National health IT infrastructure through the media lens

Health Policy and Technology (2013) 2, 203–215

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National health IT infrastructure through the media lens Sophie Cockcroftn University of Queensland Business School, University of Queensland, QLD 4072, Australia Available online 27 July 2013

KEYWORDS

Abstract

NPfIT; Cynefin; Health information systems

This paper describes a retrospective study of the big budget National Programme for IT (NPFIT) in the UK. The project is seen through the lens of the national newspapers and analysed via the Cynefin model. A set of success factors in health information system (IS) initiatives are derived from the literature, 584 newspaper stories drawn from the period October 2002, when the NPFIT programme began, until the end of 2012, are analysed using a multi method approach to identify gaps between real information systems issues and reporting. Results suggest that gaps between media reporting and success factors are captured by the less tangible (complex and chaotic) aspects of the Cynefin framework. Further, newspaper articles skirted around many human aspects of system development that were prominent in the IS literature such as of change management and user acceptance. The most commonly reported domain moved from known to chaotic as the project progressed. & 2013 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.

Introduction Lifelong online electronic health records (EHRs) are becoming a priority for the governments of most industrialised nations. Governments perceive that they can benefit in terms of informed policy development, improved resource allocation and identification of the causes and risk factors in disease. Such systems also provide more data for epidemiological research and disease monitoring. Understanding the impact of policy decisions in this environment is critical. It is valuable to policy makers to be able to identify those situations which demand action, and those to which a more appropriate response is recourse to heuristics—i.e. in some cases approaches more akin to rule of thumb or best practice can be used.

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National health infrastructures are rich and complex human systems. If they are implemented correctly, many benefits are passed on to the patient; centralisation reduces the risk of lost records, assists in emergency treatment and allows informed prescribing among clinicians, and there is the capacity for patients to have greater control over their own health information. Such systems have come under criticism from researchers [1,2] because they can be used to deliver identifiable information on individuals to third parties. These researchers posit that putting health information of virtually the entire population online; to be accessed by numerous health professionals, bureaucrats and researchers inevitably compromises privacy. Another practical point is that there is no easy migration plan when a centralised top down approach is taken with many legacy systems becoming obsolete when they do not meet national standards [3]. We explore how government decision making is reflected in the print media with regard to such records using the Cynefin framework [4]. We focus on a particular instance of such a record system the UKs National Programme for IT (NPfIT).

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204 The project was launched in 2002, and terminated in its existing form in September 2011. In order to capture commentary immediately post retirement of the NPfIT we extend our frame to include 2012. Cynefin is becoming an accepted approach in knowledge management. In particular it contributes to an understanding of “how people perceive and make sense of situations in order to make decisions”. It differs from other management approaches in that it provides some guidance on how to use stories and storytelling in organisations. Stories in this context are received rather than told, thus we assert that viewing Newspaper “stories” is quite consistent with the Cynefin approach. Given the large sample frame, Leximancer, which has the ability to analyse large unstructured bodies of text [5] is an appropriate tool. It is also provides tool for formal objective analysis. It compensates for human biases and has the potential to find patterns in data that humans would not. This paper explores two research questions and one methodological one. The research questions are: a. Did the print media take and evaluative or other role in the evolution of the NPfIT? b. How did it match existing critical success factors from the literature? c. The methodological question is: can the Cynefin framework assist in identifying complexity in health information systems projects?

Analysis of newspaper stories has been used in health studies to track public opinion with respect to specific health issues such as mental health [6–9] obesity [10,11] and antismoking campaigns [12,13]. In a similar context to the current study Collins [14] examined the newsprint effect on public attitudes to health policy in Canada. The news media can act as informer, agenda setter, framer or persuader, but Collins et al. caution around the limitations of such data i.e. it is prone to sensationalism due to its dual mandate to tell news stories and to sell papers. We acknowledge these limitations but maintain that it is worth exploring the wealth of data contained within the sample. The paper proceeds as follows. First the NPfIT is briefly described. Second, prior academic work relating to national health infrastructures is summarised to produce a set of candidate themes for the analysis. These themes are compared to themes derived using Leximancer from the corpus or narratives selected. In Section 4 the use of the Cynefin framework as a sense making tool is described. The methodology used in this study is described in Section 5 and the paper concludes with results and discussion.

The national programme for information technology Until the mid 1990s governance of the UK National Health System was decentralised, although ITwas spread across several regional authorities the management of medical functions was centrally controlled. In the mid 1990s the government saw the opportunity to use Information Technology (IT) to improve the delivery of service [15]. The NPfIT came into existence in 2002 via a government mandate to maintain and manage electronic

S. Cockcroft patient care records centrally. It was an initiative of the Department of Health agency connecting for Health (CFH) which was created for the purpose of delivering the programme. The NPfIT absorbed staff, and work streams, from the national health information authority which had been abolished. The plan was for the project to take 10 years to complete and cost d6.2 billion pounds. The NPfIT was dubbed the largest civilian IT project attempted in the world [16]. As part of the NPfIT initiative a database was set up. The aim of this was to allow authorised healthcare providers to access a patient's records securely wherever they were [17]. A further aim was to connect every family doctor and hospital in England, and provide online records for 50 million patients by 2010. The NPfIT was much more ambitious in scale than simply shared health records. It covered 330 acute hospitals and mental health trusts and primary and community care organisations across England [18]. Many features were implemented including a central link to a patient register, online booking “choose and book”, radiology picture archiving and electronic prescription facilities. Patients were ultimately expected to have access to their own health records through a service called HealthSpace. In order to manage the project, England was divided into five geographic regions each one made up of between five and seven strategic health authorities (SHAs). Regional implementation directors (RIDs) lead the implementation in each region and national standards were maintained so that data could flow seamlessly between the areas [19]. The project was dogged with management and procurement issues [20]. In particular IT vendors found the management structure of RIDs and SHAs difficult to deal with. At the time of writing the project has been terminated in favour of a decentralised system. Electronic Health Record systems present unique challenges in implementation and design, because compared to non-health information systems they have a greater biological and social complexity. In reality, banking and airline systems' customers or travellers are grossly simplified abstract versions of a person [21]. The issue of complexity in health care has been addressed by previous authors such as Plsek and Greenhaugh [22] and Sturmberg and Martin [23] Added to this there are quite considerable challenges inherent in health systems such as; mobility of patients, multiple Health Care Professionals (HCP), and frequent changes in technology and the law. Sauer and Willcocks [24] identify the main players in National EHR initiatives as; the relevant government offices, HCPs, professional institutes, patient representatives, and professional critics including audit bodies and academia. We suggest that the press is a form of professional critic since it has the power to frame issues and sway public opinion. Further we suggest that it is important for all players to understand the media landscape so that they can present their positions on critical issues. The news media are charged with covering issues in a balanced and informative manner. These issues are framed for the public by newspapers using particular language and opinions, which in turn feedback the weight of public opinion to policy makers. This study focuses on the big budget NPfIT in the UK. It reviews how the system was portrayed in the UK's major newspapers. The aim of the current project is to explore the media's role in public perception of Integrated Health Records (IHR).

National health IT infrastructure through the media lens Many countries are investing large amounts of money in national systems with the aim of improving health care. Development of such systems has, however, become a major political issue in most developed countries. Politicians, HCPs, the public, academics and professional bodies have distinct views on how health information systems should be built and managed. There are many excellent review papers regarding the NPfIT [25–29], the purpose of this work is different in that is reviews the evolution of the project purely from the perspective of the press, using a sense making framework. This work draws together academic literature from communications, healthcare and information. The key originality of this work is the use of media analysis to explore the issues in this complex health, IT and political arena.

Prior research Academic comment on National Health Infrastructures and EHR systems focuses around four main issues: (1) Technical issues of security, confidentiality, privacy and interoperability [30–32], (2) human aspects such as use and usability technology acceptance and patient consent [16,26,30,33–35], (3) aspects of IS Project Management in the health domain including issues of budget, scale, centralisation, focus, approach and evaluation [18,26,30], and finally (4) political commentary such as tensions between clinicians and managers [24], and between national and regional bodies, and between health providers and citizens with new cultural pressures to put the citizen at centre stage e.g. Currie [36] and also the field of e-government with a level of conflict between traditional bureaucracies and the “new public management” [37]. A full analysis of this literature is the subject of an earlier study (reference removed for reviewing, 2009).

205 Connell and Young [41]consider whether health systems should be evaluated differently. They note three tensions; the clinicalmanagerial distinction, whether “enterprise” is the appropriate building block in health systems, and the tension between the interpersonal and the interactive. They argue that healthcare requires more person to person knowledge transfer than a traditional enterprise might. Evaluation of IS projects is difficult in non-health applications and unique attributes of healthcare make evaluation of such projects within the health arena even more difficult. Healthcare has a rich and diverse set of stakeholders in healthcare offer unique challenges. In addition the culture of evaluation in healthcare is toward patient outcomes but the benefits of IT projects by comparison are notoriously hard to measure [41]. This insight was echoed in a review by Mark and Snowden [42] who noted that innovation in healthcare is the subject of many research journal articles but most of them concern treatments for the patient rather than the organisation. Figure 1 represents a framework of key critical success factors (CSFs) derived from the literature. This work was the

Communication

Use/Usability Human Consent

Socio-technical issues

Transparency Technical

Of the academic concerns described, the human and political aspects are most relevant to an analysis of media concerns, and particularly how they impact organisations. The reason for this renewed focus on organisational level studies is that in IS research a historical preoccupation with technical issues, as contributing factors in system success, has made way for an overt recognition of the need to consider organisational factors in recent years [18,26,38]. Doherty and King [39] conducted a survey of 593 managers and found a focus on organisational issues to be significant in project success. Organisational issues in the context of their survey were broadly divided into human centred, transitional and organisational contribution/alignment issues. Prior research in health IS infrastructure implementation reflects two important elements from Doherty and King's [39] work; the importance of reengineering and organisational alignment. Reengineering is very significant in any national health information system development because the imposition of an IT system into an already complex human system such as a health service involves, by necessity a change in the way people work [40]. Alignment issues consider the impact on organisational structure and implications for organisational culture.

Consent

Evaluation

Centralisation

Project Management

Change Management

Political

End Users

Procurement

Figure 1 Eleven CSFs derived from academic commentary on health infrastructure initiatives.

206 subject of an earlier study (The authors removed for reviewing, 2009). Consent appears in two places due to the legal and technical aspects of implementing informed consent to access health records. Shaded areas foreshadow the factors highlighted in the newspapers

Sense making and Cynefin The importance of organisational factors in evaluating the success of information systems projects is accepted. Building on this, we need to describe the space(s) in which this evaluation occurs. It operates in two dimensions. The first dimension is to do with the unit of analysis ranging from the system itself, to all aspects of running that system within society. The second dimension concerns whether the evaluation is technical, sociotechnical or socio-political. Thus at one extreme we would make a technical evaluation of (for example) usability/reliability among a small cohort of users and at the other extreme we would consider technical, social and political issues within a whole society. It is assumed that the news media undertakes a broader evaluation than simply the system itself, and does so in a political rather than socio-technical fashion. Thus we seek a means of explaining the tacit evaluation performed by the news media. Cynefin has the potential to provide such explanations by taking a broader view than the classic IT evaluation approaches such as DeLone and McLean [43]. In classic IT evaluation constructs examined generally include user satisfaction, net benefits, intention to use, and actual behaviour. Socio-political systems call for a broader analysis because the constructs mentioned are harder to get at. Simple cause/effect links are less common. Webs/loops of cause and effect occur with unpredictable emergent properties [44]. To address this level of complexity a number of prior studies have exploited the Cynefin framework [4]. It has been used in the related areas of E-government procurement [45], health promotion [44], health planning and clinical care [23], and organisational behaviour in healthcare [40] Cynefin is described as follows: “The name Cynefin is a Welsh word which is commonly translated into English as ‘habitat' or ‘place’, although that fails to convey the full meaning. A fuller translation would be that it conveys the sense that we all have multiple pasts of which we are only partly aware: cultural, religious, geographic, tribal etc. The multiple elements of this definition and the inherent uncertainty implied were the reasons for the selection of the name. The name seeks to remind us that all human interactions are strongly influenced and frequently determined by our experiences, both through the direct influence of personal experience, and through collective experience, such as stories or music.”[4] Gaps exist between what one group experiences and what another (the media) views as real. The media creates gaps in public knowledge by omitting information, such as overlooking the importance of usability or patient safety for example. Cynefin (www.Cynefin.net) describes a way of understand ing the meaning and relationships between how things are and how they are perceived. As a sense making framework it

S. Cockcroft also provides opportunity to confirm the appropriateness of different approaches under defined conditions. We analyse the results of our study using the Cynefin framework from complexity science and management. The Cynefin framework has five domains (see Figure 2). The first domain is known, in which the relationship between cause and effect is obvious to all, the approach is to Sense— Categorise—Respond and we can apply best practice. The second domain is knowable, in which the relationship between cause and effect requires analysis or some other form of investigation and/or the application of expert knowledge, the approach is to Sense—Analyse—Respond and we can apply good practice. The third is the complex domain, in which the relationship between cause and effect can only be perceived in retrospect, but not in advance, the approach is to Probe— Sense—Respond and we can sense emergent practice. Finally there is the chaotic domain, in which there is no relationship between cause and effect at systems level, the approach is to Act—Sense—Respond and we can discover novel practice. The remaining domain illustrated by the central area in Figure 2 is disorder. An earlier study by Hasan and Kazlauskas [46] leant some weight to the potential use of Cynefin in IS work. Hasan and Kazlauskas commented on the evolution of best/good practice in the IS discipline and noted the potential for many IS practices such as system development and data warehousing to be in the knowable quadrant. The entire NPfIT has been a learning experience for the information systems professions in terms of the practicalities of managing a huge IT projects and the pitfalls of centralisation. The use of Cynefin in the current context is predicated on the researchers observing the stories emerging from the NPfIT, and being able to assess which domain is represented in each story. The aim being to formalise lessons learnt from the programme according to an established framework.

Method The use of narrative as data is well established [47], Narrative is useful in studying organisations as it links

Complex

Knowable

Chaotic

Known

Figure 2 Cynefin framework [4].

National health IT infrastructure through the media lens human actions and events and also allows key players within and organisation to emphasise or ignore certain events, creating an evolving picture of what is important to the firm. The newspapers are analogous to such players in a firm when they act as professional commentators on the actions of the department of health, cabinet and National Health Service (NHS) leadership. The study focuses on stories derived from Factiva [48] from the inception of the NPfIT until it's a year after the programme was ended in its current form in 2011. For a full viewpoint it is important to include all the major newspapers, so for this study we did not restrict our search to top sources as defined by Factiva (in terms of quality and rigour) but all newsprint sources by circulation. The following query was used to identify appropriate stories (NPFIT OR “NATIONAL PROGRAMME FOR IT”) and (rst=thesun or rst=NEWSOF or rst=DT or rst=T or rst=IND or rst=OB or rst=DMIRR or rst=DAIM or rst=THEEXP or rst=GRDN or rst=FTCOM)

The sample Five hundred and eighty four stories (584) were downloaded from Factiva [48]. The breakdown of these stories is shown in Table 1. These were analysed using the Leximancer [49] to identify which of the critical success factors in the prior research were prominent in the newspapers. The Leximancer has been used in a number of prior studies [50–52]. The output of this processing is shown in Figure 3. Leximancer is a text processing software that uses proximity to automatically identify and map themes and concepts in textual data. Word frequency and co-occurrence data are used to identify families of terms that tend to be used together in the text. This approach differs from standard content analysis in that, Leximancer identifies what concepts exist in a set of texts, without prior specification by the researcher. This allows concepts to be automatically coded in a grounded fashion [51]. Words that occur very frequently are treated as concepts. The software includes an interactive concept-mapping facility, which provides an overview of the conceptual structure of the data set that assists the researcher in interpretation. Concepts that co-occur often within the same two-sentence coding block “attract” one another strongly when the map is clustered, so that similar concepts tend to settle together in close proximity. Clusters of concepts are grouped by theme circles to summarise the main ideas in particular clusters. Each theme is named after the most prominent concept in that group, which is also indicated by the largest dot in the theme cluster. The stability of the map, i.e. where the concepts fall in consecutive runs of the software, can be influenced by the presence of stop words, or sets of words with similar meaning that often occur together. The only manipulation that was used Table 1

207 to improve stability was the removal of words that occurred frequently such as “page” or the name of the newspaper (see below), and merging of concepts such as waiting list and wait list. Dialogue tagging was used first to tag the newspapers involved (Table 1). This is normally used for interview data, but it was used here to add an extra dimension to the results, that is being able to see which newspaper source “spoke” most commonly about which theme. It was necessary to format the Factiva reports prior to analysis in order to achieve this. In particular newspaper name had to come before title to enable it to be the first part of the paragraph for tagging “The” had to be removed from newspaper titles as this is a stop word, all newspaper titles had to end with colon space. Some newspaper titles such as Times and Guardian had to be changed to Times1 and Guardian1 when used as a “speaker” as they also have meaning within the text. The objective of the Leximancer analysis was to confirm the presence or otherwise of stories relating to the CSFs identified from the academic literature. Figure 3 is annotated to relate those themes to the themes in the newspapers. Political issues can be identified under two headings; the conflict between the NHS and the cabinet, where NHS professional bodies disagree with health reform, and public spending. Having completed the Leximancer analysis the stories were then manually categorised according to (a) the Cynefin framework, and (b) the dominant CSF of the subset of CSFs identified in the Leximancer analysis, namely; security/ privacy/consent, human resources, NHS vs. cabinet, health record centralisation, public spending; contracts/mergers/ procurement; evaluation, (see Figures 1 and 3). In order to classify the stories the four narratives that best exemplified the four extreme states of the framework were placed in the four extreme corners of a whiteboard the remaining stories were then placed where they best fit in the field. As a result some narratives clearly lay within each domain and some others were on a transition zone. Of the 584 stories identified, many remained in the central area ‘disorder’. Figure 4 illustrates this process with a subset of twenty two stories from the dataset. These twenty two narratives are set out in Appendix 1 showing their Cynefin classification, CSF and relevant quote. Cynefin analysis is useful when examining the gaps between how researchers see the systems and how the news media framed problems and issues. One of the reasons health IT projects often fail is that they implement isolated systems which assume that data driven clinical care can be treated as a simple domain problem [53]. Examining the results through the lens of a sense making framework such as Cynefin allows us to suggest reasons for IT failure outside a pure system view exploring communication, and other human factors. The Cynefin framework is often used as a conventional management matrix for categorising issues and strategies.

Newspapers and counts.

Source

Count

Source

Count

Source

Count

Guardian Times The Daily Telegraph

321 118 57

Financial Times The Observer The Independent

23 16 16

The Sun Daily Mail The Express Total

7 16 10 584

208

S. Cockcroft

Figure 3

Leximancer output showing major themes, and locating contributions of news sources via speaker tags.

Whilst categorising is useful, Cynefin has the potential to provide a less static and more nuanced analysis, acknowledging for example that different aspects of a project may reflect different domains at different stages. Identifying the transitions between domains and being able to develop recognise and manage them is the key to understanding the power of the method.

Results One difficulty in using Cynefin to write up a research project is that the social process and discussion used in assigning narratives to the framework is lost and there is a risk of it being interpreted as a 2n2 categorisation. This difficulty is overcome, in part, by the use of the whiteboard method described above which mimics a social process of identifying a

story, making a judgement about its proximity to other stories, and placing it in the framework. This process is captured in Figure 4 which shows a sample of the Newspaper Stories classified by Cynefin Domain. Figure 5 shows the migration of issues over time. This migration is illustrated via a count of the number of stories by CSF over time as the project proceeded with the different newspapers being shown with different patterns according to a key. Referring to Figure 5, some papers focussed most of their attention on public spending issues throughout the life of the programme. This was prevalent in the tabloids The Sun, Daily Mail and The Express but also the Telegraph. The Guardian which was most represented in the sample saw a migration of focus from discussions of procurement and contractual issues in the early days of the programme, and feature articles describing the aims of the system through the many pitfalls and ending with more evaluative commentary for example.

National health IT infrastructure through the media lens

209

Figure 4 Whiteboard method of classifying stories.

Figure 5

Migration of issues discussed in Newspaper stories.

This evolution of focus was also evident in the Observer and the Times [54]. Referring to Figure 4 it will be noted that most of the “known” stories occurred as the planning, analysis and design phases were completed. As the project progressed and hit problems, more complex and chaotic stories were reported.

Known Early on in the programme there were a number of optimistic stories describing imminent system development efforts giving details of how these systems would be developed and installed, often these stories were based on A priori implementations or pilot studies. According to the Cynefin framework such apparently straight forward projects would be classified as simple or known. One of the few stories that described a simple or known

situation was that of the success of a system, built by CSC in alliance with Hedra, a change management organisation, and iSOFT. The system was designed to maximise the efficiency of operating rooms at the Royal Liverpool and Broadgreen University Hospitals Trust by ensuring that the best possible use is made of available staff and theatre time. In addition document retrieval systems that are working in a number of sites were described. Additionally, prescribing systems were working in many places these were described by the Guardian in 2005 (see appendix 1).

Knowable During the course of the programme there were a number of cautionary stories outlining the challenges before an implementation could occur such as standards, privacy requirements

210 or interoperability. These stories are classified as Knowable. In knowable situations the issues outlined could be solved by recourse to prior solutions or, as Cynefin proponents describe them, “heuristics”. Heuristics are essentially more general, rule of thumb, approaches. The most challenging amongst such stories were those with considerable human conflict. There were a plethora of single issue stories at this knowable level regarding privacy such as hospital orderlies gaining access to records, lack of control for patients (consent) concern about what the system is to do, and bungled issues such as letters inviting patients for flu jabs before the vaccine was approved. Whilst these issues are uppermost in the public consciousness, solutions do exist for them. It would be more appropriate to define them as chaotic where they occur without prior notice and action is demanded first.

S. Cockcroft

Complex Probe, Sense, Respond Pattern Recognition INFORMAL Interdependent Human conflict, Resignations

Lost Records, Accounting Irregularities UNCHARTERED Innovation Turbulent and unconnected Act, Sense, Respond

Chaos

Figure 6

Knowable Sense and Respond Analytical/Reductionist PROFESSIONAL Logical Challenges around Standards, Privacy Interoperability

Probe, Sense, Respond Pattern Recognition Bureaucratic Structured Legitimate best practice Categorise and respond

Known

NPfIT issues in Cynefin framework (adapted from [13]).

Complex and chaotic In terms of the Chaotic and complex quadrants defined in the Cynefin framework, a large number of stories related to human resource crises where a key player resigned or pulled the plug on a key project. These were classified as complex and occasionally chaotic where the future of the entire project was at stake. Almost from the start of the project the newspapers describe an uncertain future for the NPfIT system. Much of this uncertainty derives from the scale and centralisation of the project. Stories appeared in two major areas, criticism of the NPfIT project as a whole, and descriptions of contract issues surrounding the major providers iSOFT, Accenture, BT, CSC, System C and Fujitsu. There was some concern that IT providers were being overpaid, and many stories of loss of faith in the key provider iSOFT. As the level increases to complex we find more stories of shock resignations, blocking of takeover bids. In 2008 many stories emerged from issues arising from the National Audit office (NAO) report of May that year, such as consent, confidentiality, and the confidence of doctors in the system. That lack of confidence is indicative of tensions between clinicians and managers identified in [24]. Further, in 2006 newspapers focussed on a report by 23 computer academics highlighting problems with the system, including a lack of focused management. Unfavourable comparisons were made to other European countries specifically Sweden with its mature level of e-government in 2004. At the chaotic level were stories of lost records, MPs condemning the 12 million network upgrade, iSOFT suspending one of its co-founders Steve Graham, and of an accounting irregularity within iSOFT. The level of opt-in or opt-out provided by default raised some interest as did the related issue of the damaging effects on epidemiological research of stringent privacy and consent laws. The “sealed envelope” and the possibility of overriding consent in an emergency were of interest, and finally some concern was expressed over storage of genetic information in shared database systems. Stories in the non-tabloid British press followed the project from its initial optimism, continuing on to echoing the difficulties the UK government has had in procurement and specific issues encountered with and by IT providers. In the tabloid press there are odious comparisons made between government spending and how many nurses could have been employed or how many new hospitals could

have been built. The position of these stories in the Cynefin framework is illustrated in Figure 6. (Note Sturmberg [23] originally placed medical knowledge in this framework, we place NPfIT issues therein.)

Limitations As foreshadowed at the start of the paper. The dual motives of newspapers to inform, and to sell papers is a limitation of this work. Undoubtedly, the British Press have political allegiances. The Guardian for example is a left leaning paper and was for a large part of the period surveyed tacitly backing the labour government who had established NPfIT. As professional commentators the news media do not espouse objectivity because it conflicts with the professional mandate of the search for truth. At best they strive for neutrality, but this runs the risk of presenting as “spineless” or “wishy washy” reporting.

Discussion As many authors have observed before, in complex health systems there is not a clear relationship between cause and effect [23]. Information Technology is no exception. The importance of organisational factors in evaluating the success of information systems projects is accepted. Of the themes identified in Figure 1 project management and political factors are paramount in the print media. Communications, use/ usability by end users, transparency of design [30] and change management [30] were not explicitly discussed. This is probably because they are less transparent, and are native to each part of the project in a project management sense. These issues did not make it into the public arena. None the less, the press has performed an evaluation at the national level. In terms of the role the press took it was balanced between informer/framer by the broadsheet papers who would set out the issues and update the status of the project and informer/persuader in the tabloids the thirty three (33) stories that emerged from the tabloids were heavily weighted toward public spending e.g. “They spend We Pay”—The Express 13 July, 2007 or security e.g. “Fear over NHS files” The Sun Jan 27, 2009. The “evaluation” lagged behind the academic commentators on NPfIT who, as early as 2006, were stressing the need for putting the patient

National health IT infrastructure through the media lens

Table A1. Chaos

Sample Newspaper stories from each cynefin quadrant Political: public spending

Chaos

Consent/privacy/ security

Chaos

Political: public spending

Chaos

Contracts/mergers/ procurement

Chaos

Consent/privacy/ security

Chaos

Political: public spending

Complex

Political human resources

Complex

Socio-technical

Complex

Socio-technical

Complex

Evaluation

Complex

Evaluation

Daily Mail, 31 Jan, 2006—shortfall warning sends Isoft tumbling. The value of iSoft almost halved after the health software firm issued a profits warning because it expects a d55m shortfall in full-year revenues after delays to the NHS's computer upgrade. Guardian, 9 July, 2009—NHS computer programme is five years behind schedule. At some point last November, an infection began to spread unnoticed through the three hospitals that make up Barts and The London NHS Trust in East London. This was not MRSA but the Mytob worm, a common but potent computer virus. It steadily slowed and choked the 4700 PCs of the trust's network. By noon on 17 November, a Monday, the network was effectively crippled. The Times, 17 Dec, 2012—hospitals offered cash to take ‘cowboy’ IT systems. Hospitals are being offered cash incentives to install a computer system at the centre of the disastrous health service IT programme in a deal MPs described as bribery and “mindboggling waste”. An American company, last year branded “cowboys” by the head of the Public Accounts Committee, says it will pay local hospitals millions of pounds in signingon fees to use the software because the company itself will be paid through a central NHS fund. Times, 21 July, 2006—Isoft reveals accounting irregularity fears. Isoft plunged into further chaos on thursday night when its new auditors told the struggling healthcare software group of possible accounting irregularities in its revenues during previous financial years. Isoft said it had commissioned an investigation into the possible irregularities, which affect the financial years prior to and including April 30, 2005. Guardian, 9 July, 2009—five years behind schedule. At some point last November, an infection began to spread unnoticed through the three hospitals that make up Barts and The London NHS Trust in east London. This was not MRSA but the Mytob worm, a common but potent computer virus. It steadily slowed and choked the 4700 PCs of the trust's network. By noon on 17 November, a monday, the network was effectively crippled. Times, 6 April, 2004—email failure to cost pounds 11 million. THE NHS faces a legal bill of about pounds 11 million after it decided to terminate a massive project to provide e-mail services for all its staff. The ten-year, pounds 90 million deal with electronic data systems was ditched amid worries over low take-up—only about 6.5% of staff chose to use the service—and problems with the way it worked and the speed with which it was introduced. The Guardian, 28 April, 2005—the going got tougher with resignation. Connecting for health, the agency responsible for the national programme, said on Tuesday that London's chief information officer, David Kwo, had resigned. Kwo had been suspended from duty since April 14 “to enable proper investigations into a serious allegation”. The Guardian, 15 March, 2007—fitter healthier more productive. Electronic medical records at Hyde and Portsmouth may be achieving what the national programme, conceived five years ago this spring, is setting out to do. But they are independent efforts, happening not because of the national effort but almost despite it. While Hannan and Smith and other pioneers dotted around the country have patients' full clinical details available at the touch of a button, the much-vaunted NHS programme is only now about to start loading basic clinical details on to the care records “spine”. The Times, 8 December, 2011—project blighted from the start by bad decisions; importing system from US was the first in series of wrong moves. Matthew Swindells, who briefly ran the programme after Mr. Granger and now works for Cerner, said: “when you bring an American system into the UK it is a big job to make it fit. The billing system is completely different, the reporting system is completely different”. Daily Mail, 10 October, 2006—experts warn NHS computer system may be d20bn flop. The d20billion NHS computer system may not work, Britain's leading computer scientists warned last night. The experts called for an urgent enquiry into the crisis—hit scheme— the biggest civilian IT project in the world Guardian, 5 September, 2006—spending watchdog reopens enquiry. Since June, a catalogue of problems linked to the NPfIT have emerged. The Guardian revealed last month that two of the NHS's lead contractors had serious concerns about next-generation software, called Lorenzo, earmarked for 60% of England's GP practices and hospitals, which was being developed by the financially stretched firm iSoft. The lead contractors Accenture and CSC had concluded in February that Lorenzo had “no believable plan for releases”. The Guardian also revealed that the Financial Services Authority was

211

212

S. Cockcroft Table A1. (continued )

Disorder

Privacy consent

Disorder

Contracts mergers procurement

Knowable Evaluation

Knowable Evaluation

Knowable Evaluation

Knowable Socio-technical

Known

Health record centralisation

Known

Health record centralisation

investigating past accounting irregularities at iSoft, which had suspended its co-founder Steven Graham. Telegraph, 24 December, 2007—data loss crisis spreads. The medical records of hundreds of thousands of patients have gone missing from nine NHS trusts, the Government admitted yesterday. The Department of Health said last night that it thought the lost data fiasco involved a total of 168,000 patients. They include the loss of data on 160,000 children, after City and Hackney Primary Care Trust reported that a disc failed to arrive at St Leonard's Hospital, east London. Hospitals around the country admitted to security breaches as part of an investigation into data protection in all areas of public life, triggered by the loss of 25 million child benefit records by HM Revenue and Customs Guardian, 5 June, 2007—isoft takes legal action after take over blocked takeover bid. ISoft has begun legal action against its largest customer after it refused to give its consent to a takeover bid from the Australian software firm IBA Health. In the latest twist in its attempt to secure its financial future, the Manchester-based software company claimed that Computer Sciences Corporation (CSC) had been working on its own offer for months. The Times, 23 September, 2011—connecting to nowhere; technology investment could spur economic growth. The Cabinet Office's major projects group has reviewed the National Programme for IT and decided, unequivocally, that it is not fit to provide the services that the NHS needs. Daily Mail, 23 September, 2011—NHS chiefs welcome axing of IT system. Plans to dismantle Labour's disastrous d12.7billion NHS computer scheme have been warmly welcomed by hospitals. The Daily Mail revealed yesterday that the Department of Health was scrapping the National Programme. Guardian, 26 May, 2004. Its official Swedes e-services are best in Europe. in an almost comic contrast with the NHS's pounds 6bn national programme for IT, the Swedish electronic IT project is being steered by an agency with a dozen employees and an annual budget of about pounds 200,000. Carelink, half-funded by central government and half by county councils, plans to create shared electronic health records based on extracts from hospital systems by the end of 2005. Mats Larson, the agency's director, says the link will cost each county an average of pounds 70,000. Electronic prescribing is another priority. About one quarter of prescriptions are sent electronically by doctors to the state pharmacy monopoly, Apotek. Other moves are on the way to install the final links in Sweden's e-administration. One advantage that Swedish officials have over their British counterparts is that sharing personal data by public agencies is both accepted and technically feasible. Sweden has had a central population register since 1580, which was computerised in the 1960s. Guardian, 26 October, 2006—operation choice e-bookings help patients select a hospital. Peter Christian, a GP in north London, takes a patient through the Choose and book system photograph: David Rose of all the IT-underpinned transformations in public services being driven by the government, few are as big or controversial as NHS choose and book. The idea—at the heart of Tony Blair's NHS reforms—is for patients to be able to choose which hospital their GP refers them to for an operation or tests. The technology to make this work is the first major implementation of the world's largest civil IT effort, the pounds 6bn NHS national programme for IT. Guardian, 16 March, 2005—paperless prescriptions. Doctors and pharmacies in the north-east of England have begun handling prescriptions electronically to cut costs and reduce the risk of errors and fraud. In the scheme, part of the pounds 6 bn NHS national programme for IT, patients collect a “token” from their doctor rather than a written prescription. Their pharmacist then uses this to download the prescription from the NHS data spine. Electronic transmission of prescriptions is due to be available across the NHS by the end of 2007. Times, 21 March, 2006—computer operations signal end of paper chase. Sloman says that giving people a choice of where they have their operation is only the first step in a revolution underpinned by the technology. Systems to support choose and book can also help managers get a better grip on what their organisations are actually doing, in real time. This is a breakthrough for the NHS, which has always had to react to surges in demand rather than being able to plan for them. More immediately, electronic booking means more efficient day-to-day running of the hospital. “One of the things that drives people mad is chasing paper,” says Sloman.

National health IT infrastructure through the media lens

213

Table A1. (continued )

Known

Socio technical

Known

Health record centralisation

Known

Health record centralisation

Guardian, 14 June, 2003—the foundations are in place now start building. Here are three simple steps for reviving enthusiasm for the programme. Step one: immediately abandon the pigheaded stance that patients should be assumed to have given consent for their electronic records to be shared across the NHS unless they say otherwise. Insistence on “opt out” rather than “opt in” may upset only a minority of patients, but it is at odds with the spirit of patient empowerment that is supposed to be driving NHS policy. Step two: admit defeat in the footslogging and wasteful campaign to replace basic hospital administrative systems with standard packages procured nationally through the infamous billion-pound “local service provider” contracts. Step three: find islands of excellence and build on them. Because, alongside (and in some cases despite) the national programme, the NHS has some brilliant local initiatives in which IT is transforming the whole practice of healthcare. Guardian, 03 April, 2003—Britain's doctors are about to announce a breakthrough. They have agreed on what information should go into our online medical records. The decision could change the face of healthcare. The basic idea, set out by the prime minister nearly five years ago, is that if you live in Manchester but happen to get run over by a bus in Torquay, emergency crews should have access to your medical records. Such information could be a life-saver, especially if you are on medication or are allergic to antibiotics. The Guardian, 24 July, 2003—Life—inside IT—sauce for the goose—the success of NHS Direct shows that government IT projects can work. But with public projects set to get even bigger, the private sector must pull its weight as well, writes Michael Cross.

and clinician before bureaucracy [30], considering the interrupt driven nature of work [33]. These type of issues emerged in the print media from 2007 onward. In the immediate aftermath in 2011 when a number of evaluation/review articles appeared, for example [55]. It is notable that the news media does not emphasise topics thought to be key in the health IS research, namely communication and usability issues. Socio-technical issues most did not emerge until late in the project. This shortcoming could be interpreted as the press making a judgement that these issues would not be of interest. Cynefin has the potential to provide such explanations of the tacit evaluations performed by the news media by taking a broader view than the classic IT evaluation approaches. Clearly the known and knowable strategies conform more directly to existing research models and directions such as system development methodologies. This is understandable since the appropriate reaction on identifying a known or knowable situation is to deploy a tried and tested algorithm, or employ an expert. An interesting boundary is the knowable-complex boundary where human factors, use, and usability come into play. An interesting example of a probe-sense-respond (complex) type narrative was the Guardian 2007 story of individual trusts taking information system development matters into their own hands and outperforming the NPfIT. Stories which challenged the NPfIT leadership by presenting a complex or chaotic situations are well documented by the print media and present a potential richness for research in particular situations where cause and effect are only coherent in retrospect and are not repeatable, or where no cause and effect relationships are perceivable. The contribution of this work is first, the application of automated text analysis to a large textual data set in the area of health information systems policy. It contributes to the body of knowledge in that area. The second contribution

is the use of the Cynefin framework to expand on existing work sense making [40] in health organisations.

Further work Further work could broaden the sample frame to include trade journals from the health and IT sectors. It might be informative to look at the themes emerging from the level of individual journalists as well as newspapers. It would be of interest to see if the newspaper articles which clearly follow the chronology of the programme also showed evidence of learning and development of ideas.

Ethical approval Not required.

Funding None.

Competing interests None declared.

Appendix A See Table A1.

214

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