The steadfast tenacity needed to see through a successful implementation of digital health projects and programmes, requires patient, visionary, entrepreneurial and resolute management. eHealth managers or executives can in a long-term track and organise institutional and technical changes necessary to scale and sustain implementations.
Lessons from the achievements of world-changing personalities that shaped and defined past global large-scale technology designs and implementations, are chosen to provide a guide as to how to organise, manage and scale digital health innovations.
To engineer eHealth to scale, managers must be capable of organising, on an unprecedented scale and scope, scientific and technological talents and innovations. Innovating management is evidently needed to transform the current tentative states of global and national implementations.
The defunct NHS National Programme for Health Information Technology (NPFiT) in the UK, in my opinion, partly suffered from a lack of a multi-talented entrepreneurial manager and organiser. Someone in the mould of Vannevar Bush: an interesting personality with hybrid skills that were brought to bear over the course of the 2nd World War.
An eHealth manager as an organiser must possess certain hybrid skills. He or She must possess a mixture of technical, leadership, business and political skills. As the dynamics of digital health innovations are driven by a complex and uncertain global value chain, He or She must also be conversant with rapid turnovers of talents and technologies, and track and master industrial and institutional trends and changes. Staying the course in face of constraints and risks, and by being patient and entrepreneurial, are what will keep resolute managers on course.
The impact of an individual or institutional resistance can be retrogressive for digital health adoption. A challenge that NPFiT’s implementation struggled with, as I came to realise during my membership of the NHS Faculty of Health informatics between 2006 and 2008.
Resistance to digital health adoption could arise from underprepared users or overwhelmed organisations. It is not uncommon for a new digital health implementation to catch users and organisations unaware. An unforeseen and unintended ‘care surge’ was reported with NHS 111’s introduction, for instance. Underprepared, hospitals are struggling to cope with a sudden rise in emergency medical care demands. Nonetheless, relentless innovation and constant engineering, are necessary actions to sustain and scale eHealth implementations, and to also minimise the risks of user and organisational resistance.
The Health and Social Care Information Centre (HSCIC) is pushing for an effective digitalisation of the NHS; as I learnt from a Westminster Briefings event on Transforming Technology in Health and Social Care. At the event, there was an air of optimism that the new organisation will foster and encourage local digital health innovations and enterprises. However, there is a still a conundrum on how the issue of institutional resistance would be tackled head-on, for implementations to be successful.
Notwithstanding, a digital health implementation can spur or deepen healthcare reform. For instance, in the US, a consolidation of its healthcare system is occurring, being driven by large-scale EHRs adoptions. Smaller clinics are merging together, and are being acquired by bigger ones. This consolidation could bring about health information aggregation, in the way that the HSCIC’s General Practice Data Extraction service will serve primary healthcare informatics in England.
Global health system crisis
The daily reports of dwindling finances and scarcity of skilled human resources to tackle global health problems, would strike a chord with many nations’ policymakers at the beginning of the 2nd War World. It is not overstating it, to say that the global health system is in crisis. The onslaught of life-long diseases, unpredictability of viral pandemic outbreaks and the stickiness of infectious diseases, give a sense of a crisis. If you are a doctor, manager or a policymaker, tirelessly striving to cure, manage or finance, feeling of a siege mentality, is not far-fetched.
The feeling of siege mentality that comes with a crisis, and that influences and expedites actions during wartime, might not be too different from what the global health system is being subjected to. Being under siege could be a spur for action; as opportunities abound in a crisis. Thus, implementing eHealth at scale is possible and feasible, even at this time of a global economic and epidemiological crisis.
To wit, resistance often encountered with digital health adoption in the global and national health systems, can benefit from the resoluteness and patience of a hybrid-skilled leader.
Vannevar Bush’s personality typifies a successful technology organiser and that embodied the aforementioned hybrid skills. During the 2nd World War in the US, Bush forged and fashioned a reported hugely successful national innovation enterprise – the Office of Scientific Research and Development (OSRD). The achievement was made possible by an unprecedented smart mobilisation of industrial might, technical competences, political currency, scientific talents and financial power.
In his magisterial biography titled Endless Frontier, where he was ennobled as the Engineer of American Century, the reported use of his multiple talents was evidently shown in his stellar achievements. To start with, Bush was both a public and private sector entrepreneur: an industrialist, an engineer, an inventor, and a technocrat. He co-founded Raytheon, a pioneering electronics design and manufacturing company. His entrepreneurial success also included forming a company that designed an early commercial mechanical thermostat. Google’s recent acquisition of a digital thermostat start-up: Nest certainly strikes a chord; and signals a technological and industrial progression from mechanics to electronics. He co-conceived theManhattan project, which created the first atomic bomb, and headed the Carnegie Institution of Science. As a pioneering computer scientist at MIT, he envisioned our digital age and the need for personal computers.
Professor Bush was probably the first person to articulate a vision of academia-industrial-governmental collaboration, which set an intellectual foundation for relentless innovation. His political closeness to President Frederick Roosevelt, at the time, reportedly contributed immensely to his managerial and technocratic success at OSRD. At MIT, he inspired his students and protégés to invent and innovate, some of whom later went on to implement his digital and industrial visions. For instance, his student, Claude Shannon’s Information Theory revolutionised the digital industry and Fred Terman, his protégé, went to found the immensely creative Silicon Valley in California.
Bush’s British counterpart, Sir Henry Tizard – the UK’s wartime Chief Science Officer under Prime MinisterWinston Churchill, was also an organiser and manager of science and technology. BAE’s electronics and mechanical current industrial vertical integration harks back to Tizard’s technology foresightedness.
A hybrid-skilled eHealth manager that displays patience and resoluteness is needed to overcome encountered institutional resistance, in order to both foster and forge long-term implementation, and to spur innovations. And the energy and purposiveness of a wartime techno-economy can be a guide for action.
The way the US government financed and spurred a techno-economy at the OSRD, is also being employed to take the opportunity afforded by its health system’s crisis in order to advance its national eHealth implementation. The enactment of the Health Information Technology for Clinical and Economic Health(HITECH) Act in the US is case in point. A similar act that was enacted in Australia included large-scale eHealth implementation as part of its national broadband techno-economic stimulus. An article in Forbes Magazine pointed to HITECH‘s catalytic effects on innovations and entrepreneurship, as indicated by venture capitalists’ interests in digital health start-ups and acquisitions.
The 2nd World War crisis afforded the American and British governments, an opportunity to mobilised science and technology, finances and talents at on an unprecedented scale, to urgently address – aninnovation gap. A techno-economy was created due to a bilateral open trading of talents, technologies and finances between the two countries, which bridged the encountered innovation gap. Nowadays, digital health implementations, also depend on the global value chains for acquiring talents and technologies. Already, there exists a bilateral cooperation between the EU and the US on digital health innovation and business.
Talents and technologies were exchanged between, and mobilised by, them, at an unprecedented scale and scope. And these created new machines and techniques, and the supportive institutions that drove and sustained their effective invention, production and utilisation, were forged. The massive mobilisation of public and private investments, industries and incentives, at the time, drove unprecedented streams of medical, computing and telecommunication innovations. To wit, the entrepreneurial actions, set a foundation for the technologies we are still benefiting from today. Advancements that would make Sir Francis Bacon, the 17th Century English visionary and promoter of science for the public good, grin in his grave.
The science behind some medical innovations such as MRI and nuclear medicine for cancer patients that we are benefiting from today, can be traced back to the technologies created during the 2nd World War such as radar and atomic bomb.
Organising eHealth implementations
The inspiration that can be drawn from Vannevar Bush’s achievements, and the advancements made possible by a crisis techno-economy, is that eHealth implementations can scale and sustain, if governments provide financial and institutional incentives. Creating and empowering a national implementation agency, headed by a hybrid-skilled manager, will make digital health innovations to flourish.
In encounters with managers of various eHealth projects and businesses meetings in Africa, Asia and Europe, I have noted that few managers possessed all these requisite skills on their own. It is always the case that, the preferred hybrid skills are usually distributed in a shared leadership team. Even so, shortage of in-house talents in an implementing organisation, are mainly compensated for by hiring contractors.
Not that there is something wrong with the principle of hiring contractors, but that ‘learning on the job’ builds in-house talents. Implementing large-scale electronic health record programmes needlessly be embroiled in political controversies (i.e. the Ontario, Canada national eHealth implementation contractor scandal and still raging political imbroglio), if in-house innovation and talent were nurtured.
The unfortunate premature closure of the BBC Digital Media Initiative (DMI) makes a strong case for institutionalising an in-house culture of innovation for digitally complex and spawning programmes. Though, its closure smacks more of a fiscal austerity imperative than of a Schumpeterian innovation quest – in a jiffy no mention is being made of BBC’s industry- changing innovativeness with the iPlayer. Nonetheless and with a benefit of hindsight, a NAO review, reported the contracting out of the DMI’s software development as one of the factors that contributed to its protracted development cycle and to its unfortunate, but, eventual demise.
Relentless innovation and experimentation that characterise long-term eHealth implementations go in some way in nurturing and developing talents. An inevitable organisational learning, which comes with accumulating knowledge and talents from digital health innovation ‘trial and error’ dialectics, can in the long-term cancel-out short-term gains expected from contracting-out technology development.
A patiently managed national eHealth agency ably manned by a resolute organiser will drive digital health implementations in the long-term. A politically-savvy, technically competent and business-minded leader, can network effortlessly with rapidly changing industries, institutions and global value chains. And by mobilising talents and technologies, a technically competent manager can deal with the complexity and uncertainty that typically frustrate adoptions. An organisation, headed by an entrepreneurial leader, can go a long way in overcoming institutional resistance often encountered in and during implementing digital health innovations.
The tentative states of national eHealth implementations all over the world, call for a re-thinking of the current implementation management science. Overcoming the knotty issue of individual and organisational resistance is in need of an alternative mode of managing and organising implementation and innovation.
Some countries have instituted a national eHealth agency, typically headed by a technocrat; and these seem to be doing a wonderful job in steering their national digital health implementations. A notable example is the US Office of the National Coordinator for Health Information Technology (ONC).
With no offense intended, many would agree that the heads of the national eHealth agencies are not in Bush’s mould. Most might be competent managers, seasoned technocrats, or even technically sound engineers, but there is a high probability that few had experience as private sector entrepreneurs, inventors or industrialists. I was privileged to meet an ex- ONC’s technocrat back in 2007, though an experienced physician, his resume did not include these qualities.
The constant changing of the ONC’s technocrats, suggest that they were not fully delivering on the HITECH Act objectives. They, perhaps, were not multi-talented and entrepreneurial managers; all-embracing organiser; who can foster timely innovations, and can, keep apace with organisational upheavals and technological changes. And, suggestively, there is nothing to indicate that the newly appointed ONC’s czar, an experienced technocrat, possesses the requisite business or industrial experience.
Perhaps, the expanding national eHealth implementation in China will provide us with a prospect of witnessing a successful scale. China’s plan is ambitious for its large population size and geographical expanse, but its rapidly rising digital industrial base, gives room for optimism and for breeding talents and technologies.
Forging digital health
The digital world was envisioned by Vannevar Bush back in the 1940s, but, getting digital health innovations to scale and sustain are still a struggle.
An organisation, in the kind of OSRD, is suggested as paramount for harnessing and utilising digital health’s might for fighting global battles against diseases and contagions. Marshalling the latent power of Big Data, in its self alone, can both empower and enable scientists and engineers to smartly and preparedly deal with and tackle these battles. For instance, there are always rooms for creating game-changing therapeutic or diagnostic technologies. And to accomplish these, digital health implementations, must be manned by hybrid-skilled and resolute managers and leaders. Who must as Bush, be as much visionary and entrepreneurial, in order to spur creativity and marshal large-scale implementations.
Vannevar Bush, as an organiser and a manager, brought to bear his multidisciplinary experience as, an entrepreneur, an industrialist, a technocrat, an engineer; and a scientist. He harnessed the ingenuity and resourcefulness of a crisis to set a solid and generative foundation for America’s still unrivalled scientific, entrepreneurial and industrial leadership. Individually and collaboratively, he employed men, machines and money to alter the course of technological and human advancements. His ideas for innovation-fostering institutions in education, industry and government are still inspiring for solving today’s challenges.
eHealth managers can learn from Professor Bush surprisingly technology shortsightedness. His display of a lukewarm attitude towards the prospects of the then emerging satellite and missile technologies, mentioned in his aforementioned Biography, must be avoided.
The scaling and sustaining of an eHealth implementation, require a resolute leader and a patient manager. Such a person must emulate Vannevar Bush or Sir Henry Tizard, as an organiser of science and an administrator of technology inventions and utilisations.
Digital health trade must be facilitated, as the US and UK did during the 2nd World War, but, it is advisable that managers master global chains' complexities and potential vulnerabilities.