Essential prerequisites to the safe and effective widespread roll-out of e-working in healthcare

International Journal of Medical Informatics (2006) 75, 138—147

Essential prerequisites to the safe and effectivewidespread roll-out of e-working in healthcare�

Michael Rigby ∗

Centre for Health Planning and Management, Darwin Building, Keele University, Keele,Staffordshire ST5 5BG, UK

Received 20 May 2005; received in revised form 24 June 2005; accepted 28 June 2005

KEYWORDS
Evidence;Organisationalpreparedness;Evaluation;Beta pilots;e-Working;Legal and ethical issues;Implementation
Summary Health informatics applications are advocated in many setting in manycountries, with convincing logic as to their likely benefits. But at present thesevisions are being projected to rapid enforced implementation without the necessaryfoundations of:

• empirical evidence;• beta piloting or replication studies;• appreciation of the magnitude of change for health

professionals and systems in electronic working com-pared to paper-based systems.

This is creating legal and ethical risks that are largely avoidable, all for lack of post-piloting study and adequate evidence-based preparation. Instead, roll-out should befacilitated by developing good implementation practice based on empirical evidencefrom beta sites, to cover the following aspects:

• evidence;• evaluation;• equipment;• education;• empowerment.

e-Working is an essential technology to support modern healthcare delivery. Itneeds to be as evidence-based as any other health care technology, but at presentpolicy and parsimony are forcing it to fall short of these standards, thus generatingunethical risks.© 2005 Elsevier Ireland Ltd. All rights reserved.

� This paper is based on a keynote presentation on ‘‘The Legaland Ethical Issues of Widespread Roll-out of e-Working in Health-care’’ to the EuroRec conference in Berlin, December 2002.

∗ Tel.: +44 1782 583193; fax: +44 1782 711737.E-mail address: [email protected].

1. Introduction

The application of electronic storage and dataprocessing techniques, and subsequently of infor-mation and communications technologies (ICTs),

1386-5056/$ — see front matter © 2005 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.ijmedinf.2005.06.006

Essential prerequisites to the safe and effective widespread roll-out of e-working in healthcare 139

has long attracted innovative health profession-als, and health policy makers, for good reasons.Since the publication of the seminal Institute ofMedicine study in the United States of America,there has been an increasing ground-swell of recog-nition of applications such as electronic patientrecords (EPRs) as essential goals to be achieved assoon as possible [1,2]. However, an alternative wayof viewing this drive is that it is the enforced rapidre-engineering of a complete service sector, andabove all of a complex and personalised series ofprofessional skills, without a sound research baseand without adequate preparation. Any such inap-propriately accelerated change would destabiliseimportant aspects of the health sector, and wouldtherefore have a flawed legal and ethical basis.

2. Ripples or wave machine?

As cited from the initial evidence, the early devel-opment of electronic records applications and otherforms of e-working arose from motivated pioneers;some being clinicians and some starting from atechnology view point, both working with the bestoth

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• In most cases an adequate budget will have beenidentified.

• All key players will normally be willing to workover and above their normal hours and duties inorder to support the development.

In summary, alpha sites are atypical in that theyare well supported, primarily in the form of intel-lectual support and commitment by leading advo-cates and technical innovators, but usually alsowith special practical resources. At the same timethe environment will be one which is tolerant of‘‘failures’’—–the purpose is to see if the technologyor the application will work, and to learn from it.In developmental terms, the function of the alphapilot is to provide the ripples on the pond—–to makemodest changes to the status quo, attract atten-tion, and if successful the movement should leadothers to try making their own splash.

In an ordered scientific world alpha should be fol-lowed by beta. A ‘‘beta’’ site is quite different froman alpha site, and has a very different purpose. Therole of a beta site is to take the initial innovation,and repeat it in a ‘‘normal’’ and ‘‘real world’’ set-ting. In other words, it is not testing the applicationor technology, if this has been successfully proveniafncasww

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f intentions. A scientific approach was generallyaken, assessing how new technologies could bearnessed to assist the delivery of healthcare.

.1. The alpha—beta difference

y its very nature, much of this early developmentas in what are known as ‘‘alpha’’ sites—–thosehere the ideas are first tested and validated. Inost aspects of e-health working those early sites

re well known in each country, not only from theiterature but also from oral history.

Alpha sites are vitally important—–if applicationsre not shown to work, and work effectively with-ut adverse or perverse effects in study sites, theyre unlikely to work elsewhere. If specific failingsan be identified from alpha sites, they can beorrected before implementation elsewhere. Butlpha sites have a number of unique characteris-ics.

The pioneers are on site or actively involved.The application has been developed with the sitecharacteristics in mind.There will normally have been local ongoing dis-cussion as to detail of functionality and design.Because the application is pioneering, there willnormally be a process of discussion and negotia-tion with other stakeholders.The application itself will have strong technicalsupport.

n the alpha site, but rather it is assessing how thispproach works without all the atypical favourableactors of the alpha site. To achieve this, there iso excessive preparation, the funding and techni-al support are those which would be available ingeneral roll-out setting, and above all the organi-

ation and the co-workers are not sensitised in anyay by what is seen as pioneering work. In otherords, the Hawthorn effect is carefully avoided.In a scientific setting, beta sites are seen as

mportant for proving the results of an experimenthrough replication. In policy terms or organisa-ional dynamics, beta sites are just as important aslpha sites, as an essential step in proving that gen-ral roll-out is feasible away from the stimulus ofhe pioneers. Yet far too often in the whole of the-health domain beta sites are missed out. More-ver, there is a general antipathy towards evalua-ion beyond proving technical success, for a wholeariety of reasons ranging from avoidance of delayo a belief that this is merely wasting resources bye-proving supposedly known facts [3].

.2. Beta—–the missing letter

hus in the whole world of EPR roll-out policies, andther e-health, there is no beta in the alphabet.his means that once an approach has undergone

ts initial adaptation and validation, it is con-idered ready for universal application regardless

140 M. Rigby

of the need for further evidence. In experimen-tal science this would be seen as methodologi-cally seriously flawed; by contrast, in policy termsverification is seen as unnecessary, and particu-larly in e-health contexts the drives for fashion-able ‘‘modernisation’’ and the seduction of ‘‘e-progress’’ compromise scientific principles. Thusthe modest production of ripples from a first splashhas led directly to a policy to make waves, oftenapproaching storm dimensions.

3. A radical step change

Unfortunately, the situation is more serious than amere omission of a scientific step. Rather, the wholeprocess of e-health progress is a much more radicalparadigm shift now being introduced by default. Itis as though cautious clinicians, and health man-agers, were asked to step on a staircase in dimlighting, only to find that it is a rapidly movingescalator. There are challenges to poise and bal-ance, and an accelerated enforced journey into theunknown. Not that it is to be suggested that thisis an inappropriate overall journey or direction of

record keeping, without there being any recognisedawareness of the radical personal and organisa-tional re-engineering involved, is radically differentfrom training a bank clerk to use an online cur-rent account system rather than following paper-based procedures. This lack of appreciation of thesignificant personal and organisational effects of e-health roll-out, however well intentioned and what-ever the perceived major benefits, is seriously illadvised.

The current situation in many countries is ofpolicy pressure, quite often emanating from gov-ernment or senior policy makers, to bring aboutelectronic information systems for perfectly soundreasons such as better management of care, moreefficient use of resources, and better epidemiolog-ical and outcomes data sets to facilitate improve-ment in health gain. But at this level the intro-duction of e-health working is seen as just anothermodernisation task, with the drive being to emulatethe clear and proven benefits in other commercialsectors [4]. The significance of the effects at oper-ational level, and the challenges to success, arenot understood. And this lack of awareness is com-pounded by the fact that the beta stage has beenttnpfmaitifara

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travel, but rather that it is unwise to commence thejourney without the evidence of how best to makethe transition to the next level whilst maintainingall other health care delivery principles and organi-sational factors, uncompromised by anything otherthan planned change.

3.1. Understandably reluctant players

As e-health moves from pioneering to policy, frombeing interesting innovation to mandated require-ment, it raises understandable anxieties amongsthealth professionals and others who have to makeit work. Whilst policy may be developed for soundreasons, it is not the policy makers who have tomake it work, but rather the operational staff ofthe health sector. But unlike other service sectorswhich have harnessed electronic technology suc-cessfully, such as the banking and financing sectorsand retail trade, the employees of the health sec-tor are not line-command employees whose job isto make the system work. Instead, health profes-sionals are skilled autonomous workers in their ownright, who work within an integrated organisationbut at the same time look to the organisation and itsinformation systems to support them in their pro-fessional duties as much as vice versa.

To clinicians, the changing of practice supportsystems, ranging from appointment systems topathology results reporting, from prescribing to

otally omitted, and so there is no evidence to iden-ify the issues of general roll-out of applications,o framework on which to base an implementationrogramme, and no researched evidence of pit-alls which should be avoided—–and which are muchore likely to be avoided if an evidence-based

pproach is possible. The policy maker’s alphabets quite literally a philosophy of ‘‘alpha and bet’’,aking a gamble on wider applicability of an initialdea rather than a robust alpha study being rein-orced and enriched by beta evidence. And this insetting in which clinicians are expected — indeed

equired — to operate on a strictly evidence-basedpproach.

Further more, this situation is compounded byhe fact that health resources are always underressure in any health sector, and that more-ver ‘‘administrative’’ and ‘‘managerial’’ costs —n other words ‘‘non-clinical costs’’ — are mostnder scrutiny. Thus not only are alpha-tested ideasranslated too rapidly into formal policy, but theesources which should be allocated to the prepa-ation for change are themselves severely squeezedo that even basic planning and training is compro-ised. Because the roll-out scale is widespread andispersed, the specialist help available to the alphaite cannot be offered to the ordinary site, andhere are no pioneers or key stakeholders locallyo act as advocates. Indeed, reluctance can breedcepticism and generate opposition as the local cul-ure.


3.2. The danger of the evidence vacuum

And in this situation we are now entering into a Dan-ger Zone for the effectiveness and safety of healthcare delivery. Whilst the initial evidence for mod-ernisation is strong, and the potential benefits tobe yielded are valuable, the uninformed cascadeprocess is inappropriate and fails the basic tests ofevidence-based healthcare. Yet with managementby results and monitoring of policy implementa-tion, perversely there is pressure on organisationsto achieve change in line with decreed policy, atthe very time when a considered approach is muchsounder. Organisational effectiveness and good willare likely to be compromised, challenging safetyeven further. Lack of beta evidence is taken as lackof contrary evidence.

4. A concealed paradigm shift

What is not appreciated is that the move to e-health at a dispersed operational level is a radicalparadigm shift. There is a tremendous gulf betweentaambltw

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• Retrieval skills needed are very different. Mostexperienced clinicians were trained in the daysof paper records, and they are used to lookingfor particular items in an encyclopaedic paperrecord, knowing how to find these, and interpret-ing them from a range of techniques from visualscanning to giving value to particular entriesbecause they can identify specific colleagues’handwriting. However flawed these processes,rapid substitution of standard type face, and themystiques of managing electronic file structures,are radically different and introduce new risks.

• Finally, old technology — paper and pen — areubiquitous, as well as highly mobile. Computerterminals, printers, and other input and outputdevices are not universally available, are lessmobile, and are more prone to technical break-down than the ball point pen. Health workers aredependant upon the physical and working avail-ability of these devices, which generally is lessthan perfect, in some cases to the point of totallyjeopardising applications [5].

This paradigm shift, if unplanned, has two poten-tial adverse effects. One is simply to compromisethe efficiency of the system. And even if the appli-cpamhtbannotea

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he work of pioneers in alpha sites, and generalpplication. The distance between opinion leadersnd sceptical long-serving workers, between policyakers and the operational setting, is compoundedy the lack of application evidence caused by theack of beta sites. The paradigm shift which elec-ronic record based working forces on professionalorkers includes the following features.

Process change in the way that individuals work,and the way that organisations undertake tasks.Finding information, ordering things, organisingactivities, and recording and looking up recordsare each undertaken in a radically different way.The whole record handling process is differ-ent. Established procedures honed over decades,albeit with significant weaknesses, are foregoneand electronic indexing and look-up substituted.Record keeping is totally different, and this startswith the way in which the health professionalthinks about what they wish to record. Keyboardskills are very different from earlier methods ofrecording facts, and the role of secretaries andsupport workers, and the verification of draftentries, are also radically different.A new record keeping discipline is needed, anda new routine of working. Notes cannot be writ-ten up in the same way at the end of a session ifthere is not a pile of paper charts to be checked,updated, and signed at the end of a clinical ses-sion.

ation works at face value that is different fromroving that the clinical processes and outcomesre at least as good if not improved. Secondly, theiddle and senior ranks of each profession, which

itherto have been the informal leadership withinhe health organisation, now feel anxious and possi-ly inadequate. Their confidence is compromised,nd in some settings this may be compounded ifew and younger staff with less clinical experienceevertheless are more fluent with the new technol-gy. The danger is that the health sector is forcedo move rapidly towards e-health in issues such aslectronic patient record roll-out without appreci-ting the size of the paradigm shift it is initiating.

. Change on an unprecedented scale

he drive towards electronic patient records andelated e-health operational applications is also notsually recognised as pushing towards other bound-ries of the unknown on an unprecedented scale.his has three quite separate but inter-relatedimensions.

.1. Large volume automation

n most developed economies, the health sectorowever structured is one of the largest organisa-ional systems. In broad terms it usually consumes

142 M. Rigby

between 7 and 11% of GDP, and employs some 10% ofthe workforce. Thus, though other sectors such asbanking and insurance have changed radically as aresult of electronic and real time working, these aremuch smaller in activity and transaction levels thanthe health sector. Further, those commercial sec-tor applications, like other beneficial applicationssuch as retail and manufacturing support logistics[4], have been developed as a response to clearbenefit-led demand, yet have evolved in manage-able ways.

5.2. Autonomous professional practicere-engineering

The second dimension in this respect is that thecore staff of the health sector have a significantlydifferent profile and responsibilities from core staffin other e-automated sectors. Not only are healthprofessionals highly educated and autonomous indi-viduals, but their professional duties give thema personal autonomy and responsibility which haslegal and ethical underpinning. Thus not only willhealth professionals have natural critical appraisalskills largely developed by their own professional

processes are digitised, and as health care inter-actions increase. There is scant evidence of anymodelling or scaling of the feasibility or demandsof this, yet moving to endemic electronic work-ing is largely a one-way move—–if the technolog-ical processes become bogged down, they wouldbe difficult to undo or to replace with alterna-tives, as the data are now locked into the electronicsystem.

5.3.2. Long term storage and retrievalA further technological challenge drawing downfrom the previous one is that of long-term acces-sible storage. Grimson has drawn attention to thisin a key note address to the Medical InformaticsEurope Conference in 2000, subsequently published[6]. It is normally difficult to find means of readingelectronic storage media more than 5- or 10-years-old, but patient records need to be held for thelifetime of the patient and for a period thereafter.Further more, they need to be as accessible as astored paper record (which apart from importantorganisational factors, is not technologically com-promised by age in less than a few centuries). Mov-ing towards solely electronic recording of clinicalnrbctdph

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function, but they are also within their professionalrights to resist changes which by their nature or bythe way which they are implemented put at risk, orappears to put at risk, their own professional com-petence and confidence in discharging their duties.The personal professional way of working of theseautonomous clinical professionals is in key respectsbeing re-engineered without any evidential or con-sensual approach.

5.3. Pushing technical boundaries

A third and very different consequence of movingfrom alpha site to universal roll-out as part of arapidly implemented national policy is that this ispushing technical boundaries. This has two separatecomponents.

5.3.1. VolumeThe volume of data and transactions represented bya large acute general hospital is extremely large.As health care delivery becomes both more com-plex, and more data dependant as new diagnosticand therapeutic techniques become available, sothe volumes of data and transactions will increasenot diminish. Additionally, the legitimate desirefor networking of records to form the life longpatient history is a further compounding factorthe potential volume of which is tremendous, andgrowing exponentially as more and more complex

otes, digitised X-rays, and other essential clinicalecords with the core requirement that they wille physically preserved, capable of reading, andapable of being readily accessed for up to a cen-ury, is putting a trust in the technological sectorelivering continuity of solutions and forward com-atibility in a way which has never been achieveditherto.

. The risk implications for healthcare

rom this analysis it will be seen that though thendividual component benefits of moving towardslectronic patient records and other e-health ser-ice delivery modalities each can be justified, theajor scale and pattern of change proposed has

erious implications for the healthcare sector, forhe delivery of health care, and indeed for healthrofessionals’ ability to discharge their own pro-essional duties. These are uncharted large-scalehanges which also push technical limits, yet whichre being rapidly pursued in a crucially importantnd large-scale service delivery sector. Yet the betailot stage has been totally omitted, and as a conse-uence of this omission the delivery of health careecomes itself a real time experimental environ-ent.There are previous warning signs of the danger

f radical re-engineering of health care processes


without appropriate evidence-based implementa-tion. Minimally invasive surgery was a proven majordevelopment in a health care delivery techniquewhen created and assessed by its pioneers in alphasites. However, when the pressure for general roll-out increased because of the clear patient benefits,cost savings, and the ability to treat more patientswithin given resources, based on these early find-ings, there were significant adverse sequellae whenclinicians were pressurised into changing practicerapidly. The unforeseen factor was that whereasthe pioneers understood not only the technologybut how to use it, in daily practice laproscopicworking needs very different visual, tactile, andsensory skills and perceptions compared with openincision surgery. Those who were expected to trans-fer rapidly from one to the other were not alwaysadept in the new skills, for no fault of their own,but there were cases of serious introgenic dam-age. The beta site testing of the effects uponnormal working environments, and from this pro-ducing evidence-based planning and implementa-tion strategies, was omitted at a subsequent highprice.

The application of operational electronic healthwCateciwbPotu

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tation of new replacement systems which are notproven as being equally safe in practice accord-ing to the implementation plan adopted could beconsidered ‘‘reckless’’ as legally defined. Replac-ing the safe with the unproven, let alone with asolution which still has unresolved question marks,must surely run close to crossing this legal bound-ary.

Secondly, if the EPR or similar system runs therisk of failing in any way, such as failing to presenta complete clinical history to the clinician whenhaving been obtained within the organisation, orin having significant down time or non-accessibilityof records without adequate back up, then patientsafety is directly compromised. In these circum-stances the question of legal liability must arise.A manager who implements a policy change suchas acquiring goods from unauthorised sources orequipment which is not safety certified would inmost jurisdictions be held to have a liability for thatdecision. What then is the position of policy mak-ers and their liability if they force implementationof e-health policies for which similar risks can con-ceivably be identified?

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orking carries the same unquantified risks.learly, the potential benefits and gains are large,nd are worth striving for. But the approach needso be much more researched, planned, and thusvidence-based. The health sector cannot expectlinicians to move towards evidence based caref the environment and supportive tools, in andith which they work, are not themselves evidenceased, or implemented in an evidence-based way.ressurised policy forced upon health organisationsr professional staff creates unnecessary risk in aype of way which would be deemed unethical ifsed unthinkingly by a health professional.

. The legal and ethical implications

he arguments so far presented relate primarily topplication of the technology, and to planning forignificant organisational and professional practicehange. But is it reasonable to claim that thesere legal and ethical challenges, rather than merelytrategic ones?

.1. Legal issues

ealth organisations have a legal requirement torovide an effective health care system. This mustnclude a duty to provide a safe environment, andafe stable systems. To move towards implemen-

.2. Ethical issues

he boundary between legal and ethical issues cane indistinct, though the means of assessing thems significantly different. Thus the foregoing legalssues are of themselves also ethical ones. However,dditionally the ethical dimension raises the effectspon clinicians, who have chosen to devote theirrofessional lives in the employment of a particularrganisation, but who are dependent on its envi-onment and infrastructure. In order to practiceffectively, clinicians need to draw upon supportnd enabling services and technologies in line withheir original professional training. If the organisa-ion chooses to force change upon them, such thathey no longer either have the same technical skill,r feel confident in discharging their professionaluties, in effect the organisation has underminedheir professional competence, and thereby haseduced their ability to practice effectively. Thislearly is an extra dimension regarding the deliveryf health care, but if in extreme cases it removesrom the clinician their ability to earn a livelihoodt also has a further ethical dimension.

. The E’s to ease e-working

f this paper is cautionary and cautious, it is notntended to be conservative in any negative sense.

144 M. Rigby

Having raised the challenges, it is important tomove onto identifying the approaches necessaryto provide solutions. The health domain is cur-rently fond of the ‘‘E’’ prefix, and the neces-sary approaches to enable its success with easeare:


8.1. Evidence

The need for evidence for policy change, includingoptimum ways of effecting that policy’s implemen-tation, should be self-evident. Yet evidence is themissing item, as already explained. What is missingis evidence in a number of respects:

Applications. It is important to know which typesof application yield most benefit at least risk, andwithin each type of application to know the opti-mum approaches.

Configuration. There are many alternative ways

These requirements for evidence should seemself-evident. At the same time, though, it is impor-tant psychologically to move into this ground, sothat clinicians who are now sensitised to the impor-tance of an evidence-based approach in their ownpractice are addressed in a similar language overan evidence-based EPR-based approach.

8.2. Evaluation

The argument for evidence is clear, but the sourcesof it less so. Evidence can only come from study,and the development of evaluation techniques inhealth informatics is itself a specialist scientificarea [10—13]. Alternative techniques need to beconsidered, and it has to be recognised that in manyareas randomised controlled trails are not feasible.Development of evaluation techniques is an essen-tial, as is recognition of the importance of providingadequate funding for evaluation. It can be arguedthat sound scientific evaluation as the source of evi-dence to facilitate effective roll-out is as importantas the original research to validate the techniqueunder consideration.

There is an important need to observe processamtbscao

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of configuring information systems, and families ornetworks of systems, and again greater availabilityof impartial evidence from comparable situations isneeded.

New style e-working. It is an old adage thatcomputer systems should not automate manual sys-tems. In many ways e-working in health can revo-lutionise practice for the better, in the same waythat safe minimally invasive surgery is beneficial.More evidence is needed on best practice and besttechniques in e-working, at the organisational andat general roll-out levels.

Staff preparation. Staff need to be prepared forthe change to electronic systems and e-working,not simply have a last minute training session. Whatare the best preparation methodologies?

Facilitating change. Different models exist forfacilitating the change of work style representedby electronic records and e-working. What is theevidence as to the best approaches in different sit-uations?

Successful leadership. Pioneers can lead success-ful developments; innovators are much less likelyto be effective at leading assimilation, roll-out andadaptation [7]. What are the best leadership stylesfor modernisation policies?

Benefits realisation. It is one thing to say thatnew systems will be better, it is another to achieveidentified benefits, and this must start with benefitsidentification and move into a benefits realisationstrategy [8,9].

nd behaviour, and to monitor outcomes. There isuch to commend the observatory role, as prac-

iced most prominently in Denmark, as a contri-ution towards this [14]. Thus evaluation must beeen as cost beneficial in its own right, and ofourse it must be conducted in greatest part outsidelpha sites, namely in beta sites or from widespreadbservational studies.

.3. Equipment

quipment for EPR and other health informaticspplications needs to be fit for purpose. This car-ies no connotation as to whether it has to be new,r dedicated for a single application—–the appro-riateness is in whether it is available with theunctionality, location, and time availability neces-ary. Such equivalent needs to be able to facilitatehe capture of data, to store it safely for the dura-ion required, and to enable access both for readingn screen and for printing, each as appropriate.

.4. Education

ducation needs to be considered as a separate andore fundamental prerequisite to training, which

s application specific and close to the operationalwitch-on. Education more looks fundamentally athe way professions or disciplines undertake theiruties, and how these need and should be devel-ped with the use of the new technologies. Three


broad groups can be identified with different edu-cational needs.

• Technical staff. Technical staff self-evidentlyneed to be proficient in the types of technologyand system for which they are responsible in thehealth sector. Additionally, however, it is impor-tant to ensure that they are fully appreciativeof the characteristics and requirements of thehealth sector and its applications. There is muchto commend an interchange between health andother sectors in terms of import and export ofapplications experience, but those coming intothe health sector need to be educated overawareness of the requirements and constraintsof the sector they are joining.

• Health professionals. Health professionals neededucation in three respects. They need to under-stand how using electronic equipment is verydifferent from earlier techniques, for instancehow recording into electronic records throughkeyboards is different from a secretary under-taking an initial draft from notes at the end ofa clinic for the professional subsequently to ver-ify and sign. Secondly, there should be educa-tion on e-working itself, and the benefits this

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earlier electronic systems imposed upon them canbe threatening and thus very naturally lead to anattitude of opposition and resistance. To ensuresuccess with the new technologies, it is importantfor policy makers and decision makers to appreci-ate the fundamental importance of the policies andimplementation processes being designed in such away as very specifically to instil a feeling of empow-erment of the end users.

9. What is the way forward?

Clearly, and rightly, the e-revolution in healthcaremanagement and delivery is here to stay. But aswith so many important innovations, the devil is inthe detail. The advent of e-working in health carehas been compared with the radical effects on soci-ety and operational workers of the advent of therailways, with a similar range of requirements span-ning from standardised practices and terms throughto new education and training requirements; itneeds to be addressed on this scale [15]. Thisis where the difference between success or con-spicuous failure, enthusiastic adoption or doggedrb

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can bring. Telemedicine applications are for somedisciplines particularly important potential gainsin this respect, for others it is the automation anddigitising of diagnostic facilities. Thirdly, healthprofessionals need to see the effects and ben-efits of alternative health care processes, rang-ing from the comparatively simple ward orderingof diagnostic processes, through to decision sup-port, electronic prescribing, and possible futuregreater availability of networked records.Leaders. There is a need to educate forleadership in the health information sector.This includes strategic leadership and decision-making in the health informatics support sector,and understanding of change management.

.5. Empowerment

ossibly less promoted in this context than thether ‘‘e-words’’, empowerment is in fact partic-larly important. Clinicians, managers, front lineeception and other staff reaching patients, andhose implementing and supporting health infor-atics applications must all feel confident in theay they discharge their duties. Clinicians in par-

icular, and the others to a significant degree, areducated to achieve this confidence in practice inheir basic professional education. New technolo-ies should assist them further develop this com-etence and its linked confidence, but as indicated

esistance, are determined. And it is here to thatenefits can be maximised, and risks minimised.

There needs to be a more reflective approach,ith less dogmatic policy domination driven byomparatively flimsy evidence, where currentlyvidence seldom comes from anything other thanlpha sites, subsequently talked up by aspiration.ut within the identified need for a reflectivepproach to policy development, three more spe-ific suggestions can be made.

.1. Application and impact research

irstly, in order significantly to extend andtrengthen the currently very limited evidencehich exists about the application and impactffects of EPRs, there needs to be a much greaterove towards structured evaluation. The observa-

ory approach pioneered by Denmark [14] has mucho commend it.

.2. Good European model

hilst sensitivity to individual health systems, ando the needs of individual sites and health careroviders, are both important factors, at the sameime there seems little point or justification inll health care providers having to develop theirwn implementation and application models. Thereould seem to be considerable merit in developing

146 M. Rigby

a single Good European Model for managing newimplementations of applications, and this is likelyto be more effective if created by pooled exper-tise. The emphasis would be upon a generic model,into which any user organisation would insert theirown local values and requirements. This idea wasinitially put forward at the EuroRec 99 conferencein Seville, and could well be a suitable key task forthe ProRec network of centres [16]

9.3. Developing the ECDL

The European Computer Driving Licence (ECDL) hasreceived a tremendously strong welcome withinEurope, and indeed internationally, as a commonbasic skills and competency qualification in the useof computer systems. However, it is aimed onlyat ensuring sound use of the technology, and con-tains no knowledge or competencies about par-ticular application domains. Health is a specificapplication area where there are legal and ethicalrequirements, as well as having unique character-istics about its data and the way they are handled.Following a further idea raised at EuroRec 99 [16]this initiative has been developed [17,18], and is

extending the boundaries both of technology appli-cations and organisational re-engineering in a pro-fessional service domain, needs to be appropriatelyplanned and managed, based on appropriate evi-dence. A major modernisation intended to benefitpatients and professionals should not end up beingforced forward in a way which instead puts them atrisk.

Summary pointse-Working is being rolled out rapidly across

many health systems, and affects all practi-tioners and patients in those systems.

This is based largely on vision and on pilotstudies, without beta or replication sites.

This is an inadequate standard of evidence orknowledge, and would be considered an uneth-ical policy basis in other areas of practice.

Health professionals often have thesechanges forced upon them, without adequatepreparation.

The degree of enforced process change isoften under-appreciated—–new approaches toessential daily tasks have to be devised andlearned.

R

now being pursued through the appropriate chan-nels of the ECDL foundation.

10. Conclusion

It is clear from the literature that the move towardselectronic patient records and e-working has majorpotential benefits for patient care and health caredelivery, and thus ultimately should have a positiveeffect upon health gain. However, if the EPR is inap-propriately implemented it also offers major riskswhich are foreseeable, and thus in principle avoid-able. These risks are created almost entirely by theserious deficit of evidence as to how to make bestuse of the EPR, how to optimise its implementation,and how overall to control the risks and maximisethe benefits. In seeking to harness health informat-ics and EPR technology, it is also important to movethe focus from forced implementation of moderni-sation policy with minimal evidence from outsidealpha sites, to an evidence-based policy which canbe seen and proven to assist and empower allstaff in discharging their professional duties. It isimportant to recognise that widespread promotionof EPR systems, with related processed and tech-niques, is a major process re-engineering affectingall health organisations and their professional andsupport staff, as well as changing the way patientsinteract with the service. This adventurous policy,

Reluctance to commit time or money to eval-uation studies is a compounding factor.

A further concern is the irreversible com-mitment to large electronic systems withoutadequate research into future technical issuesof scale, management or retrieval of exponen-tially expanding databases.

Consideration needs to be given to devel-oping a robust model for implementation ofe-working, based on programmes for:


If new methods of working are inappro-priately implemented this offers major risks,which are foreseeable, and thus in principleavoidable.

eferences

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Essential prerequisites to the safe and effective widespread roll-out of e-working in healthcare

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