North Tees and Hartlepool NHS Foundation Trust, which employs over 5,600 staff and has a 570-bed capacity, was the first English NHS Trust to deploy the InterSystems’ TrakCare electronic patient record, in 2015. Since then, the Trust has been using TrakCare to help it achieve its digital health ambitions. Having built on these firm foundations, the Global Digital Exemplar ‘Fast Follower’ Trust is starting to realise the multiple clinical and efficiency benefits that come with digital transformation.
The Trust has recently completed the roll out of a new electronic prescribing and medications administration (EPMA) module to all inpatient and emergency wards, marking the next stage in the Trust’s ambitious digital journey.
Described by Dr Graham Evans, the Trust’s Chief Information and Technology Officer as “one of the biggest transformational changes we will implement as part of our EPR programme,” the successful adoption of the EPMA is changing and improving the way clinicians work, cutting red tape and improving outcomes for the 400,000 people who the trust cares for every year. Consultant Physician Dr Jay Vasani and Senior Clinical Matron Claire Ranson describe the impact the new EPMA is having on patients and professionals at one of the UK’s most technologically advanced hospitals.
Improving practice
‘Dealing with hundreds of patients every day that need urgent care and support, TrakCare is changing how the busy emergency department at North Tees and Hartlepool NHS Foundation Trust works,’ says Consultant Physician Dr Jay Vasani. ‘The main benefits are that medications are visible whenever and wherever we need them, you can access vital prescribing information in seconds, which is essential in a crisis.’
The admissions and A&E departments are the latest to benefit from the introduction of a Trust-wide electronic prescribing and medicines administration (EPMA) system, part of the TrakCare deployment. ‘Patients want the person who is looking after them – the doctors, nurses and pharmacists – to have the information they need when they need it’, Dr Vasani says, a situation he concedes wasn’t possible with the previous system in place. In the past, patients admitted to A&E would be prescribed medications which would be recorded on paper, photocopied and shared across the trust. A sea of paperwork would follow patients from A&E to the admissions unit, much of it written in haste as patients rapidly move between wards and care responsibility shifts between teams.
It’s a frustrating and inefficient process for clinicians which could potentially lead to unnecessary errors with paper records sometimes incomplete, difficult to find or even lost altogether. Replacing it with EPMA has changed everything. ‘TrakCare EPMA has made prescribing much simpler and more effective,’ says Dr Vasani. ‘Clinicians can now access a complete prescribing record from the portable terminals, making it quicker to monitor and prescribe medications.’ The system uses FDB’s Multilex for its medication clinical decision support.
Comprehensive prescribing information follows the patient throughout their recovery journey, from A&E to the admissions unit to any specialist ward. The new EPMA, integrated within the comprehensive PAS and EPR systems, facilitates the effective handover of patient information between clinicians, across shifts and between wards, seamlessly connecting them all. The information can also be used to provide a complete clinical record that can be shared with GPs, with the PDF document accepted into the EMIS and SystmOne systems used in primary care.
The roll-out of the EPMA is the most recent phase of a trust-wide adoption of TrakCare, a process that began with the introduction of a new patient administration system (PAS) and electronic patient record (EPR) in 2015.
Ward-level impact
‘Nurses play a crucial role in administering and monitoring medicines, a process that’s being improved with TrakCare,’ says clinical matron Claire Ranson. ‘It’s definitely reduced the amount of time nurses spend on medication rounds. The real-time record allows all those involved in care to see what’s happening – the nurse, doctors or pharmacist – not just the person holding the piece of paper. It’s making rounds ‘leaner’ with less time spent chasing up paper records across wards,’ Ranson says, freeing up time for nurses to focus on what’s important – time with patients.
‘Anything that makes life simpler is to be welcomed,’ Ranson adds, but the new EPMA is also playing a crucial role in reducing the risk of prescription and medicine administration error. Digital records are clear and accessible to all, important in the frenetic and challenging urgent care environment where clinicians will deliver ‘stat doses’ – a drug prescribed outside of a scheduled drug round – rather than full prescriptions. ‘It’s really visible from the chart if there are any omissions,’ Ranson says, ‘they can then be rectified, reducing the risk of any negative impacts.’
The system also enables nurses to contact doctors for information, advice and support when needed. ‘You can contact a doctor directly from the ward wherever they may be. They can use TrakCare to review records and check medications wherever they are in the hospital.’ The process is saving crucial time, particularly during peak periods when doctors may be in demand or during night shifts when doctors may be working remotely or on other wards. ‘It’s a significant benefit clinically,’ says Dr Vasani.
Challenging implementation
As one of England’s most technologically advanced Trusts, North Tees and Hartlepool NHS Foundation Trust has made great strides in digital adoption – but any change of this magnitude demands solid support. ‘Any new technology meets some form of resistance,’ says Marie Graham, the Project Manager leading on the EPMA roll-out. It’s our role to work closely with all affected by the change to minimise this risk and ensure they’re able to rapidly embrace its benefits.’
‘A central part of this is about engaging clinicians and nurses from the start,’ explains Graham. The Trust has established a monthly clinical informatics group that discusses all proposed changes in technology. Chaired by the Chief Clinical Information Officer (CCIO), this provides a forum to discuss the implementation of new technologies and develop strategies to mitigate any potential negative impact. At a ward level, staff were engaged throughout the planning process to help develop solutions to potential problems, a process welcomed by both Claire Ranson and Dr Vasani.
The phased roll-out saw wards shift to the new system, with help always on hand during the switchover period. Between 8am – 11pm there was support from the digital programme team available for staff to seek help with any questions or concerns they may have had. ‘The digital programme team were on each ward, each week, as the system rolled out, helping staff to navigate it effectively,’ Dr Vasani says. The wards also benefitted from peer support, with clinical ‘super-users’ offering words of wisdom and advice on how to best use the system. ‘The technical aspect is about 25% and the rest is just workflows,’ says Dr Vasani. The roll-out programme began in March 2018 and was completed by October 2018.
The support provided during these months was intense, something that all agree was necessary. ‘I definitely think we needed that period,’ Ranson says. Once completed all nurses and doctors were comfortably embracing the new ways of working demanded. ‘It tackled some of the existing frustrations nurses had with the paper-based system,’ Ranson says.
Software is only as good as the hardware it runs on, with the Trust relying on aged infrastructure and a poor wi-fi connection, both issues have been recognised and rectified as part of their digital transformation programme. ‘There has been a massive infrastructure investment,’ Dr Vasani says. The Trust is also responding to clinicians’ concerns by rolling out single-sign on devices as standard. ‘Within a few seconds, you’re logged into systems. It’s a small thing that has made a huge difference,’ Dr Vasani adds.
Anecdotal feedback has been positive, with nurses and doctors clear about the impact the system is having at a patient and ward-level. The next stage is to undertake a comprehensive benefits realisation programme to quantify the impact that TrakCare is having on the Trust’s performance on key indicators.
Connecting the dots
‘North Tees and Hartlepool NHS Foundation Trust is one of the UK’s leading adopters of TrakCare, with a board that fully embraces the potential for technology to transform healthcare,’ Dr Vasani says. To him, the transformation journey within the hospital is one of evolution, not revolution. ‘Everybody is bought into the idea that we need to digitise a lot of processes, reduce our reliance on paper and improve clinical care,’ Dr Vasani adds.
In the near-term, the EPMA system will be rolled out to day case areas of trust. It’s the start of a more ambitious programme to embed TrakCare completely within the trust – something demanded by medical professionals. ‘In the medium to long-term clinicians want to have everything available within TrakCare, where it is quickly accessible,’ Dr Vasani adds. ‘We’re in the middle of a process that’s connecting the dots of care.’
‘The adoption of the EPMA is the first stage in a shift toward more intelligent prescribing,’ Dr Vasani says. He’s keen to embrace the potential for order sets and, in the future, more intelligent prescribing with a higher level of decision support. All will be completely digital, with the Trust hoping to go paper-free by 2024. It’s helping the Trust realise significant efficiencies, including reduced software license costs and a significant reduction in expenditure on paper. Replacing the existing Kardex paper-medicine system with TrakCare has helped the trust save over £2,000 per quarter. Across the hospital, system savings could increase exponentially. In total, the Trust hopes to save up to £8m in efficiencies and improved productivity by adopting TrakCare as the Trust’s EPR.
The next stage for the EPMA is a planned move to incorporate complex medications and ‘injectables’. The Trust is currently investigating the approach necessary to safely and successfully manage this integration. In a future phase, the EPMA system could be used in ITUs, where the real-time information exchange and prescribing information could help to improve care for some of the sickest patients being treated at the hospital.
TrakCare is changing the way North Tees and Hartlepool NHS Foundation Trust delivers services. It’s changing systems and processes and behaviours. What advice would he give to other trusts considering making a similar shift toward a comprehensive digital system? ‘Focus on the outcomes, not the technology. The best system is the one which you engage with and improve for the benefit of the user,’ says Dr Vasani. How is this achieved? ‘You need constant dialogue and engagement from all three aspects: the vendor, the project team and crucially the clinical users – doctors, nurses and pharmacists.’
‘No system will be perfect from day one,’ Dr Vasani cautions, but in time the system can be shaped and formed to deliver the outcomes trusts need and deliver the improvements in care that patients expect. In partnership with InterSystems, the Trust is doing just that – using TrakCare to join the dots, developing a connected healthcare system that inspires and empowers clinicians, enabling them to deliver on the promises of a digital future.
