A chara, – Nearly 20 years ago I was asked to review the implementation of a digital patient record system at a major general hospital in Ireland. The chief executive couldn’t believe the number of problems being encountered with the new system and wanted an independent evaluation of where the primary problem lay. The IT department was blaming the software supplier, the software supplier was blaming the IT department, and everybody was blaming “the system”.
After an exhaustive review it became clear that the software simply didn’t live up to the extravagant claims made for it by the software suppliers’ sales and marketing staff. It worked superbly in sales presentations, but less so in reality. Over 600 “bugs” were identified in testing, and these were to be fixed in subsequent releases. Unfortunately, most remained unfixed for many releases and some even reappeared having allegedly been fixed.
Every time a new release was installed, it required another round of testing by staff who already had a full day’s work to do. It was utterly demoralising for them to have to retest software they had already tested several times only to find many bugs unfixed and some new appearing or even some previously fixed bugs reappearing. A lot of expensive administrative and clinical time was wasted.
In the meantime, paper records had to continue being used in parallel with the digital system, and these files were often duplicated or lost somewhere in the system. Patients on trollies waiting to be admitted could be “lost” altogether to the system as the emergency department had finished with them, but their details had not yet been entered into the in-patient system. The handwriting was frequently illegible. Tests results from prior admissions or consultations weren’t always available or appended to the file.
If this was the situation in a relatively large and advanced general hospital, you can imagine the situation in the country at large. It was clear to me that rather than each hospital trying to implement a different system from a different supplier, there needed to be a single national system with standard functionality selected and mandated for all hospitals and related specialisms and services, and this needed to be installed and tested once in one hospital for the benefit of all having previously been exhaustively evaluated and tested by IT and clinical specialists.
My brief ended at that point, but it appears that no one within the HSE was prepared to take on the responsibility for the selection, testing and implementation of a nationwide system. It was left to local hospitals and specialisms to plough their own furrows who were then naturally reluctant to trade the familiarity of their own systems for an unknown new system, centrally imposed.
Migrating from an old to a new system is always a painful process, as both have to be run in parallel until all problems are ironed out.
A culture of avoiding responsibility for difficult tasks appears to pervade every level of management in our public service. It is always easier to soldier on with old systems and avoid confrontations with staff who have gotten used to doing things in a particular way. There are no rewards for outstanding achievements and no consequences for failures which are always carefully defined as collective rather than the responsibility of particular managers.
Staff become frustrated, disillusioned and cynical. Costs skyrocket as examinations and tests are duplicated. Diagnoses and treatments are delayed. Clinicians have to make judgement calls with incomplete information. Management layers multiply to no discernible patient benefit. Best practice in systems in use elsewhere in the world are ignored. No wonder the best staff leave. This is not a process that can be managed by politicians. Nothing will change until our public service management culture of avoiding responsibility for difficult tasks is changed, and changed utterly. – Is mise,