At HTN Now: Digital ICS, we were joined by David Kwo, former NHS Chief Information Officer, now working as an Independent Consultant.
David’s session looked at how various NHS trusts have developed their EPR Outline Business Cases (OBC), exploring strategic case (EPRs spanning primary, community, acute and social care); economic case (demonstrating value for money and return on investment); financial case (making EPRs affordable using cash releasing benefits); commercial case (designing the EPR scoring matrix); and management case (designing EPR implementation governance and readiness frameworks).
David started his session by sharing some background on his experiences. He shared how his discussion was based on personal experience of being involved in many EPR business cases over the years, including more than ten implementations and procurements. Having worked with approximately eight integrated care systems and 50 NHS trusts, David has “extensive EPR implementation experience, particularly in the Cerner and Epic spaces.”
He moved on to provide a brief introduction to the Outline Business Case, or OBC. “The OBC is part of the mandatory business case process that is required for large investments such as for electronic patient record systems,” he summarised, describing how the mandatory process covers the strategic outline case (SOC), the OBC and then the full business case (FBC). “As part of the OBC process, there is a need to provide a definition of the organisation’s EPR requirements. You need that for central funding and also to ensure a fair and open procurement for EPR systems.”
David added: “The context of EPR, these days, is around the Secretary of State’s target of levelling up EPRs across the NHS by 2025. This is based on a selection of recently approved OBCs.”
Strategic case
Firstly, David showed what is typically found in the strategic case. “There is a requirement to align the EPR OBC with the trust or organisation, with the wider ICS, with new models of care and pathways,” said David. “These EPRs are often strategically aligned to new hospital builds, but they are almost always aligned to the strategic objective for financial sustainability and improving outcomes.
“Usually there’s a ‘burning platform’, such as an expiring EPR system coming up for renewal. Often the strategic case makes reference to the need to improve the digital maturity of the trust and to improve patient safety.”
In addition, David said, they are almost always described as being clinically led.
In terms of what is trending right now with strategic cases, David said: “What we are finding that is interesting in strategic cases is reference to poor vertical integration. Some trusts deliver both acute and community care services; a few deliver social care and mental health as well. They can find that their existing EPR platforms do not integrate well across these care settings. So we are seeing some trends with regards to reimagining the future with more vertical integration, and reimagining how EPRs in the future can be used across different settings.”
The tip that David would promote in this area is to “try and be aware of the wider context of your OBC. Is it trust-focused, is it focused on an emerging or future ICS? Is it focused on reaching the 2025 central priority? My advice is that you should, as much as possible, try to base the strategic case upon the patient journey across care settings. Think about how your GPs, social care workers, community care workers and acute workers would do if they had a blank state in terms of imagining what the future of EPR would look like.”
As a process tip, David suggested starting with “the golden thread of spending objectives… these should start in the strategic case and flow through all the cases, and indeed through the procurement.”
Economic case
“Typically, the economic case will describe the ‘do nothing’ option, which is to maintain your existing systems and the ‘do minimum’ option, which is to use your existing systems but invest in optimisation. You’ll see the intermediate option, which is usually replacing with a single EPR, and then there’s the preferred option. Increasingly, the economic case argues for replacing the existing EPR with a shared EPR.”
Horizontal convergence is currently a trend in economic cases, David noted; “that’s sharing your single instance EPR with some or all of the acute trusts in the ICS.” Vertical convergence is also an increasing trend, “where the shared EPR is also used across some care settings such as community or social care, going right up to sharing with all care settings within the ICS.”
David’s tip in this area is to “begin to define your more patient-centred benefits, in particular the ones that enhance the patient experience, in terms of the horizontal and vertical convergence options.”
He picked out a quote from an OBC considered exemplar by NHE which states: “The greatest degree of interoperability is realised from shared EPRs.”
Commenting on this, David said, “We recommend this concept because I think we are finding that people view interoperability as more than just disparate EPRs adhering to interoperability messaging exchange standards – it’s about seeing the move to shared EPRs as the highest form of interoperability.”
David went on to discuss “the five stages of shared EPR or EPR convergence”. Here he shares his analysis on eight ICSs and several trusts to demonstrate EPR solution preferences. “There is some clustering,” David noted. He described how the trends indicate preference for one EPR vendor when the organisations are looking to share an EPR system across some or all acute settings within the ICS, and a separate trend for a different vendor when they are looking for an EPR to support system working across some or all care settings.
Moving onto benefits, David said, “The benefits case needs to be made in the economic case to offset the projected estimated costs. The biggest challenge has been in identifying and justifying cash releasing benefits because the experience of realising cash releasing benefits in the NHS has been relatively slow.”
David shared some examples of benefits that he has personally been involved with at Cambridge University Hospitals, University College London Hospitals and Royal Devon and Exeter Hospitals, including efficiency, clinical and patient benefits. To view the list of benefits in full, please go to 16:46.
Commercial case
“The commercial case is really about how the EPR solution will be procured. Typically, most trusts are going down the London Procurement Partnership route which has the Epic solution in it,” said David.
“The key principles of the commercial case have been around for a long time – it’s about going to market with a core scope, going to market with a patient portal, setting out interoperability standards. There is a need to build your outward-facing specification, both for central review for funding purposes and also for the evaluation of EPR vendors and their solutions.”
The trends for commercial cases, David continued, are around shared EPRs. “People are going out to market and asking the EPR pool of suppliers for their shared EPR solutions. These tend to be cross-trust, so requirements and scoring matrices are increasingly designed to assess EPR vendors’ ability to meet cross-trust and indeed cross-setting requirements. Scoring matrices, evaluation criteria and weightings are now being designed accordingly.”
In addition, David noted that there has been a “heightened sensitivity that trusts going out to the marketplace must not be seen to favour any supplier. There is an increased need these days to make sure that your commercial case and your procurement is open and transparent.” He added that there is “a central fear of market challenge” by EPR vendors, with smaller vendors afraid of being pushed out of the marketplace in favour of convergence on only a few suppliers. That’s currently a significant factor in how we are seeing commercial cases and indeed procurements being run.”
In terms of tips, David said: “Try to future-proof. Try to add neighbouring trusts and indeed neighbouring ICSs to enable potential collaborations and economic and financial savings due to economies of scale. Don’t reinvent wheels, that goes for everything we’re saying.”
Financial case
“This is largely about affordability and funding sources,” David said. “Typically, we find that the preferred option as set out in the economic case can only be made affordable with fairly ambitious cash releasing benefits assumed. That causes many trusts to think, in the financial case, that really they can only afford the cheaper EPRs and they cast their figures accordingly.
“However, we are also seeing some trends which are helping affordability in some cases. You may be aware that some of the main vendors are now offering software as a service option, to enable capital-poor trusts to afford their EPR purchases using revenue funding. We’re also finding that vendors are offering what they are calling ICS pricing. This is where an EPR supplier that used to mainly price on a trust by trust basis gives discounts for multiple acute trusts. They are also offering discounted pricing tariffs if the procurement is around all of the acute trusts, or all of the acutes and some other settings.”
Another trend, David added, sees people making their investments more affordable by consolidating IT departments, resources and functions across the ICS. “We found that the consolidation of other functions, such as finance, estates and HR, seems to be happening faster,” he noted. “Not sure why, but that’s what we’re finding. Nevertheless, I think it should be considered.”
Another tip is to line up your letters of support early, in the course of developing the OBC.
Management case
“This is where you need to prove that the procured EPR can be delivered and implemented. Typically, this is around demonstrating that you have a clear plan for implementation and a clear governance framework as well as the usual programme delivery framework. It’s also typical to see a clinical design authority for making the key EPR design decisions.”
Cross-trust procurement boards and teams are a current trend, David observed. “We’ve worked with one ICS recently where the chief medical officers of the trusts have invested a lot of their own time to play governance roles in the implementation plan and governance framework. That’s relatively new – you don’t typically find CMOs involved, but we welcome their involvement.”
Another welcome trend is the fact that leadership roles at ICS and ICB levels have been getting more involved in the EPR implementation governance framework, David said.
David’s tip for the management case revolves around what he calls the ‘critical change management pillars’. He showed a diagram at 33:02 to illustrate his point. The diagram shows the typical organisation and all its constituent parts, with what they need (same mission, shared team culture, shared priorities) to enable what they stand to gain (high performance, high agility and shared success).
“That’s what we mean by putting the critical change management pillars into your management case,” David said. “These are the ones that we have found to be critical in ensuring EPR success, or EPR-enabled transformation success.”
He added: “We’ve also found that the more complex large-scale the deployment, the more important it is that the EPR implementation is the top priority for the organisation for the next three to five years. It is foundational. All of the recovery targets, financial sustainability needs and workforce objectives of each trust will increasingly be dependent upon a sound EPR platform.”
As a final observation, David said, “We’ve found that even in the most successful EPR projects, that EPR programmes and trusts become quite fatigued after the EPR has gone live. They run out of steam, their focus goes to other organisational programmes. Typically, they run out of budget to realise benefits. Our tip for you to put in your management case and indeed your wider OBC is to ensure that you gear up, you plan for and you budget for post-live resourcing and benefits realisation.”
Market trends
“We’ve analysed the market, we know what EPR system each trust in England uses. We know what solutions they have been buying,” said David.
In terms of assessing solutions, David suggested that organisations consider a number of decision factors: lifetime cost; upfront cost; clinical usability; interoperability; technical; configurability; functional scope today; functional scope in five years; and cross-setting capability.
Key messages
David concluded his session with three key messages.
Firstly, he said, “Future-proof your OBC. Define your EPR scope so that it will enable convergence across care settings in the future. Seriously consider, in your procurement, EPRs that offer true or high levels of vertical integration across care settings.”
The second tip is to “know your cultural context. This is about recognising and having the self-insight to realise and remember that we still live in an acute-centric healthcare culture in the NHS. Writing OBCs that seek mainly acute-based EPRs does not make the digital investment the most patient-centric, so we would urge you to step back and think about how your OBC fits in the wider cultural and care settings context.”
Finally, David reiterated his point about preparing for the post-live phase. “Don’t under-resource your post-live staffing in particular,” he said. “They are absolutely needed for benefits realisation and they are most needed for patient-centric integration.”
Many thanks to David for joining us.
