Video: David Kwo on EPR strategies for ICSs

Our final HTN Now session was led by David Kwo, EPR Programme Director for Bath, Swindon and Wiltshire ICS, and Advisor on Electronic Patient Record (EPR) programmes at Torbay and South Devon, Royal Devon and Exeter, and Northern Ireland.

David joined us to discuss EPR strategies for integrated care systems (ICSs), sharing his own experiences of working with ICSs and exploring case studies with focus on design principles and emerging themes.

Starting off his session with case studies to provide examples of what existing ICSs in England are doing with regards to their EPR strategy, David describes how the first ICS case study in the presentation involves three separate trusts, at HIMSS level five or under in terms of digital maturity. He provides information on the trusts’ objectives: “These three acute trusts in this one ICS have been collaborating over the past two years,” says David, “and they’re very clear that they want to procure a single EPR to achieve HIMSS level six within 12 months of go-live, and HIMSS level seven within three years of go-live.” In addition, the trusts want to run a single instance of a shared EPR and intend to have one ICS-level configuration team to work on the EPR, in order to achieve standardised workflows.

Moving on to the second case study, an ICS with four acute trusts, David notes how the level of digital maturity differs for this ICS; for example, one has already implemented an EPR whilst another has a “burning platform”, or a system that is growing out of support. The EPR strategy for this ICS is under development; “they are considering, as an option, a shared EPR,” says David, “in this case to save costs and to accelerate the roll-out time. They are also considering running a single instance to achieve tight convergence of their EPR across the ICS – and are also considering joint configuration of the EPR to achieve standardised workflows.” David comments that this ICS is running slightly behind the first case study. “This is really just to give a contrast,” he says, indicating that the progress of the second case study may be more representative for viewers of his session.

David turns next to design principles. The first ICS case study has established a clinical design authority, to represent the clinical interests of all three trusts, and “they’ve recently created some EPR design principles which they have agreed across the three trusts to follow, to guide the way in which their EPR, when it’s procured, is implemented.” The design principles are patient-centred design; excellent patient care and experience; patient safety; self-care; population health and vertical integration; continuous improvement; create process designs from scratch; shared EPR; local configurability; efficiency; and future-proofing.

David highlights some of the emerging themes he has observed from working with ICSs; to view the full list of themes, you can go to 13:05 on the video below. David discusses the different angles ICSs can take on these themes, and how he believes the themes can impact EPR implementation.

On the topic of ambition, for example, David says: “Personally, I think it is incredibly important, in setting out EPR strategies for ICSs, to not lose sight of the level of ambition in the immediate and longer term. It’s not a transaction mindset or a transaction tone – because of how large and significant an investment an EPR system is, across an ICS in particular, one should be clear I think in the level of ambition that underpins the strategy.”

The way in which the strategy is led is also a point of interest. “I don’t see the ICSs I have been in contact with having a very clinically-led EPR strategy,” David says, noting that this is often considered “undesirable”. He adds that he tends to see “EPR strategies being more technically-led, procurement-led and financially-led.”

Other topics include the approach to integration within the ICS (horizontal or vertical), and whether ICSs take a patient-focused approach or an organisation-focused approach.

Next, David turns his attention to the potential issues that ICSs can face. “The business case remains the key vehicle for ICSs to access central funding, to procure for new EPRs. The level of cash-releasing benefits remains central to these business cases in order to make them affordable. My own observation is that cash-releasing benefits continue to be a challenge.

“I also detect that there has been a realisation or acknowledgement that there are more cash-releasing benefits made available for those EPR products that are mature, that are more clinically and patient usable, and that are the most clinically adoptable. Towards that end, I would suggest that we should keep an eye on the usability survey that’s going to be published, hopefully not before too long, by the centre, because that may help us to understand which EPR products are more usable and therefore more able to underpin cash-releasing benefits.”

David also raised the issue of actually completing the business case. “They tend to require external expertise to get them done, I’ve only seen relatively few ICSs doing [business cases] by themselves with in-house financial and technical resources. I think it’s important to try and get hold of good external resources from the usual consultancy firms, and although they come at a cost, they do make things faster. It’s something that I would advise you to do, but the other thing I would advise is to not be shy about asking me and other ICSs and other trusts undergoing their business cases to share their materials… so that we’re all learning from each other and working more efficiently.”

Implementation resources are highlighted as a potential issue. For suppliers, he says, “it’s a boom time… but their implementation staffing [can be] very stretched. I think it’s important to be aware of which suppliers seem to be better able to muster resources for implementing their EPRs than others. My advice to you is to take a very close look when you’re considering and selecting EPR suppliers. Which ones can actually come up with the staff to deploy you?

“Similarly, on the trust side, our workforce is incredibly overstretched… I think [it’s important to be] mindful and realistic of trust inputs to write the business case, do the procurement evaluation and prepare and implement EPRs. It’s going to be a real challenge going forward, that’s why some trusts are planning to create an in-house deployment team and then move them around the ICS, across trusts in a sequential fashion.”

At this point, David opens up to discussion from the HTN audience, with questions including whether an EPR in the acute space could be used in primary care, and whether he believes that there is an ambition to move towards patient-focused rather than organisation-focused EPR.

David notes that he has met scepticism within the NHS about GPs and hospitals sharing the same EPR system, but adds that he knows of a CCG Executive Director who set out to explore this question by organising a number of their GPs to assess a leading EPR product, to test its suitability for GPs: “The overwhelming conclusion that they came to was it definitely was suitable… obviously they noted that there are some reporting requirements that the acute EPR systems would need to meet… but that was deemed a simple matter of programming.” David states that in his personal view, “there is no technical barrier for primary care and acute care sharing the same EPR. It’s not a technical issue or a functional issue. For me, it’s a cultural issue and just a matter of time.”

On the topic of moving towards patient-focused EPR, David says, “That question goes to the heart of this whole topic. Yes, I think absolutely there is an ambition. My observation is that not enough ICSs focus on this ambition.”

To watch the full session, click the video below.