Let's Talk

Andy Webster and Georgie Duncan at Leeds Teaching Hospitals on their EHR, criteria led discharge, future plans

Welcome back to another episode of HTN Let’s Talk!

For this edition of our podcast, we interviewed Andy Webster (CCIO) and Georgie Duncan (Associate CCIO) at Leeds Teaching Hospitals. We discussed the implementation of their electronic health record (EHR), how its gone developing their own, challenges, benefits, future plans and more.

On their roles

To begin with, Andy and Georgie spoke about their current roles at Leeds. Andy has been a CCIO since 2018.

“I started at Lancaster in 2006 and worked there until 2011, then the bright lights of Leeds attracted me and I’ve been a consultant here since 2011 and seen massive change,” he said. “IT and digital is quite a nice job to do. It gives you a bit of variety and you can see the change you make in digital and how they lead to improvements on the shop floor.”

Georgie is a nurse and works as an intensive care nurse by professional trained background. “I’ve worked at Leeds for quite a long time but originally did my nurse training in London and worked in a number of big hospitals within London,” she said. “I moved to Leeds and held a range of roles which included predominantly working as a manager within intensive care. Then I worked within corporate nursing, so I was responsible for lots of trust-wide projects, but it also meant supporting wards where they need some help and working on quality improvement projects.”

She continued: “Within that role I got really interested in digital healthcare and developed some quality dashboards and nursing metric dashboards as well. That paved the way for moving into DIT.”

EHR in focus

Patient Pathway Manager (PPM+) is LTHT’s EHR. Designed to consolidate data from disparate systems, both within LTHT and across local organisational boundaries, it allows clinicians to view a single patient record including information from several organisations to provide an informed and rich outlook of patient needs.

The development of the EHR started before Andy’s involvement. He described how it “started out as a cancer tracking system in 2002 that tracked cancer waiting times. In about 2012-2014 it was decided that Leeds needed an EHR that catered for the whole of the trust. At the time, money was tight and we already had that experience of building the cancer waiting times electronic health record.”

It was decided that they would build a modern platform in Leeds working with other partners, in collaboration with Aire Logic who helped to develop PPM+ alongside the trust’s in-house development integration team.

“The journey has evolved quite significantly over the last eight years,” Andy shared. “We have quite a mature shared care record solution in Leeds, so that enables us to share data with our partners in primary care, adult and children social care, some third sector organisations, mental health trusts and our community health team.”

“Those digital interfaces are really important because those relationships really help in terms of our development, and they’re fundamental for patient safety and ongoing care,” said Georgie.

Andy noted that when he first started working in emergency medicine consultation in Leeds, it was not easy to get patient information such as medication and allergies after 6pm on a Friday. “If the patient didn’t know themselves you really couldn’t get any information,” he said. “Even in the day time… you had to try and get through to general practice and telephone lines were a nightmare. We initially went live with GP information using the MIG and that was an amazing transformation because we could get all that information through – allergies, medicines, encounters.”

Andy also highlighted how Leeds was one of the first trusts to connect using GP Connect, which meant that “we could actually see the recent discussions patients had had with their GPs, which gave us vital information when were making decisions in real time about what investigations they would need, whether they would need further inpatient follow up, where they could be safely discharged back to primary care. So it helps us maximise the use of our resources but also makes safer patient decisions.”

How they developed the EHR

Georgie emphasised the importance of having a good, clear digital strategy that “encompasses not just the EHR development but all digital transformation that we support. It’s about engaging our workforce including the clinicians who use it and we as a CCIO group. With our operations team, we look at how we prioritise the work that needs to happen against the digital strategy. There is lots of communication and robust analysis in terms of what we need to do and what we need to deliver on. But there’s also supporting and running a busy hospital, and national reporting requirements. There are lots of different things that come into the mix when we are considering what developments we need to do, when we need to do them and how we prioritise them. It’s very much a collaborative conversation.”

Andy explained how there were projects that they could quickly adapt and deliver in an agile way during the COVID pandemic due to the EHR. “If we had a commercial solution, we may not have been able to do this,” he noted. “For example, within two to three weeks we turned quite a paper-heavy hospital into one using real time pick up and scan.”

Another example focuses on point of care, which Georgie was also involved with.

At the beginning of the pandemic, Georgie said, “We didn’t have any vaccinations and swab results for COVID were coming back taking around 15 hours. We integrated our point of care machines for COVID swabs which meant that you could do the swab and get the result back in 20-30 minutes. With our fantastic digital team, we built a solution that integrated the results within PPM+ so the results were visible and generated alerts for our staff, keeping our staff and patients safe.”

How staff adapted

“It’s not always quick, it’s not always easy,” said Georgie. “I think sometimes part of our role is to articulate the vision and help people understand about what we’ve got and how we can use it. It’s also about that forward planning horizon scanning in terms of what does the future look like. And it’s about supporting our colleagues to articulate what they want and how they can work alongside digital colleagues – working together so that they can start to speak the same language. Mutual respect is really important in terms of getting projects over the line.”

She added: “It’s not always been that easy to adopt certain things. Sometimes you release something and you don’t get the adoption that you expect at the start. That’s why it’s important to get good data for what we’ve released and where it’s being used, and then we can concentrate on the areas where these new releases aren’t having the new functionality adopted well.”

Challenges and benefits

“Managing people’s expectations around delivery times can be an issue,” Georgie said. “It’s complicated and you can go through a testing process and find lots of bugs. I think that can be one issue.”

Andy commented that people’s expectations often expand. “When we first started, actually getting a computer that turned on, that clinicians could log into, was the level of expectation for most. But now they can see the power of digital tech and what it can do for them. We’ve got lots of clever people who can see the benefits, so for us, the challenge is delivering on all those ideas, developing and implementing them.”

Criteria led discharge (CLD)

In Leeds, criteria-led discharge is a process they have digitalised. Georgie said: “It used to be on a piece of paper – a clinician will view a patient and determine what they need to achieve, which could be getting a test result back for example or being able to eat and drink before they are suitable for discharge. The idea is that by pre-determining the criteria, a patient can be safely discharged when they achieve it without the doctor or clinician needing to re-review them.”

The team created a dashboard with widgets within the system in which they can “write down the criteria that determines that patient for discharge. Any team member involved with that patient’s care can interface to say whether that patient has achieved the criteria or if they’ve had any issues. It also takes note of their estimated discharge, and the dashboard can be seen on electronic whiteboards in each ward.”

Georgie shared that the main challenge in this is primarily embedding it in practice when people are so busy. “We need to get clinicians to use CLD as a single point of articulation for what those patients need,” she said. “For example, a lot of our surgical colleagues will write key things that patients need before discharge within the operation notes. It’s actually about transposing those or getting them to use the CLD pathways so that they can get them discharged.”

Would you develop your own EHR again? 

“Absolutely!” Georgie stated. “There definitely can be some challenges with it, but with the responsiveness we’ve got we’re able to prioritise what is needed for our organisations and for our patients.”

PPM+ has evolved over time, Georgie noted, and needs to have an element of longevity. “It’s also about learning from other people and other organisations as they develop their digital maturity as well. I would say for the period of time I’ve been in my post, I’ve learnt a lot in terms of digital.”

Andy mused: “It’s a complex question. I think it was the right thing for Leeds to do because of the circumstances at the time… I think because it’s been something that has evolved over 20 years, it’s grown and developed into a really good product now. For Leeds, I think if we were making a decision now to buy a new product off the shelf, we would have to think of all the change for the organisation, because we have this product that has developed over 20 years.”

Ultimately, Andy said, the development of PPM+ was “born out of necessity, given our historical journey and finances available at the time. The answer to this question is very nuanced – we’ve done it and it turned out to be a good decision, but when it comes to recommending another trust to do it, I would say that is down to the individual trust. It’s a complex decision. I think we have ended up with a good product and I want us to get better over the next few years.”

Lessons learnt

“Don’t underestimate how long it takes to do things,” said Andy. “Working in emergency medicine, I’m probably used to being with a patient for less than four hours. It tends to be a bit longer now. I’m used to turning things around quite quickly and I’ve got a short attention span! So I think when I first came into digital technologies, I was a bit naive in terms of thinking ‘why does it take so long to do things?’ But I understand the complexities now of identifying what you need to build, capturing requirements, checking with different stakeholders, getting time in the developing and testing cycle to define what has been built so that it actually meets your ideas… things take a lot longer. But out of the blue you might get a priority within the trust or something from NHSE, and then you have to stop developing what you’re doing and move on. These are the challenges, these never work as smoothly as you think.”

“I wouldn’t say this is a lesson learnt, but something I’d definitely recommend is learning all about technical and digital colleague roles and what they do, understanding their jobs,” Georgie said. “In Leeds we aim to ‘walk in their shoes’ which is about understanding that the decisions I make need to be the right decisions at the right time to help them do their jobs, rather than creating more work for them.”

Future plans

Leeds has a digital strategy outlined and are currently aiming to reach a HIMSS level 5. Andy said: “A lot of our digital strategy over the next couple of years is looking at the elements of our electronic health record, not just PPM+. We need to advance to meet that HIMMS level 5 and beyond – we’re not looking at that as our target, but as our minimum baseline.”

They are also looking at work areas they need to concentrate on and develop over the next three to four years. “We’re still building up to the development of two new hospitals in Leeds, there is an outline business case going through to the department of health. If we get the green light to that, it will be a massive change for the organisation,” said Andy. “What will a digital hospital look like in those new builds, what will a digital hospital or digital way of working look like for the rest of the organisation?”

Georgia added that she is looking forward to development of the What Good Looks Like guidance and “how we can do an assessment for Leeds within that framework… I’m really keen for our trust to work within the framework and see what we can achieve and what it means for the future for digital nursing.”

Another aim is to make it easier for clinicians to use digital technologies and reduce frustrations. “It’s not a perfect system, some things take longer than they should,” acknowledged Andy. “We’ve got 20 years of cancer data and ten years of observational data – how can we make better use of that data we are collecting? We’re really data rich and at times we don’t analyse it well.” He shared that they are developing a new data platform which will “give us much better access to that data and let us make better use of it for the benefit of our patients.”

Many thanks to Andy and Georgie for sharing their thoughts.