Why “Paperless” is Meaningless

Pritpal S Tamber

January 20, 2013

Because it means we pursue an idea without understanding what's really needed

The National Health Service (NHS) of England is enduring the enthusiasm of a new health secretary. As he gets to grips with his £110bn toy he is, as you’d expect, eager to make the right noises about the future of health care. One of his promises, though, is to make the service “paperless”. This only illustrates his complete lack of understanding of innovation.

Why should NHS England be “paperless”? What has paper done that necessitates its complete extermination from the service? It seems paper’s crime is that it’s not digital. The information it holds, as ancient ink absorbed onto its surface, cannot be extracted, aggregated and analysed without expensive and slow processes that endanger patient confidentiality. Becoming paperless would, as a by-product, also enrich the NHS with much needed data, its bigness being the panacea to our inadequate research information and unjustified variations in performance.

England’s politicians and bureaucrats are once again trying to sell us a big vision. The last time they tried this was with the now maligned National Programme for IT, whose only success was to be the perfect illustration of how not to implement information technology, and why top-down mandates are rarely effective. How is it, then, that we’re once again enduring a top-down mandate when we know from recent and bitter experience they simply do not work?

Well, what else can he say? He’s the new health secretary. And like all new kids at school he’s eager to impress before the bullies come looking for a fight. But by choosing “being paperless” as an aim, all he’s really doing is postponing his demise. Why? Because it’s a solution looking for a problem; it’s an innovation looking for a need.

Most people want innovation. Most people can point to some problem in their life – an activity or process – that they wish was more efficient or accurate. Many people can even tell you what changes need to be made. Some, especially younger people, see lots of opportunity for innovation because they have so many experiences of better activities and processes from other areas of their lives. What all of these innovations have in common is that they address a “user-expressed need”.

If you ask the average clinician if they want their work life to be “paperless” there are undoubtedly a few who will say yes. A large number, though, would be reserved, their reservations rightly based on government’s exceedingly poor record in delivering solutions through information technology. Many just prefer things be left the way they are. They know that when “leaders” try to change things they inevitably mess up – leaving the clinicians and patients to clean up the mess.

However, if you ask clinicians what activity or process they want to improve there will undoubtedly be an almost limitless list. Many of the solutions they’ll be seeking will be IT in nature and will likely reduce the amount of paper being used. Becoming paperless, then, is a by-product of addressing user-expressed needs. It is not the aim in and of itself.

This is not a hair being split. This is about finding the open doors that need only a little push. It’s about government – or in this case the Commissioning Board that runs NHS England – engaging the people they serve and understanding their needs, rather than dictating a solution and hoping the people will find what the problem was. It’s about creating change in places where people are inviting it. And, in the longer term, it’s about building trust so that further – and perhaps more radical – change is possible.

By its very nature, innovation happens in slow, incremental steps. It requires a meticulous understanding of what users say they want. Politicians, by contrast, look for quick-wins and headlines. The two are incompatible. I’d like to be wrong but I don’t think it’ll be long before the bullies come looking for a fight.

Competing interests: I do not believe I have any competing interests in relation to this post. 

This post was first published on my original blog, Optimising Clinical Knowledge, and co-posted on BMJ Blogs.

Pritpal S Tamber

I’m a doctor who trained as a medical editor and publisher and now researches and consults on the link between community power and health equity. My interest in community power started when I was the Physician Editor of TEDMED and is explained in My Perspective. I also work as a freelance medical editor and publisher for organisations that want to write high-quality articles and a strategy for their publishing and promotion. Find out more on my About page.

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