Too many systems, too little time  

Chair of the IMO NCHD committee Dr Rachel McNamara argues that it is time to start involving NCHDs in hospital IT design

An NCHD arrives to work in an Irish hospital. She logs in to information technology (IT) system 1 to find the locations of her patients. Next, she opens IT system 2 to check the reason for admission of any new patients. She then logs in to IT systems 3, 4, and 5, in turn, to check blood test results, radiological investigations, and any previous hospital admissions. As she and her team proceed on rounds, a cardiology referral is required for a patient  (IT system 6) and another needs sleep studies requested (IT system 7). By lunchtime, the NCHD has interacted with more software platforms than actual patients.

Meanwhile, the nursing teams on the wards navigate IT systems 8, 9, and 10 to log handovers, estimated discharge dates, and care bundle information. Health and social care professionals, pharmacists, administrators, and maintenance staff, all use their own separate (and numerous) IT systems, until the NCHD finally completes the clinical discharge summary on IT system number 10 to the power of l.

This dance between different digital platforms will sound very familiar to anyone who has worked in an Irish hospital in recent years. As it is the NCHD that is typically tasked with drafting admission notes, ordering investigations, documenting results, making referrals, and completing the discharge summary, they tend to be among the most intensive users of hospital digital software.

Like most aspects of modern life, a large proportion of medical care delivery is now mediated through interaction with digital systems. Good, intuitive, multi-purpose IT can streamline care, increase efficiency, and free up care providers to deliver excellent care to the patients who need it. Outdated, non-integrated systems promote the exact opposite and can enormously affect an NCHD’s ability to do their job properly.

Irish hospitals currently operate with a mishmash of parallel IT infrastructure that has been procured incrementally over time. These systems, though well intentioned, have evolved reactively to solve specific unmet needs within individual departments, and are rarely designed to be interoperable with each other. IT systems that do not speak to each other are an entirely foreseeable side-effect of decades of underinvestment in the area.

Funding

A lack of a multi-annual investment plan has meant that systemic, universal, and consistent IT development has never taken place. Ireland is a major outlier in digital public health infrastructure, ranking last among Organisation for Economic Co-operation and Development (OECD) countries for digital health readiness and electronic health record availability (Health at a Glance: OECD 2023, 2025).

Though digital healthcare funding is set to increase from €190 to €263 million in 2026, this still equates to less than 1 per cent of the health budget. It also falls lamentably short of the aspirations laid out in the HSE Digital for Care strategy, which recommended a 4 to 6 per cent digital spend.

It is unlikely such unambitious funding will turn the tide on this issue. Meanwhile, hospital staff, notably NCHDs, will continue to waste time on processes rather than on patients.

Administrative burden

A study from Stanford University identified that NCHDs spend up to half of their shift in front of a computer. With umpteen systems to log in and out of, which regularly glitch, fail, and update without warning, the volume of clinician screen time can stretch up and up, with negative consequences for patients, and for the NCHD trying to hone clinical skills of diagnosis and intervention. The significant administrative burden on NCHDs has been well documented. It was highlighted in the NCHD taskforce implementation plan 2024, which identified IT infrastructure as one of five priority areas for reform. While NCHD IT administrative tasks are not entirely avoidable, it would be disastrous to allow them to subsume patient-facing care altogether.

NCHDs are intimately familiar with the digital landscape of not only their current clinical sites, but indeed the range of sites through which they must rotate. Therefore, they have a unique level of understanding of the practical application and usability of software within hospital systems. By migrating through hospitals, NCHDs become inadvertent hospital IT system connoisseurs, and so they are ideally placed to identify waste, duplication, and areas for improvement. In addition, as most NCHDs are considered ‘digitally native’, they are also more likely to be able to suggest areas to streamline and modernise digital care pathways than previous generations.

Untapped resource

Unfortunately, the scoping, design and selection process for IT solutions has rarely involved NCHDs. Decisions about which software to adopt are usually made by managers and senior clinicians, ie, those who are unlikely to be the day-to-day users. In this way, NCHDs are a hugely untapped resource.

They are occasionally invited to consult on IT projects, but this consultation, if it takes place at all, often happens too late in the process to meaningfully alter or guide decisions and is more of a box-ticking exercise. The clinicians who use these systems most are often the last to be engaged in their design.

Ireland’s national electronic health record is finally on the horizon. This is a significant capital investment in digital infrastructure and the health service has only one opportunity to get it right. There is still an opportunity to tap into the NCHD workforce as a ready-made cohort of hospital IT experts. Engaging NCHDs early in the process has the potential to increase usability, acceptability, and speed of adoption of this new system, and contribute to the overall success of this enormous transition.

If we are to reverse the trend of unilateral system design and increasing clinician administration time, we need to design IT infrastructure with NCHDs, rather than for them. Such systems would enhance the patient experience and facilitate all providers to deliver excellent, integrated care with the patient at the centre. There is a narrow window of opportunity here to leverage these key NCHD insights, and it must be seized, to ensure that this major capital investment has every chance of success.