HTN Now: Apira on realising benefits and overcoming challenges for EPR implementation

For our latest HTN Now live webinar, we welcomed the team from Apira, who discussed value to your electronic patient records; the barriers to realising EPR benefits; the value available to support the workforce during the process; and the ways that resultant digital maturity adds value for patients.

Making up the Apira panel were Phill James, managing consultant; David Corbett, executive director; Sharon Hunt, senior consultant; and Geoff Broome, founding director.

Offering a brief introduction to Apira, Phill said that the company was established over 25 years ago now and has helped over 100 NHS trusts and other organisations on their digital journeys. “We’re commissioned by trusts and their clients to support additional capacity and capability, to bring our knowledge and expertise to the fold, and accelerate our client’s digital journeys,” he said. “We cover all elements of the system lifecycle, from strategy development all the way through to benefits realisation. We’re proud that we’re unbiased in our work – we’re always looking to develop the most appropriate options for our clients. Above all, we care passionately about our NHS, our patients and staff, providing value for money for our clients, the NHS, and, of course, the taxpayer.”

What value is there already in an EPR?

“Value is predominantly measured in hard cash releasing and non-cash releasing benefits in any typical business case,” Phill said, “and those are often the focus for frontline digitisation. It’s where a lot of the external monies come from, which is held to account by the treasuries, so it’s got to be done in the right way.”

An existing benefit is patient safety, Phill noted. “There’s also removing the need for paper. It increases legibility, eradicates postal delays, removes poor security associated with physical assets. It offers the ability to provide clinical decision support, which itself can lead to benefits, and can increase the consistency of care as well. It helps enforce clinical protocols in the workflow of the EPR, and it reduces the possibility of patients dropping off of lists. It provides one comprehensive and more accurate source of information, so that all caregivers at all parts of the pathway have got a more comprehensive picture. All of that can lead to better reporting, which ultimately leads to better intelligence, helping to reapply that for better care and reducing patient harm.”

Moving on to existing value in the remit of patient experience and quality of care, Phill raised how an EPR can provide access to the support of on-call clinicians, “promoting the same care wherever you are in the hospital or beyond the walls of the hospital”. It can support the provision of more joined-up care; more robust transfers and handovers of care; easier response to subject access requests; and remove the need for patients to tell their story multiple times. And obviously, if you delve down, the record contains information including history of diagnosis, meds, treatment plans, and so on.”

In societal benefits, Phill noted the potential for care across the UK to be “levelled up”, as well as reducing the carbon footprint, increasing patient productivity, and reducing patient travel. He also commented on service planning; the role that an EPR can play in better understanding of the services being offered and the quality of those services; what the caseloads are; interpretation of local determinants of health; and supporting organisations to better plan the care that is required.

For the wider health community, Phill raised the benefits of “more quality data, encouraging healthier lifestyles in terms of making information and guidance available for patients 24/7. It can instil a feeling of investment in the local healthcare economy as a whole.”

Finally, in relation to productivity, Phill reiterated the importance of reducing the need for paper documentation, reducing the amount of time spent chasing information, and having the information required at clinician’s fingertips.

What are the barriers to realising EPR benefits?

David led the discussion in this area. He said:  “We know that healthcare EPR projects are very complex; we’ve seen lots of cases where they’ve been hard to roll out and some of the benefits really haven’t been delivered. Barriers to benefits realisation, which are often unavoidable, commonly fit into three categories – technical, cultural, or operational. These barriers can also change as the scheme progresses through different phases.”

The question of ownership can be one such barrier. David commented that there are two levels. “Firstly, at the organisational level, the organisation really needs to build change capacity, and it also needs to make sure that that is built flexibly. It’s got to invest in a robust skills versus wills strategy – a people strategy. At an individual level, individuals must let go of their current reality; they need to go through a ‘confused’ period in-between what they do now, versus what they need to do in the future. Only then can we have a new beginning.”

Moving on to communication as a barrier, David said: “Communication covers all levels, from wards to boards, and beyond. We need to find potential areas of disconnect, and find ways to increase perceived values to users. We need to tie training and communication, workflow harmonisation, user support, and reinforcement with business priorities. We need to coordinate all activities with the user in mind, and we need to create an environment that reinforces desired changes. All of this needs to happen to a regular ‘drum beat’, through channels which are known to be effective in the local culture.”

Discussing change management, David highlighted the importance of not solely focusing on project management, but also taking into account process improvements and looking at the process as a set of coordinated disciplines. He said: “The process involves frontline staff, managers, senior executives and the board, along with the CEO and executives accountable for the business transformation.

“The go-live is only the start – sustainable outcomes result from the organisation’s ability to leverage the combination of six threads: vision, sponsorship, stakeholder engagement, communication, training, and reinforcement. Change management is an organisational responsibility that must create a supportive environment for change to be successful over the longer term, looking at training, resources, articulating clear direction, engaging people, reinforcing new behaviours.”

Moving onto confidence, David shared: “An EPR programme is really about equipping an organisation to reach critical business objectives. It’s about providing people with technical capabilities that make new things possible, by engaging people in changing their behaviour to actively use the new capabilities. All people are different and start at different places, with different life experiences, values, anxieties, and priorities. Change is personal, it’s local, and it’s an individual experience – it’s hard, even when self-imposed and positive. The change process is much like grief in many ways, and can’t be skipped.”

Next, David discussed complexity, saying: “We know implementing the EPR is an extremely complex set of circumstances, that marries up technology with people, with one or more cultures. The technology solution on its own is a complex mix of configuration – configuring an application to meet the needs of a wide range of use cases, often with safety as a key element. Patients need to remain at the centre of all implementation activity. Databases must have meaning, purpose, and resilience. Users need to feel empowered, skilled, confident and supported, having the self-will to embrace that change. Challenges such as ownership, misconceptions, ambiguity, finger-pointing, and risk factors need to be balanced.”

Finally, on resourcing, David said: “It’s finding the time for personnel to embrace the change on top of very busy day jobs. Looking to past experience, seeking additional investment is certainly a necessity, since recruiting fixed-term teams is not possible in a world where graduates are now paid princely sums to attract them. So blending incumbent, fixed-term and experienced contract personnel, is certainly the answer, whilst targeting the correct roles for each of them. The roles and responsibilities of suppliers and roles for change management must be clear at procurement, change champions must be recruited at the very start in order to support their influence. People want to be associated with success, so celebrating milestones and achievements on a regular basis is paramount.”

What value additions will support the workforce?

Sharon took over for the next section of the webinar, which covered value additions to support the workforce.

“There’s been much said about the relationship between workforce and digitisation, and EPR is no exception,” Sharon said. “It’s no longer acceptable for a user just to be taught their bit in a system, parrot-fashion. It’s important to look at how the workforce can be better supported within the challenge of an EPR adoption.”

First, Sharon highlighted the role of training. She said: “I think it’s fair to say that everybody learns in different ways. Some people learn better with traditional ‘chalk and talk’, and others are more comfortable with e-learning and self-serve. During a deployment, we need that planning system training to coincide with config and testing. Knowing what has gone well before and what didn’t go well, in the roll-out of a similar solution, is really helpful.

“Simulation is now playing a key role, whether that’s physical or virtual. Many end-users are learning the system ‘on the job’, as it were, which can be really daunting when they’re using the system for the first time, especially in front of a patient. It’s important for the trust to acknowledge the levels of complexity within modern EPRs, and provide end-users with opportunities to receive training. Simulation is actually an ideal way to deliver this; the caveat being that it might result in more time away from bedside for training. So during deployment, it’s important that a training plan is in place, and that each individual is allowed to pursue their own learning journey, perhaps by providing resources to allow off-the-job simulation training.”

Moving on to mobile apps, Sharon considered: “There’s a plethora of apps now available for processes such as EPMA and e-observations, for example. Some EPRs now look to the app approach to enhance the user experience, especially for clinicians who are mobile, during ward rounds, or on call. Apps that serve a purpose with and away from patients are effective, but they shouldn’t be the only way of achieving an aim. They’re best used when enhancing a desktop process, providing options for the end-user. Consideration should be given for the training of using apps; this includes business continuity and the ability for their apps to operate on- and off-network, since we know that often even the best infrastructure has its blind spots.”

Talking about context awareness and user experience, Sharon noted: “End-users are demanding the technology that better supports how they work in the real world. To address the variations in user experience, some developers are adopting systems such as using personas to develop their software, which actually individualises user experience. With regard to new technologies, such as voice recognition, these will require robust change management and training to ensure that adoption rates go beyond those who are already tech-savvy.”

Next, Sharon moved on to discuss end-user equipment and wifi. “The availability, adequate equipment and wifi has always been an issue, perhaps exacerbated with the overlay of an EPR. The lack of basic tools can really rile a workforce – it’s wasted time and energy, and can impact the delivery of EPR benefits. Give an end-user a valid reason not to use a system, and they’ll revert to using alternative methods of recording care, such as paper, and not return to the EPR, on the basis of lack of reliability and trust.

“Wifi should be available in admin and clinical areas, and should be considered as critical infrastructure. Deployment of a modern, lightweight solution with session persistence, and common experience across desktop and mobile devices, really is an expectation, and we all know that the ‘What Good Looks Like’ guidance supports this to some extent, as does the web browser-first approach to some of the EPRs on the market.”

Automation was highlighted next: “The fear of end-users deskilling was once a real concern, but automation can add a new dynamic, and with careful change control, it can achieve stakeholder buy-in. Within an organisation, automation is most effective when it performs a task quicker and it’s more accurate.”

She noted some of the examples that she has seen, such as tools that can auto-respond to completed referrals or contact patients to offer alternative appointments. “These can deliver real benefits, including safety improvements. Automation can be baked into an EPR, or it can be laid across an EPR, by one of the many RPA tools on the market. Many of these tools allow users to develop their own automation – it could be argued that users are best placed to identify where automation is best targeted, and therefore they may be less resistant to its introduction.”

Finally, Sharon talked about system availability, noting: “System availability is a solution-reputational risk. If it’s unreliable, users may choose to use mechanisms that they have more faith and control over. Availability considerations shouldn’t just be about technical robustness – they need to be about the management of upgrades and acceptable workarounds during these times.”

How does digital maturity add value for patients?

Here, Geoff led the presentation, focusing on how digital maturity can add value for patients.

Starting with safety, he said: “In terms of the value for patients, safety is something that they’re looking for. Safety really starts at the top; ownership of projects from the top is important, so that the messages to the staff on the use of the system are really clear. That helps make sure that we don’t just buy systems, we actually use them well.”

He noted that a lot of EPRs are bought and then not used to their full extent, and highlighted leadership’s role in setting the tone of how the system will be used. “We’ve heard a lot about how we engage with and train staff;  a well-configured EPR and motivated, well-briefed and supported staff base are integral to the safe use of any system. If we get that right, the exploitation of the system can develop well over time.”

On accessibility, Geoff said: “EPRs have elements of portals and patient engagement, and getting the patient involved in their own care and the co-production agenda is important. Getting them able to access the system, use it, add data, and engage with it will mean that the right care is given to the right people at the right time. That then drives better efficiency and drives waiting lists down, so accessibility is really critical, and I think will be a big focus in the coming months.”

Geoff then moved on to cover the informative element of the EPR. “The system itself, for patients, has to be informative, providing intelligent sources of information that they believe in, and enabling them to have a comprehensive catch-all of their own input into their care.”

On dependability, Geoff said: “Related to that is the dependability of information and how people can believe in the sources of data. Trust in the system has to be high, amongst staff and amongst patients. That’s the beauty of the NHS sources of information – people do trust them, but keeping that real and strong within the EPR is critical to the value you add.”

Next, Geoff looked at the tailored nature of the EPR. He stated: “For patients, English might not be their first language, or they may have sight problems or other disabilities, which mean that the EPR and the use of the EPR really needs to be thought about. For example, we do a lot of work in maternity where mothers have a range of languages. It’s important to get value for patients and to get them involved in their own care, as well as offering them choices to opt-in and opt-out of different aspects of the system. We also can’t exclude people who are not digitally enabled; so whilst we want to encourage co-production, we do have to consider people who might not be able to contribute.”

Finally, Geoff came to timeliness, which he said is “critical.” He commented on the need to “make sure that people have the ability to act as autonomously as possible, out-of-hours”. In addition, they need to be able to “use data within the system at an aggregate level, to improve the system, to manage the system, and to produce timely interventions into the care that’s being given.”

He raised how the management of information coming out of the EPR informs interventions and comes back full circle to safety. “By looking at how the system as a whole is functioning, we can support timely interventions to not only support staff, but also to make sure we can intervene in a timely way when things might not be going right.”

Many thanks to the Apira team for taking the time to join us.