Around three years ago I was invited to speak at a consultant psychiatrists committee meeting about social media and digital technology. I was mid way through my PhD and steeped in online ethnographic research about how people accessing mental health services and practitioners were making use of social networks. I had an inkling that I would have a mixed audience and I knew that not everyone would share my (then*) enthusiasm. As such I spent time preparing a range of compelling examples of digital technologies and social media practices, determined as I was to win over any detractors.
I arrived a little early and so listened in to the tail end of an exasperated discussion about the various grinding limitations, obstacles and shortcomings of the in-house electronic patient record (EPR). If my audience’s primary experience of technology in health was such a bad one, then this did not bode well for my presentation – I quickly realised I was going to have to recalibrate. How could I be so naive as to think a conversation about the future potential of digital technologies would be welcomed, when the basics of reliable and effective electronic patient records seemed like a pipe dream?
This experience came back to me whilst reading The Digital Doctor – Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age (Wachter, 2015) which is dominated by an expansive analysis of the shortcomings of contemporary electronic patient records. Wachter argues that EPRs have brought many a physician ‘to their knees’ with their clunky, confusing and complex systems (73). It is salutary to note that three years on from that consultant psychiatrists committee meeting, the basics still do not appear to be in place.
Whilst the book is set in an American context, in many ways it echoes the slim foundations we have in place for digitally enabled health care in the UK. Workforce access to smart devices, public wifi, and permissive policies for use of the internet and social media are not uniform or consistent. One sexual health worker recently recounted to me how, when collaboratively searching for information on the web with a patient, her search terms had been blocked by the organisation’s firewall. This was not only embarrassing for her but she felt reinforced the stigma associated with the sexual health condition her patient was experiencing. Her well intentioned efforts had backfired for both of them and a policy made with good intentions had impeded her clinical work.
So what is going wrong? Wachter argues that part of the reason may be that we mistakenly approach digital in healthcare as a technical problem to be solved when in fact it is adaptive – one that requires people themselves to change. Without redesign of workflows we at best risk not realising the full benefits of digital technology, and at worst run the risk of adding more work and more requirements into an already stretched system (not to mention risks).
“Health IT is not a technical project, it’s a social change project.” (243)
This quote jumped out at me as it strikes at the heart of the approach we are developing at mHabitat where we focus on people first and technology second. Too many initiatives seem to start with the technology and then look for a problem to solve. At mHabitat we already spend a lot of time on problem definition, but reading the book made me realise that we need to do more – we need to persuade health and care services that time spent understanding problems is never wasted. Not only do we need to design collaboratively for the system, we need to spend time in the system, observing it in action wherever possible. It is the insights gleaned from this approach, alongside codesign with patients/citizens and staff, that will make the difference between failure and success.
A social change project isn’t ever delivered in one go. It requires iteration upon iteration and continual tweaking and fine tuning. It is not just about work flow, it is about the workforce and about culture, not to mention leadership. This is the way we need to approach digital technology in healthcare – working in the system, diagnosing the right problems and developing, testing and seeking feedback in small iterative steps – skipping them is not an option.
Back to my consultant psychiatrists committee presentation. They listened politely to what I had to say. Some expressed discomfort at a glimpse into the future of social media and digital technologies. Others were enthusiastic. Most however, found it hard to lift themselves from the here-and-now complexities of the EPR to think about how any of this could become relevant or meaningful to their day to day practice anytime soon.
I wonder if I went back now, what would have changed?
*I remain enthusiastic but much more attuned to the limitations and challenges of digital technologies and online social networks than in the early days of my PhD research.
