- The EPR should be continuously improved throughout its lifecycle.
- EPR optimisation is not just about configuration, you need to pay attention to human dimensions of change.
- The benefits set out in an EPR should be realistic, measurable and aligned with available resources.
- It can take 5-10 years for benefits to be realised from your EPR.
- Some benefits are unintended or cannot be known from the outset.
The process of optimisation is never finished and requires continuous investment. We heard from digital leaders that the ongoing effort it takes to optimise an EPR is almost always underestimated by boards and as a result the full benefits are not realised.
Understanding the true costs of EPRs
When you receive a business case for an EPR you should already be thinking about the resources required not only for implementation, but to improve and adapt the EPR over time. Board leaders should try to distinguish between the different types of costs that may be encountered during the life cycle of an EPR:
- Running the operation. Perhaps including the cost of running a support desk.
- Essential investment and renewals. For example new hardware needed to run the EPR.
- Digital development. The cost of the EPR team driving through changes and seeking improvements.
- Transformation enhancement. The cost of bringing in further expertise and tools, such as artificial intelligence and population health management.
The big agenda in digital deployment is transformation and bringing the organisation with you. If you shortcut that then you'll fail to achieve your change objectives and outcomes. Mapping processes and redesigning services with clinicians can be difficult, but you have to do it […] Focus on what staff need to make it easier. We [digital services] are here because patients need treating by staff who need technology.Chief Information Officer, Berkshire Healthcare NHS Foundation Trust
A business case should incorporate both sufficient resources for the technology itself and the human dimensions of change. In practice this means providing the expertise, time and headspace for colleagues to learn new skills and contribute to improving the EPR over time.
The board needs to be confident it has factored in all dependencies for the EPR to function properly. This might include Wi-Fi coverage, having devices that can properly run new software, installing plug sockets in the correct place and integration with medical devices.
In our conversations, we heard of community staff being given smart devices for an EPR that only operates on a laptop or computer. We heard of the need for medical device integration on an intensive care unit that had never been accounted for, thus creating new manual entry work. Where possible, all of these problems should be avoided at the outset or failing this, quickly resolved as a result of maintaining a focus on user needs.
What benefits can a board expect to be realised from optimisation?
Trust leaders have to balance competing priorities about where and how to commit finite resources. As such, boards need to have a clear understanding of the benefits from investing resources into EPR optimisation.
EPR business cases tend to contain unrealistic expectations. This can be driven by a desire to demonstrate cash releasing benefits in order to secure additional investment from central pots. Some have described it as a game that has to be played to secure the cash. It is based on an assumption that those benefits will not be tracked or accounted for.
As a board it is therefore important to be realistic about the benefits you expect to see in a business case. But it will also require board leaders to understand that transformation benefits can take a long time to fully realise – in some instance five to ten years.
For example, many EPRs include digital support tools. Upon implementation, the EPR may push an alert to the user if a patient has any allergies, and perhaps recommend specific tasks. This could represent a core level of digital capability expected of the system and will begin to generate some improvements (for example in clinical safety). However, a more optimised EPR may generate alerts to other internal and external clinical systems (such as in primary care), which saves the time of clinicians working within the trust and in other organisations.
The real benefits of an EPR will only start to be realised once the system has been successfully implemented and begun the ongoing process of optimisation. It is therefore important to set out an EPR benefits case that is not only credible and achievable, but which is measurable and can be tracked over time.
The disadvantage of not optimising the EPR should also be set out. Trusts need to invest dedicated resources and expertise to gather and analyse data to evidence benefits. It is also important to note that some benefits may be unintended or not initially anticipated.
It is likely that benefits will cover a number of domains which include, but are not limited to the quadruple aim:
- Patient safety and satisfaction – improved through synchronous data entry at the point of care.
- Staff satisfaction – usability of the system in terms of entering, searching for and discovering data.
- Productivity – time spent by colleagues entering, searching for and discovering data.
- Population health management – recognising trends to inform service transformation to meet the needs of your population.
There are also a range of interim benefits that include but are not limited to:
- Audits and governance – productivity of audits and other forms of clinical governance using searchable and discoverable data.
- Business intelligence – for reporting and performance improvement.
- Clinical pathway redesign – improving pathways and workflows.
At the point when anticipated benefits have been set out, it is important to set a baseline against which to measure improvement over time. This will be an iterative process, so leaders should look for evidence that improvements are embedded as part of a continuous improvement cycle.
[A key benefit is] you'll only need to enter information once, and it will be clearly visible throughout the EPR […] so if we say allergies, you input them once and then if the patient arrives in A&E, is admitted as an inpatient or visits an outpatient clinic, all you have to do is validate them with the patient.Chief Nursing Information Officer, London North West University Healthcare NHS Trust
Funding transformation to focus on strategic priorities
While it is our frontline teams who understand what the potential is for transformation, as a chief executive I want to see changes in action. That way I can understand the teething issues and what the reality is for our staff on the ground.CHIEF EXECUTIVE OFFICER, BERKSHIRE HEALTHCARE NHS FOUNDATION TRUST
Berkshire Healthcare NHS Foundation Trust (Berkshire Healthcare) provides both community and mental health care services in the South East. They are in the process of optimising their EPR, Rio.
Berkshire Healthcare's digital strategy is a critical subset of the organisational strategy and an enabler to its delivery. When it comes to key strategic challenges, such as workforce shortages, the board identified advancing the trust's EPR as an investment in addressing the problem rather than a cost.
The board recently decided to agree a five-year funding plan for infrastructure. This means board level strategic discussions focus on transformational change rather than the nuts and bolts of new kit.
The trust has also invested in a transformation team. They understand it is critical for the digital team to keep focused on the organisational strategy to ensure they deliver what matters for the organisation rather than simply what might be technically possible.
The key lessons the board has learned:
- making things simple with 'one click' solutions where possible
- try to road test on a small scale
- make sure the transformation team talk in a normal language.