For a recent HTN Now panel discussion around optimising and adding value to electronic patient record (EPR) systems, we were joined by Paul Charnley, digital lead at Healthy Wirral Partnership; Kelvyn Hipperson, executive CIO at Cornwall and Isles of Scilly ICB and the Royal Cornwall and Cornwall Partnership Trust; and Dennis Rausch, chief medical officer at Dedalus.
The panel shared their insights and experience on the EPR optimisation process, considering factors such as planning, technical capabilities, workforce, culture, leadership and what ‘good’ looks like for an EPR.
Paul kicked off the session by sharing what EPR optimisation means for him, stating: “I think it’s about making the best use of what you’ve got”. He discussed two ways of looking at the process: a top-down view where you look at the organisation’s strategy and objectives, and the functionality and capabilities it needs in order to do a gap analysis; and a bottom-up approach.
Key features to consider, Paul said, include usability, the user interface, and “the ergonomics of it, so it doesn’t get in the way of things and it supports what clinicians want to do. It should be almost invisible in the way an organisation works.” Once that is in place, he continued, “you’ve got to make sure it is adopted well, that people know how to use it and how to get the best experience from it.”
Kelvyn talked about the current situation in Cornwall, explaining that they are viewing EPRs in the broader sense, across all care settings. “I’ve got a concept map that I put in front of people, which covers EMIS, TPP, primary care EPRs and the Rio platform in community mental health. We’re also just in the implementation phase now for Oracle Health in the acute setting.”
Setting all of this out is “a massively important piece of the jigsaw”, Kelvyn noted, “because it’s been a barrier to effective join-up across all of those capabilities, as we’ve still got hundreds of individual platforms in the acute setting. Taking that even further, we’re working with our council colleagues around their platform in adult and children’s social care. We’ve had some really interesting conversations with our third sector colleagues and potentially linking in a case management platform. EPR is a really important part of our ecosystem.”
Planning for EPR optimisation and challenges
When it comes to planning for EPR optimisation, our panel considered some of the key factors for consideration, and the challenges that optimisation could potentially seek to solve.
Paul shared thoughts on this, highlighting the need for “streamlining the configuration to get the best balance between compliance in terms of data capture and so on, and the ease of use.”
Referring to research showing that “less than half of clinicians using EPRs were satisfied with them”, he suggested that this reflected the experience in Wirral. “Ultimately, we need new user interfaces and to consolidate solutions, so that jumping from one solution to another doesn’t create as much friction”
Expanding on the current situation at Wirral, Paul said: “We haven’t got one EPR for all our organisations, but using shared records between our partners, it starts to feel much more like a single record. We need to go in that system-level, patient-centred approach direction, and pulling those groups together is something that I’ve been spending my time on recently.”
Over in Cornwall, Kelvyn shared that there has been work towards “incrementally building capabilities with that view to the long term goal of how they’re all joined up – we had three different GP systems and we’ve consolidated down to two, we’ve implemented our shared care record jointly with colleagues in Devon to provide a common platform across the two counties to help patient flow. We’ve also put in a referral management platform to support the movement of patients between different care settings.”
In his experience, Kelvyn said, “Often you spend years doing this stuff, and then everything comes together and you have a massive change, really quickly, when all the right enabling capabilities have come together.”
Engagement and leadership
Dennis asked Paul and Kelvyn how they ensured that staff were on board with these types of big changes, and how they had worked on leadership within this type of complex project.
Paul talked about how in his role as digital lead, he doesn’t personally use the solution; for that reason, he stressed the importance of having good clinical leadership and operational staff. He added: “The key to success is to be that person that only gets noticed when the system isn’t working, and to let everyone else take the lead on what the system needs to do for them.” In the last 5-10 years, he went on, “it’s been more about talking to patients about what they would like to see; that gives us our priorities to shape the solution.”
In terms of engagement, Paul continued, his team tries to engage across the system. “We ask GPs about our discharge summaries from the hospital; it’s not a highly technical thing, but it’s about creating the environment in which that happens.”
Kelvyn agreed with Paul’s statements on leadership and engagement, going on to mention the “wide variation in knowledge and skills between different teams we work with”, saying it can sometimes be more difficult when “something is so new and alien to people”. The best way to approach this, he continued, is “gradually introducing things, and then as people’s knowledge and experience grows, you can see the light bulb started to come on. They start to drive it, so the goal is that eventually everybody’s in that position of driving”.
Having joined the NHS from another sector, Kelvyn praised the concept of the CXIO role in the NHS. “You go to any other sector, and the best you’re likely to get is being told that you’re going to be the expert user. To actually have these as defined roles, with the thought that’s gone in to the skills required for that role and that joint working across clinical areas alongside technology, is brilliant. We probably don’t shout enough about that, because it’s actually something really good, that other sectors could learn from.”
When it comes to ensuring the representation and engagement of staff across different roles and departments, Kelvyn observed that “tends to be done quite well in big programmes, in terms of organising workshops and getting all of that input; the trick is finding ways to carry that through into the operational service delivery”. Ways of doing this in Cornwall include ward walkthroughs to chat to team members, and getting the training team to participate in collecting that kind of feedback. “I always say that feedback is the lifeblood of what we do,” Kelvyn said, “because we can’t fix things unless we know.”
In Wirral, Paul considered, there is “a formal feedback structure, because our digital programme board has transformed itself into a digital services board, where we can account for our services as well as for project deliverables. I think that helps us in a more formal sense to understand where we sit. One of the key things is digital maturity assessment feedback, and the key there is not for people like Kelvyn and I to sit in a room and sign it off, but to get people’s opinions of where we are on those questions.”
He noted that the process has “changed over the years, since more and more we are letting go of the training internally. We find it comes across better colleagues who are showing people how to do the rest of their job pick up on the EPR as well. It used to be more about which buttons to press, and now it’s much more about workflows since the departments took over.”
Ensuring the right data is surfaced for the right people, and by the right people
Moving on to discuss data, Dennis talked about the need to balance asking clinicians to provide data “which may not be their direct concern”, with ensuring that mandatory information is available when needed.
Paul’s concerns on this were around interoperability and duplication. “Ultimately,” he said, “it is our job to try and find the easiest way for the right information to be recorded and then later located.”
Kelvyn said that he had “seen both extremes”, in terms of things being either overcomplicated or “instances where something’s been designed locally by clinicians because they feel really confident about what they’re doing, and it’s really lightweight”. On balance, he conceded, “there tends to be more of a pressure towards overcomplicating these things. I feel strongly that a multidisciplinary approach to asking those questions is of benefit, because of the strength in a group of people deciding things. The alternative is somebody feeling all of the accountability and that driving them towards going overboard with it.”
An important thing to consider on this topic, Kelvyn highlighted, is that “so much of clinical training is geared towards trusting your judgement and the information you’ve gathered, which means that even though we’re now often sharing information, there’s still a tendency to recheck it. Somehow we’ve got to get into the space of clinical professions and technical professions meeting up at a much higher level, to tackle some of these deep philosophical questions about how you capture information in a way that protects the individual and that people we’re serving.”
Kelvyn acknowledged the shortages of skilled people, adding that it is not a problem that is unique to health. “That’s definitely an area where we’ve got a lot to do in terms of usability of our platforms. Actually I think providers are starting to wake up to that, starting to recognise the sorts of usability improvements that have been made in other sectors with the use of AI and automation. We’ve got to go down that path, because expecting everybody to be a deep technical expert is just not reasonable.”
“Every workforce in every sector will have people who don’t have the digital skills,” Paul agreed. “We have tried different ways of making it easier for those who are less technical, like having barcodes that could be scanned every time a vital sign was taken to connect into the EPR, so staff were motivated to use the technology, and the transaction was less technical.”
From a supplier perspective, Dennis talked about the possibility of assuming a basic level of technical knowledge based on the prevalence of things like smartphones and everyday IT use. “If we design our systems in the right way, we should be able to create a similar experience to what is happening in consumer computing.”
Tackling variations and the future of EPR
Talking about the challenges that can arise from differences between different departments, Dennis asked Paul and Kelvyn for their perspectives on how to leverage synergies between different specialties.
Kelvyn discussed progress on the implementation of an acute EPR in Cornwall, and work on “trying to build links with other hospitals that are much further along the journey”. He said: “Often, it’s a unique combination of similar things in that particular place; so generally, you can identify whether there are key things or common themes.”
Paul voiced his disappointment around the lack of sharing of good practice when it comes to EPR development, saying, “I think there will be a move for us to come back to sharing these things between organisations and implementing them, because we each can’t afford to have that size team. It’s not only to create new things – every time a core upgrade to the EPR comes along, you’ve got to test it all again. We’re working on creating a common assessment between social care, community nursing, and hospitals, and that’s still defeating us, so it’s not just a problem within one EPR. Then we’ve still got work to do on end of life documentation, to standardise that and make it easier to move those sorts of things around.”
Dennis asked the panel whether they thought that initiatives around OpenEHR could help to resolve this in the future.
Paul talked about how that might help with the alignment of standards between organisations and systems, and allow for local EPRs to be adapted and worked into that framework over time, whilst Kelvyn commented on how the pressures of the market “will see greater interoperability, whether that’s the OpenEHR standard or other ways of enhancing interoperability.”
In an ideal world, Kelvyn said, “I would probably not even start in any of our clinical settings, and actually start with the people that use our services; I want to turn it on its head and for all of our services to be in the service of the people who use them. I’m still saying that our EPR work is going to get harder before it gets better, but it’s worth doing that, because you’re aiming for something better in the future.”
We’d like to thank our panellists for their time, and for sharing their insights with us on this topic.
