- Clear governance with delegated authority from the board is key to ensuring clinically-led improvements to the EPR.
- Governance arrangements should be underpinned by a team with clinical and design expertise to manage the flow of EPR improvement.
- Standardisation of clinical practice enables data to flow between clinical services, pathways and between different EPRs.
- Unwarranted variation in EPRs creates complexity and downstream configuration and maintenance costs.
Effective governance helps create the right conditions for EPR optimisation, empowering teams to prioritise requests and deliver changes across multiples sites and pathways.
Managing change requests
Over the course of the EPR life cycle, staff will submit ideas to change aspects and functions of the EPR. To manage these, many trusts have put in place an accountability group to review and approve requests. Sometimes this is called a clinical design authority.
This clinically led group should have delegated authority to make decisions about optimisation and prioritise changes. Using a value versus cost matrix can be a good way to make informed decisions about prioritisation within limited resources. The group should meet regularly with attendance mandatory to minimise any backlog in improvement requests.
Where an EPR is being optimised across a number of NHS trusts, this group should represent each organisation and have shared delegated authority as well as clear escalation routes in case of disagreement. A board level senior responsible officer from each organisation is critical to ensuring top level steer and accountability.
Along with a decision-making group, a defined process should be put in place to develop as well as assess change requests, calculate cost implications and map out unintended consequences (including the inter-relationship between proposed changes).
Clinical colleagues need to have the opportunity to work through challenges and disagreements so they own the change and its implementation in practice. This should all be codified in Terms of Reference that are agreed and reviewed on a regular basis.
Governance across London trusts to drive change
One thing I always wish we’d done in advance [of scaling] is outline the governance for escalation. The change board was always there, and everyone agreed as long as the change wasn’t too controversial, but we realised we needed something more robust for when we have divergent views. Now we have a route to the executives and a route to go down when we don’t agree. My learning is, sort that out and everything else becomes easier.JOINT CHIEF NURSING INFORMATION OFFICER, IMPERIAL COLLEGE HEALTHCARE NHS TRUST, CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST, THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST
All four acute NHS Trusts within the North West London ICS are in the process of joining a shared version of Cerner by the end of 2023. The decision to converge in this way was driven by a desire to enable care to span the four trusts, develop shared care pathways, reduce costs along with the ability to merge the digital teams. Key to realising the benefits of convergence has been creating common ways of working that drive shared benefits.
Clear accountable governance is key to facilitating consistency across sites. Chaired by the CIO, the Change Board meets weekly for two hours and is attended by clinical, IT and operational staff from the four trusts. The EPR supplier also attends the board. The breadth of representation ensures that interdependencies and unintended consequences are identified early.
All trusts are required to agree on a change before it is implemented. If agreement can't be reached, the case for variation has to be made, citing evidence and national guidance where appropriate. Cases for non-standardisation are considered by the trusts' chief executives and are the exception rather than the rule. The leadership of the boards has been pivotal in enforcing the position to avoid non-standardisation wherever possible. This has been driven by medical directors, chief nurses and the non-executives.
Any business case for optimisation needs to have funding agreed in order for it to become a project. Funding is in addition to the business-as-usual EPR team so that they can continue their everyday operations.
You need to use data to focus your optimisation, because otherwise you only ever optimise for whoever shouts loudest […] whereas actually a workflow is potentially broken and 90% of staff have just got used to the fact that it's broken and aren't telling you it's broken anymore.Joint Chief Nursing Information Officer, Imperial College Healthcare NHS Trust, Chelsea and Westminster Hospital NHS Foundation Trust, The Hillingdon Hospitals NHS Foundation Trust
How standardisation can transform services
A well optimised EPR containing high quality data is a firm foundation from which to create insight for service transformation across clinical pathways.
As discussed in earlier chapters, this foundation is built on standardisation of clinical practice which is codified in the EPR and enables data to flow between services, along pathways and between organisations. This data enables the entire patient journey to be understood when redesigning clinical workflows and patient journeys.
Standardisation makes it easy for colleagues to work across teams and for locums as well as students on rotation between services and trusts. It reduces the burden of learning a new system and improves productivity and satisfaction.
While an ICS may have a variety of EPRs, standardisation of pathways will enable the whole patient journey to be visualised and understood. A bespoke EPR creates upstream costs in configuration as well as complexity in ongoing maintenance.
However, these foundations are not easy to establish. There is wide variation in practice, not just between NHS trusts, but even between similar services within one trust. There is often an absence of national guidance on standards from which to agree consistent models of care (although work by the Professional Record Standards Body and others is looking to improve this).
Where there is a strong Improvement culture, it can be helpful to frame standardisation in terms of warranted and unwarranted variation in clinical practice. Driving out unwarranted variation and complying with best practice standards should always be the aim of clinical services. Involving colleagues and user experience (UX) designers is invaluable in redesigning services that offer consistent models of care.
Finally, while standardisation is key to EPR optimisation, we also heard that the ability to personalise the interface (for example, being able to set favourites) is an important facet of feeling positive about the EPR. It is therefore important that colleagues have the right support so that they know how to personalise the EPR interface to meet their preferences, where this is appropriate. The International Organization for Standardization's ergonomics of human system interaction principles are relevant here as well as the NHS design principles which are inspired by the NHS constitution.
I’d like to see a patient acuity dashboard that assigns a scoring system to flag clinical priority. We’d have prioritisation of workload and resources based on patient information, thus making our service delivery more targeted and user centred.Associate Chief Clinical Information Officer, Somerset NHS Foundation Trust
Digital and data as an enabler to service transformation
The biggest benefits [from a shared instance across four trusts] are going to be the fact that the EPR is integrated both within our organisation and across the sector, so the data will flow across the modules which is very different to what we currently have, which is many IT systems with information not flowing. The benefits to staff are that they'll only need to enter data once and the information will be clearly visible, whichever part of the system you're in.CHIEF NURSING INFORMATION OFFICER, LONDON NORTH WEST UNIVERSITY HEALTHCARE NHS TRUST
London North West University Healthcare NHS Trust is a large acute trust that has collaborated with the other three NHS trusts in the patch to implement Cerner Millennium.
The digital team has successfully collaborated with the QI team on projects such as patient flow to combine expertise and resources in order to transform services. Similarly they have found that the clinical safety team should collaborate more closely with the patient safety team to join up safety assurance for the trust as well as national reporting.
A big improvement from a converged EPR is that staff only enter information once and it will be visible in all parts of the system. Key to transformation has been engaging with clinical leaders, focusing on ensuring benefits are meaningful for them. As well as using data to inform improvement and service transformation, they have used improvement methods such as plan, do, study, act (PDSA) cycles to implement changes.