The digital age is transforming our world. As Keeler wrote, a twelve-year-old can now hit speed dial on the telephone to automatically order her 'usual' pizza (or curry) for delivery. The pizza parlour's computer recognises her phone number and is able to obtain her name, address, and all orders placed within the last three months. In most rent-a-car or airline companies, the customer's name and account number allows employees to access billing information and their preference instantly. Yet today, at the beginning of a new millennium, healthcare's reluctance to truly embrace the power of computer technology is failing to remedy long-standing major shortcomings in how care is delivered and health is maintained.

Further day to day examples of the power of automation include:

• Use of ATM machines for the majority of personal banking needs at home and overseas
• Purchase of fuel from fully automated pumps
• Bar coding that instantly registers price, updates stock levels, and records personal buying patterns
• Hand-held devices that constantly monitor the locations of parcels world-wide
• Internet connectivity for shopping, educational, business and communications
• Office networks and robotics transforming the workplace and productivity

Although modern society has adapted to the above innovations in other industries, healthcare continues to lag behind:

• The overwhelming majority of computers in healthcare are for simple accounting and statistical reporting purposes
• Due to the lack of adequate support systems, most clinicians continue to practice 'memory-based medicine' with explicably wide variances in diagnosis, treatments and outcomes
• Almost no attempt is made to collate the documented historical personal information on family/personal health history combined with genetic make-up and lifestyle, or in order to create a risk assessment to possibly predict and prevent disease.

A nationally recognised American consultant recently articulated a compelling lament about healthcare's current state as it relates to the use of computer technology. She remarked: 'It is a travesty that a grocery shop assistant has more power in his or her hand performing inventory than I am given in seeing my patients'.

As reported by Skinner, much has been written about deriving business value from computer technology investments in industry. One would think the process, metrics, and leadership required are well understood and widely practised now. However, in healthcare that does not seem to be the case. Departmental managers, clinicians, and senior executives little understand or believe in the value of computers in healthcare. By most accounts, despite their ready acceptance of enormous information technology-based changes in their daily lives, they find the prospect of such successful innovation in healthcare almost impossible to envisage. Healthcare may have a wonderful opportunity because of the size of the potential improvement but it also faces severe challenges to harness computer technology. Not the least of these, it seems, is first to persuade its own staff that technology can help patients and improve the way they work.

Healthcare is slowly attempting to follow the path blazed by other industries in realising the benefits of computer investments. Many technologies within departments such as ICU or of PACs are often quickly adopted. However, healthcare is at least ten years behind most other industries in knowing how to significantly redesign its business and clinical practices to optimise the use of technology across departments and services.

Why is healthcare lagging behind?

The first barrier to achieving value from healthcare computer investments is simply the complexity of the organisation and its wide variety of legacy systems. It is quite common to find midsize healthcare organisations with a collection of hundreds of computer systems, each supporting a different business unit and most sharing little to no information with the others. Experience suggests that if the investment requires integration of information and processes across these systems and business units in order to be cost-effective, then re-organising processes, changing responsibilities, re-training large numbers of staff, and finding additional funding can be an incredibly complex undertaking.

A further complication is that, as Skinner and others have pointed out, healthcare does not have the standards in place that other industries do. Such immaturity means that vocabulary standards, transaction standards and performance metrics still vary, as does the practice of medicine itself with few standard processes.

The result of this combination of these variables is that it is particularly difficult to automate healthcare efficiently. The language used in financial services, transportation, retail and other industries has allowed the design and imposition of standard processes and the application of metrics to measure and govern those processes. The threat of competition has also allowed a calculation on the likely return on investment. In healthcare, however, each organisation still speaks its own dialect and it is an industry where co-operation, not competition, is the norm.

Healthcare investments in computer technology have not traditionally been made in support of core business (ie clinical) processes. Ancillary departments such as laboratory, radiology, pharmacy and admissions have long been automated, but nursing units, clinics, and surgical services are only recently beginning to use computers to support patient care directly. Even in the support departments, in many if not most cases, computers are used for scheduling, inventory management and other tasks that support the core work of the department but do not actually change that work. Therefore, while laboratory technicians no longer manually perform many tests - which are automated - high volume, large scale laboratory consolidation, totally automated order entry or distribution of the results is not common practice. In radiology, film has been increasingly eliminated by using PACs, but interpretations still are not being made offsite or around the clock to optimise costs.

The promise of computer technology is in enhanced customer service, the development of new products and services, and the ability to deliver services without many of the traditional constraints. Computer technology helps eliminate many of the constraints of time and location for customers in many industries. We can bank from almost anywhere at anytime; we shop around the clock, even internationally. Yet, we can only receive information from our healthcare providers or schedule services with them during prescribed business hours.

Considering the customer service dimension, computer investments in healthcare have traditionally supported back office operations. Accounting, payroll, and materials management systems are all examples of automating the back office mostly for productivity and cost-reduction benefits. In many industries, scheduling and registration are examples of front-office functions that have been automated, with benefits from improved productivity and throughput as well as increased customer satisfaction. However, in healthcare these systems are often not implemented enterprise-wide, thus reducing the potential benefits. Imagine having to make multiple calls to multiple people using different computer systems to reserve connecting flights on the same airline. That is exactly what happens to many patients trying to make multiple appointments for different services in the same hospital.

Skinner has much sound advice:

'Increasingly, healthcare organisations are recognising that:

1. they require more and better information to support quality improvement initiatives
2. their manual processes must be replaced by automated processes to achieve the quality improvements they are seeking

The difficulty with computer systems employed to support quality improvement efforts centres around the need to achieve agreement on the data to be used, its accuracy, the rules to be used, and the processes to be changed. This agreement is difficult to achieve in a single department like the pharmacy, and it is orders of magnitude more difficult across multiple departments and disciplines, as is required for a physician order entry system or a medication administration system. Notwithstanding these difficulties, the demand for quality improvement in healthcare clearly will continue, and computers will be a major tool used to increase quality and safety.'

Computer technology provides great potential for improving the effectiveness and efficiency of healthcare processes, but it seems that, to realise this potential, processes must in general be changed (re-engineered) to take full advantage of computer technology. If reengineering does not happen, any computer system is likely to be used to reinforce the old ways of working rather than 'integrated within' a simplified new process; the result is often higher costs and failure to deliver value. Second, the computer department staff is frequently viewed as being solely responsible for delivering the required process re-engineering. Computer department staff can assist in defining how the process could be re-engineered, but it is up to the operational head of the affected area to ensure that the required changes occur. Realising benefits from computer technology must be written into the performance expectations of line managers, systems managers and physician leaders.

The way forward in capturing benefits from computer technology investment requires the recognition that such investment needs to be an integral part of a greater programme of process innovation and improvement. The success of the computer technology investment must then be directly linked with the success of that process innovation and improvement. In fact, the computer technology investment must be assessed or evaluated only as part of the process improvements - what has changed and is that change worthwhile?

Having established the process innovation and improvement element of a computer technology investment, it then follows that computer technology professionals will rarely be the most appropriate individuals to initiate or lead such projects. The principal stakeholders of computer-enabled, or even computer-driven process improvements, need to be line managers and clinicians who, at the same time, are the system's investors/users/owners. Given that one of the key factors to the success or failure of computer technology investments rests with the skill and commitment of the computer systems' principal stakeholders, that is the clinicians - a group which is still highly sceptical - they need to have evidence of the benefits presented rigorously and clearly.

As the Gartner Group advises, failure to realise value is seldom due to a tool's need for changes but to a mindset that is not motivated to work with the tool as is. Most clinicians understand this and readily adopt technology where they see direct benefits. But configuring computer tools in healthcare requires changes by a combination of people - by users and to business processes. Imagine using a chainsaw the same way as a handsaw - sawing back and forth - perfectly possible, but clearly not the best way. Or using an ATM to request that the cash be posted to you! Computer tools are no different. When the tools change, the people and the processes must adjust. Value increases when users are determined to work with the new tools, but the value decreases when the users are not motivated. The tools will never be perfect but, in this arena, an 80% solution will usually be better than the status quo.

In closing, healthcare computer investments are frequently made without redesigning the processes they are to support. To be worthwhile, computer investments should focus more on enabling more new and more efficient work and clinical processes, rather than modifying old ones. Changing processes is hard, detailed, and somewhat risky work, but it is almost always required to achieve value from computer investments. Yet, all too often, new healthcare computer systems are purposefully configured to replicate historical functions and processes. Are we now not at the point where healthcare should be concentrating on 'doing the right things' - not just 'doing things right'?

References

• Bates D & Gawande A. Improving Safety with Information Technology. New England Journal of Medicine. 348:2526-34. 2003
• Gabler J. Business Value of IT: Measuring the Value. Gartner Group Research Note 11. July 2000.
• Keeler J & Newman J. Paperless Success: The Value of E-Medical Records. HIMSS Proceedings. Vol. 2, Session 45. 2001
• Skinner R. The value of information technology in healthcare. Frontiers of Health Services Management. Vol. 19, Iss. 3. Spring 2003.