Medway NHS, Dudley Group, Imprivata and Mid and South Essex and Essex Partnership discuss approaches to EPRs

For HTN Now, we were joined for a panel discussion on the topic of optimising and adding value to EPRs by an expert panel including Ciara Moore, unified EPR programme director at Mid and South Essex and Essex Partnership University; Neill Crump, digital strategy director at Dudley Group NHS Foundation Trust; Stacey Spence, EPR programme manager at Medway NHS FT; and Andrew Harrison, product manager at Imprivata.

The session focused on approaches to EPR and next steps following initial implementation, as well as what the future holds for EPR best practice, with our panel considering strategies for continuous optimisation, balancing the addition of new features with the development/optimisation of existing features, maintaining engagement and workforce understanding, and more.

Current state and EPR implementation to date

Neill began the introductions, citing his 25 years of experience across the commercial, public and third sectors, adding: “My remit at Dudley Group is wider than the EPR; it’s very much the whole digital plan and integration piece.” Work at Dudley started back in 2006 with the implementation of a patient administration system, he told us, “and ten years later we signed a contract to retain that system and to add clinical functionality using the Altera product”. That’s everything from clinical documentation and e-prescribing to order comms and test results, Neill continued, “with e-observations and vital signs starting in 2018, with the bed director sharing within minutes that he was starting to see better clinical safety”.

The implementation at Dudley then continued through key areas such as the emergency department, before the trust began to carry out pilots around medical devices and look to enhance areas like e-observations that had already been established. “We rolled out e-prescribing during COVID, and that rollout was massive across the whole trust,” Neill said. “We then had the national frontline digitisation programme and the digital core capabilities associated with that, so we’ve just gone on that optimisation journey to where we are today.”

Sharing her own journey with Mid and South Essex, Ciara told us how her team have branded their programme as Nova, “developing a first in type EPR covering acute, mental health and community across Mid and South Essex and Essex Partnership, as well as reaching out across five ICSs, so it’s quite complex”. As part of that, there are 23,000 members of staff to engage with and 84 main sites, she continued, with 140 GP practices also to engage with along the way.

“Our aim is to take our ten EPRs, seven in mental health and three acute, and turn those into one unified EPR,” Ciara said. “We’ve got our Nova branding and our memorandum of understanding, which I always refer to as our prenup agreement; and we’re at the implementation stage of our programme, so really ramping up the change and engagement, and getting people on board to start doing those all important current state reviews and future design.”

At Medway, the EPR programme started back in 2021, Stacey told us, and proceeded through “quite a rapid phased implementation”, going live with clinical documentation with nursing and doctors alongside AHPs within less that six months, before moving on to emergency department and an EPMA implementation that happened just a few days apart. “We then followed that with order comms,” she went on, “we’ve gone live with paediatrics recently, and we’ve completed a full system upgrade in the last nine months as well.”

As the programme nears its four-year mark, Stacey noted in-flight projects including the outpatient programme, surgical care and e-observations, integration with medical devices, and opportunities for further integration. “Our focus moving forward is on how we can integrate to support user experience,” she said, “and my remit is managing the implementation of our product and how we optimise it, as well as looking at the return on investment and benefits not only to support the NHSE frontline digitisation programme, but also from a trust perspective. We work very closely with our colleagues in the region, as three of us are on the same system, so there is a lot of shared work that supports the development of an EPR strategy to support our patients in Kent and Medway.”

“I have a slightly different lens on the discussion today,” Andrew shared, “because in my role with Imprivata, a healthcare-focused identity and access management company, we look at how we can support clinicians in gaining access to systems such as EPRs.” Although the company is based in North America, he continued, “we have a significant presence here, with around 70 to 80 percent of acute trusts using Imprivata in England, all of NHS Scotland, all of Northern Ireland, Southern Ireland, and most of Wales as well”.

In his role as product lead for international business, his expertise is in identity access management, Andrew told us, “and in the UK I own our Spine access products that help clinicians gain fast and efficient access to the NHS Spine”. Imprivata’s vendor partnership ecosystem also allows EPR vendors to integrate with its solutions, he said.

Approaches to implementation

At Mid and South Essex, the decision was made to adopt a “big bang” approach, Ciara told us, with the first of these for acute scheduled for September 2026, followed by Essex Partnership acute and mental health in January 2027. Support from Oracle Health, NHSE and partners in the region has been essential, she said, “and our journey didn’t just start a year ago, we’ve been working toward this for about three years, focusing on our major digital change approach before we even got into the implementation”.

The invitation to tender involved full oversight from clinical leaders, CCIOs and CNIOs, Ciara said, “and most people are lucky to have one or two of those, but I have six, and because of their passion and engagement, we wrote a really good business case”. Rather than approaching it in the traditional way, the team devised five scenarios with clinicians, she elaborated, designing for end-to-end flows of pathways, and then asking vendors to demonstrate how their product could support the needs of those. “We realise that we’re following in the footsteps of giants who’ve done major implementations as well,” she said, “so we have taken lessons from the NHS Futures website and other organisations, and we’ve collated over 200 lessons learned and then flagged them across our whole plan”.

The core piece of implementation has got to come back to the people and the purpose, according to Ciara, and clinicians across the region have been helping to lead that, getting their peers and colleagues engaged in designing for the future. “It’s been phenomenal the amount of people who want to be part of the programme, and we’re not afraid to take freebies either, so we take any advice, guidance, and free workshops; we’re really conscious that as a first in type we’ve got to get this right.”

Neill referred to Dudley’s experience as a “progressive approach”, noting how since beginning his work in healthcare he has been interested to observe a more measured approach to projects like EPR, compared with his prior work in other sectors which saw “really big teams delivering at pace, getting the main system in, going live, and then doing this optimisation afterwards”. After starting in 2018, Dudley has met 95 percent of the national digital capabilities framework, he went on, “and we’re immensely proud of the work we’ve done with that pull factor from our clinicians who have been prioritising what we need to go live with and where we’ve got the biggest bang for our buck, and then getting our IT teams co-producing and delivering”.

Taking a step back, however, “that’s a massive period of time”, Neill considered. “COVID was during that timeframe, but I think as the NHS we need to work out how we can do things better at pace, and I just wonder whether or not this implementation done at a single-trust level is the right way to do that in future. I think technology is done better at scale.” If we took an approach of thinking about clinical models that could be adopted in the same way across multiple trusts, it would be possible to deploy in tandem and get quicker results, he added.

“I second that,” Andrew agreed, “because in my experience in enterprise deployment, it was relatively straightforward in industries like finance to deliver something in a very short time period – you could remotely wake up every computer at different sites across different countries, install something, close them down on a Saturday morning and it would be ready on Monday morning.” In healthcare, however, that model does not exist, he continued, “and it’s definitely on suppliers to be aware of that and the fact that health is 24/7, so you cannot just apply a standard deployment model, it’s much more complicated than perhaps the IT industry realises, and going that extra mile to understand the environment does make an enormous difference”.

The phased approach is also the approach chosen for Medway, Stacey shared, “because as a small trust I don’t think a big bang approach would have been viable, and because we’re a very hybrid site, we had to focus on bringing staff along on that journey”. COVID helped to expedite a lot of the trust’s digital activities and going live within six months for all adult wards was “such an achievement”, she said, “but it did mean we went straight into optimisation; we worked on a section of the hospital, a section of different clinical workflows, with clear requirements from a clinical-led perspective and from the BI team”.

In an ideal world, Stacey considered, all phases would be rolled out and then optimised after, but this can potentially create a negative user experience for staff, who want to be able to have open conversations about what works for them and any challenges they might be experiencing. “I would say that lessons learned include not to underestimate the scope of what you’re going to go live with,” she continued, “because for me that has generated how big optimisation is – if I compare phase one of clinical documentation to phase two of order comms, the optimisation from order comms has hardly been anything. Plan for that optimisation scale, because user experience and patient care will be impacted if you’re not continuously improving and listening to your end users, because they’re key in it being successful or not being successful.”

Picking up on user adoption for successful implementation, Andrew outlined one key area of focus: “make it easy”. He elaborated by stating that, “clinicians jobs are to make patients and people well. Their job is not to interact with technology, That’s a byproduct of what we need them to do.” It’s for this reason why Imprivata’s portfolio of products are primarily focused on access, Andrew noted, “whether that be access to a medical device or access to a mobile device or access to a traditional workstation”.

Customisation versus standardisation

Moving on to consider the balance between customisation and standardisation, Ciara told us how her team’s work was focusing at a greater level on current state, mapping every single service within Essex Partnership and providing 200 process maps to their supplier. “We spent a long time trying to understand our own services and what the problems were, with the idea that if we standardise as much as we can now, that would make implementation easier. Some core things like booking outpatients in will be standardised, and we did a paper picnic which gathered 6000 documents, much of which repeated the same information with just one little bit that might be different.”

Now that all of that preparatory work has been done around standardisation, Ciara said, “we can move to look at future build and design, and people are already comfortable with how it’s going to look, we’re aiming to get everyone comfortable, trained and familiar with the core product as much as we can, so post go-live, that’s when the big optimisation can start to happen”. Building that confidence with teams will help to drive that optimisation forward, she concluded.

Neill also shared some collaborative work with Dudley’s supplier Altera to highlight some of the different configurations and approaches taken by various providers. “Learning how those organisations have already configured that solution offers us an opportunity to do better standardisation in future, to look at what has worked and what hasn’t, because what we don’t want to be doing is constantly configuring for the first time in the NHS,” he said. An example would be the maternity product developed at Dudley, he explained, “because often people go out and buy a separate maternity solution rather than actually integrating it into their EPR, which is what we did, because our frontline clinicians wanted to see everything in one place. We spent about two years developing that, and now Bolton have decided they want to do the same, so we’ve got a digital midwife from Bolton coming to understand how it works, so that they can standardise that based on the effort that has already gone in.”

“I’d be interested to hear everyone’s perspective on that,” Andrew said, “because I see how as a clinician, a single application that serves all of my needs would be perfect – I probably don’t want six different things to interact with and six different passwords to remember. Logically it would make more sense to invest in the core EPR and keep all of the services within it.”

That’s definitely the direction we need to be headed in, Neill agreed, “but I think currently that suppliers don’t always have the functionality to meet that end objective, so I think having a real clear mandate about what an EPR is and its capabilities would be helpful to give them something to aim for”. That would allow procurement decisions to be made based on what clinicians want and need around things like having everything in one place, one login, and so on, he shared.

A national mandated framework would give suppliers something to work to, Stacey said, “and it’s also about interoperability and being able to have suppliers integrate with each other and offer more flexibility”. Considering whether having one EPR is feasible is important, she went on, “because there might be a real reason we have a standalone product for areas like ICU, in which case the next stage is interoperability and being able to share that data”.

Stacey talked about how to tackle interoperability and the potential for measuring progress toward that goal. “We started with what my CCIO calls the low-hanging fruit,” she told us, “so looking at what other trusts have done that we can easily do, maybe how we can do medical device integration for observation data coming in or how we can get point of care testing results in.” The same goes for all optimisation and planning, she considered, “looking at what the needs are and the patient safety elements, working with end users and finding out what would benefit the patient, then having that data shared”.

Work is still ongoing at Medway, according to Stacey, “and we’re probably on our second reiteration of how we want to run the optimisation programme, because it has evolved as we’ve moved through”. The opportunity to learn from and copy others is something to consider, she added, “because that has opened lots of doors for us to be able to look at integration opportunities”.

At Dudley, the trust has done remote care virtual wards, according to Neill, with a separate product from a separate supplier which posed interoperability challenges that meant the trust was stuck with what were effectively two separate records: the EPR and then the virtual wards remote record. “When we go out to our next procurement, interoperability will be built in, so there will be an improvement there,” he went on. The other area Neill sees room for progress in is around patient access to health records, predicting a “massive push” over the next three years for patients to have their own record and to become more of a part of that care journey.

“We’re all now in the business of digital transformation,” considered Andrew, “and what we’re trying to do is take technology and ensure that it supports efficient patient care, whilst still dealing with all of these challenges around things like cyber threats and regulatory compliance. Accelerating user adoption at the outset is where I see great benefits – everywhere else you have a user at their desk with their laptop, but clinicians don’t always work like that, they have to interact with shared devices, which makes fast access all the more important.”

The proliferation of medical devices is also increasing the burden on clinicians to learn new things and interact with new technologies, Andrew went on, “and those are being passed around and having multiple different people logging in and out on the same device, which isn’t perfect, but focusing upfront on seamless access and giving back that time to care can be success indicators of how well an EPR is adopted and rolled out”.

We’d like to thank our panellists for taking the time to share their insight and experience with us.