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Cited by 119Evaluation and Performance AssessmentHealth Policy Implementation ScienceElectronic Health Records Systems

Why National eHealth Programs Need Dead Philosophers: Wittgensteinian Reflections on Policymakers’ Reluctance to Learn from History

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GREENHALGH, TRISHA, RUSSELL, JILL, ASHCROFT, RICHARD E., PARSONS, WAYNE·2011·Milbank Quarterly
DOI 10.1111/j.1468-0009.2011.00642.xPMC PMC3250633
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Abstract

CONTEXT: Policymakers seeking to introduce expensive national eHealth programs would be advised to study lessons from elsewhere. But these lessons are unclear, partly because a paradigm war (controlled experiment versus interpretive case study) is raging. England's $20.6 billion National Programme for Information Technology (NPfIT) ran from 2003 to 2010, but its overall success was limited. Although case study evaluations were published, policymakers appeared to overlook many of their recommendations and persisted with some of the NPfIT's most criticized components and implementation methods. METHODS: In this reflective analysis, illustrated by a case fragment from the NPfIT, we apply ideas from Ludwig Wittgenstein's postanalytic philosophy to justify the place of the "n of 1" case study and consider why those in charge of national eHealth programs appear reluctant to learn from such studies. FINDINGS: National eHealth programs unfold as they do partly because no one fully understands what is going on. They fail when this lack of understanding becomes critical to the programs' mission. Detailed analyses of the fortunes of individual programs, articulated in such a way as to illuminate the contextualized talk and action ("language games") of multiple stakeholders, offer unique and important insights. Such accounts, portrayals rather than models, deliver neither statistical generalization (as with experiments) nor theoretical generalization (as with multisite case comparisons or realist evaluations). But they do provide the facility for heuristic generalization (i.e., to achieve a clearer understanding of what is going on), thereby enabling more productive debate about eHealth programs' complex, interdependent social practices. A national eHealth program is best conceptualized not as a blueprint and implementation plan for a state-of-the-art technical system but as a series of overlapping, conflicting, and mutually misunderstood language games that combine to produce a situation of ambiguity, paradox, incompleteness, and confusion. But going beyond technical "solutions" and engaging with these language games would clash with the bounded rationality that policymakers typically employ to make their eHealth programs manageable. This may explain their limited and contained response to the nuanced messages of in-depth case study reports. CONCLUSION: The complexity of contemporary health care, combined with the multiple stakeholders in large technology initiatives, means that national eHealth programs require considerably more thinking through than has sometimes occurred. We need fewer grand plans and more learning communities. The onus, therefore, is on academics to develop ways of drawing judiciously on the richness of case studies to inform and influence eHealth policy, which necessarily occurs in a simplified decision environment.

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Research works printed but not linked: 4

  1. Brown, N. 2007. Shifting Tenses-From Regimes of Truth to Regimes of Hope? Configurations 13(3):331-55.
  2. Latour, B. 1996. Aramis, or Love of Technology. Trans. Catherine Porter. Cambridge, MA: Harvard University Press.
  3. Markus, L.M., and M. Keil. 1994. If We Build It, They Will Come: Designing Information Systems That People Want to Use. Sloan Management Review 35(4):11-25.
  4. Shekelle, P.G., and C.L. Goldzweig. 2009. Costs and Benefits of Health Information Technology: An Updated Systematic Review. London: Health Foundation on behalf of the Southern California Evidence-Based Practice Center, RAND Corporation.

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Authors
GREENHALGH, T., RUSSELL, J., ASHCROFT, R. E., & PARSONS, W.
Affiliations
Queen Mary University of London (GB)
Corresponding author
GREENHALGH, TRISHA
ORCID
Venue
Milbank Quarterly
Publisher
Wiley
Published
2011-12
Volume
89
Issue
4
Pages
533-563
ISSN
0887-378X (ISSN-L)
DOI
10.1111/j.1468-0009.2011.00642.x
PMC
PMC3250633
OpenAlex
W2121034333
Cited by
119
References
60
Citations by year
2024: 4 · 2022: 2 · 2021: 4 · 2020: 6 · 2019: 34 · 2018: 4 · 2017: 8 · 2016: 4 · 2015: 10 · 2014: 15 · 2013: 12 · 2012: 14
FWCI
18.19
Type
journal article
Language
en
Open access
Licence
Locations
  • Milbank Quarterly (publishedVersion, public-domain)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Social Sciences › Decision Sciences › Management Science and Operations Research › Evaluation and Performance Assessment
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
  • Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
Keywords
eHealth policy, Wittgenstein, language games, bounded rationality, policy making, learning from history, health information technology, stakeholder complexity, learning communities, health care complexity, realist evaluation
MeSH terms
Famous Persons, United Kingdom, Health Plan Implementation, Health Planning, Health Promotion, Humans, Philosophy, Medical, Policy Making, State Medicine, Total Quality Management, Health Care Reform, Internet, Social Marketing, History, 20th Century

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