Electronic Patient Records (EPRs) are a major part of healthcare IT today. Determining your approach to EPRs is likely to be the biggest technology decision a trust will take: a huge investment with consequences that will last for decades. Going live is just the start. Here are some questions boards should consider when making decisions on EPRs.
Should we adopt a trust-wide EPR?
Many trusts have decided to adopt a single trust-wide EPR – 'one system to rule them all' – rolled out across the whole organisation. These systems promise to enable virtually everything a trust would need: patient record keeping, prescribing, diagnostics, decision support, task management, communications, appointments, transfer of care, planning, analytics, finances, patient apps and modules for every clinical speciality.
The alternative to a trust-wide EPR is often presented as 'best of breed', where trusts adopt the 'best' system available for each function or speciality, integrating them where it makes sense. This allows trusts to retain systems that are already working well, and reduces the risk of lock-in to a single vendor.
For some, trust-wide EPRs are the only truly viable option. The ability to share clinical records across the organisation and enable cross-department communications is usually the winning argument for adopting and sustaining this approach. Having a single source of truth, and one tool with one login for staff to use are seen as major benefits.
However, trust-wide EPRs have attracted criticism from frontline staff as clunky, poorly designed systems that slow down, rather than speed up, care. In the US, where EPRs have been widely adopted for years, there has been vocal criticism of them from some clinicians.
The danger is that these large systems need to serve lots of different needs, which makes it less likely they will serve all of them well. When compared to modern consumer technology, these systems can fall well short of expectations.
There is no universal right answer to whether your trust should adopt a trust-wide EPR: this will depend on the context of your organisation, the needs of your users, the maturity of your existing systems and available technology skills.
An increasingly important follow up question will be to ask whether the EPR should cover more than one organisation. Some ICSs are now looking for a single EPR system that will cover multiple providers, reducing the need to integrate shared care records and opening up more opportunities to collaborate.
What problems will this EPR solve?
It can be tempting to use all the features provided by an EPR from day one, but this will add considerably to the complexity of your implementation. Instead, it’s best to focus on the functionality that will deliver the biggest benefits. That’s why "go live" is only just the beginning of your EPR journey.
Will this EPR be the only system we need?
Although trust-wide EPRs may promise to provide virtually everything you need, it may not be the best solution for everything. In reality, once fully implemented trust-wide EPRs become a trust’s major system, but far from the only system.
Make sure you understand the weak points of the EPR. It may make sense to keep some of your existing systems (or adopt new technologies alongside the EPR) and integrate them, rather than use a sub-par solution provided by the EPR. Ease of integration and costs will be major considerations here.
It is also likely that – even with an EPR – you’ll need to build some of your own software, or get someone else to on your behalf. See Should we buy or build?
Is this EPR right for your type of organisation?
Perhaps you're a community and mental health trust with a dispersed workforce, where remote access is critical. Or perhaps you're a highly federated trust, with very different ways of working across the organisation. It’s important to understand the EPR’s model of how an organisation should work, and how compatible it's with how yours actually works.
Is this EPR really a single system?
Despite appearances and marketing materials, EPRs may not deliver the fully integrated nirvana they promise. Often, EPR vendors have grown through acquisition of smaller technology companies, resulting in a suite of products that aren’t well integrated with each other.
How does it really work in practice?
Boards should go beyond the flashy presentations. If possible, visit other trusts where the EPR is working – and not just the flagship implementations with visits stage managed by vendors. Speak to frontline staff and see how it is working for them, ideally in a trust similar to yours. Speak to other board leaders too. And – if you can – try before you buy. Put it to work in one part of your trust to learn more about the system.
Don’t think of it as being just about the technology implementation. It is about technology and culture change. Never forget that. Before you implement anything, go out and see it in action. Make sure your board colleagues, multi-disciplinary clinicians and patients have too.
Chief Executive, Northern Care Alliance NHS Foundation Trust
What about open source EPRs?
EPRs are usually commercial systems, although some trusts have adopted systems that are – to some extent – open source. Some commercial vendors are also adopting an open specification to guide the design of their systems. Proponents of open source or open specification EPRs point to lower risks of vendor lock-in, greater flexibility, lower licensing costs as key benefits. Trusts should look at the range of EPR options emerging, and decide what is most suitable for their needs.
How can we reduce the impact of lock-in?
Lock-in is inevitable when adopting a trust-wide EPR: whatever you adopt, it is likely to be around for a long time. While this provides more long term certainty, it can also reduce your flexibility and introduce some commercial risks. There are ways you can reduce the negative impact of lock-in:
- Think about how you’ll move away from the system before you start using it. The cost of change will be high, so make sure you’ve factored that into your business case.
- The more modules of the EPR you use and the more widely you roll it out, the deeper ingrained it will be in your organisation. Think carefully about how far you want your EPR implementation to go, and whether it makes sense to put some of your eggs in another basket.
- Understand what you will be able to do with this system in-house, and what will you be dependent on the vendor or third party consultants for. Vendors often have commercial incentives to sell services on top of the software, so make sure you understand how system improvements can be made without expensive contract changes.
- Understand how you can get data in and out of the EPR. Just because this is your main system, it will never be your only system. What guarantees do you have about APIs (Application Protocol Interfaces – connections between systems that enable data to be shared) and data standards? Will you need to pay the vendor more money to build integrations when you need them?
- Finally, avoid customisations that substantially increase the risk of lock-in to the EPR. The more bespoke changes made to the system, the harder it can be to upgrade, integrate and support. While some customisation is necessary to make the EPR work for your trust, you should be careful not to lose the benefits of a standardised 'off-the-shelf' system used by lots of other organisations and supported by the vendor.
How mature is the EPR's ecosystem?
When you adopt an EPR, you're not just buying into a system, you're making a bet on the health of the ecosystem around it. Make sure your trust understands this:
- How many technology specialists with expertise in this system will be around in the next few years?
- Will there be a healthy market of third party plugins, apps, devices and integrations that extend the functionality of the EPR?
How much will it cost?
- Implementation costs are likely to be higher than you plan for. Optimism bias – the tendency of individuals to expect better than average outcomes from their actions – explains why projects often take longer, cost more and generate lower benefits than anticipated. Rolling out a major system across your trust will require changes to the way people work and changes to the system that are hard to predict before you start.
- Running costs are more than licensing, hosting and staff costs. You should also account for an ongoing cost of change. Once the EPR is implemented, it is far from ‘done’. Your organisation is always evolving, and your EPR will need to keep pace with changes to your structures, ways of working, clinical practice and regulations.
- Long term costs: Your EPR will be around for a long time – probably longer than the initial contract. What assurance do you have that the supplier will price it fairly and not hold you to ransom for an ageing piece of technology?
- Beware hidden costs: Licensing deals can be complicated. Push for as much simplicity as possible, and make sure you have a clear agreement for the cost of changes.
What is the supplier's commercial model?
Before entering into a commercial relationship with an EPR vendor, your trust should have a good understanding of when and where they are making their money. Is it in upfront costs or further down the line in terms of development and licensing? How does the supplier make decisions? Who is authorised to make decisions and what is the process? When can the supplier help you and when will they not have the answers? And equally, when they want something from you, what will be the cost to the trust?
Should we roll out the EPR in a 'big bang' or gradually?
Implementing a trust-wide EPR is a significant undertaking that will change how staff work across the trust. Some trusts take the view that it’s best to get the pain out of the way in one go by launching the entire system for everyone at the same time. Many trusts take the view that they need to launch across the whole trust at the same time to realise the benefits of deploying a trust-wide EPR. There may also be practical reasons for this: the need to avoid dual running costs, contract end dates, the added burden of staff working across multiple systems and the complexity of keeping data in sync across old and new systems.
However, this approach carries risks: if something goes wrong, the impact can be severe. Modern technology practice is to test and iterate before rolling out a new product. While this may be more difficult to do with a large EPR system, testing the system with a smaller set of users before your main rollout will help you identify problems early, in a lower stakes environment.
Beyond implementation
Whether you decide to do a 'big bang' launch or not, there is still much to do after an EPR is rolled out. Implementing an EPR is not a straightforward technical change. It is a complex development that requires clinicians, managers and technology experts to work together to adapt ways of working and optimise the system.
Calderdale and Huddersfield NHS Foundation Trust categorised their EPR journey into four stages, which only started with implementation and "go live". This was followed by a stabilisation period, where enthusiasts were identified and where the trust began to understand how the tool was being used. Since then, the trust has been optimising their solution, ahead of what has been identified as the "full transformation phase".
Throughout an EPR's life, there will also be a need to develop new documentation processes for clinicians. Jim Ritchie, chief clinical information officer at Salford Royal NHS Foundation Trust has identified nine design principles for doing this (although some are more relevant to acute settings):
- The document serves the patient and the user, not the organisation: Prioritise patient care needs over commissioning for quality and innovations (CQUINs) and key performance indicators (KPIs).
- Better doesn't always mean faster: Quality is paramount.
- An EPR is not an implementation tool: Documentation supports process and behaviour change but it cannot enforce them.
- Clinical documents are part of a workflow, not the workflow: Understanding what else the users' need will identify further opportunities for improvement.
- Show don't tell: The clinical documentation must ultimately give clinicians the right information at the right time.
- Nudges do work: Users will respond so don’t be afraid to experiment.
- Reuse, reduce, recycle: A lot of this is about ensuring consistency across the organisation.
- Don't ask impossible questions: "Looking at documents in use and critically examining for gaps, workarounds or fields that promote garbage answers is vital to allow informed iteration and improvement."
- Integrate, don't segregate: EPRs need to reflect the multidisciplinary nature of health and care delivery.
Case Study
Ensuring EPR launch readiness at Lancashire and South Cumbria NHS Foundation Trust
“It sounds obvious, but change is hard, people don’t read their emails, they forget their training. You have to accept people will struggle with a new system (but never accept risks to safety). So don’t underestimate the level of support needed during deployment. Ask the questions you may not feel comfortable asking. My job as a CCIO is to make board leaders feel comfortable.”
Deputy Chief Medical Officer and Chief Clinical Information Officer, Lancashire and South Cumbria NHS Foundation Trust
Context
Lancashire and South Cumbria NHS Foundation launched their new RiO EPR system during the middle of the pandemic, with minimal disruption. Leading up to the launch, the trust’s leaders took necessary steps to thoroughly mitigate risk and ensure organisational readiness for the new system.
Approach
The project team focused staff readiness for launch across three areas: operational, technical and clinical safety. Crucially, this 'tripartite of readiness' had executive oversight. Regular deep dives, chaired by either the chair or the chief executive and with several executive directors present, were regularly taken throughout the build up to go live. These deep dives increased accountability, built relationships with frontline staff, and created a buzz and momentum about the new EPR.
The board hasn't been naive: there has been negative feedback, some reporting has gone awry. It's been important to avoid getting lulled into a false sense of security as some of these issues have only materialised after the first few weeks. There has been a clear support system with escalation routes for when issues arise, including silver command that escalated more major risk issues to executive directors. Gold calls were previously scheduled daily but stood down after a couple of weeks.
Key considerations for boards
- Explore your options: There’s no right approach to EPR, this will depend on the context of your trust, the needs of your users, the maturity of your existing systems and technology skills.
- Go in with eyes open: Once up-and-running, EPRs provide huge benefits. But getting to this point can be an arduous – and expensive – journey.
- Try before you buy: Go beyond the marketing materials: find out how the EPR works in practice, in trusts similar to yours. And then try it out on a small scale before making a big commitment.