Dr Jonathan Kay, of the Oxford Radcliffe Hospital, in a study of Electronic Patient Records (EPRs) explains that, ''Many departments have chosen systems which are best of breeds, but this makes it difficult for a clinician to have one source of access to all." (CSW Health, 2003).
St Mary’s Hospital set up an information strategy group in 1990, the purpose of which was to report on the hospitals IS needs at that time. It was decided that St Mary’s needed to become independent and fully “self sufficient in information and it supporting technology” (Hackney and McBride, 2002). For this to happen it was
St Mary’s IS Strategy
“IS strategy is demand oriented, focusing on information and system requirements in meeting business objectives….. The IT strategy, on the other hand, is supply oriented and concerned with specifying the technology as to how to deliver these applications.” (Hackney et al, 2000)
Key influences
Many separate bodies had influence over the IS strategy of St Mary’s Hospital. Most important of all were the actual staff of the hospital that would be using the systems – they were represented by an in house information department which produced the various proposals. Initially the Regional Health Board had control over the allocation of funding and approval of investment in the Hospital though this later changed with the advent of NHS trusts. Project proposals were required to be submitted to each of these governing bodies for each individual project planned for St Mary’s.
National Government also had a strong influence over the development of the IS strategy of St Mary’s since white papers produced at the time of the planning (‘Working with Patients’(1989) and ‘The Health of the Nation’(1992)) resulted in a rethinking of the demands of the system being proposed.
Key Elements
The original strategy proposed by the IS team at St Mary’s called for “the phased implementation of an integrated hospital information system” (Hackney and McBride, 2002) and that St Mary’s should be “self sufficient in information and its supporting technology” (Hackney and McBride, 2002). In order to implement the integrated Hospital Information System (HIS) the first proposals asked for a dedicated computer room, a Local Area Network (LAN) and Nurse Information and Patient Administration systems (NIS and PAS).
The LAN was a central feature for the program as it is the backbone of the HIS where every service should interlink enabling information to be transferable between each individual system.
A case mix system was suggested to enable the costing of individual clinical procedures and the PAS system enabled the patient’s records to be kept and transferred throughout the hospital.
An IT room was thought to be required for the housing of PC systems relating to the running of the hospital and a training centre was also planned, which would take up the space of an old ward. It was also planned for the HIS to be linked to GP surgeries in the local area.
Strategy Implementation
In 1991 St Mary’s submitted a business IS plan to Wessex region. The bid asked for a hospital wide network, a system for information transfer and a dedicated computer suite. The bid was amended, on the wishes of Wessex region so that the IT suite and network were submitted as two separate bids. One year later Wessex region granted £21M for the introduction of a new system to replace the current PAS setup. St Mary’s had to resubmit its initial report in order to receive a share in this money.
Already the hospital’s original plan had been changed 3 times due to issues out of their control.
In 1992 a White Paper entitled “The Health of the Nation” set out some key principles for hospital IS systems these were:
- That information system would be ‘person-based’
- That hospital Systems should be integrated
- Information should be derived from operational systems
- The Information should be secure and confidential
- And the Information should be shared across the entire NHS.
(Jones, 2002)
With the introduction of these guidelines, the hospital had to again, renew its IS strategy and this led to further set backs in implementing the systems specified by the document. By the time that approval for the computer room had finally been given there were new issues which had arisen- the previous system of Regional Health Authorities had given way to the new system of Hospital Trusts, this led to more confusion as to who should deal with the approval of St Mary’s IS scheme. The proposals for the PAS system, in particular had to be re-costed for approval by the new authorities and later, the LAN approval was withdrawn pending a re-submission of a new proposal for both LAN and PAS systems.
It was not until 1994 that these LAN and PAS systems were both approved, and not until 1995 was the work on the LAN completed due to further costs and delays. This substantial delay in the implementation of the HIS can be linked almost entirely to the problems of changing roles played by the government and the changes in internal NHS structure.
In 1995 a new strategy was put forward by the PAS manager at St Mary’s, this new scheme tried to address the problems with the old strategy but ultimately led to more confusion. The Case Mix program was abandoned due to its cost which meant that all of this information would continue to be processed using text files and spreadsheets downloaded manually from existing systems rather than being part of an ongoing automatic system, this meant that only a few staff members could perform these processes.
The proposed NIS system was also abandoned in favour of a traditional card index file system which was cheaper but far from ideal in the hospital. By 2000 this system was still in operation and the full integration of hospital information systems had still not been completed.
Review of Implementation
The system at St Mary’s has been flawed from the outset. A combination of many factors has stopped a series of systems being implemented on schedule and in many cases these systems have been integral to the whole process. Whilst it seems that the hospital has been able to function properly throughout these problems it must be recognised that by refining the current plan there can be a huge increase in productivity and reduction in costs and time wasted.
The main problems with the original strategies were that they were too ambitious to start with, ultimately leading to corners being cut and ideas being dropped. There was no focus in the strategy either and the plans were very much aimed at the short term rather than looking to the future.
Generating Future Strategic Options
There are two distinct methods which could be undertaken by St Mary’s in order to improve their Information Systems handling. These are an E-Business approach to hospital work and the use of outsourcing.
Outsourcing
“Many firms have adopted outsourcing in recent years as a means of governing their information technology (IT) operations” (Bahli and Rivard, 2003). Outsourcing “is the practice of contracting Computer centre operations, telecommunications networks, or applications development to external vendors” (Laudon and Laudon, 1998). It is becoming used more and more in Pubic sector organisations as a way of reducing costs and maximising value for money. “Although the term outsourcing may be relatively new… Historically, numerous businesses have enlisted the help of outside experts to assist with tasks too cumbersome to complete in-house.” (Hozmozi et al, 2003).
Benefits
Outsourcing can be used to control the costs of an Information System setup. Since an outsider is undertaking most of the work and owns the systems being used then the client only needs to pay for what they use. It is also said that outsourcing “may help clients achieve major benefits such as cost savings, increased flexibility, higher quality services and access to new technology” (Bahli and Rivard, 2003).
In the case of St Mary’s hospital, this could mean more money could be spent on the improvement of other services. The fact that the physical systems are controlled by the 3rd party ensures that there is no maintenance costs to pay on the equipment which again would save time and money for the hospital. Outsourcing can also reduce complications in managerial tasks and eliminate tension in the hospital between medical staff and IT staff. It would also reduce the amount of training the staff would need in order to work.
If St Mary’s had outsourced it’s IS when it first produced an IS plan then many of the problems which have plagued its development would not have occurred. Since all of the IT would be controlled by external sources then there would have never been any of the regional politics problems which occurred when deciding who should deal with what part of the IS system. It would not have cost the hospital any money to upgrade the existing system since the equipment would have been owned by the service supplier and training would be conducted by the supplier or would not be necessary.
Outsourcing is especially suited in applications where there is a poor system already in place or where the client’s IS capability is limited - This is exactly how the hospital is currently running.
Disadvantages
Unfortunately Outsourcing has several disadvantages. Michael J. Earl, a leading academic in the field warns that there are several risks involved with out sourcing IT including:
- “The possibility of weak management
- Inexperienced staff
- Business Uncertainty
- Outdated technological skills
- Endemic Uncertainty
- Hidden Costs
- Lack of Organizational Learning
- Loss of Innovative Capacity
- Dangers of an Eternal Triangle
- Technological Indivisibility
- Fuzzy Focus”
(Earl, 1996)
It would be especially important for a hospital to retain control of key aspects of its IS systems due to the important nature of the work and for the information kept on the network and on 3rd parties’ systems to be secure due to its sensitive content. If the hospital outsourced some of its key data to an outsider it is conceivable that the outsider could tamper with the information or perhaps not have stored it securely enough to prevent hackers from accessing it, which could lead to terrible consequences.
St Mary’s as a Centre for E-Business Excellence
E-Business is literally ‘Electronic Business’, or the use of IT to revolutionise the way a business is run. IBM calls it “the use of Internet technologies to improve and transform key business processes” (IBM E-Business Overview, 2004).
The idea for St Mary’s Hospital to become a centre of excellence in the field of E-Business is an interesting one. In order for this to occur, St Mary’s would need to perform further analysis of its current needs using SWOT and PEST analysis techniques (Quick MBA, 2004) to create a new IS strategy.
The E-Business philosophy is for all of an organisation’s day to day business is carried out in a digital format using linked computer systems on a network.
Benefits
If St Mary’s adopted an E-Business plan then they could conceivably perform the following online processes:
- use the system to support decision making for managers and doctors alike
- perform staff training online in order to free up rooms and time slots
- optimise individual supply chain activities such as renewing supplies of drugs or re-ordering consumables
- quickly share information throughout the hospital e.g. Memos etc
- respond to problems quickly and efficiently since
- automate repetitive tasks such as weekly or daily report generation
- real time communication between departments could speed up tasks
- Allow GPs to access the web based interface to admit patients. This would streamline the process of admitting patients making the whole system work in a far less hectic manner.
- Allow doctors to view patient information from anywhere in the hospital. A doctor could check on patients records from his office without leaving his terminal or a nurse could check up on each patient in a ward from a central PC.
- Allow medical staff to access knowledge bases on the internet or local intranet from anywhere in the hospital. This could allow doctors to check up on information quickly and not have to rely on textbooks. This could save time and possibly lives.
This system would be absolutely ideal for the hospital environment as it would answer many of the problems which have plagued the current system. Most importantly, it meets all the requirements set out by the NHS and by the original IS strategy.
Disadvantages
The costs involved in adopting this strategy is very high and would require much of the annual budget just to initiate the development of the system. The fact that the hospital will need to purchase new machines and software and employ specialists to set up the system would mean that the system could lead to budget cuts in other important areas such as treatment of illnesses and buying expensive equipment such as CAT scan machines etc. Training would be required for the new system, though this may be able to take place online and the dedicated help desk facilities offered by such as system could help get around this.
In addition to this, there would need to be a back up system in place, in case of a failure with the system – a power failure, for example or a computer virus could wreak havoc with the system, this would not be a concern with a system run by a third party.
Planning for the Future
Regardless of which strategy the hospital decides to implement further, long-term focus will need to be regarded as an essential feature of the “strategic” information system and technology plan (Segars et al, 1998). One of the reasons the original strategy failed was due to the fact that it did not look towards the future but merely to the short term. A rethinking of this strategy could help the hospital decide on a system which would last far longer that one designed to meet current demands only.
Recommendations
It is recommended that St Mary’s management look very closely at the costs involved with outsourcing its IS requirements and also investigate further the costs of implementing an E-Business solution. The preferred option for St Mary’s hospital should be to implement an E-Business solution to IS since this allows the greatest amount of control and flexibility out of the two strategies and also would be easily adaptable to future changes. If funding for an E-Business based strategy could not be acquired then outsourcing its IS could provide a suitable solution though care would need to be taken in choosing suppliers and making sure that contracts signed allow for flexibility and that some of the IS system remains under direct control of hospital staff.
The Use of Theory
At an initial meeting, the general manager at St Mary’s commented that “using business theories, concepts and frameworks designed predominantly for the private sector have little value when applied to public sector organisations.” This comment is a common misconception made by many managers in the public sector.
“Historically, the application of private sector models for Strategic Information Systems Planning (SISP) to the public sector is a controversial issue” (Dufner et al, 2002). It has been shown that there are important differences between public and private sector organisations, especially when it comes to the special requirements of this sector. (Dufner et al, 2002). For example, “economic considerations, while present, are less dominant in the public sector, and IT is placed lower in the hierarchies of public organizations than in the private sector” (Dufner et al, 2002)
In particular, the public sector relies on middle managers to perform strategic planning whereas the private sector relies on top level executives for this, even though input is gathered from those lower in the hierarchy” (Dufner et al, 2002).
Other writers have observed that “In the business world, the processes of setting objectives and carrying them out are closely integrated; while in government these processes are loosely coupled” (Rocheleau, 2000). This is obvious in the case of St Mary’s hospital where many systems have been proposed but few have been properly implemented due to the way the government operates being fundamentally difficult to a regular business. Where a regular business needs to change rapidly, the government itself changes so much in short periods of time during elections; this has a negative impact on decision making and has affected St Mary’s on several occasions during the SISP process.
The use of business IS concepts could make a huge difference to the running of St Mary’s if performed in a manner more suited to the task. Other hospital trusts have successfully implemented IS solution through business planning including North Trust Acute Hospital (Waring, 2004) so it can be proved that such implementation of ideas does work, even with the differences between the public and private sectors.
Conclusion
This report makes several conclusions on the case of St Mary’s Hospital.
Firstly, the use of SIS planning has been performed poorly in the past and this has led to problems later in the implementation of the systems. There have been several factors out with the control of the hospital which has affected planning, but these should have been thought of before the strategies had been conceived.
The system at St Mary’s has been flawed from the outset. A combination of many factors has stopped a series of systems being implemented on schedule and in many cases these systems have been integral to the whole process. Whilst it seems that the hospital has been able to function properly throughout these problems it must be recognised that by refining the current plan there can be a huge increase in productivity and reduction in costs and time wasted.
The main problems with the original strategies seem to be that the hospital has been too ambitious at the planning stage, ultimately leading to corners being cut and ideas being dropped. There was also no focus in the strategy and the plans were very much aimed at the short term rather than looking to the future.
In order to change the SIS use at St Mary’s either an E-Business attitude to the running of the hospital could be adopted (this is the preferred option) or several key parts of the existing IS program could be outsourced in order to save money for other hospital processes (this is a good 2nd choice if funding for an E-business style strategy is unavailable), though this strategy would need to be reviewed annually in order to keep up levels of productivity and cost effectiveness
Finally, it is clear that SISP frameworks and concepts used in the private sector can be implemented in the public sector effectively - in contrast to the opinions of the general manager of St Mary’s .
References
Hackney R. and McBride, N. (2003) “Case Study: St Mary’s Hospital” [provided with coursework brief).
Jones, M. (2001) “Implementation of an Electronic Patient Record System”, Cambridge University [online at]
http://www.jims.cam.ac.uk/research/seminar/ slides/011024_2pm.ppt
Earl, M (1996) “The Risks of Outsourcing IT”, in ‘Sloan Management Review (Spring 1996)’
IBM (2004) ‘E-Business Overview’ [online at]
Bahli, B. and Rivard, S. (2003), “The information technology outsourcing risk:
a transaction cost and agency theory-based perspective”, Journal of Information Technology (September 2003).
Segars, A. H., V. Grover, and J. T. C. Teng (1998) “Strategic Information Systems Planning: Planning System Dimensions, Internal Coalignment, and Implications for Planning Effectiveness”, Decision Sciences, 29(2), p303-245.
Dufner, D., Holley, L. and Reed B.J. (2002) “Can Private Sector Strategic Information Systems Planning Techniques Work For The Public Sector?”, Communications of the Association for Information Systems (Volume 8, Spring 2002) p413-431.
Hackney, R., Cowan, E. and Dhillon, G. (2000) “Challenging Assumptions For Strategic Information Systems Planning: Theoretical Perspectives”, Communications of the Association for Information Systems (Volume 3, April 2002).
Hormozi, A., Hostetler, E. and Middleton, C. (2003) “Outsourcing Information Technology: Assessing Your Options”, Sam Advanced Management Journal (Autumn 2003), p18.
Quick MBA. (2004), “SWOT Analysis” [online at]
Quick MBA. (2004), “PEST Analysis” [online at]
Rocheleau, B. (2000). “Prescriptions for Public-sector Information Management: A
Review, Analysis, and Critique”, American Review of Public Administration, 30(4), p414-435.
Waring, S. (2004). “The Challenge of emancipation in Information Systems implementation: A case study in an NHS Trust Hospital” [online at]