Date Published: November 2, 2010
Publisher: Public Library of Science
Author(s): Trisha Greenhalgh, Jill Russell
Abstract: Trisha Greenhalgh and Jill Russell discuss the relative merits of “scientific” and “social practice” approaches to evaluation and argue that eHealth evaluation is in need of a paradigm shift.
Partial Text: Much has been written about why electronic health (eHealth) initiatives fail –. Less attention has been paid to why evaluations of such initiatives fail to deliver the insights expected of them. PLoS Medicine has published three papers offering a “robust” and “scientific” approach to eHealth evaluation –. One recommended systematically addressing each part of a “chain of reasoning”, at the centre of which was the program’s goals . Another proposed a quasi-experimental step-wedge design, in which late adopters of eHealth innovations serve as controls for early adopters . Interestingly, the authors of the empirical study flagged by these authors as an exemplary illustration of the step-wedge design subsequently abandoned it in favour of a largely qualitative case study because they found it impossible to establish anything approaching a controlled experiment in the study’s complex, dynamic, and heavily politicised context .
Catwell and Sheikh argue that “health information systems should be evaluated with the same rigor as a new drug or treatment program, otherwise decisions about future deployments of ICT in the health sector may be determined by social, economic, and/or political circumstances, rather than by robust scientific evidence” (, page 1).
“Scientific” evaluation aims to produce statistical statements about the relationship between abstracted variables such as “IT response times”, “resource use”, and “morbidity/mortality” . But the process of producing such variables may remove essential contextual features that are key to explaining the phenomenon under study. Controlled, feature-at-a-time comparisons are vulnerable to repeated decomposition: there are features within features, contingencies within contingencies, and tasks within tasks .
MacDonald and Kushner identify three forms of evaluation of government-sponsored programs: bureaucratic, autocratic, and democratic, which represent different levels of independence from the state . Using this taxonomy, the approach endorsed by the previous PLoS Medicine series – represents a welcome shift from a bureaucratic model (in which management consultants were commissioned to produce evaluations that directly served political ends) to an autocratic model (in which academic experts use systematic methods to produce objective reports that are published independently). But it falls short of the democratic model—in which evaluators engage, explicitly and reflexively, with the arguments exchanged by different stakeholders about ideas, values, and priorities—to which our own team aspired. “Independence” as defined by the terms of autocratic evaluation (effectively, lack of censorship by the state and peer review by other academics who place politics out of scope) pushes evaluators to resist the very engagement with the issues that policy-relevant insights require.
Lilford et al. identify four “tricky questions” in eHealth evaluation (qualitative or quantitative?; patient or system?; formative or summative?; internal or external?) and resolve these by recommending mixed-method, patient-and-system studies in which internal evaluations (undertaken by practitioners and policymakers) are formative and external ones (undertaken by “impartial” researchers) are summative . In our view, the tricky questions are more philosophical and political than methodological and procedural.
eHealth initiatives often occur in a complex and fast-moving socio-political arena. The tasks of generating, authorising, and disseminating evidence on the success of these initiatives do not occur in a separate asocial and apolitical bubble. They are often produced by, and in turn feed back into, the political process of deciding priorities and allocating resources to pursue them ,. The dispassionate scientist pursuing universal truths may add less value to such a situation than the engaged scholar interpreting practice in context ,.