BMJ 2013;347:f6911 doi: 10.1136/bmj.f6911 (Published 18 November 2013)

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NEWS If at first you don’t succeed with IT, keep trying, conference is told Nigel Hawkes London

The NHS will need to transform the way it uses information technology if it is to improve quality and reduce costs, delegates at the King’s Fund annual conference heard on 13 November.

sparingly on the basis of mutual trust. “Patients want better IT, but only through a personal doctor,” he said.

Bill Wright, executive medical director of Colorado Permanente (a branch of California-based Kaiser Permanente) which provides healthcare to half a million people in the Rocky Mountain state, said that the success of its electronic health records system had followed a “painful” failure to co-develop such a system with IBM.

But accessing appointments through the 8 am call was difficult. “How many people fail to get through and finally say, ‘forget it, I’ll be all right,’?” she asked rhetorically. As for electronic care records, “the difficulty we have is that we’ve failed for ten years,” creating an environment in which she doubted whether some clinicians would ever be willing to tear up their paper records.

The costly failure of Connecting for Health, which promised much but delivered little, should not discourage a fresh attempt: others have failed equally catastrophically but gone on to deliver successful systems.

And Brent James, chief quality officer of Intermountain Healthcare, which runs 22 hospitals in Utah, said that his organisation had failed twice before achieving success, failures that had cost two vice presidents their jobs—“good men,” he added. Wright agreed with the suggestion from Chris Ham, chief executive of the King’s Fund, that Kaiser had “bet the farm” to develop its paperless care records system—but it had been a wise decision. “We wouldn’t go back,” he said, though he remembered people crying as the trucks turned up to take all their paper records away. The key to success was not simply better record keeping, but the use of the tool to redesign care—without that the system would achieve little, he said, highlighting the equation OO+NT=COO (old organisations plus new technology equals costly old organisations).

There are many places where an electronic records system can help create better care, Wright said, not least in enabling patients to access their records, make appointments, email their doctors, get laboratory results, and reorder prescriptions. It had led to better relations between patients and their physicians—“patients can ‘own’ their own healthcare as they couldn’t before”—and it improved the care of chronic conditions, said nine of 10 patients surveyed. “It looks as if it reduces care downstream, with fewer emergency room attendances and specialist referrals, but while it cements relationships with primary care it doesn’t reduce the load there,” he said. Doctors had feared they would be swamped with emails but, with the exception of a few, most patients used the system

Beverley Bryant, director of systems strategy and technology at NHS England, said that it was going to take “a leap of faith” to implement an online appointments system in primary care, even though IT systems in primary care in the NHS were very good—among the best in the world.

James, who gave his presentation online from Salt Lake City, said that Intermountain’s first efforts had failed because of data shortages. “We thought we had a very rich data environment,” he said, “but we were missing 30-50% of the critical data, so we began to collect it and it transformed the situation.”

Intermountain has used the data to investigate variations between units and individual doctors, with some surprising results. In surgery to remove the prostate, for example, they found that some surgeons completed the operation in as little as 38 minutes while others took as long as 90 minutes, and the amounts of tissue removed varied threefold, from 13 g to 42 g. “The longer you take, the less tissue you remove,” he said. “The cost varied by a factor of two, and there were striking differences in outcome. People were shocked.” The data were put to use in designing an advanced training programme, which had become a mainstay at Intermountain, with all doctors having to graduate from it. The aim was to improve frontline work and change the culture, with the changes paying their own way.

“Most often, better care is cheaper care,” he said. “But you need a shared vision, and that comes from the training programme. While you never get 100% compliance, when professionals realise they are different from colleagues their behaviour changes. Our training systems show why change makes sense in professional terms, and it renews professional faith.” Could the NHS do it? James could see no reason why not. Cite this as: BMJ 2013;347:f6911 © BMJ Publishing Group Ltd 2013

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BMJ 2013;347:f6911 doi: 10.1136/bmj.f6911 (Published 18 November 2013)

Page 2 of 2

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If at first you don't succeed with IT, keep trying, conference is told.

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