By David Kwo, Dr Nick Beard, Dr Fortunato Castillo, Jagdip Grewal, Dr Alec Price-Forbes [i]
Trends in electronic patient record systems (EPRs) deployment in UK and US hospitals, where EPRs are used across care-settings, have potentially significant implications for Integrated Care Systems (ICSs).
What types of EPRs are there?
There are two types of EPRs (based on Gartner[ii]): (1) best of breed EPRs and (2) integrated EPRs. Best of breed EPRs are those based on interfacing systems from different vendors while integrated EPRs are those based on a single database schema and software development team. Examples of integrated EPRs in the UK include those from Allscripts, Cerner, DXC, Epic, IMS Maxims, Meditech, System C and TPP. There are differences in both the scope and functional capabilities of such integrated EPRs and the term also covers in-house developed EPRs and those built on open source software. While integrated EPRs are intended to cover a wide range of core organisational needs in a single “mega-suite”, they are not usually expected to replace all existing systems, and interfaces to specialist systems (e.g. PACS and radiotherapy) are common.
What types of EPRs are used in England?
Analysis of the EPR system used by each of the 146 acute hospitals in England[iii] (as of July 2020) shows that 54 hospitals (37%) use best of breed, 82 (56%) use integrated EPR solutions and 10 (7%) use in-house EPRs, as shown in Diagram 1:
Diagram 2 shows the trend in best of breed and integrated EPR types (excluding in-house) in English hospitals from 2000 to 2020 (the uptick in 2003 is due to the National Programme for IT):
The move to integrated EPRs in the US has been more pronounced as the use of best of breed and in-house EPRs in the US[iv] declined from 14% in 2006 to 0.3% in 2013 (Diagram 3).
Who are the current EPR suppliers in the UK?
Diagram 4 shows the current EPR suppliers in the UK as of July 2020 and the number of contracts signed in the UK (as reported in the health IT media). Updates welcomed, please use email at end.
Who shares a single integrated EPR across hospitals?
The following are examples of UK hospitals either using, or planning to use, a single integrated EPR system across multiple hospitals:
- Imperial College Healthcare and Chelsea & Westminster Hospital (Cerner, separate Trusts, in live use)
- University College London Hospital (covers 8 hospitals) (Epic, same Trust, in use)
- Bradford Teaching Hospitals and Calderdale and Huddersfield (Cerner, different Trusts, in live use)
- Manchester Foundation Trust (covers 9 hospitals) (Epic, same Trust, planned)
- Royal Devon and Exeter and North Devon Healthcare (Epic, different Trusts, pending approval)
- Guy’s and St Thomas’, Royal Brompton and Harefield and King’s College Hospital (Epic, different Trusts, planned)
- Northern Ireland (Epic, 5 separate acute hospitals, planned)
This trend suggests that UK hospitals believe that a strategy for sharing single integrated EPRs can reduce costs and reduce unwarranted variation and ultimately improve the quality and safety of care for patients.
Who shares a single integrated EPR across care-settings?
The following are examples of UK organisations using, or planning to use, a single integrated EPR system across acute and non-acute care-settings:
- Royal Devon and Exeter (in live use across acute and community care settings)
- Guy’s and St Thomas’, Royal Brompton, King’s College Hospital (planned use across acute and community care settings)
- Northern Ireland (planned use across all 5 acute hospitals, community and social care)
- Devon STP (there is a plan to use a single integrated EPR system across acute, community and social care organisations, subject to approval and funding).
The following are examples of organisations outside the UK that are using a single integrated EPR system across care-settings:
- South Bronx, New York, USA. Montefiore Hospital, as reported by the King’s Fund[v]. In live use across primary, acute, community, mental health and social care.
- Kaiser Permanente, Washington Region, USA. In live use across primary, acute, community, mental health and social care.
- Providence Health, USA. Based in Washington. In live use across primary, acute, community, mental health and social care.
- Trinity Health, USA. Operating in 22 states. In live use across primary, acute, community, mental health and social care.
- Alberta Health Services, Canada. Operating in 400 facilities across the province. In live use across primary, community, mental health and social care.
- Apotti Project, Finland. Covering 30% of Finnish population. In live use across primary, community, mental health and social care.
- Aster Region, Finland. Covering 19 Finland regions. Recent signing by a major EPR supplier. Planned to cover health care and social services.
- Trondheim Region, Norway. In live use across primary, community, mental health and social care.
It has been reported to us by multiple sources that most primary care doctors in the US share a single integrated EPR system with their acute hospital(s) and we continue to investigate this area.
What lessons can we draw from these trends?
The trends above show that hospitals in the US and the UK are moving away from best of breed EPRs. The reasons for this movement are due to inherent problems with best of breed EPRs which include:
- DATA ISSUES: (a) data quality issues due to multiple data models; (b) data not in real-time and less reliable due to multiple versions of the truth; (c) data ownership unclear due to multiple data versions and handlers; and
- FUNCTIONALITY/EASE OF USE AND COST ISSUES: (a) lack of integrated functionality resulting in users having to navigate multiple legacy systems to take actions (order tests, prescribe drugs, schedule appointments/MDTs, communicate with multiple agencies, document care, use decision support, drill down into past data, plot real time vitals); (b) need for multiple IT skills and support teams; (c) multiple suppliers, contracts, upgrades; (d) potentially higher costs over time. These issues are not resolved by open interoperability standards or FHIR. The authors are preparing a separate paper addressing these factors.
These challenges will apply equally to the IT strategies considered for an Integrated Care System such as the Shared Care Record. Shared Care Records are extracts from other information systems to facilitate read-only information access by staff in other facilities. They are based on interfacing systems from different vendors and so share the same problems as those that attend best of breed EPRs. The problems may be more severe as they may stack best of breed on top of best of breed and potentially amplify the risks. The Shared Care Record, while providing real clinical value (in terms of presenting a non-real-time subset of cross care setting data to clinicians for the first time) does not overcome the challenges of best of breed EPRs. The evidence from both the UK and abroad is that shared care records may be useful in the short-term but that in the longer term, single integrated EPRs, being used across care settings within the health and care continuum, will support ICS clinicians and patients at a granular and functional level. Such an ICS vision has been described as an “Electronic Citizen Record” or ECR. Shared care records may also be useful for across-ICS boundary patient flows. The authors will assess data on clinical adoption rates for integrated EPRs and shared care records in a subsequent article.
It has been reported[vi] that integrated EPRs are unaffordable for all NHS Trusts. The evidence from NHS Trusts of all sizes and budgets, in addition to academic research[vii] on the impact of IT investments in healthcare as well as other industries, who are presumably realising economies of scale from shared integrated EPRs, casts doubt on this view. The evidence suggests that a single integrated electronic patient record system for each ICS should be provided by multiple EPR suppliers to keep prices and the supplier market competitive at an ICS level.
Healthcare technology developments currently receiving considerable attention, such as population health management, pandemic management, personal health records, healthcare research, AI and analytics all depend on granular, real-time reliable data and seamless rich clinical functionality across care settings (with lots of APIs) to ensure clinical adoption. This then implies getting the basics right which starts with effective, comprehensive and reliable electronic patient records as the digital foundation for health and care transformation.
Comments and updates welcomed davidkwo@peoplesource.co.uk
References
[i] David Kwo, Digital Healthcare Specialist at PS Consulting (david@peoplesource.co.uk); Nick Beard, MD Co-Founder and President at Brightplate Inc.; Fortunato Castillo, Ph.D, Principal Enterprise Architecture & Data Management Consultant; Jagdip Grewal, MBA, Digital Transformation Director; Alec Price-Forbes, MD, Consultant Rheumatologist, University Hospital of Coventry and Warwickshire NHS Foundation Trust, CCIO for Better Health, Better Care, Better Value (Coventry and Warwickshire STP).
[ii] “For Healthcare Delivery Organizations, Application Integration Does Not Produce Truly Integrated Applications”, Wes Rishel, former VP and Distinguished Analyst at Gartner Research, 12 February 2013
[iii] Based on published responses to Freedom of Information requests and reports in digital health media.
[iv] Based on data published in previous KLAS Research Reports received in July 2020.
[v] “The Montefiore Health System in New York”, Ben Collins, King’s Fund Report, July 2018
[vi] “Digital Transformation in the NHS”, Section 23., Public Accounts Committee, 6 November 2020
[vii] “Information Technology and Hospital Performance”, N Beard, E Kinga, L Hitt, M Housman, G Mansfield, PriceWaterhouseCoopers, 2007
