For a recent HTN Now session on the topic of EPRs now and in the future, we were joined by digital leaders including Sally Mole, senior digital programme manager – digital portfolio delivery team at The Dudley Group; Keltie Jamieson, CHIO at Bermuda Hospitals Board; and David Newey, digital health expert and executive CDIO.
We heard in depth from our panel in terms of their EPR journey, sharing their approach, examples, challenges and lessons learned. We went on to discuss the current position with EPRs, the opportunity, and the current need. Looking ahead, we discussed what the future of EPRs looks like in the short, medium and longer term.
Introductions and EPR journeys to date
Keltie shared how she has been in her current role at Bermuda Hospitals Board for three years now, prior to which she spent seven years as CIO in Nova Scotia, Canada, and also worked for Alberta Health Services, Canada. Those experiences offered the opportunity to work on a number of different EPRs, including Sunrise, Oracle, and Epic.
In her role as digital programme manager at The Dudley Group, Sally has experience of heading up a number of digital projects, and 23 years of experience in pharmacy along with the digital aspects of community, hospital, and pharmacy, she shared. “When I started at Dudley I was a clinical configuration analyst, so actually building the EPR, before moving into a project manager, and then a programme manager role. I’ve been at Dudley for the entire EPR journey, with lots of lessons learned, and changes.”
Dudley’s EPR went live in 2017, Sally shared, and whilst initially the plan was to go with a “big bang” approach, “that quickly changed once we realised it was far too ambitious and the organisation wasn’t ready – we started breaking down the programme into more individual deliverables across electronic observations, sepsis, order comms, referrals, ePMA, and so on”. To date, the team has had a multitude of different modules released within the EPR, a series of major releases, and an update to infrastructure to move to the cloud.
David also gave us a brief introduction to his current role and his experience with EPR programmes. “I’ve worked for suppliers and the NHS, taking Royal Marsden through its EPR journey in implementing Epic, and taking Barking, Havering and Redbridge through its Oracle journey,” he said. “I’ve had some experience with Nervecentre as well, so I’ve covered a number of trusts and different approaches to implementations – there’s no easy path.”
Lessons learned
“What I’ve seen work really well is spending about a year before working with your vendor to make sure you’re cleaning up your processes, understanding how you want to take care of patients, so you can actually design the system to do that,” Keltie reflected. “I think a lot of places think the project starts with the vendor, but at that point you’re on a bullet train and it’s very hard to be figuring out how you’re going to do things while you’re madly building, testing, and things like that.”
“Going live with an EPR in itself is a success,” Sally considered, “because there are lots of things that go on in the background to get you to that point.” When Dudley was first starting out, it was almost like learning about EPR capabilities alongside the current processes within the organisation, meaning a “huge shift” and a steep learning curve to get the benefits that accompany that. The main thing, according to Sally, is understanding the baseline, so that when you do build on that and implement new processes, you can articulate your journey and the differences from the way things are currently done.
Ensuring that the EPR is clinically-led is key, Sally told us, “as although the IT team have the technical ability to implement and make changes, it’s the clinical team that need to assess things like impact on other services, and the things that the IT team might not think of in the first instance in terms of clinical safety”. Dudley has always done a clinical safety review after the design and implementation process, she went on, “so we have multiple touch points where we’re designing-out clinical safety risks before we get the the point of implementation”. A key improvement has been the work done to engage with the organisation and make sure the right people are involved, so that the EPR can be owned by there services, and not by IT.
Sally’s team has also been focusing on benefits realisation, as funding often requires that you’re able to demonstrate what the return on investment is. This has involved a lot more upfront planning and time-in-motion studies, which makes it easier to anticipate benefits and then monitor those post-implementation. “We’ve really embedded our governance processes so the organisation knows how we deliver projects, which makes it a lot easier because we’re no longer spending the time talking about all the boring stuff in the background. We’re actually now able to really focus on the outward design of the solutions.”
Most of the programmes David has worked on have involved organisations sharing an EPR, he told us, which brings about its own set of unique challenges. Royal Marsden’s shared EPR with Great Ormond Street “worked quite well” due to overlap in clinical process, he considered. “It’s where those clinical processes are different or third-party systems are different that makes things challenging. It isn’t just the technology piece either – those organisations that have operational and clinical ownership and leadership at the very top, rather than having it delegated out to the IT team, are the most successful.”
A key thing is getting clinical leadership to understand how important their involvement is from the beginning of the process, rather than in the weeks leading up to the go-live, David went on. “One of the ways I’ve addressed this at one organisation was running workshops, war-gaming what the go-live will look like, what could go wrong, and how we can mitigate that.” A lot of the time, there can be “naivety” around what goes into a shared EPR, which filters down to testing and training. “You can’t just lift and shift the test material from the donor organisation or host organisation, because of the differences in clinical processes.”
Some areas have been better at managing resources than others, but one constant is that EPR programmes tend to get going with an under-resourced team, ending up with areas such as integration falling behind, David noted. Having a detailed implementation plan in place is essential, with tasks for both the trust and supplier side listed, to prevent delays that could have a knock-on effect and undermine the whole programme.
Overcoming challenges
It’s important to be aware that making changes to processes in one place within an EPR can affect hundreds of other places, due to the fact that the data is linked to a multitude of different areas, Sally explained. “We have a demand meeting every Monday, so every request for a continual improvement we’ll review, starting from a problem and opportunity statement – it’s basically don’t tell us what your digital solution is; tell us what the problem is that you’re trying to solve.”
That meeting is headed up by the CIO, CCIO, CNIO, and clinical safety officer, alongside the IT team, Sally shared, “so we’ve got the right specialties to be able to assess impact, as well as the team that have got the background experience on what has already been implemented”.
At Barking, Havering and Redbridge, David helped introduce Corgis – clinical and operational readiness groups – led by divisional directors, to oversee the approval and testing of EPR content in their area. “On reflection, I think if it’s led from the chief executive and the COO, and if the divisional directors, clinical directors, and operational directors are tasked with running workstreams or leading task and finish groups, it helps them get involved and there’s a greater chance of it succeeding.”
“Every organisation I’ve worked at has looked at optimisation from an EPR-first angle,” David shared, “and consolidating down to the EPR has advantages in reducing annual support maintenance and the need for integration, as well as reducing the risks associated with reliability and availability of the systems you’ve got things hosted on.” The downside is the compromise on functionality, “as some of these systems are a foot wide but a mile deep, whereas EPRs can be a mile wide and only a foot deep in terms of their functionality”.
David’s hypothesis is that with the use of AI and prompt engineering, teams could start generating systems to fill gaps, and writing that back to the main EPR. “Users and power users will start dropping in these smaller systems to the EPR, and I think what we now need to see is strategies from our EPR vendors that will enable that ecosystem to be developed.”
Benefits realisation and future opportunities for EPR
Sally talked about how Dudley had to write a business case a couple of years ago to bring the portfolio in from six-and-a-half years to three, by increasing funding and increasing resource. “As part of that, we had to demonstrate that we could make about a million pounds worth of savings. With EPR, where you really get your efficiencies is in the clinical time you can free up, and in the last two years when we looked at that, it was 20,000 hours of clinical time given back to the organisation.”
Dudley has also been working on ambient voice and digital letters, Sally noted, adding that the 10-Year Plan’s focus on integrating AI will likely be where the biggest benefits are in the future. In general, there is a lot to be said for relieving staff burnout, and walking the shop floor and talking to clinicians about their experience with the solution has shown that often they just appreciate the fact that the information they enter is being recorded correctly, she continued.
Next steps for Dudley will be to digitise what remains on paper across the trust, Sally said, with key areas being outpatients, community, and paediatrics. In community, the team is currently in phase two of a five-phase rollout. “Our community portal sits across multiple systems and pulls information from them for community staff to be able to see in the primary care setting,” she outlined, “and we’ll be looking to expand that, joining forces with different trusts, as that will be an easy solution for us to be able to give access to our care model in a mobile environment, pulling information from multiple EPRs.”
David discussed some of the future opportunities for EPRs, highlighting the need to ensure that every trust has implemented an EPR, and the potential for funding challenges to affect those implementations. “In the medium term, I think we’ll start to see more hospitals that have had EPRs in situ for 10 – 20 years, looking for contract renewals and reevaluating what’s on the market.” In the longer term, there is likely to be a reduction in the number of specialised clinical systems, along with more integration with the Federated Data Platform. APIs will be required for the single patient record, which will remove vendor lock-in and see the creation of a vendor-agnostic record, he considered.
On balancing customisation with standardisation, David highlighted how vendors may advise you to stick as closely to standardised content as possible, “the reason being that there’s a lot of experience out there, and the more you customise an EPR to meet your needs, the harder and more expensive it is to test or upgrade”. A lot of workarounds end up being introduced due to localised processes, making it a difficult line to tread, but understanding why those are there is key. “In the future, we’ll probably see a lot of customisations handled by AI, but it’s an ongoing challenge between standardisation and optimisation, and in the shared model it becomes even more important.”
Keltie is currently exploring opportunities around AI. “New iterations are starting to emerge, and I’ve seen feedback on some of those that you barely have to train staff to use them, as they’re more intuitive and easy to use than what we have today,” Keltie stated. “Lots of things are coming, which will make a big difference to how clinicians are using the system, the efficiencies, and the benefits realisation,” she continued.
Getting buy-in from the beginning and ensuring that “it’s not an IT project; it’s a clinical transformation project” is integral, Keltie stated. “I think that’s where we saw a lot of EPR failures in the early days – they were run as IT projects, not as clinical projects. To get your clinical team on board, they need to be able to see where the value is.”
We’d like to thank our panellists for joining us to share their insights on this topic.
