The HTN Festival concluded with a live session by Open Medical on adding value to your electronic patient record (EPR) and what it means in the context of digital health, delivered by Medical Director and orthopaedic surgeon Michael Shenouda.
Michael began by laying out important questions to consider around the digital ecosystem (a group of interconnected information technology resources that can function as a unit).
“Everyone talks about digital ecosystems, but what are the needs of a digital ecosystem?” he asked. Noting that there has been a lot of discussion recently about NHS trusts moving to EPR systems and some of the benefits such as saving clinicians time, Michael added that it is important to consider, “What exactly do we need to do to achieve this? And how do we set up and support an EPR to maximise its value?”
The needs of a digital healthcare ecosystem
Michael summarised the three key aspects of what a digital healthcare ecosystem needs: to be transformative, future-proofed and user-centred.
The needs that the ecosystem must meet are often “vast, complex and wildly variable”, he said, with differences between trusts, within hospitals and even within specialties. They must address multiple needs and work across different teams, and this is “critical to getting the most out of an EPR”.
Michael took some time to focus on how the wide variety of needs can affect EPR implementation and success, highlighting how factors such as integration between clinical and administrative workflows or cohort and volume traffic management can become potential issues. “When these factors arise and are present and problematic, EPR introduction can cause friction,” he said. “These issues become barriers to technological adoption.
“What it comes down to is that EPR implementation in whatever model you use has to be truly transformative,” Michael said. “It has to be consultative-led implementation and really change the way processes are performed and managed. We always say: digital transformation is transformation first and digital second. If you take legacy processes that were designed for a different era and different needs and layer in a software on existing processes, ultimately what you end up with is legacy processes on a screen. What you need to do is work to transform those processes first, and really get them right and suitable for the current technological capabilities that we have, but also for the current clinical and healthcare needs.
“Once you’ve done that,” he went on, “it becomes a lot easier to layer in technology, and allow that technology to come into its own. It will help you utilise the technology you have to deliver the best patient care.”
Digitising patient records in the sense that you can look at your patient records on a screen should be the “minimum baseline,” Michael said. It should “serve as the starting point, not the target endgame.”
This is aligned around the need to future-proof; Michael highlighted the importance of “thinking, when looking at an EPR, what do we want to achieve at the end of the transformation? What does digital health in two, five or even ten years look like? We have to future-proof our electronic records for things that we know are to come and will be increasingly prevalent.”
This includes looking at the system from a technological sense as well as a clinical perspective; on the technology side, Michael suggested, future-proofing could mean increasing the use of ML and AI algorithms. From a clinical perspective, it could mean allowing for a more in-depth focus on regional, speciality-specific pathways or collaborative cross-site working.
“That’s future proofing for the things we know about,” Michael continued. “But what about the things that we don’t know yet? How can we future proof for advances in technology that we don’t have sight of yet?” The concept of future proofing for the unknown unknown is more difficult, he noted, and can seem abstract. “But it’s essential to think in those terms when looking at EPR implementation, to get the greater value from the EPR – not just immediately but in the medium and long-term as well.”
On the need to be user-centred, Michael commented that it’s important to be user-centred across the board – in design, workflow, the way the interface works, functionality and more. “The success of any digital solution within an ecosystem really depends entirely on the engagement of its users and stakeholders,” he said. “Stakeholders are often multiple; in a single hospital they may stand at thousands – clinical, administrative, managerial, all with different levels of digital literacy, digital engagement and internal or external commitments and pressures. Therefore, the engagement that you get can be quite variable.” Michael emphasised that ensuring user-centred design is critical in achieving the required engagement, although he acknowledged that it poses a challenge to meet the needs of so many different stakeholders.
Approaches to EPR
“So how do we streamline all of this into an EPR?” Michael asked. “Fundamentally, this requires us to really imagine what the role of an EPR actually is.”
There tend to be two main mindsets when it comes to EPR, he shared: EPR as a software, or EPR as a concept.
In regards to the first, Michael said: “The software is designed as the data layer, and also as the user interface, to document stories and the clinical workflow all into a single solution.” This does have advantages, such as reduced integration needs and overcoming the need for staff to learn how to use multiple systems.
However, using this model also has its downsides: “Often, the one-size-fits-all model doesn’t end up fitting anyone very well.” You can end up creating more add-ons to support the system, Michael said, such as additional word documents, spreadsheets and WhatsApp groups to try and get around problems, which can result in “clinical teams communicating together in an ungoverned manner to coordinate their clinical workloads because they’re unable to achieve that through the single interface that they’ve got”.
Michael noted that if the EPR is not implemented properly, it can also stifle innovation. “It can lock hospitals or departments into processes that are then inflexible as the organisation’s needs evolve,” he said.
“The second approach in considering an EPR is taking the patient record as a concept,” Michael continued. “Effectively, it’s decoupling the patient record from utility and software. The record captures information and data, it creates relationships within and between the data, regardless of where that data comes from.” This means that the software is used to capture the data from various sources, and the data is then decoupled from the software and tailored to the needs of specific users.
In terms of advantages, this can allow innovation of best-in-breed solutions, Michael said, and “it also allows maintenance of the integrity of the single data record held centrally on the patient record.”
However, “arguably this is a more difficult strategy to deliver,” Michael continued, “because there are some key fundamentals that come associated with it that are often great in theory but a little more difficult to deliver in practice, such as API-driven patient record that is not directly reliant on user input alone. It requires a common language between systems to ensure consistency in the data modelling. It requires interoperability… and it requires proper scrutinising of the software solutions that feed into the record, ensuring they are fit for purpose, they are secure, and they meet the appropriate cyber security standards.”
Another positive is this approach’s ability “to innovate to a greater degree across the entire industry, as innovation is no longer reliant on a single system or a few main systems,” Michael commented.
Digital transformation has to happen at all levels, from individual departments, across hospitals and specialities, and across regional pathways that encompass many care settings. It’s about “creating an ecosystem of solutions that together are greater than the sum of their individual parts,” Michael said.
This comes back to the topic of future-proofing. By ensuring that digital transformation has happened across all levels, Michael noted, it “allows you to ensure that you can scale up your innovation frequently, and stay current with guidelines that are specific to individual departments or teams or specialities. It also allows you to capture the targets that are specific to those specialities at a very granular level, all whilst integrating with the patient record through single data repository available and accessible by everyone within the organisation.
“I think that getting that implementation and transformation right is critical to the EPR,” Michael said, “regardless of what EPR concept is chosen. Without this level of transformation, you have to go back and ask whether you are digitising for the sake of digitising? Are we really getting the greatest value out of this opportunity?”
Next, Michael highlighted some of the common themes in EPR transformation that he has seen resonate with frontline users, that must be taken into account if the transformation is to be a success. Some of the themes listed included flexibility of systems making up the EPR; the guidance of an experienced team who can provide consultancy and help frontline workers explore what they want the EPR to achieve; and the availability of modular solutions that can be plugged in and out as required in an integrated fashion, dependent on the setting’s functionality needs.
Michael moved on to share Open Medical’s mantra: “Joining the healthcare provider on their journey of digital transformation to deliver streamlined clinical workflows as part of an interoperable digital ecosystem. Bringing the gap across primary, secondary and tertiary care while transforming the existing processes.”
On this, Michael said: “Any healthcare organisation going on a journey – it is a journey, it’s not a one-off, it’s going to adapt and evolve constantly over the years. We in the industry need to partner with healthcare organisations on that journey, providing our expertise in healthcare consultancy, digital transformation, software engineering, to guide the provider to achieve their own strategy aims. This is the key… we have to help them realise the value that they are getting from their patient record, rather than simply inserting our own solutions.”
Michael then provided some more information on Open Medical, including Pathpoint, their modular patient pathway platform which is active in over 100 NHS sites, across more than 20 clinical sub-specialities. It has processed up to 1.5 million patient pathways to date. Pathpoint is interoperable with most of the other major healthcare solutions available, Michael said, as well as national systems such as the NHS e-Referral Service.
The session rounded up with case studies focusing on Open Medical’s work with three different NHS organisations: regional multi-site trauma and orthopaedic care at Surrey and Sussex NHS Foundation Trust; trust-wide multi-service transformation at the Royal National Orthopaedic Hospital NHS Trust; and regional cross-site multi-EPR teledermatology at Our Healthier South East London ICS. To listen to Michael describe the work undertaken in these case studies, go to 20:40 on the video below.
Many thanks to Michael for his time and for sharing his experiences.