As part of HTN Now focusing on electronic patient records (EPRs), we were joined by a team from Apira Ltd, a consultancy support organisation assisting NHS trusts and regional and national NHS organisations with digital transformation projects.
The Apira team consisted of Director of Client Engagement David Corbett, Director of Professional Services Alan Brown, Managing Consultant and Head of Procurement Richard Scowen, Senior Consultant and Requirements SME Kiran Dave, and Managing Consultant and Head of Deployment Iain Borland. They kindly joined us to provide insight into their work, best practice in the development of EPR business cases, procurements and deployments, key lessons learned, and developments in the EPR landscape.
David set the scene by sharing Apira’s digital pathway, starting with strategy and business case development, moving through requirements development, procurement, project delivery and building meaningful buy-in, and finishing with realising benefits from the digital journey. “It’s important to note that we remain benefits-focused throughout,” said David. “It’s a really key part of the foundation to bake benefits into the business case and the requirements – obviously benefits to patients being provided with care, and those who are delivering care. Typically, we support all clients along that pathway, but sometimes we just support them with part of it.”
Alan took over here to discuss EPR business case best practice. “We always talk about de-risking people’s digital journey, and a business case does that through its own process,” Alan said, “going from strategic outline case to outline business case to the full business case. At each stage the risk reduces, the certainty increases, and you move from considering what could be quite a lot of different options to having a single supplier chosen through a procurement process.”
Moving on to business case in context, Alan said, “We talk about the strategic outline case (SOC) and outline business case (OBC)… they are different, but more and more, trusts are beginning to merge them.” Alan discussed how different trusts approach businesses cases differently, with one example producing an OBC which covered OBC and SOC in one, and another example developing an SOC followed by an OBC.
Alan noted that there are “lots of things outside the pure business case process that are really important.” He highlighted the need to have strategies in place to begin with, both within the trust and regionally, along with the need for market intelligence to help the trust understand what it might want, and help suppliers work out whether the trust is a good fit for them. “It’s very much a two-way thing,” Alan said, “and it really helps a trust to shape its procurement.”
Following on from procurement, “you move to full business case, which allows you to take what is now a single supplier’s costs and build that into the case, and that leads to deployment.”
Next, Alan shared the “five case model” which asks “five key questions – why are we doing this, is it value for money, how are we going to buy this system, how can we afford it, and will it deliver?” As well as setting out the questions against the necessary cases (strategic, economic, commercial, financial and management), the model highlights what the business case must demonstrate, such as a clear case for change, that options have been considered and the preferred way forward considering cost, benefit and risk, and availability of funding.
“At the SOC, it’s very much about ‘is this the right thing to do, what’s the preferred way forward’,” said Alan. “The OBC starts to bring in the costs, starts to reduce the options and sets up a procurement. By the FBC (full business case), all five cases should be complete. You should know exactly the value for money, the affordability, what the contract’s going to look like, and how it’s going to be delivered.
“Fundamental to all of this is buying the right system in the first place,” Alan continued. “Part of that is deciding on your requirements and specifications.”
Here, Alan handed over to Kiran.
Kiran explained how there are a specified set of requirements for an EPR system. “It supports the clinical and healthcare professionals and wider trust to deliver safe and efficient patient care. It also allows the trust to meet statutory and operational requirements, it leads to improved efficiency and the most important thing is, it puts the patient at the heart of the focus and supports the patient journey across health and care systems.”
The requirements stress the importance of being clinically-led and meeting the needs of other users such as operational staff, as well as ensuring that the system is designed around problems that the trust needs to solve, and recognising that current processes will have to change.
“Our approach is to identify key groups to work with, to develop the requirements,” said Kiran, noting that it’s important not to “underestimate the effort and commitment required” to do this. “Engagement is really important to ensure that we get it right, that it meets the needs of the trust. It’s also really important that the key trust project team members are involved in bringing clinical and operational teams together. I can’t emphasise enough about how important engagement is for the Output Based Specification, and don’t underestimate how long this can take.”
Kiran shared an example of the functional and non-functional dimensions and sub-dimensions that Apira put together, including areas such as clinical functionality, electronic patient medicine administration (EPMA), results reporting and integration and interoperability. It can be viewed on the video below at 14:42.
“Having this structure makes it easier to further drill down, to match your requirements,” she said. “This structure is designed to highlight specific features of the EPR which distinguish between other suppliers. It’s important to specify the output.”
Kiran added: “The questions in each of these sub-dimensions are specific to national and local requirements without defining the exact workflows.”
Next, conversation moved to the current EPR landscape, with particular focus on the Convergence Agenda and the upcoming EPR deadline.
“Convergence is a very simple, straightforward word, isn’t it?” said Richard. “The problem is, we all have slightly different ideas of what it might mean, particularly when we’re thinking about EPR and the ICS context. It might mean for one ICS that you move towards all of the trusts being on single shared instance, but you might also be thinking about convergence based on how your patient flows work, and thinking about how information needs to follow patients as they move through shared care pathways.
“I think convergence is a tricky word and we’re still trying to understand what it might mean and if it’s going to be the same everywhere.”
The deadline for 90 percent of NHS trusts to have an EPR in place is December 2023. “As we’ve already heard from Kiran, we shouldn’t underestimate the time needed to prepare things like specifications, or to get through the approvals process for your business case,” Richard commented. “What do you think are some of the challenges that might come out of that deadline?”
Alan considered: “Time is always a challenge. We’ve seen in the past how a policy date can end up not being a real date that people can achieve. Certainly December 2023 is a very tight date for anyone to implement an EPR if they’re not well on that journey already. But there’s no reason why a trust can’t have a strategy and an approved business case in place by then, and most of procurement complete. There’s plenty of time to get a lot of that done in the next 18 months. Benefits won’t be realised, not all systems will be deployed, but there are things the centre can do and is doing to streamline the process.”
A challenge that Apira are currently seeing in the EPR landscape is supplier capacity; with the market so busy, with everybody recruiting from the same pool and suppliers are picking and choosing where to compete. With the cost of living crisis, day rates for suppliers are increasing, making the process more expensive. “I think one of the things trusts have always slightly struggled with is how best and when to engage with suppliers in order to ensure that their procurement moves quickly and at pace, which is what we need it to do.”
“Engagement has to start early and often, whether it’s internally with clinicians and stakeholders or externally with suppliers,” stated Alan. “The more a supplier knows about a trust, the more likely it will be to decide to bid in a procurement, and also, form a solution that meets the needs of the trust.”
Richard added that there is central support available for implementing EPRs, such as funding and guidance, and templates for business cases and procurement documents.
The team turned to procurement and where it fits into the process, with Richard leading the discussion.
“Before we even get to procurement, we’re developing our OBC, we’re thinking about what our routes to market are, how we are going to buy, what it is we want to buy,” said Richard. We run our procurement and then we theme the output into the development of the FBC. So procurement and the business case run side by side.”
Richard shared the four key principles that must be followed during any procurement process, drawn from the public procurement policy and statutory obligations flowing from the Public Contracts Regulations 2015. The principles are equal treatment, non-discrimination, transparency and proportionality.
“One of the key topics at the moment is collaborative procurements,” Richard said. “Much like how there can be different versions of what convergence means, there are different types of collaborative procurements. A key thing that will drive the approach to collaboration is timing. Are you in a place where you’ve got another trust in the same place as you? Do you have an agreed OBC? Do you have a well-engaged clinical workforce? Do you have a clearly articulated strategy about where you’re going and when you want to do it. If you do, great – you’re a prime candidate for typical collaborative procurement. You come together, develop your requirements together, you go out and you procure together.
Richard pointed out that a trust may well not be in this position for a variety of reasons. “You may not be able to follow that classic collaborative procurement approach,” he said. “But that’s not a problem. You can design your procurement in such a way that you can run a procurement and then other trusts can join in.”
Next, Richard covered preparations for procurements. “I’m going to keep repeating the message you’ve already heard – this takes time,” Richard stressed. “You shouldn’t cut corners when you’re getting ready for your procurement.” Aside from the OBS and the documents needed to prepare that, “there are a bunch of other documents that you need to prepare – for example, telling the market a bit about yourself, what’s the size and scope of the thing you’re trying to buy? Why are you trying to buy it – what are the key problems you are trying to solve?”
Richard showed a graphic splitting the necessary preparation into four categories: documents issued as part of the procurement, internal documents used to support the process, people (covering identification of people involved to show evaluation, identification of those not involved to show moderation, and identification of approval/governance/assurance group), and market (supplier briefings and so on).
Next Richard displayed a chart demonstrating the procurement process, from launch to shortlisting and moderation consensus through to score evaluation and a successful bid. The chart can be viewed at 30:45 on the video.
Pointing out the evaluation components on the chart, such as strategic presentation and financial evaluation, Richard said: “I would say to you that the most important thing to do is to look at those components, decide which are important to you and weight them appropriately. Different weightings on different parts of this will give you very different outcomes.”
Iain moved the conversation on to the five best practice principles for deployment. “We’ve gone through the process, we’ve justified what we want to buy, we’ve specified what we want to buy, and we’ve actually bought it,” said Iain. “Now, we have to deploy it.” The best practice principles are “things that I’ve come across, in my experience of deploying systems, that really help – it’s by no means exhaustive, but hopefully there will be some useful ones for you.”
The principles are categorised under initiation (such as avoiding scope creep and ensuring a mix of staff); change project (such as ensuring that the change team is appropriately staffed with experienced leadership); staff engagement (such as having a clinically-led steering group and creating a network of change champions); technical (such as starting early with data migration and defining the scope in the strategy); and comms/training (such as ensuring a dedicated communications resource and remembering that ‘go live’ is not the end point). Iain’s full list of tips for best practice can be viewed at 32:30.
Iain went on to share some of the lessons learned from his experiences in deployment; sometimes trusts have struggled with resourcing if they have gone either all internal or all external, he said, so it’s good to have a blend of experts leading and training internal staff. Scope creep can be another issue, with extra ‘small’ bits of function or services getting added into the project. Data migration, change and data can present difficulties too, if trusts don’t engage widely on strategy, position somebody with enough experience to lead the change team, or leave it too late to sort out the quality of data.
The discussion wrapped up with a question and answer session, available to watch from 42:00.
Many thanks to the team at Apira for taking the time to share their experiences and views with us.
You can watch the full session here