IT case study



Transforming healthcare: policy discourses of IT and patient-centred care

Ela Klecun

Department of Management, London School of Economics, London, U.K.

Correspondence: Ela Klecun, Information Systems and Innovation Group, Department of Management, London School of Economics, Houghton Street, London, WC2A 2AE, U.K. Tel: +44 (0)20 7852 3693; Fax: +44 (0)20 7955 7385; E-mail: [email protected]

Received: 11 September 2012 Revised: 8 August 2014 Accepted: 9 September 2014

Abstract Information Technology (IT) is increasingly seen in policy and academic literature as key to the modernization of healthcare provision and to making healthcare patient-centred. However, the concept of Patient-Centred Care (PCC) and the role of IT in the transformation of healthcare are not straightforward. Their meanings need unpacking in order to reveal assumptions behind different visions and their implications for IT-enabled healthcare transformation. To this end, this paper reviews literature on PCC and IT and analyses England’s health policy between 1989 and 2013. English policy has set out to transform healthcare from organization-centric to patient-centred and has placed ITas central to this process. This policy vision is based on contested conceptualizations of PCC. IT implementa- tion is problematic and this is at least partly because of the underpinning goals and visions of healthcare policy. If this misalignment is not addressed then producing technologically superior systems, or better IT implementation strate- gies, is unlikely to result in widespread and substantial changes to the way healthcare is delivered and experienced. For IT to support a healthcare service that is truly patient-centred, patients’ needs and wants need to be identified and designed into IT-enabled services rather than simply added on afterwards. European Journal of Information Systems (2016) 25(1), 64–76. doi:10.1057/ejis.2014.40; published online 28 April 2015

Keywords: information technology; health information systems; patient-centred care; health policy; organizational transformation; discourse analysis

Introduction ‘An IT-enabled transformation of healthcare is just beginning, and it cannot happen too fast’ declared Lucas et al (2013, p. 377). Transformation of healthcare is often depicted as being necessary and

urgent because of the rapidly rising costs of healthcare and changing requirements. This stems from the widely presented view of the challenge of providing care for an ageing population in an era of increasing levels of chronic illness. Often such transformation is envisaged as a shift from an organization-centred model of healthcare to a patient-centred or person- centred model (Davis et al, 2005; Krist & Woolf, 2011). Information Technology (IT) is proposed in national policies of a number

of countries (e.g. in the United Kingdom, United States, Canada, Australia and Singapore) and in academic literature as key to this transformation, not only having direct financial or clinical impacts but also enabling or facilitating new forms of care delivery (Agarwal et al, 2010). The information systems (IS) literature in this area tends to outline macro-level visions of IT-led healthcare transformation, or produce micro-level empirical, often qualitative accounts of implementation and use of particular IS. Such accounts highlight the

European Journal of Information Systems (2016) 25, 64–76 © 2016 Operational Research Society Ltd. All rights reserved 0960-085X/16

importance of organizational environment, stakeholders’ interests and work practices for IS implementation efforts and their outcomes (Barley, 1986; Oborn et al, 2011; Barrett et al, 2012). There is also a significant body of literature that describes particular technologies, concen- trating either on their design or on testing pre-defined variables. Articles focusing on policy and its implications for healthcare transformation are less common in IS journals, with some exceptions, including a number of papers in the Journal of Information of Technology discussing the U.K.’s National Programme for IT (NPfIT) (Currie & Guah, 2007; Sauer & Willcocks, 2007; Currie, 2012). Policy analyses appear in journals such as Health Affairs but ICTs are not seen as central in those publica- tions. Perhaps the scarcity of policy analysis within the IS literature arises because of perception of policy as a topic on the fringes of, or beyond, our field. However, I would argue that policy is important for understanding the role of IT in healthcare transformation, and thus a legitimate subject for an IS scholar. Policy may open up new possibilities and rules for organizational legitimacy and societal relations (Motion & Leitch, 2009). In the United Kingdom, the role of public policy is particularly strong since the vast majority of healthcare is provided by the National Health Service (NHS). Policies and strategies influence the NHS ethos, priorities and organization, as well as both the organizing vision of IT innovation (Swanson & Ramiller, 1997), and implementation of IT. In doing so, they have a direct impact on people’s lives. Similarly, in the United States, current health policy initiatives explicitly assign a role for IT in healthcare transformation. The U.S. Health Information Technology for Economic and Clinical Health (HITECH) Act, a part of much larger stimulus bill, also known as the American Recovery and Reinvestment ACT of 2009 is described as ‘an unprecedented effort to reengineer the way the country collects, stores, and uses health information’ (Blumenthal, 2011a, p. 2323). The HITECH act authorizes Medicare and Medicaid to provide health professionals and institutions (e.g. hospitals) with incentives to implement and demonstrate use of electronic health records and other types of IT. The subsequent demonstration of use, known as ‘meaningful use’, outlines functional IT requirements and IT-related benchmarks required from healthcare providers. Thus, in the United Kingdom and the United States (and in other countries), policy is shaping both – the healthcare field and the IT field. Much of the rhetoric in healthcare policy is about re-

organizing healthcare around patients and providing Patient-Centred Care (PCC). The aim of the paper is to gain an understanding of how policy interpretations of PCC, as well as visions and specific strategies for IT shape the transformation of healthcare in England. This aim translates into the following research questions:

1. What visions of healthcare and its transformation are constructed in English policy discourse?

2. What roles and meanings are assigned in policy to IT?

3. What are the implications of those visions and mean- ings for the way IT-enabled transformation of health- care in England is taking place?

I refer to England because other devolved nations in the United Kingdom have their own national NHS organiza- tions and set of relevant policies. This paper analyses English health policy documents between 1989 and 2013. The analyses are informed by concepts of transformation, as developed by institutional scholars (Ashburner et al, 1996; Scott et al, 2000), and the sociotechnical approach to IS (Coakes et al, 2000; Kling, 2000; Berg et al, 2003). The paper employs the notion of discourse to address the research questions. In taking this approach, this paper aims to avoid two simplifications: (a) a technology- deterministic account of the potential of technology, which underplays the complexities of institutional trans- formation, and (b) a fixed notion of healthcare, and specifically PCC as a ‘given’ rather than as having different, sometimes disputed, meanings. This paper is structured as follows. The following section

outlines theoretical assumptions that have guided this research and develops a conceptual framework that pro- vides a structure for the analysis of policy discourse. This is followed by a description of research methods and an overview of the literature on PCC and IT. The subsequent section introduces the NHS in England, and analyses PCC and IT discourses in policy. Discussion and Conclusion section outlines the implications of this analysis for healthcare transformation and sets out the agenda for healthcare policy and IS research in this area. It closes with an outline of this paper’s contributions and limitations.

Theoretical perspective: transformation, technology and policy discourse This paper follows Scott et al (2000) in defining transfor- mation as a radical (i.e. substantial) change in the institu- tional environment that gives rise to new governance systems, logics, actors, meanings and relations and which leads to shifts in the ecology of organizations. Transforma- tion can be spurred by social upheaval, technological disruption or regulatory change (Greenwood et al, 2002). Ashburner et al (1996) propose potential key indicators of transformational change: a multiple and multi-related change agenda, rise of new organizational forms, develop- ment of new roles, reconfiguration of power relations, new ideologies and systems of meaning. Most institutional theorists study transformation at a macro level and see it as discontinuous and episodic. Others, however, point out that patterns of transformation might arise from the cumulative influence and interaction of institutionally triggered and technology-triggered change processes (Davidson & Chismar, 2007). While aiming to contribute to the understanding of the

process of IT-enabled transformation of healthcare this paper adopts a focus on IT and PCC discourses constructed in policy. These discourses are seen as a part of a wider organizing vision of IT for healthcare (Swanson &

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Ramiller, 1997; Klecun-Dabrowska & Cornford, 2002; Davidson & Reardon, 2005). There are many definitions of discourse but this paper

refers to discourse as meaning-making resources having capacity to constitute social reality, forms of knowledge and identity within specific social contexts and power relations (Hall, 1997, p 220). Discourse is taken here not as purely linguistic or textual device but as being multi-modal (Iedema, 2007, p. 937) and ‘institutionalized and repro- duced in social and material practices’ (Doolin, 2003, p 755). Discourse is historically situated (Iedema, 2007, p. 931) and constructed in a particular context (Fairclough & Wodak, 1997, p. 277). Thus, the way IT in health are debated and adopted depends on country-specific regula- tory structures, their respective values, actors’ organized interests, the status of health professionals (Mathar, 2011) and other resources they can draw on, as well as user practices (as depicted in Figure 1). Actors can include organizations, groups and individuals. Their resources may be financial, institutional (e.g. as afforded by BritishMedical Association), cultural (e.g. the status of medical profession) andmaterial (e.g. journals). Moreover, discourses are always interlinked (Fairclough&Wodak, 1997, p. 277). PCC and IT discourses are not only interlinked with each other but also with other discourses, including New Public Management (NPM), e-Government, Evidence-Based Medicine (EBM) and Health economics. ‘Meta’ discourses are deployed locally in organizational discourse and become reconsti- tuted in the process (Jian, 2011). Discourse, delineating what is legitimate and what is not, may be perceived as a strategic resource that governments and other types of organizations can draw on to bring about and legitimize change (Motion& Leitch, 2009). For example, Bloomfield & Hayes (2009) have shown how the major modernization programme for local government in the United Kingdom

was legitimized through the appeal to the importance and centrality of the citizen/customer. Such a conceptualization of discourse informing this

research envisages technology as constructed in discourses (e.g. of organizational transformation and PCC) and in turn as influencing those discourses. It does not, however, deny themateriality of technology. Doolin (2003) suggests that discursive analysis tends to relegate technology to an element of context, or treat it as independent of human mediation and that this should be avoided. I see IT as implicated in and co-constitutive of social practices and linked to systems of politics and power relations (Kling, 2000; Berg et al, 2003). Viewing IT a socio-technical net- work or ensemble suggests that its implementation is an ongoing social process influenced by stakeholders’ needs, interests, norms and ways of doing things. The design of IT involves interrelated decisions about technology and the organization of work (Kling, 2000). In conceptualizing IT role in transformation I followDavidson &Chismar (2007) in treating technology analytically as an integral compo- nent in the change process not as a static, external change trigger. Technology both shapes and is shaped by pro- cesses of change. The framework in Figure 1 presents a discourse view on

healthcare transformation. On this framework, the areas that this paper concentrates on are highlighted in bold. The arrows depict flows that are considered important for the construction of this paper’s arguments. For clarity other flows have been omitted (e.g. it could be argued that policy is not only influenced by other discourses but it influences them as well).

Research methods The analysis described in this paper is confined to a study of meanings through ‘formal arrangements’ and ‘vocabul- aries-in-use’ (Hasselbladh & Bejerot, 2007, p. 178) con- structed in policy. I studied texts (i.e. policy statements) and the context in which they were developed and might have been interpreted. Texts can be defined as a manifesta- tion of discourse and the discursive ‘unit’ on which the researcher focuses (Chalaby (1996) referenced in Grant & Hardy (2004)). Hence, discourse analysis is the systematic study of texts. I placed detailed analysis of meanings produced by actors and their situated actions outside the scope of this research. Following Hasselbladh & Bejerot (2007, p. 178) I see it as a deliberate research strategy that seeks to focus on ‘what cuts across and shapes different contexts of action’, that is, what conditions transforma- tion of healthcare. I analysed health policy and information strategy papers

for England between 1989 and 2013, focusing on the two recent documents (DOH, 2010; DOH, 2012). My starting point is the 1989 policy paper because it introduces major reforms of the NHS and themes that are of relevance to PCC discourse (although this term was not explicitly used there). The 1992 policy paper (DOH, 1992), as far as I am aware, is the first health-policy paper that discusses to any

IT discourse

PCC discourse

Other Discourses (New Public Management, e-Government, Evidence-Based Medicine, Health Economics …)

Technological innovations

Policy discourse of IT- enabled transformation of healthcare towards PCC

Transformation of healthcare

Regulatory structures and governance systems, actors’ organized interests, resources and user practices

Legitimizes a particular vision of healthcare, sets

strategies for its realization


Figure 1 A discourse view on healthcare transformation.

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extent the role of IT in healthcare. My analysis of policy papers focused on visions of healthcare transformation, meanings of PCC and the roles ascribed to IT. These were placed in the context of history of reforms in the English NHS, in particular changes to regulatory structures and governance systems. I also conducted review of literature related to the role of

IT in PCC. Publications from IS, organization studies and health informatics fields were reviewed. The search was conducted using multiple databases and terms including ‘patient centred healthcare and information and systems’ (and their different combinations and spellings). The search returned 166 articles with all of those search terms appear- ing in papers’ abstracts. After reading all their abstracts I selected 57 articles for further reading, based on article’s scope and approach. Articles describing technologies, rather than their application, were disregarded. In addition, papers that were most referenced by the selected articles were read. As with policy analysis, the literature review was concerned with visions of healthcare transformation, meanings of PCC and the roles ascribed to IT.

Patient-Centred Care and IT discourses in the literature

PCC discourse A patient-centred approach to medical care, often referred to as PCC, has been advocated in the medical literature for at least four decades. However, there is no one definition of PCC. Research has shown that different healthcare groups tended to focus on different aspects of PCC, reflecting their professional interests and norms (Kitson et al, 2013). PCC discourse can be generally divided into two strands, labelled by Vikkelsø (2010) as philosophical and manage- rial. The philosophical strand advocates a whole person approach to care and focuses on understanding patients’ needs, preferences and experiences, and providing care that is closely congruent with these. Decisions about treatment, for example, are negotiated between healthcare professionals and patients (Mead & Bower, 2000). PCC advocates suggest that it would help patients to access appropriate and preferred medical care when and where it is needed, potentially leading to positive health outcomes. The managerial strand conceptualizes PCC as reorgani-

zation of services around patients’ care plans requiring changes to the entire organization of work and relation- ships related to patient trajectory (Lutz & Bowers, 2000) and as a transformation of healthcare towards optimal care (Davis et al, 2005). It is underpinned by a belief that PCC not only leads to better patient satisfaction and health outcomes but also to economic gains. Patients are seen as a ‘resource’ that can be utilized to contain costs and improve quality, for example, through assessment of service qual- ity, partaking in management of hospitals and taking increased responsibility for their own health and health- care. The managerial PCC discourse is linked to an IT discourse. Vikkelsø (2010, p. 341) suggests that ‘[t]he managerial version of PCC aims to integrate information

technology in every link of the care chain in the belief that web-portals, distributed records, and online access facil- itate relationships between professionals and patients by providing, for example, sufficient information, patient engagement and mutual feedback’.

IT discourse The IT discourse expounding transformational potential and benefits of health IT takes place in journals belonging to different disciplines, including information systems (Agarwal et al, 2010; Fichman et al, 2011; Gianchandani, 2011), health informatics literature, organization and pub- lic sector management (Ranerup, 2010; Vikkelsø, 2010), and social science, health and medical fields (Hillestad et al, 2005; May et al, 2005; Krist & Woolf, 2011; Kerr & Hayward, 2013). The literature identifies a number of different technolo-

gies that are transforming healthcare. For example, elec- tronic infrastructures and applications, such as electronic health records (EHRs) and e-prescribing systems, and deci- sion support tools are seen as altering the way healthcare professionals coordinate care and collaborate. Data ware- houses and data analytics tools are described as facilitating medical research, planning and management of healthcare (Hayes, 2010). Health related sites and social networking applications, Personal Electronic Patient Records and dis- ease management systems are promoted as enabling the transformation of passive patients into informed and empowered consumers of healthcare services, giving patients control over the management of and responsibility for their health (Murray et al, 2008; Hogarth et al, 2010). Telecare applications (such as monitoring systems) are seen as enabling self-care. Emails, texts, instant messages and video chats are proposed as means of improving access to healthcare professionals, and allowing for richer engage- ment and deeper doctor-patient relationships resulting in better care for patients (Hawn, 2009). Developments in genetics and informatics are seen as opening a new dawn of personalized medicine that is tailored to the needs of individuals (Gianchandani, 2011; Lucas et al, 2013). These developments have given rise to different technological terms, such as Health 2.0 (Murray et al, 2008) and more recently Health 3.0 (Gagnon & Chartier, 2012) with their implied claims of a paradigm-like shift in the way health- care is delivered and experienced. Success stories, such as those from the Veterans Health Administration and Kaiser- Permanente’s, have acquired almost mythical status in the academic and practitioner literature (Perlin et al, 2004; Chen et al, 2009), and play an important role in the discourse on IT-enabled transformation of healthcare. These visionary accounts range from thoughtful and

measured to technologically-deterministic visions of the (near) future. In many of those accounts technology is seen as more or less unproblematic, and the difficulties of modelling healthcare work in a computerized information system remain unaddressed or are merely mentioned in passing.

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To date evidence for the benefits of IT-based interven- tions is inconclusive (Black et al, 2011; Buntin et al, 2011; Wootton, 2012), although some argue that it is simply too early to see the benefits (Jones et al, 2012). The IS literature points to difficulties of implementing large-scale IT systems in healthcare and highlights challenges of translating pol- icy into practice. It notes diverse interests, norms and values of different stakeholders, highly institutionalized, often politicized environment characterized by conflicting institutional logics, as well as complexity of healthcare work and technical challenges (Currie & Guah, 2007; Ure et al, 2009; Aanestad & Jensen, 2011; Rivard et al, 2011; Currie, 2012; Klöcker et al, 2014). Adoption and use of IT may potentially influence formal

structures and authority (e.g. changing locus of decision- making), stakeholders’ power and identity, division of labour and distribution of tasks (Barley, 1986; Cho et al, 2008; Petrakaki et al, 2014) but the same IT used in different organizations may have diverse, even contra- dictory, outcomes (Robey & Boudreau, 1999; Aarts & Berg, 2006). Major IT-enabled programmes of change, such as an EHR implementation, do not automatically lead to transformation (Greenhalgh et al, 2009). Techno- logical effects are indirect and vary over time (Kling, 2000). In summary, the literature delivers diverse accounts of

transformational potential of IT that are underpinned by different conceptualizations of PCC and IT. There is tension between visions of a paradigm-like shift in healthcare facilitated or brought about by IT, and the evidence that IT is neither easy to implement, nor, even if implemented, that it leads to expected outcomes. Few IS scholars conduct longitudinal studies at the level of institutional field linking policy and practice, although there are some notable excep- tions (Currie & Finnegan, 2011; Currie, 2012). It is to this type of studies that this paper aims to contribute.

The U.K.’s national health service (NHS): IT and PCC discourses in policy This section begins with a brief historical overview of regulatory structures and governance systems in the NHS. This is followed by critical analysis of PCC and IT dis- courses in England’s health policy.

Regulatory structures and governance systems in the NHS: historical overview of reforms In the United Kingdom, the majority of healthcare is provided by the NHS free at the point of delivery (with some exceptions). The NHS represents a series of organiza- tions that are publicly funded through general taxation. It is divided into primary and secondary care. Primary care is the first point of contact for most people and is delivered by a wide range of independent contractors, including general practitioners (GPs), dentists, pharmacists and optometrists. Secondary or acute healthcare includes elec- tive care and emergency care. The NHS organizations such as primary care practices, hospitals, mental health and ambulance services are grouped into Trusts. The Trusts

enjoy varying levels of financial and operational auton- omy. The overall responsibility for funding, directing and organizational transformation of the NHS and social care rests with the Department of Health. The Department publishes strategies and policies on wide ranging issues that are relevant to the NHS. In this study I am interested in the papers that set the overall health policy and information strategies for the NHS in England. Since the inception of the NHS in 1948 it has been

subjected to countless initiatives to transform it from a succession of U.K. governments (Ashburner et al, 1996; Oliver, 2005). One of the most fundamental administra- tive reforms was the establishment of an 'internal market’ (DOH, 1989). This involved the separation of the service into purchasers (primary care practitioners) and the provi- ders of care (secondary care). GPs were given an option to become fundholders, that is, to control allocated budgets for purchasing part of the secondary care for their patients. The Labour government that was brought in office in

1997 re-organized the NHS and promised the replacement of the internal market with integrated care (DOH, 1997). In 1998 the GP fundholding scheme was abolished, but from 2002 a new wave of market-based reforms was intro- duced. Overall, the period of Labour government (1997– 2010) saw the emergence of a new model for the NHS based on choice, competition, payment by results and a plurality of providers (including the increasing involve- ment of private providers). Trusts were encouraged to apply for fundholder status giving them semi-autonomy from the central management of the NHS. In 2010, under the new Coalition Government, another

major re-organization of the NHS was announced. The vision for this is set out in the policy paper ‘Equity and excellence: Liberating the NHS’ (DOH, 2010). The policy sets objectives to bring more power to local organizations, closer to patient needs. Newly established GP led commis- sioning consortiums are made responsible for buying in patient care. This policy can be viewed as a continuation of the market reforms that begun in the early 1990s, opening the door for more involvement from private companies by forcing commissioners of care to tender contracts to any willing provider, including voluntary sector organizations and commercial companies. Overall, the last 25 years can be described as a period of

transforming the NHS, characterized by multi-related change agendas, establishment of new organizations and roles and emergence of new ideologies (such as PCC, NPM and EBM).

PCC discourse PCC discourse in policy can be traced to the early 1990s. A health-policy paper from this period (DOH, 1992) stresses the importance of people taking responsibility for their health and promised individual opportunities and wider choices. The paper states the need for comprehen- sive health monitoring and for the measurement of health outcomes.

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In a later paper, the choice agenda is taken a step further with a promise of more rights and more choices for patients, such as participation in decision making about care received and in management of the NHS Trusts (DOH, 1997). The NHS is to be ‘built around the needs of people, not of institutions’, for example, by becoming more flexible and supporting local ways of delivering healthcare, as well as integrating health and social-care services. The ambition is to change the whole system to create a patient- led NHS (DOH, 2005). The choice agenda presented in the earlier papers of the

Labour Government era is expanded in the Coalition Government policy. Patients are given rights to choose a provider organization, consultant-led team, or GP practice and take part in decision making about care received. This is coupled with a promise that patients will have control over their health records, initially envisaged as ability to access the record, see any amendments to it and determine who else is allowed to access it. The foreword to the 2010 policy paper (DOH, 2010) proclaims that ‘patients will be at the heart of everything we do. So they will have more choice and control, helped by easy access to the informa- tion they need about the best GPs and hospitals. Patients will be in charge of making decisions about their care.’ Overall, the following proposals relevant to PCC discourse can be identified in the recent policy (DOH, 2010): Patient perspective:

● more convenient care (easy access to services, new services and …