Governments around the world are investing in large scale information and communication technology projects that are intended to modernize and streamline healthcare through the provision of nationally accessible electronic health records. In this way, they hope to `tame' the complex `wicked' problems facing healthcare, such as rising costs and fragmented delivery. However, these projects often encounter difficulties. Using a case study of Australia's 20-year journey towards a national electronic health record system, we show how these projects can ironically take on the characteristics of the `wicked problems' they are intended to solve, and how a failure to recognize and cope with these `wicked' characteristics can lead to waste, conflict and frustration among potential users. We suggest some alternative approaches to the management of large-scale ICT projects in healthcare and other public service sectors that deal with complex, sensitive data.
DunleavyP, MargettsH, BastowS, TinklerJ. Digital era governance: IT corporations, the state, and e-government. Oxford University Press; 2006.
2.
GauldR, GoldfinchS. Dangerous Enthusiasms: E-Government, Computer Failure and Information Systems Development. New Zealand: University of Otago Press; 2006.
3.
McLoughlinI, WilsonRG. Digital Government at Work: A Social Informatics Perspective. Oxford: Oxford University Press; 2013.
4.
McLoughlinI, GarretyK, WilsonR. The Digitalization of Health Care: Electronic Health records and the Disruption of Moral Orders. Oxford University Press; Forthcoming.
5.
StaffordN. Germany set to introduce electronic patient cards despite doctors' opposition. British Medical Journal. 2008; 336: 689. doi: http://dx.doi.org.ezproxy.uow.edu.au/10.1136.
6.
ZwaanswijkM, PloemMC, WiesmanFJ, VerheijRA, FrieleRD, GeversJK. Understanding health care providers' reluctance to adopt a national electronic patient record: an empirical and legal analysis. Medicine and Law. 2013; 32(1): 13-31.
7.
CurrieWL. Health IT Policy in the UK: The Case of Electronic Health Records. In: MichellV, Rosenorn-LanngD, GulliverS, CurrieW, editors. Handbook of Research on Patient Safety and Quality Care Through Health Informatics. Hershey, PA: IGI Global; 2013. p. 363-81.
8.
BaconR, HopeC. Conundrum: Why Every Government Gets Things Wrong - And What We Can Do About It. London: Biteback Publishing; 2013.
9.
KingA, CreweI. The blunders of our governments. London: Oneworld Publications; 2014.
10.
RittelHW, WebberMM. Dilemmas in a general theory of planning. Policy sciences. 1973; 4(2): 155-69.
11.
Australian Public Service Commission. Tackling Wicked Problems: A Public Policy Perspective. Canberra: Commonwealth of Australia; 2007.
12.
FerlieE, FitzgeraldL, McGivernG, DopsonS, BennettC. Making Wicked Problems Governable? The Case of Managed Networks in Health Care. Oxford University Press; 2013.
13.
HeadBW. Wicked problems in public policy. Public Policy. 2008; 3(2): 101-18.
14.
ShawSE, RosenR. Fragmentation: a wicked problem with an integrated solution?Journal of Health Services Research & Policy. 2013; 18(1): 61-4. DOI: 10.1258/jhsrp.2012.012002.
15.
FloodC. International health care reform: A legal, economic and political analysis. London: Routledge; 2000.
16.
TwaddleAC, editor. Health care reform around the world. Westport, Connecticut; 2002.
17.
PatonC. Garbage-can Policy-making Meets Neo-liberal Ideology: Twenty Five Years of Redundant Reform of the English National Health Service. Social Policy & Administration. 2014; 48(3): 319-42. DOI: 10.1111/spol.12044.
18.
Canada Health Infoway. Electronic Health Records: Canada's next generation of healthcare at a glance [Internet]. 2006. Available from: https://www2.infoway-inforoute.ca/Documents/Vision_Summary_EN.pdf.
19.
Commission of the European Communities. e-Health - making healthcare better for European citizens: An action plan for a European e-Health Area [Internet]. Brussels; 2004. Available from: http://eur-lex.europa.eu/LexUriServ/ LexUriServ. do?uri=COM:2004:0356:FIN:EN:PDF.
20.
Department of Health and Human Services (HHS). Using the Power of Information Technology to Transform Health and Care [Internet]. 2008. Available from: http://www.healthit.gov/sites/default/files/hit-strategic-plan-summary-508-2.pdf.
21.
BurnsF. Information for health: an information strategy for the modern NHS 1998-2005 [Internet]. London: NHS Executive; 1998.
22.
BallMJ, Carla SmithN, BakalarRS. Personal health records: empowering consumers. Journal of Healthcare Information Management. 2007; 21(1): 77-86.
23.
BrennerSK, KaushalR, GrinspanZ, JoyceC, KimI, AllardRJ, et al. Effects of health information technology on patient outcomes: a systematic review. Journal of the American Medical Informatics Association [Internet]. 2015 [cited 2016 Jan 8]; Available from: http://jamia.oxfordjournals.org/cgi/doi/10.1093/jamia/ocv138.
24.
RAND Corporation. Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Use Functionalities [Internet]. Santa Monica, CA; 2014. Available from: http://www.healthit.gov/sites/default/files/systematic_review_final_report_508_compliant.pdf.
25.
National Health and Hospitals Reform Commission. A Healthier Future for all Australians: Final Report [Internet]. Canberra: Australian Government; 2009 Jun [cited 2011 Mar 15]. Available from: http://www.health.gov.au/internet/nhhrc/ publishing.nsf/Content/nhhrc-report.
26.
HealthConnect. HealthConnect Business Architecture version 1.0. Canberra: Commonwealth of Australia; 2003.
27.
National Audit Office. National Programme for IT in the NHS. London: Stationery Office; 2006.
28.
GarretyK, DalleyA, McLoughlinI, WilsonR, YuP. Managing collaboration across boundaries in health information technology projects. In: MaederAJ, Martin-SanchezFJ, editors. Health Informatics: Building a Healthcare Future Through Trusted Information. Amsterdam: Ios PressInc; 2012. p. 58-63.
29.
GarretyK, McLoughlinI, WilsonR, ZelleG, MartinM. National electronic health records and the digital disruption of moral orders. Social Science & Medicine. 2013; 101(0): 70-7. DOI: 10.1016/j.socscimed.2013.11.029.
30.
GarretyK, McLoughlinI, ZelleG. Disruptive Innovation in Health Care: Business Models, Moral Orders and Electronic Records. Social Policy and Society. 2014 Oct; 13(4): 579-92. DOI: 10.1017/S1474746413000560.
31.
DunleavyP, MargettsH, BastowS, TinklerJ. Australian e-Government in comparative perspective. Australian Journal of Political Science. 2008; 43(1): 13-26. DOI: 10.1080/10361140701842540.
32.
DugdaleP, HealyJ. The Australian Health Care System, 2014. In: International Profiles of Health Care Systems. Washington DC: The Commonwealth Fund; 2015. p. 11-20.
33.
TsoukasH. Craving for generality and small-N studies: a Wittgensteinian approach towards the epistemology of the particular in organization and management studies. In: BuchananDA, BrymanA, editors. The SAGE handbook of organizational research methods. Los Angeles, London: Sage; 2009. p. 285-301.
34.
GreenhalghT, RussellJ, AshcroftR, ParsonsW. Why National eHealth Programs Need Dead Philosophers: Wittgensteinian Reflections on Policymakers' Reluctance to Learn from History. Milbank Quarterly. 2011; 89(4): 533-63. DOI: 10.1111/j.1468-0009.2011.00642.x.
35.
LeMayR. E-Health: Australia's $5bn black hole. ZDNet Australia [Internet]. 2008 Dec 15 [cited 2010 Jun 24]; Available from: http://www.zdnet.com.au/e-health-australia-s-5bn-black-hole-339293816.htm.
36.
PearceR. 2.5m Australians sign up for eHealth records. Computerworld [Internet]. 2015 Oct 27 [cited 2016 Jan 8]; Available from: http://www.computerworld.com.au/article/587547/2-5m-australians-sign-up-ehealth-records/.
37.
FlyvbjergB, BruzeliusN, RothengatterW. Megaprojects and risk: An anatomy of ambition. Cambridge University Press; 2003.
38.
Australian Health Ministers' Conference Working Party. A National Health Information Systems and Technology Strategy. Canberra: Australian Health Ministers' Advisory Council; 1992.
39.
LeyS. Media release: Patients to get new myHealth Record [Internet]. 2015 [cited 2015 Jun 7]. Available from: http:// www.health.gov.au/internet/ministers/publishing.nsf/Content/DCF48150452A3F8FCA257E4100088F92/$File/SL050. pdf.
40.
National Electronic Health Records Taskforce. A Health Information Network for Australia. Canberra: Commonwealth of Australia; 2000.
41.
BrookS. Health data on network. The Australian. 2000 Jul 28.
42.
DearneK. Abbott forces pace on e-health. The Australian. 2004 Mar 16.
43.
KingA. Abbott Puts His Foot down on EHR Delivery. The Age [Internet]. 2005 Sep 30 [cited 2008 Sep 17]; Available from: http://www.theage.com.au/articles/2005/10/03/1128191644067.html.
44.
RichardsD. Your life history, online. Sydney Morning Herald [Internet]. 2005 Jun 16 [cited 2010 Apr 29]; Available from: http://www.smh.com.au/news/Health/Your-life-history-online/2005/06/16/1118869018806.html?from=moreStories.
45.
Boston Consulting Group. NEHTA Review [Internet]. 2007 Oct [cited 2009 Jun 22]. Available from: http://www.docstoc. com/docs/69750313/NEHTA-Reviewhttp://www.docstoc.com/docs/69750313/NEHTA-Review.
46.
DearneK. A simple message from hospital to GP will launch a new era in e-health. The Australian. 2005 Oct 11.
47.
Department of Health and Ageing. Draft Concept of Operations: Relating to the introduction of a personally controlled electronic health record (PCEHR) system. Canberra: Australian Government; 2011 Apr.
48.
CoieraE, KiddM, HaikerwalM. A call for national e-health clinical safety governance. Medical Journal of Australia. 2012 Apr 16; 196(7): 430-1. DOI: 10.5694/mja12.1047.
49.
Senate Community Affairs Legislation Committee. Report of the Senate Inquiry into Personally Controlled Electronic Health Records Bill 2011 [Provisions] Personally Controlled Electronic Health Records (Consequential Amendments) Bill 2011 [Provisions] [Internet]. Canberra: Commonwealth of Australia; 2012 Mar. Available from: http://www.aph.gov. au/Parliamentary_Business/Committees/Senate_Committees?url=clac_ctte/pers_cont_elect_health_rec_11/index.htm.
50.
FooF. More bumps in e-health road. Australian IT [Internet]. 2012 Nov 27 [cited 2013 Jan 7]; Available from: http:// www.theaustralian.com.au/australian-it/government/more-bumps-in-e-health-road/story-fn4htb9o-1226524 459540.
51.
DunlevyS. Doctors shun e-health records scheme [Internet]. news.com.au. 2013 [cited 2013 Feb 28]. Available from: http://www.news.com.au/national-news/doctors-shun-e-health-records-scheme/story-fncynjr2-1226578254203.
52.
National e-Health Transition Authority. NEHTA Scorecard August 2013 [Internet]. 2013. Available from: http://www. nehta.gov.au/component/docman/doc_download/1777-nehta-scorecard-august-2013?Itemid=.
53.
McDonaldK. PCEHR exposes more examples of PBS errors. Pulse+IT [Internet]. 2013 Aug 26 [cited 2013 Dec 4]; Available from: http://www.pulseitmagazine.com.au/index.php?option=com_content&view=article&id=1565:pcehr-exposes-more-examples-of-pbs-errors&catid=16:australian-ehealth&Itemid=327.
54.
BraceyA. ``Garbled and confused'': trust in e-health dives. Medical Observer [Internet]. 2014 Feb 18 [cited 2014 May 27]; Available from: http://www.medicalobserver.com.au/news/garbled-and-confused-trust-in-ehealth-dives.
55.
DunlevyS. Outrage as eHealth record sign-up squads hit Australian hospital patients in bid to boost numbers. Herald Sun [Internet]. 2013 Apr 14 [cited 2013 Jul 22]; Available from: http://www.heraldsun.com.au/news/national/outrage-as-ehealth-record-sign-up-squads-hit-australian-hospital-patients-in-bid-to-boost-numbers/story-fncynkc6-1226619874 616.
56.
DunlevyS. $1 billion e-health system rejected by doctors as ``shambolic'' [Internet]. News.com.au. 2013 [cited 2013 Oct 2]. Available from: http://www.news.com.au/lifestyle/health/billion-ehealth-system-rejected-by-doctors-as-8216shambolic8217/story-fneuz9ev-1226722256752.
57.
HeathJ. More money for eHealth scheme. 2013 Jul 18 [cited 2013 Oct 1]; Available from: http://www.afr.com/p/ australia2-0/more_money_for_ehealth_scheme_51OBlYOalDkyQQhdLaxlFJ.
58.
StewartJ, WilliamsR. The wrong trousers? Beyond the design fallacy: Social learning and the user. In: HowcroftD, TrauthEM, editors. Handbook of critical information systems research: theory and application. Edward Elgar Publishing; 2005. p. 195-221.
59.
Chief Information Officers Council. Federal Enterprise Architecture Framework Version 1.1 [Internet]. 1999. Available from: http://www.enterprise-architecture.info/Images/Documents/Federal%20EA%20Framework.pdf.
60.
DH4 Pty Ltd. Public Consultation on Development of Systems Architecture. Report on Analysis of Responses. Version 2.0. 2004.
61.
Australian Nursing Federation. Draft HealthConnect Business Architecture Consultation Submission #31. 2002.
62.
Royal College of Nursing Australia. Submission re Draft HealthConnect Business Architecture. 2002.
63.
General Practice Computing Group. Submission to HealthConnect Business Architecture 1.9. 2005.
64.
HealthConnect. Implementation Strategy. Canberra: Commonwealth of Australia; 2003.
65.
Fujitsu Consulting, Australian Department of Health and Ageing. The HealthConnect Benefits Realisation Framework V1.0. Canberra: Commonwealth of Australia; 2004.
66.
PatersonM. HealthConnect and privacy: A policy conundrum. Journal of Law and Medicine. 2004; 12(1): 80-91.
67.
Australian Medical Association. AMA submission: PCEHR/HI Legislation Discussion Paper [Internet]. 2015 [cited 2016 Mar 30]. Available from: https://myhealthrecord.gov.au/internet/mhr/publishing.nsf/Content/consultation-submissions/ $FILE/105%20-%20AMA.PDF.
68.
Royal Australian College of General Practitioners. Position Statement: GP e-health summary [Internet]. 2011 [cited 2011 Mar 14]. Available from: http://www.medicalnewstoday.com/articles/215669.php.
69.
Australian Medical Association. Media release: Medical advice missing from e-health records plan [Internet]. 2011 [cited 2011 Sep 27]. Available from: http://ama.com.au/node/7163.
70.
Australian Medical Association. AMA submission to the Department of Health and Ageing on the Draft Concept of Operations Relating to the introduction of a Personally Controlled Electronic Health Record System [Internet]. 2011 [cited 2011 Jun 15]. Available from: http://ama.com.au/node/6777.
71.
DunlevyS. AMA attacks e-health record plan. The Australian [Internet]. 2010 Dec 1 [cited 2011 Feb 7]; Available from: http://www.theaustralian.com.au/national-affairs/ama-attacks-e-health-record-plan/story-fn59niix-1225963522922.
72.
FooF. Forum slams doctor PCEHR e-health record control. The Australian [Internet]. 2013 Nov 27 [cited 2014 Jan 23]; Available from: http://www.theaustralian.com.au/technology/forum-slams-doctor-pcehr-e-health-record-control/story-e6frgakx-1226769779430.
73.
Australian Privacy Foundation. APF feedback about the exposure draft PCEHR Bill 2011 (PCEHR Draft Bill) and exposure draft PCEHR (Consequential Amendments) Bill 2011 [Internet]. 2011 [cited 2012 Mar 10]. Available from: https://www.privacy.org.au/Papers/DoHA-PCEHRBills-111027.pdf.
74.
DuttonP. Media release: Labor's $1 billion E-Health Debacle [Internet]. 2013 [cited 2013 Oct 1]. Available from: http:// www.peterdutton.com.au/MediaHub/MediaReleases/tabid/75/articleType/ArticleView/articleId/403/Labors-1-billion-E-Health-Debacle.aspx.
75.
RoyleR, HambletonS, WalduckA. Review of the PCEHR [Internet]. 2013 [cited 2014 May 29]. Available from: http:// www.health.gov.au/internet/main/publishing.nsf/Content/46FEA5D1ED0660F2CA257CE40017FF7B/$File/FINAL-Review-of-PCEHR-December-2013.pdf.
76.
Royal Australian College of General Practitioners. RACGP Submission: Review of the Personally Controlled Electronic Health Record (PCEHR) [Internet]. 2013 [cited 2013 Dec 4]. Available from: http://www.pulseitmagazine.com. au/images/stories/pulse/pcehr/racgp.pdf.
77.
McDonaldK. DoH aims for pathology and imaging on PCEHR by December. Pulse+IT [Internet]. 2014 Jul 21 [cited 2014 Aug 12]; Available from: http://www.pulseitmagazine.com.au/australian-ehealth/1978-doh-aims-for-pathology-and-imaging-on-pcehr-by-december.
78.
RACGP. Submission to the Department of Health on the Electronic Health Records and Healthcare Identifiers Legislation Discussion Paper [Internet]. 2015 [cited 2015 Jul 9]. Available from: http://www.racgp.org.au/download/Documents/ Reports/RACGP-Submission-to-the-Department-of-Health-on-the-Electronic-Health-Records-and-Healthcare-Identi fiers-Legislation-Discussion-Paper.pdf.
79.
Australian Medical Association. AMA submission: PCEHR/HI Legislation Discussion Paper [Internet]. 2015 [cited 2016 Mar 30]. Available from: https://myhealthrecord.gov.au/internet/mhr/publishing.nsf/Content/consultation-submissions/$FILE/105%20-%20AMA.PDF.
80.
Australian Privacy Foundation. Feedback on the PCEHR/IHI Legislation Discussion Paper [Internet]. 2015 [cited 2015 Jul 9]. Available from: https://www.privacy.org.au/Papers/DoH-PCEHR-150624.pdf.
81.
Parliamentary Joint Committee on Human Rights. Twenty-ninth Report of the 44th Parliament [Internet]. Canberra: Commonwealth of Australia; 2015 Oct [cited 2016 Jan 8]. Available from: http://www.aph.gov.au/Parliamentary_Busin ess/Committees/Joint/Human_Rights/Completed_inquiries/2015/Twenty-ninth_Report_of_the_44th_Parliament/c01.
82.
PearceR. Inquiry backs legislation for ``opt-out'' eHealth record. Computerworld [Internet]. 2015 Nov 10 [cited 2016 Jan 8]; Available from: http://www.computerworld.com.au/article/588570/inquiry-backs-legislation-opt-out-ehealth-record/.
83.
Department of Health and Ageing. HealthConnect Evaluation. Canberra: Commonwealth of Australia; 2009.
84.
SchoenC, OsbornR, SquiresD, DotyM, RasmussenP, PiersonR, et al. A survey of primary care doctors in ten countries shows progress in use of health information technology, less in other areas. Health Affairs. 2012; 31(12): 2805-16. DOI: 10.1377/hlthaff.2012.0884.
85.
CodagnoneC, Lupiañez-VillanuevaF. Benchmarking deployment of eHealth among general practitioners [Internet]. Luxembourg: European Union; 2013 [cited 2015 Jul 5]. Available from: http://dx.publications.europa.eu/10.2759/24556.
86.
CurrieWL, SeddonJJM. A cross-national analysis of eHealth in the European Union: Some policy and research directions. Information & Management. 2014 Sep; 51(6): 783-97. DOI: 10.1016/j.im.2014.04.004.
87.
Health Information Strategy Steering Committee. Health information strategy for New Zealand. Wellington: Ministry of Health; 2005.
88.
KierkegaardP. Interoperability after deployment: persistent challenges and regional strategies in Denmark. International Journal for Quality in Health Care. 2015; 27(2): 147-153. DOI: 10.1093/intqhc/mzv009.
89.
TsoukasH. The tyranny of light: the temptations and the paradoxes of the information society. Futures. 1997; 29(9): 827-43.
90.
CallenJC, AustinEK. Deterritorializing Utopia: The Possibility of Techno-Utopias in Societies of Control. Administrative Theory & Praxis. 2016; 38(1): 19-36. DOI: 10.1080/10841806.2015.1128220.
91.
RowleyD. New ePIP rules ripe for gaming RACGP.pdf. Medical Observer [Internet]. 2016 Jan 15 [cited 2016 Feb 3]; Available from: http://www.healthandlife.com.au/wp-content/uploads/2016/01/New-ePIP-rules-ripe-for-gaming-RACGP.pdf.
