Professor Enrico Coiera Explores Why Health IT Is So Hard. A Very Good Read.

This appeared in the Medical Journal of Australia today.

Why e-health is so hard

Enrico Coiera
Med J Aust 2013; 198 (4): 178-179.
doi: 10.5694/mja13.10101
We need to respect the basic rules of informatics and invest in e-health expertise
Medicine holds dominion in the microcosm of molecules and genes. It is in the macrocosm of people and organisations where things seem to fall apart. Modern health care appears unsustainable in its current form,1 and information technology is increasingly seen as a major intervention that can drive “reform”.
Evidence for e-health’s potential to improve the safety and quality of care grows,2 but remains patchy.3 The long list of disappointments and failures,4,5 locally and internationally, is also hard to ignore. There is a real dissonance in the discourse between what research evidence tells us is possible and what often happens with large-scale e-health projects in practice.6
The literature repeatedly describes basic “rules of informatics” for implementation success: the need for stakeholder engagement, culture change, user training, slow and considered implementation, and user-friendly systems that fit into clinical workflow.7 The very first rule of informatics tells us to start with the clinical problem we want solved rather than the technology we want to build.8 Yet, too often, large-scale e-health projects break this most basic rule, focusing on technology rather than compelling clinical problems.5 We are often told that national e-health projects must first lay down basic technical infrastructure and that high-value clinical systems will naturally follow, in the same way that laying railway lines is a precursor to delivering transport services.9 But railways can be too expensive, over-engineered, or not take us anywhere particularly useful — unless there is a destination on which we can all agree.
Why so many projects repeatedly fail to observe these basic rules of informatics remains a mystery, but it probably reflects that there are still very few people with deep expertise in e-health.10 Despite the crucial role of the informatics workforce in e-health success, and the billions spent on e-health over the past decade by government, barely a dollar has been in direct support of informatics workforce training.
E-health is hard because it is a complex intervention in a complex system.11 Indeed, e-health projects are probably among the most complex interventions we can undertake, especially at a national scale. The rules for designing e-health at the level of clinical practice are not the same as those at large scale, and the gap is as wide as that between in-vitro and in-vivo clinical studies. This explains why success at individual sites is no guarantee of success elsewhere.
Just because e-health is hard does not mean we can ignore it and do something else instead. The goal is worthy, and alternatives are thin on the ground. We do, however, need to urgently invest in the informatics workforce, as this is no game for amateurs. We must also respect the basic rules of informatics. Like the laws of physics, they exist, whether you like them or not.
---- end article.
If you have access to the MJA go here:
If not, for the full article, references and so on you can e-mail Professor Coiera. He has kindly agreed to send a .pdf of the full article to all who ask. (Be gentle).
You can e-mail him at
Many thanks for making this article freely available to those who don’t have access to the MJA directly.

Also, an interesting paper of a NSW Emergency Department System is found here in the same issue here:

Effect of an electronic medical record information system on emergency department performance

Murugabalaji K Mohan, Rod O Bishop and James L Mallows
and there is commentary here:

Good HIT and bad HIT

Jon D Patrick and Susan Ieraci
Both these are freely available to read at the site! Thanks MJA!

Good to see so much e-Health in the MJA!