Físico

Literature discussing the challenges and benefits of IS/ICT indicates that proposals to realise efficiency, effectiveness and increased quality of patient care via IS/ICT has the properties of a ‘wicked’ problem (Clarke & Stewart, 2000; Rittel, 1984 [1972]). Discourses on the need for health system transformation are characterised by crisis and conflict.

HEALTH IN CRISIS: IS/ICT AND SUSTAINABILITY

Sustainability of health service delivery due to ageing populations and advances in medical knowledge and technologies are at the forefront of most political and policy agendas (Alvarez, 2005; Caro, 2005; Oliver et al., 2001). E-health initiatives have been identified as critical to respond to the crisis (Pagliari et al., 2005).

E-health and health system transformation discussions concentrate on the need to provide information to: 1) support health services practitioners in the conduct of their work (Winthereik & Vikkelsø, 2005); 2) measure health services practice for quality assurance (Clarke, 2003) and 3) support health service clients in making decisions related to their physical well-being (Adams & de Bont, 2007; Suggs, 2006). However, the “tribal” characteristics of relationships between health service professionals (strong professional identities and loyalties; hierarchies and ‘turf

protection’ activities) is an apparently intractable problem and barrier to health service reform (Braithwaite, 2005) both in terms of redesigning work processes and providing ICT-based information support.

HEALTH CONFLICT: MODELS ASSURING QUALITY AND SAFETY

The role of regulatory frameworks for controlling how organisations conduct their enterprises and community has a long history, including the area of health service provision. McEachern’s (1934) call for a national mandate for public health service that provided control, coordination and correlation, standards and accreditation for education and practice of health professionals in concert with public education has been largely realised. However, nearly eighty years later, research indicates problems emerging from forces for management and regulation of services and service providers (Abma & Noordegraaf, 2003; Cooke, 2006) as well as the benefits of regulation and measurement of professionals providing proof of the quality of services (Kuhlmann, 2006).

ICTs have an integral role in quality assurance of health services: they enable collecting and managing vast quantities of data onto digital information systems and interrogation of the system to evaluate an organisation’s compliance to the standards (Clarke, 2003). They are a critical component of every approach proposed for improving the health system (Grol, 2001).

In particular, preventative care and population health services are intrinsically suited to IS/ICT efficiencies due to the large scale and repetitious nature of work such as

screening for cancer (Bar-Yam, 2006). In fact, the emergence “of automated

information systems and the need for public health entities to manage large volumes of data and information were a perfectly timed match” (Lumpkin, 2003: 27).

However, information relevant to health care decision-making is context sensitive and context dependent, a mix of formal and informal considerations with the result that information that matters in a health setting is fluid and subject to change (Moser & Law, 2006). ICTs that too rigidly define information flow and the possible uses to which clinical practice will put information can damage other forms of information flow in a health decision setting, the informal and unpredictable considerations about a patient’s specific situation that are included in a situated process of simplification and identifying relevant boundaries:

The large ICT programmes in health care seek to make information flow in ways that are predictable and seamless. Unpredictability or turbulence are seen as problems. But here is the rub: unpredictability cannot be banished from health care. Clinical decision making is often, perhaps almost always, unpredictable (Moser & Law, 2006: 56).

Health service organisations and health professionals who work for them are increasingly subject to quality assurance processes and accreditation requirements (Braithwaite et al., 2006). Positively, institutional cooperation and compliance with evaluation requirements of its operations is strong in contexts when there is a strong link between compliance and funding (Segerholm, 2001). But recent research raises

questions on whether the abundance of very costly accreditation processes delivers better health systems (Braithwaite et al., 2006) and little is known about whether they provide comparative measures of quality (Kerr et al., 2007). Scrivens’ (2007) suggests a limited number of parameters should be used to assess health service organisations in order to not unduly burden them in demonstrating they meet quality requirements for health service delivery.

Different models for achieving patient-centred, high quality health care reflect tensions in health care service delivery (Editorial, 2006). EBM is focused on changing medical practice such that clinicians follow standard clinical guidelines in delivering health services (Timmermans & Berg, 2003). EBM is philosophically at odds with an approach that trains clinicians in cultural competence in medicine (CCM) and relies on clinician expertise and judgment, client by client (Editorial, 2006).

EBM is criticised as top down and failing to account for the complexity of real world clinical practice and contradicting the nature and practice of professionalism (Grol, 2001). However, self-regulated requirements for continuing medical education (CME) does not provide evidence of competence without some external systems for external assessment (Grol, 2001).

The hierarchy of evidence within the EBM approach to clinical practice (the ‘gold standard’ evidence is randomised control trials) can hinder use of other types of knowledge that are useful for treatment decisions that are tailored to individual clients (Mantzoukas, 2008). Mol (2006) challenges the adoption of clinical trials as the ‘gold standard’ for health care research, noting:

… however well clinical trials might be able to prove or disprove therapeutic claims, and however strong their credentials when it comes to seeking evidence, they have their limits when it comes to assuring good care (p. 406).

The notion of what constitutes ‘good care’ has been extended by socio-technical research to include the lived experience of patients (Mol, 2006). The nature of

professional health care is then more than following standardised principles for clinical decisions, it involves “creative calibrating of elements that make up a situation until somehow they fit – and work” (Mol, 2006: 411).

The concepts of profession and professionalism are increasingly applied in modern work life paradoxically just as the necessary conditions of professional practice (trust, discretion and competence) are being challenged, particularly in the health and education contexts of changes to funding, organisation and administration (Evetts, 2006). ‘Evidence-based practice’ is part of the performance-oriented culture in modern organisation life. It is considered good for society because decisions are more likely to be based on well-informed judgements, based on evaluations that fulfil the three purposes of: accountability; learning about process and learning about effects (Lewis, 2001).

The relationship between professional and client is also changing with power shifting from the producer of expert services to the consumer (Pfadenhauer, 2006). Client / patient trust is also an important issue in terms of the role of professionalism in building trust (Kuhlmann, 2006) and the relationship between professional governance systems and state regulatory control (Allsop, 2006).

While clinical professions have benefitted from standards and clinical guidelines they also are construed as “undermining clinical expertise and rendering the profession vulnerable to oversight, substitution and interference” (Timmermans & Berg, 2003: 84). Thus, the requirements of training, certification and accompanying responsibilities of individuals to demonstrate participation in continuing professional development are related to establishing and maintaining legitimacy to practice, and also to establishing means of controlling members of the profession (Evetts, 2006; Timmermans & Berg, 2003).

It is not clear whether the broad purpose of evaluation of improvement and learning is connected to decision making for improvement (Alexander, 2003). However, a

framework for routine, integrated service evaluation that provides client outcome data to clinical staff members provides an effective evidence base to inform and improve practice (Lucock et al., 2003). Evidence based guidelines for clinical practice can change the behaviour of physicians when accompanied by education as an ongoing process that has practical and discussion elements based on research (March, 2006).