Key takeaways

  • A user-centred design approach to EPR improvement helps you focus on human factors and change management.
  • Designing with the staff creates benefits in terms of productivity and can reduce training and other costs.
  • Most EPRs are not easy to use and training is required for their effective adoption in everyday practice.

The usability of an EPR is not a trivial issue. A poorly designed and configured system will have a big impact on everything from productivity to patient safety. Poor usability results in workarounds, including the creation of what is known as shadow IT. That might include spreadsheets, word documents and other background systems that have no governance and create all sorts of unquantified risks.

A design-led approach to understanding users' needs is a proven way to making your EPR as usable as possible. This is often undermined when digital transformation is funded by one-off capital injections from the centre which encourages teams to focus on purchasing capital items rather than on optimising their systems.

The NHS user-centred design principles and manual provide guidance for how to design, build and implement digital services. Some NHS trusts (for example, Surrey and Borders Partnership NHS Foundation Trust) have incorporated user researchers and user experience designers into their teams to ensure usability is a key component of EPR optimisation. Other trusts, such as Moorfields Eye Hospital NHS Foundation Trust, have applied user centred design to other areas of their digital portfolio.

Understanding user needs and goals may take time, but we heard from our interviewees that it pays dividends in creating systems that people want to use and even love to use. It is also important for equality, diversity and inclusion. For example, while a trust's EPR may be compliant with the accessible information standard, it may fail on other needs unique to certain groups. A user centred approach will help identify and address these needs.

Remember that while staff are the end users of an EPR, it is ultimately there to underpin patient care. Taking time to understand patient needs, goals and preferences can help you engage and involve staff in making changes to how they use the EPR in clinical practice.

Case study

Optimising your EPR through user experience

It's a mindset shift more than anything else […] rather than trying to fund a technology implementation, we're really trying to fund a team that can think through how we need to use the product from an experiential perspective. And that has allowed us to drive change in a way that we weren't succeeding at before.


Surrey and Borders Partnership NHS Foundation Trust (SABP) is a leading mental health and learning disabilities provider in the South East. With SystmOne as their electronic patient record, the trust is in the process of optimising its EPR.

Following a difficult EPR implementation a few years ago, SABP decided to switch focus away from traditional programmatic approaches and towards user centred design to deliver a better user experience. They shifted their core focus to the usability of the product. By creating a design team, with user researchers, designers and developers, and involving operational teams better, it became possible to improve the EPR experience beyond the constraints of the system.

The SABP digital team has been nominated for awards for their fusion teams approach which brings together a range of skill sets to design for the desired outcome based on a deep understanding of users' needs. Designers customise an interface for the EPR which is bespoke to each team in order to make it as easy as possible for them to use. The EPR looks more like a website and presents the key features and functions needed to use in a user-friendly way. Behind the interface, the core EPR remains the same.

This approach started as an experiment that has paid off. The digital team began small to test the approach and has grown the team as it has created value. From clinical team feedback it is clear they are delighted with the results, with benefits in terms of satisfaction, efficiency and productivity.

Furthermore, SABP has focused on 'unifying the tribes of change' in programmes by bringing quality improvement, digital, strategy/transformation and operational/clinical capabilities together to create the 'fusion' team needed to achieve effective change. They have found that working in this way and designing for the outcome has resulted in more successful implementation and adoption of change.

Technology is not a passive agent in the system, it is persuasive. If configuration and personalisation can increase the level of use and compliance, then do it.

Dr James Woollard    Chief Clinical Information Officer, Oxleas NHS Foundation Trust

Investing in learning and development – the benefits

The truth is most EPRs are not intuitive or easy to use. The more configured an EPR, the more options there are to input data in different ways and in different places. All this variability has implications for productivity, staff satisfaction and of course searchability and discoverability of data for use both in clinical practice and for secondary purposes.

Results from the acute EPR usability survey showed that 46% of the variation in EPR satisfaction can be attributed to the individual user (rather than attributed to the vendor or organisation). This highlights the importance of training for adoption and effective use.

It is for these reasons that learning and development are key components of EPR optimisation. If you don't have a consistent approach to teaching people how to use the EPR, it is likely that busy staff will learn workarounds or input the same data in different places or in different ways. This results not only in poor functionality but also duplication of effort and wasted time. These bad practices emerge as busy clinicians look for the quickest and most convenient way to enter data without appreciating the implications for data quality.

Learning needs to be meaningful, useful and accessible to busy EPR users. As well as the content being designed with clinicians in mind, learning should align to people's personal preferences and fit into their working day. Bite-sized learning, classroom sessions, e-learning and drop-in refreshers can all be effective. The key is to keep learning relevant and easy to digest. Handy resources such as user guides which have been designed by and with clinicians can be useful on wards and clinics.

[The ePCR] is something that people are using every day. Downstream, the data that’s captured is relied upon for audit, and identifying health outcomes at both local and national levels. So we need to get good data in and you only do that from having a usable product that users understand how to use.

Jon Yates    Product Manager – ePCR, London Ambulance Service NHS Trust

It can be helpful to think of learning as creating rings of support for EPR users, from helplines through to floor walkers who can answer questions and solve problems as they occur. It is possible to use back-end data from the EPR to identify who might be having difficulties using it (for example, excessive time spent entering data) and provide additional targeted support to those who need it.

While board members themselves will not be providing this support, it can often reassure staff that their needs are being taken seriously if they see leaders asking how they're finding the system, or even watching them use it.

Having one influential person on the board who is actively involved [not just in name only] taking a true interest and leading the programme board is really critical.

Robbie Cline    Joint Chief Information Officer, London North West University Healthcare NHS Trust and The Hillingdon Hospitals NHS Foundation Trust