To decay is system: The challenges of keeping a health information system alive

Abstract

Health information system (HIS) architecture and socio-technical approaches for system deployment have been topics of systematic research for decades. Sustainable operation in gradually changing environments, however, has not yet received sufficient attention. Even HIS that have gone life to the satisfaction of their developers and end-users may degrade gracefully or fail catastrophically if not continuously and thoroughly kept in sync with their environment. Critical environmental changes may owe their origins to the complexity of health care and its delivery. Seemingly minor environmental changes can result in significant failures on the part of the information system and may adversely affect the quality of health care delivered. Such minor degradation or near failure may go unnoticed for a while and then hit unexpectedly. Five origins of decay will be analyzed. Methods of systematic observation and containment of such decaying processes will tentatively be presented. Some origins of system decay exist in the immediate hospital or regional setting of usage. Indicators to identify processes of decay will be suggested and methods to preemptively reduce the risk of decay will be presented. Other origins span national health care systems or beyond. Not all such risks can hence be controlled locally. Software Oversight Committees may be an instrument to monitor those risks that cannot be controlled through routine local management.

Introduction

Designing and building information systems for the health care industry has received attention for at least three decades [1]. Despite remarkable technical progress, failures have still been reported when integrating technically sound systems into processes of care [2]. An IMIA IT in Health Care—Socio-technical Approaches Conference in 2004 reflected this theme in its title “To err is system”, alluding to the 2000 Institute of Medicine report “To err is human” [3]. The socio-technical approach of system development and introduction [4], attempts to handle change [5] or user expectations, strains and strain relief systematically [6], beneficial as they may be, cannot prevent significant failures from occurring. The impact of one such failure in 2003 was so deep that it created headlines in national newspapers [7]. But what happens down the road, when a system has been successfully integrated into work processes and has been well accepted by its clinical users, remains to be studied. Will the system remain ‘as is’ for the next month, year, or decade or will it have to be continually altered to suit the changes in the organizational environment? Is it an inherent trait of systems to decay, unless carefully safeguarded against all kinds of influences? This paper points out that seemingly minor environmental changes may cause a system to deteriorate in its usability in non-anticipated ways unless it evolves or its users evolve. The paper also demonstrates that regular upgrades and creative, partially subvert workarounds by flexible end-users can compensate for the process of system deterioration. Other imposed changes can cause catastrophic failures. Mechanisms of decay will be classified according to their origins. Most of these decaying effects will be substantiated by reference to published reports or episodic and systematic observation from the author's work environment. Some speculative ones will likely resonate immediately with professionals in the field.

This is a conceptual paper intended to direct attention to the factors that become effective as soon as a system has gone live. For some of the phenomena of decay a frame of investigation will be suggested. This frame is intended to guide future empirical work in the field of medical or health informatics towards systematic observations that may eventually support or reject the conjectures made in this article. Some suggested concrete methods to prevent decay systematically and to steer systematic evolution need further investigation.