Playing devil’s advocate

I suppose someone has to be the naysayer, so let it be me. I’m not exactly against the idea of chief clinical information officers per se, and I’m certainly not against clinical involvement in IT decisions.

However, I do think the EHI CCIO Campaign – which wants every NHS provider organisation to consider appointing a CCIO to lead on IT and information projects - is a bad idea for a number of reasons:

Some fundamentals

First, in general, I don’t think it’s a good idea to dictate management structures to supposedly self-governing organisations.

Does Tesco have a chief retail information officer? I doubt it; but if it does it will be because it thinks it is a good idea and not because the Secretary of State for Shopping has said it must.

Second, unlike, say, Caldicott Guardian - which is a role typically taken by the medical director (sorry, chief medical officer) - the implication is that the CCIO holds an established post.

What will a CCIO cost? It’s difficult to imagine the all-up cost being much less than £100,000 a year. There are more than 200 acute and mental health trusts in the UK, so that’s £20m a year.

Now I know that’s only 0.02% the NHS’ annual budget. But still, this proposal is not exactly in the tune with the zeitgeist. Alright, so what if this isn’t a full time post? A half-time post? (£50,000 per trust; who’d notice?)

Or maybe CCIO becomes a role more akin to the Caldicott Guardian. Perhaps it should become an extension of the Caldicott Guardianship.

However, this would surely represent a major dilution of the original concept. The open letter to health secretary Andrew Lansley that kicked off the campaign states that “NHS information projects need to be designed and led by clinicians”. We’re not talking about figureheads here.

Finding applicants:

And who’s going to take the job? It won’t be difficult to attract applicants (I’m quite tempted myself, actually), but will they be the right people with the right skills?

One of the problems with getting engagement on this sort of thing from doctors, in particular, is that they don’t want to commit professional suicide by diluting or taking time out from their medical practice.

So it’s unlikely we’ll find enough doctors to fill these posts, unless it is clear that it is worth making a permanent career shift to get them.

The EHI CCIO Campaign implicitly recognises this by using the term CCIO rather than CMIO (chief medical information officer, which is what hospitals have in the US).

So then, will they be mostly - I’d bet overwhelmingly - nurses, radiographers and physiotherapists? And if they are, will they be up to the task? Will they have the necessary clout?

Or could these posts be filled by non-clinicians? There are, I believe, nine institutions in the UK offering post-graduate courses in health informatics. Could the graduates of these courses take on the task?

Possibly, but aren’t these the same people who take on information management posts in the NHS anyway? I’m not sure how this moves us on.

Promoting division?

Let’s assume the NHS could afford a CCIO in every trust, and let’s assume decent candidates could be found to fill each post. Is the principle of a CCIO sound? I’m not sure that it is.

Firstly, where does the role sit against that of chief information officer? Will the next step be to appoint a CIO/CCIO liaison officer? The serious issue here is that the CCIO role seems to me to accept and even promote the split between the ‘clinical front end’ and the ‘back office’ domains.

This doesn’t really exist in practice, or at least it shouldn’t. Information is information; if it doesn’t support the operation of the trust in carrying out its role, then the trust has no business in capturing or managing it.

To take an example I came across recently: education and training. It’s about booking people on courses and recording their attendance, right? Well yes, but it’s fundamentally about competence, and competence is based on supervision and experience as well as classroom (or CBT) based instruction.

It’s increasingly about the competence of the teachers and supervisors as well as the students, and about evidence of competence.

So, where is the evidence to be found? Why, in the body of data about clinical transactions carried out in the trust. In other words, the same source as the electronic patient record, just with the lamp shone on it from a different angle.

Any information regime that regarded the patient record and the clinician record as separate would be doomed to failure. This is not to say that the creation of a CCIO post would necessarily lead to data and system fragmentation.

However, I do think it’s a danger, and I certainly don’t think it’s going to help solve the data fragmentation that already exists in most NHS trusts. At the very least, a CCIO post should not be created without very careful thought as to the role and its relationship to other functions.

Ignoring data

The final reason why I’m a CCIO-sceptic is that I’m something of an information-sceptic generally. Or rather, I’m sceptical of the claims made for information in isolation of its poor relation, data.

However, it is data that is the more immediate problem for the NHS. Data has to be captured as a by-product of work. Too often electronic data is not and therefore lacks the timeliness, accuracy and relevance needed for it to be trusted by clinicians.

This presents huge challenges in all kinds of areas: the mobility and accessibility of systems, the quality of applications and their interoperability, the support given to processes and to decision-making.

I believe that the NHS is still way off in this regard and needs to place much more emphasis on enterprise architecture as a means of tackling these challenges. Only then will the informaticians have the raw materials to work with.

The NHS not employing enterprise architects because it can’t afford them and diverting money to CCIOs instead would be a positively harmful outcome of this campaign.

No road to sainthood

I started writing this as an exercise in devil’s advocacy, prompted by the near universal approval that the CCIO campaign seems to have attracted.

I’ve ended up convincing myself that it is at best an irrelevance and at worst, an expensive distraction from the things that really need to be done to provide better information to the NHS.

With the right person in the right organisation a CCIO might work well. But in the context of the NHS as it currently is, I doubt if either of those conditions will be met in many cases.

In an informationally immature organisation it will be a distraction from the core problems: a mandate complied with; a box ticked; a problem not gone away; a patient still dying.