Organisational Barriers to The Implementation and Adoption of Health Information Technology (HIT) In the UK – A Systematic Review of Literature

Chapter One: Introduction

1.1 Introduction

The health information technology is among the key tools that have been developed to facilitate provision of better patient care and help in the realisation of health equity (Wachter 2016). Nonetheless, the adoption of these technologies has not been successful in most countries including the United Kingdom (Wachter, 2018). Therefore, the present systematic review of literature is focused on assessing and reporting the organisational factors that prevent implementation and adoption of the health information technology in the UK’s public health sector. The primary purpose of this chapter is to provide background information about health information technologies as well as to state the problem statement for the present study. The chapter also explains the purpose and significance of the review, formulates the research question, identifies aims and objectives and provides a comprehensive explanation of the structural organisation of the whole project.

1.2 Background Information

Health information technology (HIT) is made up of a variety of technologies for transmitting and managing the health care data used by all the stakeholders in the sector (Wachter, 2018). These stakeholders include the payers, providers and all other groups which have interest in the health care technology in general (Nugroho et al., 2016). Health related information technology is an important aspect of the public health sector because it is the foundation for campaigns, policies and programmes which are specifically aimed at promoting, maintaining and improving the quality of health care services offered to the general population. Albeit information can be derived from different channels, important types of data rich sources such as the vital statistics and cause-of-death statistics often play a central role during the formulation and implementation of public health policies (Wager et al., 2017; The King’s Fund 2019). The health information technologies of a country are made up of different population-based and health facility-based data sources. Nonetheless, there are still important disparities that exist among different countries especially since there is still limited improvement in the quality and amount of data among the developing countries compared to the developed countries (Sun and Qu, 2015).

HIT plays an important role in improving the patient safety, enhancing the efficiency of health care organisations and promoting the satisfaction of clients within the health care sector (DHSC, 2019). Conversely, a randomised clinical controlled study by Lin et al. (2015) established that the computerised physician order entry with decision support services helped in reducing the occurrence of serious medication errors by 55%, hence improving the efficiency of the health care technology. Additionally, it is reported that the electronic medical records (EMR) promote realisation of positive returns on investments within the health care technology (Wachter, 2018; DHSC, 2019). Even though the use of these technologies has been associated with positive results, their adoption rate is still limited. THIS leads to the need to research, report and critically appraise the factors influencing the reduced rates of adoption and use. It is understandable to seek short-term financial return on investments following the adoption and use Health Information Technology but such outcomes are likely to be registered in terms of quality and safety improvements rather than raw financial terms. The cost savings may take up to 15 years or more to be realised because the explanations for such gains are in the form of reconfiguration of the workplace, improvements in technology and reimagining of the work (Nugroho et al., 2016; NHS England 2018).

Remarkably, the England General Practice sector started its digitisation process in the 1980s and most of their activities were almost 100% digitised by the mid-2000s (Wager et al., 2017). By contrast, the NHS developed an ambitious programme to facilitate the digitisation of the secondary care sector, the National Programme for Information Technology (NPfIT) in 2002 but was later shut down in 2011 because of its inability to achieve most of its intended goals (NHS Improvement 2019). The programme was mainly criticised for being too centralised, failing to engage with the trusts and their health care professionals and focusing on achieving too many goals within a short time. As a result, the health care stakeholders reached a consensus that there was a need to develop more strategies for ensuring that the digitisation process of NHS is fully realised, with the Treasury allocating £4.2 billion for financing the digitisation process in 2016 (Mackert et al., 2017). Furthermore, the need to promote successful adoption of HIT led to the formation of the National Advisory Group on Health Information Technology in England so as to guide NHS England and the Department of Health on the most appropriate strategies that can be used for digitising the secondary care technology.

Utility of HIT within clinical settings both in the United Kingdom and globally has attracted a lot of debates in the recent years. According to NHS England (2018), some health care stakeholders believe that the implementation of these technologies would help in improving the overall quality of care because of the ability of the health care managers to make ethical and timely decisions influenced by real data. However, increased cost associated with the implementation of the health information technologies has limited its adoption (Nugroho et al., 2016; Wager et al., 2017). Electronic health records (EHR) are currently being moved from institutional to inter-instructional, an act which has raised a lot of concerns regarding the privacy and security of the shared data. For effective prevention of any threat associated with the HIT adoption in the health care sector, EHRs must adhere to three important security goals such as integrity, confidentiality and availability (King’s Fund, 2019). In line with the arguments by NHS Improvement (2019), the clinical decision support technologies have the ability to improve the quality and safety of healthcare by providing professionals with the comprehensive information they need for clinical decision-making processes. The uptake of these clinical decision support technologies has increased in the recent years despite the need to improve its effectiveness and ensure patient safety.

The availability of a tax-funded and competent National Health Service may influence one to perceive that the UK is well positioned to effectively formulate and adopt the use of HIT as well as roll out other forms of eHealth innovations (Mackert et al., 2017). However, the health market of the UK is often significantly complex compared to how it is appreciated by the outside technologies (Wachter, 2016). The first factor that has led to such complexity is the devolution of the National Health Service which has resulted in the occurrence of significant disparities within the health technologies for different countries in the UK (Sun and Qu 2015). NHS Scotland, Northern Ireland and Wales are very different from the NHS England. Also, NHS England is mainly characterised with a mixture of centralisation in terms of policy setting, information governance and regulation framework, but highly fragmented in terms of the general organisation and delivery of care. These factors make it difficult for eHealth companies seeking to enter the UK health technology and scale up innovation (Lin et al., 2015). For example, Office of Life Sciences developed a £35 m Digital Health Technology Catalyst Fund targeting the small and medium sized enterprises involved in the development of health technologies and this initiative was to motivate more companies to invest in the development and provision of health information technologies as an approach for promoting the digitisation of the NHS (OLS, 2015).

1.3 Problem Statement

Formulating a health care delivery technology which is highly responsive to future challenges associated with the aging population is among the key priorities in most of the higher income countries experiencing late epidemiological and demographic transition, and the United Kingdom is no exception (Wang et al., 2014; Rittenhouse et al., 2017). According to the ONS (2019), the average age in the United Kingdom exceeded 40 years old for the first time in mid-2014 and it is projected that 1 in every 7 people would be 75 years old and above by 2040. The trend is likely to be characterised by different incidences such as increased rates of chronic conditions prevalence, cognitive impairments, multi-morbidities and long-term frailty. The government projects that the adoption of advanced technologies would help in the provision of high quality healthcare support to its aging population and management of other health care conditions affecting the general population (Wachter, 2016). The United Kingdom was among the early adopters of health care information and communication technologies in primary care and scoring relatively high among the European member countries in terms of the use of technologies in General Practice. Nonetheless, the country currently registers lower rates of electronic prescribing techniques compared to the Nordic countries, and registering low scores in the digital health technology adoption and eHealth interoperability (NHS Improvement, 2019).

Even though most hospital departments in the UK might have competent specialist information technologies (Lin et al., 2015), the adoption rates of electronic patient records (EPR) technology in England and Wales are still very low and the digitisation of the community health services has not been fully achieved by the National Health Service (Wachter, 2018). The existence of low HIT adoption rates in the UK has negatively impacted the quality and efficiency of information sharing among different providers and the general coordination of care. Additionally, a meta-analysis conducted by NHS England (2018) including studies published between 2010 and 2013 revealed that current literature has not provided comprehensive discussion on the effects of health information technology adoption or how it influences improvements in healthcare outcomes. Some of the probable factors that led to the generation of such outcomes include insufficient measurements and reporting of information about the execution and context of health information technology use, such as the implementation approach, settings, the information technology intervention details, in addition to the application of non-standardised protocols and simple measurement approaches.

1.4 Purpose of the Study

Though the Health Information Technology are often made up of large sets of modules and functionality, most health information technology adoption studies have mainly focused on precise components such as the computerised order entry, clinical decision support and electronic health records (Agha, 2014). However, the factors that limit successful adoption of these technologies have not been extensively researched. Therefore, this is an important gap in literature which the present study would be focusing on bridging. In order for the NHS to continue providing high quality health care services at affordable costs, it must adopt new techniques that promote its modernisation and transformation, which are characterised by varying changes within its culture, governance, structure, workplace and training (DHSC, 2019). None of these transformations can be as important and challenging as the creation of a fully digitised NHS. That is why the present systematic review of literature is focused on identifying and reporting the different factors that act as barriers to effective digitisation of the NHS. The knowledge generated from this review can be used to develop appropriate strategies for addressing the identified barriers; hence leading to improved adoption rate of the Health Information Technology within the NHS.

Although over-centralisation is the key factor that led to the failure of NPfIT, it is essential to note that centralisation can sometimes help in improving the efficiency of the national health technology (Mackert et al., 2017). Hence, this review focuses on assessing effective strategies that can be used by the NHS to develop an appropriate balance between local or regional control and engagement and centralisation. Additionally, data privacy and safety have also been identified as some of the key challenges associated with Health Information Technology adoption (OLS, 2015), and as such, concerns raised about confidentiality and privacy can hinder efficient data sharing process which is necessary for effective management of the patients and health care research. Therefore, the present study also determined to generate new knowledge that can be used for achieving the balance between health care data usage and confidentiality protection without causing harm to the health care service users, such as the patients and care professionals.

1.5 Significance of the Study

Despite the availability of different policy developments such as the Accelerated Access Pathway (for prioritising strategic innovation in health care), the Innovation and Technology Payment (for reimbursing the providers of small number of assorted innovations and provision of additional funding to the Academic Health Science Networks) among others, the NHS still registers lows scores in terms of basic digitisation and interoperability compared to the other high income countries such as the United States and Germany. So, the generated knowledge from this study about the organisational barriers to effective implementation and adoption of Health Information Technology would be used to formulate effective strategies for bridging the digitisation gaps currently experienced in the NHS. Successful digitisation of NHS through the adoption of Health Information Technology would foster better patient care and experience via review of healthcare information, diagnosis and minimisation of errors. Furthermore, the outcomes from this systematic review literature may be used for developing a protocol for implementing the newly formulated Health Information Technology, as previous literature in this area have reported that most of the HIT programmes often collapse at the programme implementation stage.

1.6 Research Question

What are the key organisational factors that prevent successful implementation and adoption of Health Information Technology in the United Kingdom?

1.7 Structure Organisation

The dissertation is organised into five chapters. Following successful identification of the research problem and aims in the first chapter, the second chapter identifies, explains and justifies the research methods and methodologies employed during the database identification, literature search process and generation of themes from the reviewed literature. Chapter 2 also explains the inclusion and exclusion criteria that were utilised to identify the appropriate literature for review. In the third chapter, the outcomes from literature search process are presented using a PRISMS diagram and the selected studies for review are critically appraised to enhance the generation of important themes about the organisational barriers to effective implementation and adoption of Health Information Technology. A summary table describing the aims, methods, results, limitations and implications for each of the selected study for review is also presented in this chapter. In the discussion chapter, the generated themes following the review of the selected studies are presented, discussed and interpreted to enhance development of new knowledge about the organisational barriers to successful implementation and adoption of Health Information Technology. In the last chapter (conclusion and recommendations), the research question is restated to determine whether it was comprehensively answered, and recommendations for both health care practice and future research are also provided.