We recently spoke with The Royal Marsden NHS Foundation Trust’s chief information officer David Newey on his latest digital projects and experiences, including the trust’s EPR go-live in March this year.
Royal Marsden’s EPR plans
“The procurement for our electronic patient record (EPR) originally started back in 2019, off the back of our digital strategy at the time,” David said. “After many years of software testing, business cases and benefit profiles, we commenced the project in September 2021 with an implementation timeline of 18 months.”
This was an “ambitious timeline”, David noted, for a number of reasons. “The first one was that not only were we implementing an EPR, it was replacing our existing EPR which we had developed in-house. Also, we were extending the coverage to incorporate the replacement of the JAC pharmacy system and the Technidata laboratory system.” He described both of these areas as “very complex to address on their own”, aside from the rest of the EPR implementation.
Another complicating factor was the number of protocols that the hospital uses, given that that it is a specialist cancer centre that operates “on the highest levels of clinical drug trials in the country”. This meant that it was a “significant hill to climb in terms of building the system, having it tested and implementing training.”
In terms of scope, the trust had over 6,000 devices to deploy and over 90 interfaces to redevelop, along with a need to test more than 4,000 devices over a 10 week period. In addition, they had to migrate data from their legacy EPR.
“One of the ways we approached this was by developing our legacy clinical viewer, which is a fully embedded read-only view of our old EPR data,” David explained. “We developed this from the ground up, mainly because our old EPR was solely reliant on internet explorer 11. We had to ensure that the legacy viewer was able to run on modern browser technology.”
Sharing resources with GOSH
David described how a decision was made to join a connect model with Great Ormond Street (GOSH), who themselves had gone live in 2019. This enabled Royal Marsden to share resources with GOSH, leveraging GOSH’s experience, and using GOSH’s experienced configuration teams to assist in building the system.
The challenge here was that GOSH’s team did not know The Royal Marsden as a trust; in order to tackle this, an operationally-led clinical network was developed early in the programme. David commented that the network was “reflected in the success of staff engagement and also the way in which the operation was able to respond to request for change in the configuration and building of the system.”
He explained how having GOSH’s support in place meant that when The Royal Marsden went live, the connect team knew the system “inside out” and was well placed to respond to any issues.
“We had a very strong set of clinical champions, including two divisional chief clinical information officers and a chief nursing information officer,” David said. “The CNIO role was also quite pivotal because it took responsibility for clinical safety, making sure the clinical risk was managed throughout the project. The clinical risk was very well managed on this project, and that continued along a 12-month trajectory.”
As the go-live date approached, go-live readiness assessments were undertaken, whereby teams came together to share where they were with regards to the completions of key tasks.
“Each team worked incredibly hard to deliver the plan,” David said. “As we approached the final go-live, we continued to roll out training, running several courses a day and offered a mix of virtual and in-person training. This ensured staff were familiar with the system prior to go-live.”
How did staff feel, prior to go-live? “We went through a rollercoaster of emotions as any staff group would, given the amount of hours and hard work the team was putting in to test equipment over a 10-week period,” said David. “By the time we went live at four o’clock, I think the whole hospital was actually very pleased and relieved. It was one of the smoothest go-lives I’ve been party to in all the years I’ve worked in the NHS. It was pretty remarkable, what we were able to achieve.”
Developing pathways and workflows
“In terms of data migration, we had to migrate both patient administration system (PAS) data and electronic patient record data. The PAS data was migrated in a structured format, whereas the EPR data was migrated using HL7 interfaces. We set a window for each time per day that we were migrating. The scope was big – with some data sets, we’d migrate three years’ worth of data,” David noted.
“I think one of the things that has really set The Royal Marsden apart from other trusts has been our own development team and our own EPR,” he added. “It meant that we were able to respond very quickly to changes in the data migration requirements, of which there are many. As you are building a system, your migration requirements and coding changes to reflect that; the development team did an amazing job of reflecting those requirements. The other big piece of work here is the development of our own legacy clinical viewer, which provides us with about 30 years of historical data.”
In terms of pathway development, David described how the teams worked through the different clinical groups and incorporated them into the training.
“From go-live onwards, that’s actually where you start ironing out the kinks,” David commented. “Generally speaking, when you’re designing pathways, it’s the 20 percent of outliers and variations that can sometimes catch people out. The really important message here is that you’ve got to be aware of the variations – that’s where your staff need support and aid in terms of how to use the system.”
Key lessons and advice
“Before we went live, we visited Manchester and spoke with the team who were very candid and open with their lessons learned. They were very transparent in terms of what went well and what went badly. From that, we listed those issues and then we wrote a mitigation plan and applied it to our own hospital. That was staggeringly helpful.”
The Royal Marsden wants to do the same, David added. “We’ve written out our own lessons in terms of what went well and what didn’t go so well, so we can pass our learnings on as well. Learning from other sites is really key and being able to apply your own mitigations and assess them against your own implementation is tremendously helpful.”
A key point from David: “Don’t underestimate the amount of staffing that you need and the amount of equipment you need to buy. There are so many things that need to be taken into account because they can be detrimental to an EPR programme. For example, if your infrastructure isn’t in a good state; if your WiFi isn’t up to scratch; if you haven’t got enough deployment engineers or project managers; if you’re not working closely enough with your supplier and third parties and aligning them to your timelines. These things can all have an effect.”
How have staff taken to the EHR?
It’s important to remember that staff build up muscle memory, David noted, and that includes muscle memory of how to operate the old EPR for over 30 years. “Every click, every tab, every field, every button, people get so used to it and they do it intuitively. However, I have to say that staff have really adapted well to Epic and are really loving it.
“The nurses are finishing on time because their documentation is being done as they go. The voice recognition software that we’ve deployed to replace digital dictation has been really well adopted too.”
On that note, David commented: “I think being able to personalise your own tests, workflows, smart phrases et cetera is absolutely key to adoption. We are focusing on residual training and we’re about to roll out a training refresh programme to ensure staff are supported with any issues they might be having.”
Alongside the EPR launch, the trust has recently rolled out MyMarsden, a patient app and website designed to support citizens in accessing parts of their healthcare records from computer, tablet or mobile.
“We are trying to move away from paper for a variety of reasons – reducing costs like postage, achieving our green plan, and so on,” David said. “The MyMarsden app gives patients and staff the ability to see their own Royal Marsden test results, see their clinical correspondence and to be able to communicate with their clinical teams without them having to phone or necessarily wait until the next outpatient appointment. This is great because it reduces stress on the patient, it keeps them informed and up to date. So far, 30 percent of our patients check in using their app, rather than checking in when they visit the hospital.”
Since launching it, David shared, the trust has seen 13,000 active patients using the app, correlating to 34 percent of their patient cohort, which he called “very impressive.”
He added: “We’ve had over 1,600 medical advice requests via the patient portal so far. In terms of clinical documentation, 52 percent of nursing staff are using their handheld device to complete documentation, which has shown a significant improvement in terms of patient management and communication.”
In terms of challenges, David said, “The biggest hurdle we’ve had in terms of the app was in creating a helpdesk for patients with regards to how to use it – I think we underestimated the amount of effort we needed to put into that, to begin with. We are also conscious that we need to ensure that we don’t introduce digital exclusion for patients, so that’s an ongoing focus.”
Digital plans for the future
David highlighted how The Royal Marsden is currently in the process of rolling out a unified comms platform across the trust, which he said in some ways is “almost as big a transformation project as the EPR launch”. This project includes work such as moving people from telephones to Microsoft Teams, or changing people’s devices from desk phones to smartphones.
David commented that they had assumed that introducing Android smartphone devices across the trust would be easier than it was, as they believed that the majority of staff would be comfortable with using Android systems. “It’s been difficult for people to adjust to the new paradigm,” he acknowledged, “but I think we’ve reached a point where we are able to reflect on what went well and what didn’t go so well, and use those learnings to inform the way in which we roll out projects across the trust.”
In addition, The Royal Marsden is looking at ways to use artificial intelligence. “We already use over 30 AI algorithms within the trust and are looking to increase that,” David said. “In particular, we’re working with our colleagues across South West London Integrated Care System (ICS) to help improve their cross-organisational working, as well as improving the trust’s financial position.”
Many thanks to David for joining us.