Cross Talk looks beyond good/bad
In the latest of his regular columns, Mike Cross admits that, as a journalist, he’s often asked to make binary judgments – but a more sophisticated approach is needed when it comes to healthcare IT.
We live in a binary world. For once, I'm not talking about computers, but our cultural tendency to consider the world around us in terms of yes/no, black/white, good/evil.
It's so ingrained, we generally don't realise we’re doing it. Indeed, life would be impossible without reducing everyday decisions to a simple either/or.
I suspect that someone who habitually answered the question "Coffee or tea?" with something like "45% of my preference lies in the set designated coffee" would not stay married for long. (Or, come to think of it, would not be married in the first place.) “To our infantile clamouring for a yes/no answer to the question ‘is the electronic summary care record a success?’, the researchers have a grown up answer: it is simply too early to say.”
Fuzzy policy
However, public policy isn't like that. Its decisions are rarely binary; its choices are rarely between good and evil. It’s fuzzy.
Healthcare, of course, is fuzziness on stilts - however much we try to codify protocols and outcomes, every single decision is unique, and sets in train a uniquely variable set of outcomes; so all we can do is take a stab at the best balance of probabilities. This, of course, is one reason why medicine relies so much on professional judgment.
Add IT to the equation and the fuzziness multiplies. The pace of technological development and the transformative effect of instantly available information are disruptive in even the most mundane of environments. In healthcare, we are only just beginning to guess at the possibilities - that's why it's so exciting.
Beyond certainty
And yet we still crave binary certainties. A technological development must be good or bad. An implementation programme must be a success or a failure.
Of all the millions of words of commentary written on the national programme to computerise the NHS, almost all have been couched in such binary terms. Politicians - and newspaper editors - demand it. “The Greenhalgh report finds that the standard of deliberation has been lamentable, with ‘polarised claims’ on both sides, generating more heat than light.”
As a result, we're all poorer. Professor Trisha Greenhalgh from University College London recently published a study of the first phase of the NHS Summary Care Records programme. And one of its most powerful conclusions is that we need a more sophisticated policy debate.
The care records service, the study points out, is what's known in policy-making circles as a "wicked" problem. "It raises complex questions to which many people expect science to provide 'objective' answers, but which are actually questions about social priorities, and which therefore require citizens and policymakers to deliberate about ethics and values as well as about scientific and technological facts."
To date, though, the report finds that the standard of deliberation has been lamentable, with "polarised claims" on both sides, generating more heat than light. As a journalist, I can only agree with Professor Greenhalgh and her colleagues that some parts of the press have contributed to the mutual demonisation.
Wicked questions, complex answers
To our infantile clamouring for a yes/no answer to the question “is the electronic summary care record a success?”, the researchers have a grown up answer: it is simply too early to say. This is not diplomatic ducking; it is based on a well-argued case that it is far too early to start laying down definitions or metrics of success.
Professor Greenhalgh and her team argue that these should be developed organically as the technology comes in to use, and change people's behaviour.
For example, the report says that at this stage it is meaningless to write off the HealthSpace web portal as a failure because few patients have signed up - a meaningful criterion of success can only be set once patients have started to take more control over their own information and healthcare.
There's a great deal more good sense in Professor Greenhalgh's report. If you read only one document about NHS IT this year (as if that were possible), make it this one. I know that's another good/evil judgment, but sometimes a binary vision is useful.
Related Links
- Read Professor Greenhalgh's report in full
About the author: Michael Cross is a freelance journalist specialising in healthcare informatics and e-government. He is a member of the British Computer Society.