By Gary Mooney, InterSystems
Electronic Patient Records (EPRs) are increasingly performing an essential role in enhancing the efficiency and performance of healthcare services, whilst providing a platform to pave the way for future models of healthcare that is more connected and patient-centric. The essence of EPRs lies in their ability to streamline care workflows, promote interdisciplinary working, and provide on-demand access to comprehensive patient information across healthcare teams.
The value and potential of EPR solutions is reinforced by benefits commonly reported by healthcare services. However, adoption has had limited impact to date when it comes to driving and supporting reform for models of care delivery. For NHS England, this position has been recently reinforced by a conclusion drawn from Lord Darzi’s independent review of the NHS in England:
“Over the past 15 years, many sectors of the economy, in this country and internationally, have been radically reshaped by platform technologies. From the way we shop, to the way we socialise and how our politics is conducted, technology has transformed daily life. By contrast, while there are many excellent examples of technology having an important impact in the NHS—from virtual wards to remote dermatology consultations—it has not radically reshaped services. The NHS remains in the foothills of digital transformation.”
This article will explore value resulting from EPR deployments within current models of care, and consider potential new value opportunities to enable and support new models of integrated care.
Models of EPR
The term EPR can reflect different types of digital solution that provide a range of different functional scope and support for healthcare domains. Broadly, these can be categorised as follows:
- Clinical EPR: solutions that focus solely on the clinical elements of a healthcare service, and typically acute/tertiary care. Such solutions require integration with a Patient Administration Solution (PAS). Whilst offering some benefits in relation to speed of deployment, artificial digital barriers can remain between patient management, clinical workflows, and datasets, and reinforce traditional models of care
- Specialist EPR: solutions designed to meet the specific needs of sectors and services such as primary care, mental health, and community services. Such solutions commonly struggle to scale to meet the demands of larger healthcare domains (e.g. transitioning from primary care solutions to acute care)
- Enterprise EPR: solutions architected to cover the end-to-end business needs of a health care service and including both PAS and Clinical capabilities. These may still require integration with highly specialised service solutions (aka best-of-breed solutions), but promote improved communication and workflow across clinical and patient management teams, and provide a more comprehensive dataset from which to draw analytical service insights
- Unified EPR: solutions which include the capabilities of an enterprise EPR, but have been architected to support the delivery of care across healthcare economies and sectors. For example, a unified EPR could be deployed to support the needs of an integrated healthcare system, with information seamlessly accessible across acute, tertiary, primary, and community care services.
For the purposes of this article, reference is most commonly made to the Enterprise and Unified EPR solution types, with the greatest potential to deliver further value for new models of integrated care.
Value Themes
Commonly reported benefit and outcome improvements following the adoption of an EPR solution can be categorised under the following groups:
- Patient Safety: the removal or mitigation of risks that can result in patient harm or sub-optimal therapeutic interventions
- Clinical Outcomes: the ability to more consistently and predictably deliver better care outcomes relating to measurable positive changes for a patient’s health or quality of life
- Service Efficiency: the management and delivery of care interventions whilst reducing the associated resources required for their delivery
- Financial Performance: the ability to deliver services for a lower monetary cost
- Patient Experience: an improved experience of the services provided by patients and their carers/families
Examples of reported value delivered by EPR solutions, from a range of suppliers, include the following, which broadly deliver a range of benefits:
- Capacity and Demand Management
- Real-time visibility of a single source of truth for waiting lists to promote equity of access to services and manage waiting time durations
- Reduced processing times for referrals whilst providing real-time vetting lists
- Ability to prioritise referrals and waiting lists to mitigate against the risk of service users significantly deteriorating whilst waiting for a care intervention
- Real-time activity insights to assist with workload distribution to maintain and enhance service responsiveness
- Promoting equitable access to services based upon healthcare needs and acuity
- Care Documentation
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- A ‘single source of truth’ for the patient record to promote more timely and appropriate care, integrated clinical decision support for documentation sets such as Early Warning Score (EWS) that can help to detect deteriorating patients earlier for key risks such as SEPSIS
- Efficiency and consistency for the planning, communication, and implementation of care protocols and pathways, where pre-configured documentation sets can be proactively proposed to, and accessed by, care providers, to reflect individual patient needs
- Precise monitoring and visibility of a service user’s response to their plan of care to offer opportunities for earlier interventions
- Reduction in expenditure for paper documentation sets and improved compliance with environmental standards
- Decisions enabled by improved communication across the healthcare team with on-demand access to legible, complete, and unambiguous documentation
- Medicines Management
- Reducing the number of adverse medication incidents through active decision support
- Quicker medication administration rounds to release more time to care
- Improved communications across transitions of care for admission, discharge, and step up/down levels of care
- Improved management and visibility of missed and late doses and root causes
- Reduction in incidence of wrong drugs for the wrong patients at the wrong time (e.g. Using capabilities such as barcode enabled dose administration)
- Better compliance with prescribing good practices through pre-defined concepts such as order sentences, order sets, protocols / regimens, and pathways
- Enhanced opportunities for clinical pharmacist reviews to intercept prescribing errors and issues for general prescribing and specialist medications (e.g. Iv antibiotics) without the need to trawl drug charts
- Improved communication, including decision making, with services such as primary care regarding changes to a patient’s medications (e.g., when discharged from hospital)
- Service Insights & Compliance
- Activity insights to assist with workload distribution, helping maintain and enhance service responsiveness that reflects capacity and demand
- Timely visibility of service performance KPIs relating to enterprise and specialty measures to improve the timeliness and appropriateness of service management interventions
- Reduced overhead and timescales to produce regulatory and compliance datasets
- Patient Experience
- Reduces incidence and risk of delayed or inappropriate care decisions that can result in adverse responses, sub-therapeutic outcomes, and extended stays of care (for inpatient services)
- Removes the frustrating experience of having to repeat the same information across different specialties and care providers
- Enhanced patient empowerment where complementary technologies such as patient portals are available to support on-going communication and information sharing between patients and care providers
Delivering Value
Whilst there is a wide range of data to support the value of EPRs, their implementation and ongoing optimisation is not without challenge. The adoption of EPR solutions by healthcare services requires a well-executed change management initiative involving meaningful and continued engagement with already pressured and time-poor staff.
It is not uncommon for EPR, and other digital deployments, to focus upon the expression of value in organisational terms, typically detailed by a funding business case. This can result in frontline staff having to extrapolate meaning for their day-to-day working practices, which may or may not happen. For large and wide-reaching solution deployments, this can result in change management challenges resulting from poor motivation for adoption from frontline staff, who can feel the challenges of change without the awareness of value to them as individuals.
The articulation of value in terms that resonate with frontline staff can help to maintain momentum and enthusiasm for change. Established techniques from other industries, such as persona analysis, provide a helpful tool to express role-specific value definitions. Persona analysis will commonly include details such as a role profile description, top-of-mind concerns, and role specific solution benefits and outcomes (e.g. using the solution in this way will…).
The collection of qualitative and quantitative data is fundamental in being able to evidence and communicate the value of a deployed EPR solution. Good practice has this activity planned and actioned prior to go-live, to ensure that credible baseline data can be established against which post go-live data can be compared, to determine the nature and quantum of value delivered. This includes any areas of unanticipated dis-value for prioritisation in post go-live continuous improvement programmes.
A Journey, not a Race
The delivery and articulation of EPR value is not an event, but rather an ongoing journey. Whilst post go-live analysis is likely to focus upon a defined set of benefit and outcome measures (possibly described by the original business case); an ongoing programme of solution optimisation and value measurement will help to ensure the solution evolves with the service needs, whilst identifying any aspects that are underperforming and requiring corrective intervention.
An important post go-live dataset that is commonly overlooked, relates to solution adoption and activity. This data clearly highlights areas of solution functionality and configuration that are performing well, or requiring further intervention, to better promote their use and uptake. Such interventions may relate to anything from user training, through to changes in solution configuration. The use of automated adoption dashboards, such as the example shown in Figure 1, provide dynamic insights that can be monitored post go-live, and especially for the initial phase of post go-live adoption.
Figure 1 – Example post go-live adoption dashboard
Technological Advances and EPR Evolution
The evolution of EPR solutions will likely be shaped by continuous technological innovation and the changing demands of healthcare services. EPR solutions need to be architected with evolution and change in mind to be able to respond promptly and cost effectively to value opportunities presented by advances in technology, science, and models of service delivery.
The rapid advances that continue to be made for Artificial Intelligence (AI) and Machine Learning (ML) are increasingly making these new technologies a realistic and affordable option to enhance the quality and outcomes for care interventions. For enterprise-scale EPR solutions, it is hard to imagine a solution not offering AI capabilities as standard within the next two years. A key consideration is currently regulatory compliance (e.g. Medical Device Regulations) for the use of AI technologies with patient data.
Examples of generative AI solutions can already be observed to be helping care professionals to consolidate, synthesise, and summarise patient record data to improve the efficiency and precision of care planning and interventions. ML examples include examples of predictive analysis, such as identifying patients at a higher risk of readmission, developing conditions, or unexpected deterioration.
The integration of interoperability standards, such as Fast Healthcare Interoperability Resources (FHIR), will increasingly become crucial. These standards facilitate the sharing of structured, coded, and actionable patient information across health and social care services, enhancing the efficiency and effectiveness of care transitions and collaborative decision-making.
The rapidly-evolving field of genomic analysis and pharmacogenomics will, in the coming years, see Enterprise EPR solutions providing integral genomic capabilities relating to test orders and results, and importantly, pharmacogenomic decision support to guide and inform the correct and appropriate use of medications that reflect an individual’s genomic profile. This understanding, combined with EPR technology, has the potential to deliver care outcome transformation on a scale similar to the introduction of antibiotics.
Figure 2 illustrates how a pharmacogenomic alert could be seamlessly embedded within existing ePrescribing workflows.
Figure 2 – Example pharmacogenomic decision support alert
New Models of Care
The term ‘digital transformation’ is one that is hard to escape across many professional domains, and certainly in healthcare. But what does this mean for healthcare services adopting an EPR solution?
In its purest form, digital transformation can be considered as a fundamental re-wiring of an organisation to create value both for the organisation and consumers of its products / services. Such transformations drive new and innovative models of business. Whist there are examples of initiatives to deliver modernised or new models for care interventions such as video consultations, virtual wards, the NHS app, and AI technologies; adoptions of such technologies have been largely to enhance and support existing models of care.
Digital transformation in healthcare can often result in the adoption of new technologies to support existing business models, to deliver more efficient, safer, and performant service functions.
The concept and fundamental need for new models of care that reflect the demands of modern societies is rapidly gaining pace within many international regions. Models of integrated care, such as those set out by NHS England the Health Service Executive in the Republic of Ireland, are reliant upon the ability of EPR platform technologies to support the seamless flow of information across healthcare services and sectors for the planning, management, allocation, and delivery of healthcare interventions. This progression is outlined in Figure 3.
Figure 3 – EPR enabled integrated care model transformation
The transformation of healthcare services to deliver truly patient-centric and joined-up care workflows, will require significant service reforms and a paradigm shift for many healthcare services; moving away from the traditional dominance of acute care. For healthcare professionals, working as a member of an interdisciplinary team spanning care sectors will also be a significant change and challenge.
EPR solutions will need to provide a critical enabling and supportive role for the unimpeded flow of information that can be accessed and acted upon across a healthcare region, to inform the joined-up planning, management, allocation, and delivery of timely and appropriate care interventions.
Whilst the value delivered by EPR solutions described earlier in this document are significant and important, the overwhelming value for a modern day EPR is in being able to support the much-needed new and emerging models of care that reflect the demands of modern society.
