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Hospitals and Management

1.1. Introduction

At a time when new information and communication technologies (NICTs) are disrupting our daily life and, every day, exerting greater influence on our private life, it is instructive to study what impact they will have in the hospital field. It is important to ask ourselves how these technologies can be used in the future. Let us state this right away: health establishments are not best prepared to optimally use NICT. Information technology (IT) has been disliked in this field for quite some time.

The hospital world is one of those rare spheres where, even today, secretaries frequently use typewriters for letters. The blame for this can be apportioned among several parties: any number of health ministers have extended an outdated system, preferring written documents and physical consultations over paper-free exchanges; any number of hospital directors have regarded digitization as an expense rather than an investment; any number of doctors have resisted attempts to digitize medical files.

The aim of this chapter is not to point fingers, but to establish the current state of IT in health establishments, specify what needs to be done and to look at the possible uses that can be made of NICT.

1.2. Imperfections in hospital information technology

Hospital IT systems often suffer from the same shortcomings - from seven deadly sins! These are as follows: the engineer's dream, the lack of support, the jargon, hospital-centrism, ergonomic heresy, forgetting productivity and the absence of an IT strategy.

Here again, I do not wish to accuse any specific entity, especially not the IT teams, who are doing their best in a hostile world. The weight of local tradition, budget problems, the present offering available, generational problems, power structures within an institution as complex as a hospital - all these are so many obstacles to finding the optimal solution.

One can be aware of these difficulties and still be clear-sighted and wish to do better - so let us first begin with a diagnosis of the problems that often plague hospital IT systems. The engineer's dream is characterized by a constant striving for technological excellence at the cost of all other considerations, especially those of cost, utility and functionality. In all my postings as directors, I have always had the privilege of having an office telephone with at least 30 buttons on it (I have had machines with up to 60 buttons!) and - I assume - countless functions that they can perform. I say "I assume" because I was almost never told how exactly this telephone worked. On the few occasions it was explained to me, I remembered nothing, either because most of the functions were of no use to me or because I used them so rarely that I forgot how they worked (often a complex process) in the interim. I only ever used about 10 or 20%, at most, of the functions offered by these technological marvels - the perfect example of sheer waste born out of the best of intentions. The people who had bought it wished to offer me the ideal product, without considering the cost, what I would really require from a telephone, nor the ergonomics of the apparatus; sometimes I was not even told about the functions or working, because it seemed so obvious to the technician! What was true for the telephone holds true for pure IT: nobody has seen it fit to explain to me the in-house programs on my PC desktop and I have never bothered about them since I never use them.

The lack of support is another recurrent failing. Without an adequate budget, future users of these programs never receive sufficient training. The effectiveness of the training is very rarely verified after a few weeks or months of use. Newcomers who may have missed the initial training are sometimes trained on the job. Being chiefly passed on through oral instruction, the available knowledge on equipment and software soon peters away and consequently we also lose out on the professional benefits that could have resulted from it. It is essential to remember that oral transmission of learning is not the best tool to safeguard and record information. Furthermore, even the simplest software needs to be learned, especially since knowing how to run it is not the same as being able to use it correctly. One simply needs to sit through a few Powerpoint presentations to see the truth of this. Who has not seen an overcrowded slide, with the font size so small that even those right in front of the screen are unable to read what is written? If the text is legible, then the presenter insists on reading it out verbatim to their literate audience. Thus, this presentation tool, intended to make material come alive and be easily memorized, becomes an instrument of torture and boredom and, therefore, leads to poor attention and forgetfulness.

The communication gaps between the computer scientists and the rest of the hospital staff contribute to this. Of course, every profession has its own jargon and guards it jealously, but I find that the chasm between the IT world and the medical world is especially wide, despite the medical world seeing a wave of newcomers who take the Internet and digital resources as much for granted as their seniors do running water and electricity.

Hospital-centrism is another problem that is not only restricted to the context of IT. We are only too prone to reproduce what already exists in health establishments, without looking to other domains for innovations. Thus, we keep looking out for references to hospitals in the range of functions offered by products or services that are really not specialized. I have seen this with elevators. What difference can there be in how people are transported up and down a building, regardless of whether they are sick, healthy, nurses or bankers? The only result this has is discouraging many companies and reducing the number of suppliers to a hospital.

These suppliers often tend to perpetuate this herd mentality by offering one hospital what is already being used in other hospitals. They can thus avoid renewing their service offerings. For instance, I have had architects suggest, for a new building under construction, light fittings that are identical to those in another hospital building that was built a dozen years ago, as if technology and design have not changed in over a decade! This also exists in the IT world. To give you just one example out of many, medical file editors still function with an MS Office suite type of ergonomics, light years removed from the Android and iOS models that dominate the world today. All of this limits innovation and ends up costing the hospital dearly.

The lack of ergonomics is common and is almost a trademark of first-generation mass-market IT products, especially in their PC versions. As proof I offer this anecdotal, but illuminating, question: why did it take until Windows 10 before users no longer had to click on "Start" to shut down their PC? One of the reasons for this situation being as it is that designers of IT tools sometimes forget to step into the shoes of future users or even end up giving greater value to their comfort compared to that of the users. For example, on Windows PC keyboards you need to press on two buttons for a colon (:) but only one for a semicolon (;). But who really uses a semicolon? The average end-user, who chiefly uses the colon for punctuation, very rarely uses the semicolon and it is in fact the programmer who needs to use it very frequently. However, programmers make up a tiny fraction of the overall users of a PC! End-users of technological products are looking for practical and, if possible, aesthetically-pleasing products; as with any other consumer, they prefer products with a good design. It was based on this observation that Steve Jobs relaunched Apple - and so successfully that the company eventually overtook Windows to reach the number one spot on the stock markets. It began with the iMac in 1998, which was infinitely more elegant than the PCs of that era; then came the iPod, which wiped out the Walkman; and then, finally, the smartphone that dethroned Nokia and Blackberry.

Of course, hospital staff are subject to the purchasing decisions carried out by their institution. But though they lack the power to choose the product that pleases them, they can still ignore that which is offered to them. Passive resistance results in an enormous loss of money, efficiency and energy, even if it is overcome - which is not always the case. Then again, IT is an investment. At a time when hospital budgets are being strictly controlled, they must improve productivity. Unfortunately, this imperative need is sometimes forgotten. It may even happen that the IT products used add to a person's workload instead of reducing it. Lawmakers have sometimes contributed to this by mandating, for many long years, that hospitals conserve paper records, as well as digitized records. While this requirement has been lifted, it has not completely solved the problem: even today, physical medical files often co-exist with the digitized files.

More generally, investment in IT is only rarely accompanied by the implementation of a programme that studies and produces figures for the return on investment. One of the reasons for this gap is that IT has almost never been at the heart of hospital strategy. As Seneca said, "If one does not know to which port one is headed, no wind is favorable." In this respect, the law that made it compulsory for hospitals within one territory to work together was immensely innovative as it...