been divided into five geographic clusters, and are being serviced by four local-serice providers. In order to achieve maximum management control, the teams have been divided into core bundles, additional bundles and future bundles, together they encompass the entire gamut of operations within their respective domains. ("Carelink"). Risk of implementation: Patient care data is an extremely sensitive issue to doctors. This is a very serious area of concern in implementing NPfIT; privacy and security have been the hallmarks of the British Medical system; now the whole proceedings are on the brink of opening up to a central database system with a careful tab on who is what. Not many doctors are comfortable with the idea because, to a doctor, confidentiality of patients' records means everything, and cannot be compromised whatsoever. Quality of management of implementation processes: Quality is the most burning issue in any industry today, and why should NHS be any different to its implications. Fortunately, NHS has a plethora of key features and independent bodies to assure the quality standards are always put in place. A complete list of such undertakings from Advisory Boards to TUPE (Transfer of Undertakings- Protection of Employment) has been given in CfH's webpage on Quality, http://www.connectingforhealth.nhs.uk/jargonbuster/ . In addition, it's been also mentioned that agencies like British Telecom (BT) are stepping in to aid technology-driven quality initiatives. Recommendation plans and series of action In the light of above discussions, it is important that a technical analysis must be done to address the concerns of all major stakeholders; the doctors and the health care workers, the patients, and the taxpayers. The primary problem discussed in this study has centred around inefficiencies in system design, and wasteful expenses incurred on that count. Whenever management of large chunks of information gets beyond the scope of conventional wisdom, strategists and planners talk about information management systems. Laudon describes the significance of information systems as such, "Information systems help a company reach faraway location, offer new products and services, reshape job and workflows, and perhaps profoundly change the way they conduct business" (Laudon, 2003, p.4). The first step towards implementations of any information system lies in a carefully drawn-out technical audit. Without a broad-based framework to regulate future course of action, it is difficult to supplement project leads. A goup of 23 leading computer science academics have written an open letter towards an independent technical assessment of the "National Programme for IT" ("E-health insider, 11 May 2006). The experts' recommendations lay down a list of specifications that require the architecture and components of NPfIT to meet the following criteria; current and future needs of stakeholders, a 24/7 healthcare IT support to fully address patient safety and organisational continuity processes, and last but not the least, maintain confidentiality under the Data Protection act. The basic characteristics of any such system in place, should be responsiveness, reliability, resilience and recovery under routine and full system load. Perhaps this set of measures will help offset some of the issues earlier raised on the problems grappling the massive IT initiative. Business Process Outsourcing (BPO) is the current fad among large MNC's. The ability to achieve efficient quality at a fraction of mainland costs gives handsome bottomline returns. The NHS too, of recent, has taken up this strategy very seriously. It recently started sending blood and urine samples to India so that non-pathological testings are done at extremely low costs. A laboratory in Bombay, India conducts a test within 24 hours, and quickly updates the relevant information into special networks linked directly to NHS centres in the UK (Wikipedia). Conclusion All seen and done, the NHS mission to provide cutting-edge technological solutions to its nationwide network of clinics and hospitals, can make efficient health care accessible to one and all, and at the same time be consistent with shoestring budgetary allocations. According to the Medix survey, currently, only 1% of doctors feel good about the ambitious programme. Some are not comfortable with the idea of losing their autonomy due to the upcoming emergence of a computerised database. Others are beside themselves with their worst fears in mind: a violation of privacy rights regarding care records and a possible compromise on patient secrets can turn into a very ugly episode. An unrestrained array of expenditures is a big concern for the taxpayer who is ultimately, going to shoulder the burden of health care expenses; the only way to check such a voracious appetite is by installing proper checks and measures in place. Enough precaution must be taken so that inaccurate/fraudulent data never finds its way out of the records. The role of end users' must be expanded and stringent quality norms should be followed, to the book. A high degree of front-end management support is required to instil professional values in the implementation regime. Some discussion was spared on the methodology to implement "change management" within the colossal framework of NHS; automation of equipment and processes have been described as central to achieving higher value for the same input of service. The entire setup then, has to be rationalised for updates following feedback. BPR was seen as a key paradigm in instituting change in business models for better value. Our analysis concluded with an easy-to-follow MIS database entry system to scientifically deal with the entire gamut of technical/business operations. Finally, the "hot" and controversial theme of outsourcing non-pathological findings to low cost destinations such as India, was discussed in brief. Works cited E-health Media (2005). Local trust data overwritten by Choose and Book E-health insider. Retrieved 12 May 2006 from http://www.e-health-insider.com/news/item.cfmID=1573 British Council (2003). Is the NHS falling apart Retrieved 12 May 2006 from http://elt.britcoun.org.pl/elt/h_nhs.htm British Medical Journal (2006). Challenges for implementing the National Programme for Information Technology. Retrieved 12 May 2006 from www.bmj.com Tony Collins (2006). Various articles. Retrieved 12 May 2006 from www.computerweekly.com Igbowke, Obi (2006). The National Programme for IT: An Intro. Biomedical Informatics Limited. Retrieved 12 May 2006 from http://papers.biohealthmatics.com/FeaturedArticles/NHSIT/0000000018.aspx Primary Care Informations Group. (2006). Retrieved 12 May 2006 from http://www.connectingforhealth.nhs.uk/nhais/usergroups/pcis/ School of Health and Related Research (ScHARR) (2000). Reengineering Leicester Royal Infirmary. Retrieved 12 May 2006 from http://www.shef.ac.uk/scharr/lri/ NHS official site (2006). The NHS from 1998 to present. Retrieved 12 May 2006 from http://www.nhs.uk/England/AboutTheNhs/History/1998ToPresent.cmsx Carelink (No date). National Program for the IT and the local service providers. Retrieved 12 May 2006 from http://www.carelink.co.uk/templates/Page.aspxid=393 Wikipedia (2006). NHS. Retrieved 12 May 2006 from www.wikipedia.org Laudon & Laudon (2003). Managing Information Systems: Managing the digital firms (9th edition) Read More