We posed a question to a number of digital-focused NHS professionals: Is there anything that you think is usually or often missed from EPR business cases, and what would your key lesson(s) around that be?

To begin, we heard from Tamara Everington, chief clinical information officer at Hampshire Hospitals NHS Foundation Trust.

“If I’m honest, I don’t think we are good at business cases in the NHS in general,” Tamara said. “Cases are often thrown together in short order to fix an immediate gap in current practice or respond to a cash drop. Some attention is given to describing the context but we often build cases based on the problems we see today rather than taking time to reflect on what might be needed as healthcare naturally evolves. To ensure our case progresses, we tend to wildly overstate the benefits and fail to take into account hidden costs, impacts and what we can sustainably afford. It is rare that we take time to say, ‘OK, if we are going to start doing this new thing, what are we going to stop doing because we have limited resources’. Because business cases are often requested in tight timeframes, it is common to see that end users have not been involved in considerations.

“Too often new EPR digital solutions are considered in isolation – this is like buying a beautiful new cooker which does great things, but doesn’t fit in the kitchen you actually have. You then end up having to demolish the rest of the kitchen to accommodate your new toy and spend a deal of time living in chaos. That doesn’t feel great.

“The alternative approach is to invest time in building your business case working directly with end users to understand what gets in the way of them doing their job well and what they need from a future system. Don’t think about it the other way round and prioritise data over human factors. Ultimately, if the new solution works for your end users, the data coming out the back end will be reliable in real time and your business will be supported to run more effectively. This means better personal care for all in need.”

Picking up on the theme of human factors, it’s all about getting the culture right for Chris Mason, chief information officer at Wirral University Teaching Hospital NHS Foundation Trust.

“I think an EPR business case will largely focus around the technologies – your hardware, your software, the EPR supplier and so on. What cannot be undervalued is the transformation change and the change agents in your organisations who make that difference,” Chris said.

“Sometimes it doesn’t matter how good the technology is. If you’ve not got the appetite for transformational change and people on the ground who are willing to embed that change and show people the way forward, describing what the future looks like, then I don’t think it makes any difference how good your system is functionality-wise. If you’ve not got the right environment to change people’s behaviours and the way they work going forward, then something really important is missing.

“Considerable attention should be paid to the business change element – you want to ensure that you’ve not only got the system to achieve your goals, you’ve also got the right workforce with the right skills in digital.”

Katie Trott, head of digital delivery and engagement for New Hospitals Programme at NHS England, reiterated Chris’s point around the importance of having people in place who can drive ongoing change.

“From experience, I would say that the most often overlooked aspect in an EPR business case is the permanent team who remain after go-live,” Katie said. “We consistently say to stakeholders that go-live is just the start and the EPR is a foundation. It should be used as a springboard for ongoing digital maturity that drives better patient care, better staff experience and improved data use.

“For the use and optimisation of EPRs to be effective, it’s essential that you have a permanent team of clinical digital experts and change advocates, along with those with sufficient technical knowledge, to drive improvements. Without them, true adoption will be slow to achieve.”

It is a sentiment shared by Andy Webster, chief clinical information officer at Leeds Teaching Hospitals NHS Trust.

“I would suggest that when building businesses cases, don’t underestimate the size of change and the workforce one needs to identify the change between the current state and the delivery of transformation to a future state,” Andy said. He noted a particular challenge: “This can both be hard in obtaining the finances, but also in terms of finding the right skills to deliver.”

It’s not just having the right workforce in place, but also ensuring that they have the resources to support the change, said Nick Venters, clinical information officer at Leeds and York Partnership NHS Foundation Trust.

“One omission from many health tech business cases is the clinical time required to make them a success,” Nick pointed out.

“Will staff be able to attend design workshops given all the other pressures on their time? Will removing staff for training be possible; and have you planned in case they cannot? Will your new technology free up time for administrators and managers by placing an additional burden on the front line? How will you spread adoption across an organisation which is already likely to be working at capacity. All of these questions should be considered at the business case stage.”

Matt Connor, chief information officer at Liverpool Women’s NHS Foundation Trust, agreed on the importance of organisational change and added a point around how buy-in is needed from colleagues across the organisation, not just digital staff.

“Business cases often focus on the more tangible aspects of the EPR investment, while cost consideration of the organisational change component is less defined,” Matt said. “Reinforcing the importance of organisational change activities should be clearly captured in the business case, it’s more difficult to bolt this on later. Securing organisational commitment and ownership outside of digital and data departments is essential as is managing expectations and ‘what’s in it for me’ benefits of the EPR programme.”

Dr Sunil Rathod, North & Mid ICB clinical digital lead at Hampshire and Isle of Wight Integrated Care Board, highlighted another key challenge: “The biggest issue with EPR business cases blind spots is around cross integration across platforms along the patient pathway.”

Chris Beadle, EPR project manager at Nottingham University Hospitals NHS Trust, commented on how businesses cases can sometimes lack detail or the necessary resourcing behind them.

“We have seen where EPR benefits can on occasion be partially overlooked. If we don’t have the full detail, due to the scale of work usually involved in a trust-wide EPR, or the resource to carry out the baselining exercise, we can find that operational pressures occur,” Chris said.

“The information lacking could be anything related to the above – for example, understanding how long it takes a user to access a specific piece of patient information with their current system, or understanding the cost of printing physical letters for a patient to take home. This then leads to the benefits analysis being carried out post-delivery of the project, which can impact the accuracy of the benefits realisation.”

Dr Penny Kechagioglou, chief clinical information officer and deputy chief medical officer at the University Hospitals Coventry and Warwickshire, noted a further two issues.

“Defining EPR financial benefits from a transformational lens and committing to waste reduction and lean process adoption with new EPR systems is often missed in EPR business cases,” Penny said. “To achieve that, there needs to be good knowledge of current state processes and an ambitious plan to transform services through digitisation. By doing so, more financial benefits can be identified and organisations can commit to transformation as early as the business case stage.”

Penny also picked up again on the issue of human factors: “Another aspect that is often missed in EPR business cases is accounting for the long term establishment of sustainable digital informatics teams. The short-term investment in clinical informaticians to drive EPR implementation does not match the long-term requirements for post go live EPR adoption and innovation. A clinically-led digital informatics team needs to be resourced for the whole duration of the programme including the post go live phase.”