The drive to convert paper-based data into digital has rapidly increased from the visible benefits it brings to service providers, users and recipients, writes Naveen Madhavan PhD MBA MBCS, Senior Product Specialist (Pathology) at the NHS Wales Informatics Service.

Digitisation has transformed even healthcare with the efficiencies of processing data to facilitate coordinated care. But, while digitisation provides the fundamental building blocks for technological progress, its true value is in its adoption, applicability and user experience. In other words, digitisation cannot overlook the human factor at any stage.

The digital revolution

Since the first digital message was sent by Ray Tomlinson in 1971 and the first internet browser developed in 1990, the increase and accessibility of online data has tipped the economic balance from what was primarily a product-driven paradigm to an expanding service-driven economy. Products primarily manufactured on a factory floor and later marketed to customers, are now backed up by services that are created in the presence of the customer.

The resource focus has altered from raw materials for physical goods to an urgent and growing need for digital knowledge and skills to provide services. At the same time, customer awareness and expectations have increased, fuelled by easily available service information and service quality reviews.

Healthcare in Wales

In its 72nd anniversary, the NHS faces increasing pressures from successful treatments, an ageing population and resource allocation. The urgency to meet demand has stressed the need for improvements in productivity and patient outcomes.

Digitisation has made the difference by enabling the capture, update, re-use, presentation and sharing of data between clinicians or locations. It has acted as a catalyst to meet new demand and continues to influence this demand, which inadvertently initiates the need for even further change. However, healthcare still trails behind other sectors in fully harnessing the benefits of digitisation.

The Welsh government set an aspiration to capture information electronically, use the data collaboratively for treatment, use technology routinely in all care settings and use health information to understand treatment outcomes. The principles of ‘Prudent Healthcare’, ‘Once for Wales’ and a whole system approach now form part of informatics strategies to induce joint, flexible and innovative national healthcare solutions.

One such initiative is the Welsh Clinical Portal: a clinical information system developed in 2009 through a collaborative effort by informaticians from the NHS Wales Informatics Service and clinicians, to integrate multiple data streams into a single web-based information system. This digital platform used in secondary care by over 20,000 clinicians now provides a single access point to patient information, allowing users to access any patient record in Wales from any secondary care location to:

  1. update patient records
  2. view GP records
  3. request pathology tests
  4. view pathology / radiology results
  5. maintain clinical documents
  6. maintain clinical notes
  7. share discharge letters with primary care

Coproduction

Two reasons for project failure have been repeatedly identified as: 1) an overly centralised approach by providers and 2) a limited understanding of user requirements. Elinor Ostrom conceptualised coproduction in the 1970s from observations of combined efforts by the police force with the local community in the US to reduce crime. The concept gained renewed interest in the late 1990s and now forms an integral part of service improvement strategies for health and social care in Europe, Asia and North America.

Yet coproduction that primarily centres on provider-user engagement isn’t without its challenges, such as achieving a consensus on new functionality; translating requirements into design; ensuring compatibility with local processes and controlling scope creep. As system adoption plays a significant role in justifying digitisation, providers now reverse-engineer user requirements to plan and prioritise various system iterations.

Culture

Digitisation is complex, as people are complex in terms of their bias, recall and tolerances. The cultural influences on digitisation are not easily apparent and seldom discussed. Where there are groups of people, a culture emerges. Culture is ubiquitous - influencing attitude, behaviour, actions and decisions. From family units to organisations, cultural influences vary between different locations within the same organisation; different teams on different floors and different teams on the same open space.

User requirements are inherently complex to document, which becomes even more challenging for national systems when a consensus is needed between multiple organisations on behalf of the larger user base. Discussions on digitisation are traditionally attended by senior managers, who use and understand the information system under discussion far less than their junior counterparts.

Final decisions are more likely to veer in the favour of stronger-minded participants in the room, motivated by authority, while the rest of the group adopt the easier route by conceding on a final decision for the sake of project completion. There are also moderating and mediating factors on system decisions from those enablers who are open to new systems or functionality and the blockers who are reluctant to give up the familiarity or convenience of legacy systems with a silently growing list of data vulnerabilities.

User experiences of digitisation are varied on events pertaining to success or failure. Experiences of failure are easily evoked above positive events that are expected as the norm and therefore, easily forgotten. Digital compatibility with local processes can pose a challenge where workflows differ between organisations and even different locations within the same organisation. Hospital staff working in the same room, using the same system, doing the same job, following the same process, regularly admit to carrying out tasks slightly differently to their colleagues.

Providers have to determine whether new system change requests are essential or nice-to-haves as they contend with challenges such as untangling legacy spaghetti code to rewrite these for new requirements. What was considered as a logical design at initial review is quite likely to go through several iterations to satisfy a decision point, before finalised requirements begin to alter, once again, to meet the changing demand landscape. In the final analysis, where consensus eludes, the provider ‘makes a call’ to select items by priority for the next round of digitisation.

Value

The availability of ‘big data’ has facilitated analysis and insight to inform strategy since the 1990s, but there is a rapidly increasing resonance and appeal for current information or breaking news. This is even more emphasised in healthcare where real-time clinical information is arguably of higher value to deliver critical diagnosis and treatment.

At the same time, it is intrinsically difficult to place a value on digitisation on its own without an evaluation of the systems that host, process and present it. Conversely, it's fair to assert that the value of an information system alludes to the value of the digitised content within it.

As such, a recent study draws on a literature review, qualitative data and quantitative data to identify the value of an information system. Users at different hospitals identified value-related aspects of the information system that they ranked by importance (in descending order):

  1. process (the system works with local workflow processes)
  2. safety (the integrity and security of data are ensured)
  3. accuracy (the data is legible, error-free and verifiable)
  4. accessibility (there are multiple access points and login is easy)
  5. consistency (the screens, buttons and data-format are standardised)
  6. relevance (the data displayed is appropriate to tasks)
  7. intuition (mouse-clicks, scrolling and navigation on screens are minimal)
  8. integration (the system facilitates interoperability)
  9. communication (the system has alerting, notification and messaging capability)
  10. availability (the system is always useable on demand)
  11. dependability (the system does not freeze or crash) 
  12. speed (data retrieval is quick)
  13. differentiation (all necessary data is available under a single login)
  14. support (incidents are resolved within agreed timescales)

A digitisation project that is completed within timescales and budget does not necessarily imply its success. The value of digitisation is extrinsic in the sense that its reward primarily manifests in a successive outcome. Alternatively, it can be argued that this success is more appropriately assessed by those who ultimately utilise the digitised data in an information system’s context. It is this value derived from experiential use where digitisation efforts would derive its purpose and motivation.

About the author

Naveen Madhavan PhD MBA MBCS is a Senior Product Specialist (Pathology) at the NHS Wales Informatics Service. His doctorate explores the value of clinical information systems and he is a guest lecturer to doctorate and master’s degrees programmes at the University of South Wales, UK.

Further reading

  • Academy of Medical Royal Colleges, 2013, i-care: Information, Communication and Technology in the NHS.
  • Maguire, D., Evans, H., Honeyman, M. and Omojomolo, D., 2018, The Kings Fund: Digital Change in Health and Social Care.
  • Schwartz, S. H., 1992, Universals in the Content and Structure of Values: Theoretical Advances and Empirical Tests in 20 Countries.
  • Welsh Government, 2015, Informed Health and Care: A Digital Health and Social Care Strategy for Wales.