Monday, February 18, 2008

More woes for NHS

When I was younger, I took an immersion Russian course at Norwich University in Vermont. On the first day, our teacher, who was himself a gifted, fluent non-native Russian speaker, asked each of us why we wanted to learn Russian. One of the students said "I've always dreamed of reading War and Peace in the original." The teacher responded in a joking tone that revealed the hard truth: "Yes, and I too hope to be able to do that someday." We all realized in that moment that we had a hard slog ahead.

I was reminded of that moment when I read an article in this week's Economist magazine about the UK National Health Services's much troubled "Choose and Book" system (see Notional Health Server). The goal of the system is to "allow patients in the National Health Service (NHS), advised by their doctors, to choose the treatment they want, and book an appointment when they want it." Unfortunately, after 3 years of hard work, it still hasn't worked out that way. Over 50% of physicians have a negative view of the system according to the British Medical Association. One of the physicians interviewed said that in her experience the system is so slow that it takes about 2 minutes for each visit request, and even then, it functions properly only 10% of the time.

Those familiar with health IT will immediately recognize how ambitious Choose & Book goals are and, I suspect, feel sympathy for their plight. As the article put it, the system will only perform as designed if everything goes right, meaning that the hospital, physician, and health trust systems that it needs to interact with fit together perfectly, and that the physicians and administrators who use those systems fit together perfectly as well. You would think that this could be accomplished in a government-owned health system...........and you'd be wrong. Which leaves those of us living in a highly decentralized system wondering just how ambitious we should be.

Unfortunately, users, and especially physician users, assume that they'll immediately be able to do the kinds of things that Choose & Book is supposed to, and it's often hard to ratchet expectations back to reality. In the MAeHC pilot projects, we're launching health information exchanges in three pilot communities and we're constantly in the struggle of trying to prevent the perfect from being the enemy of the good by reminding physicians that the first version is "Version 1.0" which will be improved over time. It's fantastic that our users are engaged and they want to get value out of the system; it won't be fantastic if "Version 1.0" isn't good enough to want them to stick around for Versions 2, 3, and 4.

I find managing this tension -- between designing the perfect architecture vs launching something good and attainable -- to be one of the biggest challenges in the health IT space. The most difficult part of the challenge is that the culprit isn't the technology, it's the lack of alignment of the technology and processes used by the most important data sources, hospitals and physician offices. It's the same problem faced by Dossia and Microsoft's Health Vault and Google Health -- will our users be willing to wait for the system to catch up with the technology?

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