The Future of Healthcare Services Technology?

The NHS National Programme for Information Technology

Final Project for MBA 290T-1 Innovation in Services and Business Models 12/10/2009

Gabor Foldes Ushan Ganeshananthan Jean Lu Kieren Patel

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I. Introduction The United Kingdoms National Health Service (NHS) launched the largest civilian information technology (IT) project to date: the National Programme for Information Technology (NPfIT). Faced with antiquated, inefficient, and often incompatible IT systems, the UK government launched the NPfIT in 2002 to revolutionize healthcare services. The NPfITs central vision is to introduce electronic health care records for patients, facilitate online access to patient records, and provide electronic booking and management services to all patients, and physicians, clinicians and other healthcare professionals throughout the UK. NHS Connecting for Health (NHS CFH), a directorate of the Department of Health, is in charge of managing and implementing the NPfIT project as the owner and service provider. The vision behind the project is to create efficiencies and increase quality in the delivery of healthcare to citizens of the UK by making information more open, standardized, and accessible. The stakes are high for a project of this magnitude. The NPfIT serves as the benchmark not only for the UK but for the future of public healthcare IT worldwide. Initially budgeted to cost 2.3bn with targeted completion by 2006, the program is now estimated to cost 20-30bn with completion of many programs uncertain. With low user rates, enormous cost overruns, and an increasingly dissatisfied public, the NPfIT provides an ambitious yet cautionary example of services innovation at such a scale. We analyze the major themes that underpin the NPfIT intiatives, based on tools and frameworks discussed in the Innovation in Services and Business Models class. We highlight specific initiatives and relate them to service innovation concepts. Then, we critique some of the critical design and implementation decisions so far and provide recommendations for

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improvement. Lastly, we conclude with next steps for the program, including the boundary conditions and lessons relevant to similar IT projects in the future. II. The Many Pieces of the NPfIT The NPfITs core is an integrated system called NHS Care Records Service. This consists of two parts. The first part is a local detailed clinical patient record used by local service providers where the patient receives most of her care. It is a comprehensive report that is usually required by general practitioners (GPs), community clinics, and hospitals and includes information such as test results, drugs administered in the patients past, and records of hospital visits. The second part of the service is called the national summary care record, a snapshot of a patients record that is accessible on a national level to facilitate emergency care for people away from their own local service providers. There are 35 additional different systems and services planned, ranging from the maintenance and transmission of medical records, to the secure access for specialized NHS professionals, to e-booking for appointments (Fig. 1). We primarily focus on the most novel service components of the NPfIT at the national level. Holding the Pieces Together With the SPINE The central IT component of the system is the SPINE, a set of IT solutions that provide storage of and access to patient information.1 It serves as an aggregator of demographic information about patients, their clinical records (such as allergies, adverse reactions to medicine, treatment plans, etc.) and other data to create reports and statistics for research, planning, and public health delivery. Once fully implemented, SPINE will allow for secure access to summary information wherever and whenever a patient seeks care from the NHS. This

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aggregated data will help facilitate better care by providing doctors with higher quality patient information and assistance in formulating a treatment plan (Fig. 2). The SPINE also includes a set of security services to ensure the secure and controlled access and transfer of confidential information. Security is a major issue surrounding electronic health services and it is a point of great scrutiny for the NPfIT project.2 Private solutions in the past have failed to reach economies of scale partly because of their inability to persuade enough people that their personal data are safe. Safety and data protection proves to be one boundary condition that can limit the openness of services in general. The SPINE contracts with vendors who are leading IT providers to create the IT infrastructure. This practice exhibits outside-in openness, although only to a limited extent. Vendors were originally organized to provide expertise on different components of the NPfIT and manage IT infrastructure on a regional basis (Fig. 3 and 4). For example, BT was awarded a 10-year, 620mm contract to establish the data storage facilities and the broadband communication backbone. Another vendor, Atos Origin created the Choose and Book

scheduling system.3 As discussed later, this fragmented approach lacked coordination from the outset and caused frustration and low adoption rates among doctors, as later discussed. The SPINE is the first step in the establishment of an electronic healthcare ecosystem. Each of the additional 35 services will touch the SPINE in some way. It will allow the establishment of a multitude of applications that handle patients health records, transfer images, and manage the development of NHS staff. In the future, the SPINE could become a major source of inside-out openness as the aggregated data on patients and treatments will provide opportunities for predictive care and further research. The ecosystem will undoubtedly need outside companies to continue to innovate.

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An example of the ecosystem the SPINE helps to foster is the Blood Safety Tracking service.4 Every year, around one million blood transfusions are carried out in the UK and a significant risk is administering the wrong blood type during transfusions. The Blood Safety Tracking service tracks blood from sampling to transfusion using a smart device. Blood bags are tagged using active radio frequency identification (RFID) technology. At the time of transfusion, staff will use hand-held readers to access the passive RFID chips embedded in each patients wristband to confirm identification and blood type. In addition to increasing safety, the system also provides more detailed data on the collection and usage of blood. Accessing the NPfIT Services: Creating and Maintaining Knowledge via Platform With a multitude of services offered at local and national levels, the central planners of the NPfIT sought to centralize service delivery through a user-friendly interface. HealthSpace (HS) is the personalized portal for the patient, giving her access and management tools for her medical information. Patients can access Choose and Book, their Health and Medication details, Summary Care Records, a Calendar function and personalized library of websites from the HS portal. HS is a foundation for economies of scope. Through HS, the NPfIT can expand its offerings to the patient seamlessly. Once patients use HS, the acquisition, marketing, and distribution costs to deliver each new service is lower. There are also synergies between the services; for example, a patient who schedules his appointments through Choose and Book will likely also use the calendar functions. In this way, HS is a one-stop shop. HealthSpace also enables co-creation between doctor and patient and increases the utilization of knowledge through its use of platforms. Unique to HS is the patients ability to edit their records for accuracy and healthcare providers access to these records. This is designed to prevent medical mistakes and reduce multiple tests, such as X-rays, ultimately translating to - 5 -

lower healthcare costs. The power of this innovation is the indestructible nature of information. For instance, if an allergy test requires assessment by a specialist, electronic test results can be perpetuated across the entire system with better fidelity, thereby boosting the utilization of the test.5 Furthermore, by placing the information on a platform accessible to both the patient and provider, the health care record can improve the quality of care. Precious face-to-face meetings can focus on tailoring a better treatment plan. Less time is devoted to a patient's mundaneand possibly flawedrecounting about the other care she has received. Using co-creation is both necessary to bring patients on-board and may prove useful if patients better comply with recommended treatment plans. Another example of one-stop shopping is eSpace, a portal devoted to healthcare providers.6 It is an online portal available to all doctors and staff, full of updates and information about various initiatives. As is the case with many IT projects, eSpace also allows for economies of scale as the fixed setup costs are spread over an increasing number of users. By building this platform, CFH makes each incremental initiative (e.g. a referral system for job hires) cheaper too. Slotted under the "Capability & Capacity" initiative, eSpace can help doctors share the tacit knowledge that is essential to their profession. eSpace offers a learning community for practitioners so they can query colleagues and build relationships, expanding their networks beyond those they regularly meet. A doctor can also access his peers to learn how to navigate the complex changes and updates to the NPfIT. Thus, the doctor is co-creating his understanding of medicine and experience, representing one of the most fundamental shifts in modern medicine. Finding a Doctor Through Markets and Networks The Choose and Book (CaB) service, as mentioned before, is exemplary of a two-sided market. CaB is an online booking service that allows patients to choose and book their hospital - 6 -

and clinical appointments. Previously, the GP would direct a patient to a specific hospital. Now CaB functions as the platform, which connects patients, primary care clinicians, and secondary care clinicians. Under the new system, the patient consults with the GP on which kind of secondary care is appropriate. Then, GP provides the patient with an appointment request letter with a unique booking reference number, NHS number, and a list of suitable hospital options. The patient then chooses the provider and the time and date of his appointment. The platform also provides crucial performance information regarding the quality of care to the patient. There are cross-sided networks effects: the more patients there are in the system, the more hospitals will use the platform and vice-versa. As with all platform strategies, it is critical to persuade the distinct user groups to use the system. Table 1 summaries the potential benefits offered by CaB to different users of its twosided market.7 Table 1: Benefits offered to different user groups of CaB Patients Choice regarding healthcare service More convenience regarding scheduling appointments Less waiting time More transparency Primary Care Providers Better referral and communication procedures with hospitals Less administrative time on checking appointments No paper trail Information at fingertips Secondary Care Providers Reduction of patient noshow ups Better communication with GPs Better management of clinical workload Less paperwork

Similar to how Intel faced resistance from its customers and the creators of the components when it introduced the PCI bus as the cornerstone of its platform strategy, the NHS also faced many GPs and hospitals that refused to adopt CaB. Despite their reluctance and technical shortcomings of the system, 97% of the GP practices use CaB with over 16,000 bookings per day.8

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Innovations in Data and Knowledge Utility One of the intended consequences of using the NPfIT platforms to aggregate, organize, and publish information is higher data utilization. The Secondary Uses Services (SUS) exemplifies this by aggregating statistics about appointments and overall service and storing it onto a central warehouse. The CFH recognizes that medical appointments generate much information that "is of value for many other purposes to support healthcare."9 SUS collects the data and provides a "dashboard" for providers to compare their progress to that of other providers. This tool allows for the recycling or re-use of information by boosting utilization. This system might provide statistics on how much time certain doctors spend with their patients, how successful certain doctors are in treating diseases and other metrics related to success. Given that the system aims to provide "health surveillance and monitoring, doctors can compare practice habits and performance levels, which may lead to better guidelines for the standardization and improvement of medical procedure.10 A successful implementation of SUS would take

advantage of the R=G, N=1 paradigm mentioned by Prahalad and Krishnan.11 By casting a wide net for resources such as care information, a doctor is better informed about how to treat the next patient. Ultimately, informed decisions through higher utilization of data housed on a standard platform will result. Another interesting service tool is the The Map of Medicine, a tool for achieving clinical consensus throughout a healthcare community.12 It collects and organizes best practices related to treating about 400 different conditions, contextualizing facts into tacit knowledge. Doctors and clinicians tend to operate in silos and some of their specialized knowledge is difficult to access. The Map of Medicine attempts to create a consensus based on the current and evolving knowledge of these specialists. The service currently details best practice procedures for

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accidents and emergencies and in fields such as cardiology, dermatology, elderly care, and obstetrics. Similar to blueprints, the Map of Medicine is a visual tool that lays out the treatment process from the patients perspective. III. Criticisms and Recommendations Despite its ambitious goals and small wins to date, the NPfIT has been mired by numerous delays and isby any measurea financial black hole. Originally budgeted at 2.3bn, the project is expected to cost 20-30bn and with a completion date in 2-5 years or beyond. Furthermore, mismanagement on many levels has spurred two of the largest IT contractors Accenture and Fujitsuto leave the project. A growing dissatisfaction among both patients and doctors has lead to low user rates of the system. While there are numerous factors contributing to this crisisranging from political to managerial to financialwe focus on flaws related to both design and execution of the services. Each recommendation summarizes the current debate and relates suggestions for improvement to service innovation concepts. Recommendation 1: Embrace Openness in the NPfIT Design One of the most fervent debates surrounding the NPfIT is whether a centralized SPINE service is needed at all. The imposition of a monolithic central database and record service has created great friction between GPs and the government as well as great anxiety among patients. From the GPs point of view, the central SPINE database mandated that they adopt new platforms that often had limited functionality, to the potential detriment of patient care.13 The designers of the SPINE system overlooked the fact that GPs were nearly 100% computerized by time SPINE came into effect (Fig. 5). Before the SPINE system was implemented, many GPs took the time to engineer their own systems, to determine what was possible, and to implement

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what was best for their practices. The needs of doctors working at University Hospital in London are fundamentally different than those of a clinic operating in rural Scotland.14 In an effort for mass standardization, the NPfIT planners disregarded the tacit knowledge reflected in the customization of lead users in the GP community who had built and developed their own IT office systems with functioning tools. From the patients perspective, there is a strong and persistent public fear that centrally stored data, away from local hospitals and clinics, is unprotected and susceptible to privacy invasion. Electronic medical records present major issues for security which have been addressed in part but have yet to earn public trust.15 Given the spiraling costs and GPs resistance to adopt SPINE-based systems, we recommend that the central system should be scaled down in favor of an open and modular system that relies on interoperable local systems. In this new arrangement, all records are created and stored locally at the hospitals and clinics where patients receive care. This change would keep records closer to the doctor-patient relationship and in the immediate future, allay concerns about security. To provide the ability to access records anywhere in the UK, the government must lead the establishment of standards and protocols that facilitate interoperability and communication. Standards for functionality and data are required to be set centrally to ensure that local systems can communicate with one another. Rather than punish non-adopters, the government could instead offer rewards through a national accreditation system, encouraging IT providers to innovate and design systems for local customers. Accredited systems can be listed in a catalogue, including prices previously negotiated and set with the government. Public funds should be directed only to suppliers who meet these standards. An accreditation process would ensure that systems last for a sufficient period of time and remain flexible to future technologies,. Local

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hospitals would maintain the option to customize their systems to suit a range of idiosyncratic needs. This model would reflect a fundamental change in strategic design of the NPfIT. Rather than a top-down centralized system focused on control, this bottom-up approach based on open innovation principles involves doctors, patients, the government and third party IT developers. By opening up the system, GPs, doctors and hospitals can choose which system is best for them. This open complex adaptive system would then become a mix of customization to address local needs and standardization to satisfy the communication needs of a larger network. Furthermore, local communities, hospitals and doctors do not face the prohibitive cost of replacing legacy systems that were sufficient. The government should now act as a coordinator of standards, negotiator of prices, and administrator of accreditation, leveraging the knowledge used to customize and maintain current systems.16 Recommendation 2: Refocus on the Patient The NPfIT requires a system overhaul for simplification and consolidation. There are too many components and systems to manage effectively at this point of the NPfIT. In order for patients and doctors to benefit from healthcare IT solutions, there must be a change in the way that IT is viewed from an institutional standpoint. To examine the shortcomings of the NPfIT, we laid out two simple business models, per Osterwalder.17 In the current design, the value proposition centers on creating large-scale centralized databases (Fig. 6). This approach where systems that collect data yet bears little direct relevance to patient care should be abandoned or assigned lower priority. Instead, the NPfIT systems must deliver clear benefits to the care of the patient and the care provider (Fig. 7). Given this burden of proof, it is not clear that the benefits conferred by a program such as SUS - 11 -

outweigh the complexity it adds to the healthcare service process and frustration it causes doctors. From a practical standpoint, the time it takes for a doctor to record minutiae related to each appointment or summarize the treatment outcomes of her patients might interfere with patient care. In the worst case, the fixed cost related to the doctors operations may be underutilized, as she sees fewer patients resulting from more administrative tasks or directs time to gaming the system with her SUS reports. Thus, the NPfIT should conduct a thorough and independent review of all the service components and retain only those that have an immediate impact on patient care. Perhaps in the future, with better IT automation for data collection or other innovations, services such as SUS will become more cost-effective and thus impactful. Recommendation 3: Redesign Change Management Strategy to Increase Usage One of the major reasons underlying barriers to adoption for most physicians is difficulties with technology, interdependent updates and support, and electronic data exchange. The complexity of the systems increased physicians initial time investment and reduced the financial and quality-of-care benefits, leading to apathy and outright dislike of the NPfIT systems.18 In a 2008 poll commissioned by the House of Commons, most respondents considered highly regarded, industry-leading electronic medical records to be challenging because of the poor interface design.19 The complexity of joining these multiple systems resulted in a vast number of screens, options, and navigational aids. A service blueprint for a hypothetical patient consult highlights the complexity imposed by the current NPfIT intitiatives (Fig. 8). The Onstage Contact row now refers to the onstage NPfIT initiative, instead of an employee with whom the customer interacts. The row is populated with over seven different interfaces for a doctor, each requiring a change in his behavior. These substantial time costs and insufficient - 12 -

training by the government prevent doctors from obtaining benefits, ultimately lowering the potential for improvement in the quality of care. In addition to overburdening doctors, the central managers of the NPfIT project blundered by ignoring the lessons of change management. Early in the process, the NPfIT planners aimed for speed, spending billions of pounds in procurement contracts in less than a year without first consulting doctors, clinicians and hospital administrators. Planners did not fully appreciate the time needed to: 1) persuade and educate all users of a need for a redesign and 2) develop and deploy fully functioning IT systems. There was a fundamental disregard and inability to formulate a coherent strategy for change management in implementing these new systems. Planners ignored the opportunity posed by co-creation, to invite doctors to actively participate in the design, procurement and implementation. This fundamental error has led to the inability of central planners to get doctors to take ownership of the NPfIT services that were funded for their use. Though change management consultants were hired, the overarching strategy of service delivery without listening to the customer limited their effectiveness. Professor John Kotter, a leading thinker on change management, wrote: The change process goes through a series of phases that, in total usually require considerable length of time. Skipping steps creates only the illusion of speed and never produces a satisfying result. A second very general lesson is that critical mistakes in of the phases can have a devastating impact, slowing momentum and negating hard-won gains.20 As a result of this flaw, skepticism, confusion and disappointment ensued. Excluded from the original design phase and entrenched in their previous behaviors, potential users naturally became skeptical of these new systems. Many hospitals and clinics had little idea about what services they were to receive from the NPfIT. Furthermore, many expectations were not met by

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the delivered systems, contributing to delays as the vendors scrambled to change systems to suit customer needs. The inefficiency in this development process contributed to the friction and frustration between IT vendors and the NPfIT planners, eventually leading to the departure of Fujitsu and Accenture. Going forward, the NPfIT needs a clear and thoughtful change management strategy that engages doctors and clinicians on all levels of service. Additionally, the NPfIT planners must make a greater concerted effort to persuade doctors and end users that change is needed. This change must involve end users on the local level with the support of local leaders and suppliers who agree to accommodate and adapt to the needs of users on the front line. The complex relationships between suppliers, central planners, doctors, and change management consultants precluded early interactions with the doctors. The correct management structures facilitate direct contact between suppliers and end users and allow them adequate time to develop operational systems.21 Using tools such as service blueprints could improve understanding of each user groups needs and motivate the disparate vendors to work cross-functionally. The NPfIT should also consider studying various customer segments (by specialty, age, geography and role in the care delivery process) in their natural habitats. This would not only improve the service design but also provide honest feedback about already launched systems. IV. Summary and Conclusions The NPfIT is an ambitious project that attempts to advance one of todays hardest service innovation problemsthe efficient use of IT in the healthcare sector. The system exhibits central concepts in service innovation, such as: Standardization: the main reason for this project was the need to create standards for the digitization of the healthcare industry. - 14 -

Aggregation: the system at its core is a very large scale collection of data. Economies of scale: the creation of standards for medical records requires resources and participation on a scale that the private sector has so far failed to achieve. The UK government stepped in to correct this market failure, rolling out a system so that IT and human resources are used efficiently and information collected reaches a critical mass.

Economies of scope and one-stop shopping: many of the systems are designed so that they provide access to multiple related services.

Increasing utilization: the electronic records enable the re-use of information. One benefit is that the data is available with no delay, which prevents the need to recreate data. Also, the existing data can be used in new ways for better diagnoses and treatments.

Co-creation: patients can choose what goes on their health records and doctors can collaborate with them to establish best treatment plans.

Platforms and two-sided markets: the system provides many ways to connect patients with doctors and GPs with specialists.

Fostering an ecosystem: the design of the NPfIT aims to create an ecosystem of services around a centralized database though the implementation fell short. While the NPfIT implemented many of these concepts at the service level, it failed to

apply them on the whole system. The system includes many platforms, such as HealthSpace and eSpace, and created too many standards. The system itself is disjoint and requires a great deal of customization. Similarly, even though many of the individual initiatives were designed to enhance co-creation with the user, the system was designed top-down without meaningful input from the doctors or patients. This led to the biggest fault of all: the attempt to innovate in a closed system instead of embracing open innovation. Many care providers had already

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implemented systems prior to the NPfIT. Given the lead users in the industry, it was a mistake to impose a new system instead of designing one that would incorporate already successful innovations. A natural extension of allowing for outside-in openness would be to allow for inside-out openness. Going forward, the NPfIT should work on providing a secure framework for private enterprises to build services and find new ways to utilize health data. This could result in new innovations, advancements in medical research and predictive forecasts (e.g. early discovery of pending pandemics). Even though it currently does not meet expectations, the NPfIT underscores many important lessons for services innovation: Customer primacy as a design principle: whenever you design a complex innovative service, study, understand, educate and co-create with the customer. Focus on the core services: get the most important services right, then tackle the remainders. Implementation focus: have great service ideas, but even better implementation. Involve all stakeholders: platform strategies touch a lot of different players; they have to be won over to make the platform work. Also, national IT services for healthcare pose interesting challenges to the lessons from private industry. Some boundary conditions where such a program in the public domain would not succeed include: Short-term benefits to end users do not compensate for large initial investment, because long-term benefits are difficult to measure and communicate. Data protection and security concerns limit openness. Inability to win over users and other stakeholders.

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Inability to build an ecosystem; no one wants to build the complements. Failure to set up standard that are both clear to promote innovation and yet flexible for local needs. The successful implementation of the NPfIT program would be the proof of concept for

standardizing healthcare IT records and building ancillary services. If it succeeds, a global wave of innovative IT healthcare services and the large-scale adoption of unified healthcare records should follow. If it fails, more resources will be wasted, hampering other nations from launching similar systems. We hope that the NPfIT is able to deliver value to its patients, healthcare professionals, and the overall public in a timely and cost-effective way.

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Figure 1: Service Components of the NPfIT

Source: Department of Health: The National Programme for IT in the NHS. House of Commons Committee of Public Accounts. Session 2006-7. Pg.45.

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Figure 2. The SPINE of the NPfIT

Source: Department of Health: The National Programme for IT in the NHS. House of Commons Committee of Public Accounts. Session 2006-7. Pg.14

Figure 3. Regional Division of IT Vendor Services

Department of Health: The National Programme for IT in the NHS. House of Commons Committee of Public Accounts. Session 2006-7. Pg.16

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Figure 4: Contracted vendor assigned to select NPfIT initiatives

Source: OBrien Stephen and Hayes, Glyn. Independent Review of NHS and Social Care IT. House Commons Audit Commitee, August 2009, pg 40.

Figure 5: The Growth of GP Systems

Source: OBrien Stephen and Hayes, Glyn. Independent Review of NHS and Social Care IT. House Commons Audit Commitee, August 2009, pg 68.

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Figure 6: Current business model for NPfIT endorses top-down planning

Key Activities Develop a plethora of services to exploit opportunities provided by a central health database

Client Relationship Top-down planning, cocreation in using services but not in design Value Proposition Large-scale centralized and accessible health data Distribution Channels

Client Segments Primary care providers (doctors), secondary care providers (clinics and hospitals), patients (taxpayers)

Partner Network Outside IT vendors

Key Resources IT developers, experience with NHS practices SPINE, mandatory adoption

Cost Structure

Revenue Flows

Paid for by taxpayer, major cost overrun

N/A

Figure 7: Proposed business model for NPfIT facilitates co-creation through flexible standards

Key Activities Provide standards and a unified platform to create services built around electronic heath data Partner Network Outside IT vendors, doctors, clinics, hospitals Value Proposition Organize health and social care information

Client Relationship Co-creation in design, focus on patients, provide platform for doctors to use customized systems

Client Segments Primary care providers (doctors), secondary care providers (clinics and hospitals), patients (taxpayers)

Distribution Channels Key Resources IT developers, experience with NHS practices, access to doctors/patients Selective adoption of services

Cost Structure

Revenue Flows

Paid for by taxpayer

N/A

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Figure 8: Blueprint for the NPfIT Initiatives: Aiding doctor through hypothetical consult
Source: http://www.connectingforhealth.nhs.uk/systemsandservices

Notes: Because Connecting for Health is mainly a system of IT platforms, we amended the service blueprint in the following ways: Physical evidence is accessed through a "one-stop shop" of the NHS Portal. While different programs may use another specific software package or an intranet, we abstract these programs to one term to maintain simplicity. Customer action is the action from the perspective of the doctor, a general practitioner in this case. Onstage Contact to be the specific NHS CFH initiative used for the doctor's action. Backstage Contact was amended to mean the out-of-sight or overarching CFH programs needed for the action. Support processes are other people or "actors" needed to finish the service to the patient. Again, the initiative is ITfocused so we place the IT functions in the foreground and the other actions in the background. One could, of course, blueprint these services for the other actors (e.g. patients booking appointments).

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www.connectingforhealth.nhs.uk/systemsandservices/spine en.wikipedia.org/wiki/NHS_National_Programme_for_IT#The_Spine_.28including_PDS_.26_PSIS.29 3 www.connectingforhealth.nhs.uk/industry/suppliers/ 4 www.connectingforhealth.nhs.uk/systemsandservices/bloodpilot/about 5 www.webmd.com/allergies/allergy-tests/ 6 www.espace.connectingforhealth.nhs.uk/content/frequently-asked-questions/ 7 www.chooseandbook.nhs.uk/staff/overview/impact/primary/ 8 Department of Health: The National Programme for IT in the NHS. House of Commons, Twentieth Report of Session 2006-2007, p.112 9 www.connectingforhealth.nhs.uk/systemsandservices/sus/background/ 10 www.connectingforhealth.nhs.uk/systemsandservices/sus/background/whysus/ 11 C.K. Prahalad and M.S. Krishnan, Processes: Enablers of Innovation, Chapter 2 in The New Age of Innovation, pg. 45-79. 12 www.connectingforhealth.nhs.uk/systemsandservices/mapmed/ 13 OBrien Stephen and Hayes, Glyn. Independent Review of NHS and Social Care IT. House Commons Audit Commitee, August 2009, pg 9. 14 Department of Health: The National Programme for IT in the NHS. House of Commons Committee of Public Accounts. Session 2006-7. pg. 20 15 Ibid. pg 111 16 OBrien Stephen and Hayes, Glyn. pg. 131 17 business-model-design.blogspot.com/2005/11/what-is-business-model.html 18 OBrien Stephen and Hayes, Glyn. pg. 79 19 Robert H. Miller and Ida Sim. Physicians Use Of Electronic Medical Records: Barriers And Solutions Health Affairs, 23, no. 2 (2004): pg. 116-126 20 John P Kotter, "Leading Change: Why Transformation Efforts Fail," Harvard Business Review (March/April 1995), pp. 5967 21 OBrien Stephen and Hayes, Glyn. pg. 158-159
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