Creating a cohesive flow of digital information across all providers in a Trust’s geographical footprint is the aim of many digital transformation teams in the NHS. Electronic Patient Records, which can allow for easier access and referencing of key patient information, are increasingly prominent in many organisations priorities when it comes to digital transformation in the NHS.
However, extremely disjointed existing IT processes and systems makes this a challenge. To make an EPR work for your organisation and to enhance patient care a Programme Director needs to bring together a lot of parts that don’t always work harmoniously together. To give you some insight into where to even start we brought together two Programme Directors to discuss how they’ve gone about implementing their EPR solution, the challenges they’ve faced and the learnings they’ve gathered.
Jane Saunders is the EPR Programme Director at Maidstone & Tunbridge Wells. Starting off as a registered Nurse and moving into Programme Management and Digital Strategy, Jane’s career in the NHS spans 30 years.
Having joined the Programme after 6 months from its launch, Jane has now overseen the project for another two years. During that time, Jane has had to contend with a number of delays and setbacks including problems with their antiquated pathology systems and COVID-19.
“We are due to go live soon with our first phase. Despite the setbacks we are trying to regain some of the time back, and bring benefits quicker to the organisation we are trying to do more of a big bang approach this year. It’s a big task but I think we’re up for it.”
Andy and Gloucestershire’s journey with EPR started, rather uniquely, with Nursing Documentation scheduled to launch in June 2020. After getting fantastic levels of engagement from Nurses and the Nursing team, they were able to deliver early in November 2019.
“We decided to focus on nursing staff first and getting them involved early was key. They were involved in both development and testing, shaping how the system could help them to provide much better patient care and safety.”
Using Allscripts blueprint, an EPR shaped by other similar NHS hospitals, Gloucestershire were able to configure a tried and tested system to suit it‘s own needs. This gave clinical teams confidence and nursing super users would demo the system to other nurses . Bringing the end-users into the development of the system was a major driving factor in the early delivery of this aspect of the EPR.
In early 2020, COVID hit and after reviewing it Andy and the Trust decided to proceed with plans to go live with Electronic Observations despite the strain COVID had already put on the NHS.
“That was absolutely the right decision. It allowed us to instantly start to track our unwell patients which was a significant challenge in a paper-based organisation where the two acute hospital sites , Gloucester and Cheltenham, are 10 miles apart.”
With the Electronic Patient Observation system set up, Andy has had examples of clinicians being able track deteriorating patients and being able to intervene quickly. This is a large improvement on the previous system that Relied on paper notes.
“We’ve just recently gone live with ordering and reviewing results electronically across the entire organisation for all inpatient areas, and this is another significant improvement for our organisation.
Introducing an EPR system will mean all patient information will be available electronically, on screen, at any hospital location, at any time. It will transform the way patients are admitted, treated and discharged. The benefits are varied and far reaching. We asked Jane and Andy what they believe are the most important benefits an EPR brings to a Trust.
Andy believes the amount of time that EPR saves already busy clinical staff is a key benefit for implementing EPR. This is in no small part due to the fact that paper-based patient records are often hard to track down.
“Your electronic patient record can be in as many places as you want, at any one time. It’s not a set of case notes locked in someone’s cupboard or have been taken away for review. And it’s not buried at the bottom of health records library somewhere.”
EPR not only saves time in bringing all of these documents together and storing them in one place, but it also makes them significantly more reliable by speeding up the time it takes to audit this material.
“Audits have been going on for many, many years taking hours of clinical time to routinely audit case notes. EPR makes it easier and quicker for medical staff to understand a patient’s journey.
For Jane, one of the key benefits of an EPR is on the financial side.
“ One of examples is that you stop producing paper, it means you won’t need to send documents to the printers, you won’t need the folders that hold all of the paper notes, it frees up the time of the e people that move the paper around the organisation to do other tasks In addition there will be systems that you can disinvest from because EPR takes over and incorporates their functionality aided by integration
However, the single most important benefit of EPR that both Jane and Andy cite as their main benefit, is the improved time to care.
For Jane, who was a Nurse herself many years ago, this is key.
“I would write something, and a doctor would write out exactly the same as what I had just done. And this would happen every day and if you combined all the hours of every single individual, this was a lot of time. None of us went into healthcare to write lots of forms.”
While the same information is being submitted, the EPR allows for greater versatility, agility and visibility around where, how and when that information is submitted.
“So, I can remember ringing up a doctor and saying someone needs painkillers. The Doctor was able to look at the patients drug card from across the ward and prescribe that drug without moving.”
The Doctor didn’t have to walk across the Ward, the patient didn’t have to wait, and the Nurses didn’t have to leave the care of the patient. The Patient received their care, but with significantly less busy work between.
Another point that Jane raises is the fact that information will process a lot quicker with EPR.
“We won’t have to wait for letters to be dictated to find out what the next step is, we won’t need to be chasing people to find out when tests have been done to book their next appointment, because we’ll be able to see that through a computer system. And patients won’t have to answer the same questions over and over again, because it will be there in front of the person that’s seeing them because they can see everything that everyone else has done.”
Andy echoes the same sentiments when it comes to helping clinicians and releasing more time to care for patients.
“It can be as simple as flags on the ward tracking boards (screens) just to alert that a patient might be at risk or has a specific infection, so needs to be tracked. These little markers did not exist previously, just bits of paper on the files on the nurse’s station.”
Clinical staff can now carry out checks and update patient notes on mobile computers at the bedside rather than completing paper notes at nursing stations.
Staff feel confident using mobile computers and spend more time with patients at the bedside, not away from them. Time wasted looking for notes is reduced, and everything is all on screen, in one place, for everyone to access when they need it.
Pulling together what, in some cases, can be completely independent systems can be a challenge. Add to that the fact that you’re speaking to multiple stakeholders and users who all have different requirements.
To bring parity to this article, we asked Jane and Andy what they believed were the biggest challenges they’ve faced during their time with the EPR programme.
For Jane, the main challenge came from engaging the six and a half thousand staff across the organisation and cascade the right information down.
“You need to get hold of their managers and try to cascade that information down wherever possible.”
One of the other key hurdles that Jane had to overcome was unique to her oragnisation but may well present problems for other looking to implement new digital systems.
“We decided to go for an EPR but we didn’t necessarily put the investment behind the scenes to make sure that we’ve done all the servers and the networks. We did it alongside and that’s probably not the best thing to do, I think it would be to have a platform that you’re stable. So you’re building on concrete, rather than trying to build on sand that you’re pouring cement into very quickly to make it solid. Trying to do the two at the same time is not a great idea.”
In institutions that have been relying on manual systems for a long time, a certain stigmas form around digital projects. Namely, that they are often delayed. This stigma can be damaging to a project’s health. For Andy, the key to breaking this stigma lies in delivering something early that shows a tangible benefit.
“That’s what was great about the first nursing document, it was a non-biased group of people. Nurses generally, apart from using the service desktop, their email, password reset, didn’t have a massive engagement with it before. It wasn’t the sort of thing they had. So, it was a great opportunity to take an unbiased part of the organisation and prove that we can deliver value.”
Digital transformation projects in a healthcare have far-reaching implications for many different stakeholders – the main difference, however, is the fact that one of those stakeholders are busy caregivers who often have very specific ways of doing their job. Engaging them early gives you the opportunity to build a service they will actually want to use as they already know the value. This was the case for Jane, who was working with people with a very specific use-case.
“You basically start with a blank sheet of paper. And it means that if particular people want to work in a certain way, within a department, you can do that. So, we’re not having to be so prescriptive and say, sorry, this is a document, that’s the only way that you can work. Instead, you have to mould it.”
However, taking this approach also comes with drawbacks. Engaging too many people, too early can sometimes lead to too many opinions.
“ I think it’s really important when you embark on an EPR, that you get the clinical engagement right up front, that they’re involved in the decision process of who you buy your system from, and that you have the right groups to keep that conversation going the whole time, and that they’re willing to make the decisions and put their head above the parapet if their colleagues don’t quite agree with the decision of a group. They have to be that voice.”
For Andy, who had clinicians at the CCIO level taking a lead on the workstreams, the EPR programmes he’s worked one have been completely Clinically led. The most obvious demonstration of that is the Nurses Documentation.
“It was nursing first. What you guys need we will deliver. We’ll throw you some pointers as to what we think might work for you but it’s your system, you’re going to own it, and you’re going to be the ones using it. You’re the ones who are going to care about it.”
Bringing all these aspects together asks a lot of the Programme lead. We asked Jane and Andy what they think is the most important trait a Programme Manager needs to be successful on an EPR programme and, by extension, digital transformation projects in general.
For Jane, Resilience is probably the biggest trait that a Programme Manager needs.
Trying to find a middle ground and, in some cases, compromising can be very difficult, especially with COVID. But if you can master the art of bringing different people together to work on a single goal is key.
“You go through these peaks and troughs have good days and bad days. And you have to find your own resilience to not dwell on the bad days because the good days will come. But you also sometimes get setbacks where you think, Oh, yeah, we’re doing really well. And then something will happen in the software. Or another system that you’re trying to integrate with doesn’t work in the way that you want or your supplier lets you down.”
Understand the core essence of what you’re doing while delivering an EPR programme is key. For Andy, those successful in programmes like this will be completely tuned in to the clinical side of what they’re doing.
“The technicalities of how we deliver as an IT team is irrelevant at the end of the day. We pride ourselves on the fact that all our teams, including the service desk team, have all been out on the wards they’ve all been out seeing how it works on a clinical side. At the end of the day, you are working for the patients. . Everything you’re doing is enabling that whether you’re configuring a wireless network or making sure that a Windows PC boots up.”
Finally, we wanted to sign off by asking about what the pair have taken away from their on-going work with the EPR programmes.
For Jane, the key lesson learned was to get your engagement up and running so that you can quickly gain advocates. Getting some extra help doesn’t hurt either:
“I’ve probably underestimated that and to get people in who can win the hearts and minds like organisational development experts right from day one probably would have benefited us where we’re just about to embark on getting some extra help. “
Understanding that you aren’t alone in your programme and that there are others out there who have walked the same path as you can go a long way in motivating you to take the next step.
“Within an EPR team programme, you can get so bogged down into your own programme that you don’t even have time to kind of get off the hamster wheel to talk to others. And when you start talking to others, you find out you’re not alone. And actually all the problems you’re experiencing is quite normal for any EPR programme. So I think we need to do a bit more about networks. For those of us who are involved in EPL programmes, and sort of shout about it to say we need the rest of the organisation to actually get involved. It’s not my programme, it’s their programme kind of thing.”
Considering the way you portray yourself and the solutions you’re providing should be something a programme manager is always thinking about. For Andy, developing a brand is part of his process for implementation and engagement.
“Build a brand around what you’re trying to do. Help the organisation understand that it’s not something IT bought, it’s an organisational programme, and the organisation has almost requested the digital team to help deliver that EPR. It’s getting that message right to every organisation that you work in and detaching yourself from the kind of potential IT projects have passed that may or may not have failed within the organisation.”
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