Health IT - an elegant exercise in wishful thinking

Health Information Technology has been in the headlines this past week with Jeremy Hunt committing the "NHS to be paperless by 2018".  Why: because it will "save billions, improve services and help meet the challenges of an ageing population".  £4.4bn of savings in fact according to a PwC report.

It all sounds perfectly plausible, but the savings will be completely illusory.  Take a look here for a brilliant exposition by Systems Thinking for Girls as to why.  In fact, I predict that the investment in health IT, as currently proposed will cost, not save money.  Given that successive governments have been going at this 'problem' since 1998 and the £12bn debacle that was NPfIT (the Public Accounts committee concluded that electronic records system was 'unworkable' and the government admitted that it had wasted the money and was closing down the programme) making such a prediction has to be one of the closest things to a 'dead cert' bet.  The expected savings from these programmes can never be realised because the underlying logic about how savings are generated is flawed.  These wrong headed expectations are probably exemplified best by a 2005 report by RAND. 

In it RAND predicted that adoption of an Electronic Medical Record would generate savings of $81bn PER YEAR for an investment of $20bn.  These savings are based on extrapolating the savings generated from the reduction in time people spend 'doing' things.  The approach to health IT is a manifestation of the dominant command and control management paradigm.  The logic is:

  • identify how much work is coming in
  • work out how many people there are doing the work
  • assess how long it takes for people to do things
Under this production-driven view activity equals cost.  With this logic efficiency becomes; the more we reduce activity times the more we cut costs.  Leaders then focus on three things:
  • standardising work
  • reducing activity times (because activity = cost)
  • driving out waste

From this logic, if Health IT reduces the steps in a process, or prevents duplication, or speeds up the time it takes to get information, this all saves peoples time and, as a result, will save money.  These savings can be extrapolated across the whole system and, voila, several billions can be saved.  With respect to the RAND study the President was convinced and the investments were approved.  It sounds unbelievable that such extrapolations would be made - but it is unsurprising given the above perspective about how the work works.

Equally unsurprising, the savings failed to materialise as a revised Rand study shows.  Rather than saving money it seems the investment may have cost money .  Healthcare spending in the US has, in fact, risen by $800bn since the 2005 report.  It seems that the billions invested in IT have made it easier for providers to bill for services.  How ironic.

From our studies, massive investment in Health IT, aside from there being no evidence of their benefit, is the wrong problem to solve.  Developing and tending to relationships, end-to-end over time, understanding what matters to people in the context of how they live their life is what the system needs to orientate itself to.  But there will be no time for people to do this because they will be spending countless unproductive hours either implementing a new electronic system or dealing with the problems the system will cause.  There will be much gnashing of teeth as NHS staff will appear to look even more unproductive.  'We need another technological solution' will be the cry.  And so the cycle will continue...

The argument for Health IT is that by putting all the information relating to all a persons transactions in one place better clinical decisions will be made.  It will be safer; cheaper.  But here's a test.  Take a persons current paper medical records.  Place all the assessments end to end.  Would reading them give you a sense of the person as a whole and help you to understand them and the context in which they live their life and thereby help the system to solve their problem?  Our evidence is that it will not.  That evidence alone should be enough to prevent this headlong dash into doing more of the wrong thing faster.  But that is not the only evidence.

A long term US study of people going online to view their clinical records concluded that online access, rather than reducing demand on health services, was associated with more use of clinical services.   “Contrary to expectations and the results of some prior studies,” the study authors found “a significant increase in the per-member rates of office visits and telephone encounters” by online patients. There was also a significant increase in clinic visits after hours.

But stark evidence of failure is not enough to convince supporters of the redemptive powers of Health IT that their logic is wrong.  Instead they argue that what is needed is more and better application of the same flawed logic.  To be fair to PwC, despite making grand claims about the savings to be realised, they at least say “significant further work is required to further substantiate some of the evaluations of potential benefit, and especially the evaluations of potential financial benefit.”

This will not stop leaders:

  • ignoring negative reports
  • committing millions to 'incentivising' providers and doctors to use new systems or
  • estimating quality and productivity benefits that do not (and cannot) materialise
It's why Groopman and Hartzband call investment in Health IT an 'elegant exercise in wishful thinking'.  I wonder if Health IT and the benefits claimed for it are more like the management equivalent of homeopathy, something close to the Secretary of States heart.

The way Health IT is currently conceived will cost not save money.  Worse it will not solve peoples' problems, the real point of leverage in the system.  There is a better way, one that might end up with an electronic patient record, but certainly doesn't start there.

By the way, it's not all bad news.  RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005.