- Every EPR requires adjustment and improvement once it has been successfully implemented.
- Optimisation is a continuous process which should be planned over the life cycle of the EPR contract.
- Ongoing optimisation is underpinned by an empowered digital team.
- A non-optimised EPR creates burnout and frustration for staff.
Optimising is asking the question 'What helps to make your day as productive as possible while delivering safe care?'Associate Chief Clinical Information Officer, Somerset NHS Foundation Trust
Investing in continuous improvement and optimisation
An EPR deployment journey starts with board approval of a business case through to the point at which the system goes live. The lead up to implementing an EPR takes a huge effort from everyone involved, with executive and non-executive directors focused on ensuring the organisation is prepared for go live.
At this point, the project team typically tapers off their support and eventually withdraws. The responsibility of the EPR is handed over to a business-as-usual team whose key responsibilities is to handle change requests and manage the supplier relationship.
However, the point of go-live is just the start of the EPR journey. Beyond the initial planning, testing and training, the EPR needs to continually adapt and evolve as clinical practice and business intelligence requirements change.
It is only after go live that further requirements emerge, things that never would have been picked up at the outset. Leaving these issues unresolved will impact both the workforce and workflow. Recent research has found that over a third of staff in acute settings were frustrated by the EPR system operating within their trust.
The promised benefits set out in the initial business case will only be achieved if a concerted effort is sustained to optimise the EPR over the life cycle of the contract. Digital leaders have told us that the real benefits of an EPR may take five years or more to be fully realised and have factored this in accordingly. For example, Sussex Community NHS Foundation Trust has set out their EPR optimisation plan as part of their latest digital strategy.
Optimisation is a continuous process which improves an EPR's usability and functionality over time. This may mean adding features to the EPR. But it is just as likely to mean removing features, making it simpler and easier to use. Successful trusts make judicious use of benchmarking tools such as HIMSS EMRAM for technical infrastructure, but optimisation is ultimately about a usable system that makes the lives of staff easier and helps manage change on the basis of data insights.
Rather than thinking of optimisation simply in terms of functions and features, it can be more helpful to think of it through the lens of quality and improvement. Improving the EPR means improving the experience of those who use it every day. It is the digital backbone to clinical and operational practice.
If a trust does not understand the importance of continually improving the EPR, it will have invested a substantial amount of money in a system that creates frustration and burnout rather than value.
Optimisation is a dynamic, continuous process to enable your EPR to support an efficient and well-designed workflow that allows the ability to record the right things in the right way.Chief Clinical information Officer, Oxleas NHS Foundation Trust
Optimisation is a continuous process
You don't just put something in and expect it to work. It's a constantly evolving environment with new user requirements, new technologies that need to be introduced, inevitable policy and legislative changes.CHIEF INFORMATION OFFICER, UNIVERSITY HOSPITALS SOUTHAMPTON NHS FOUNDATION TRUST
University Hospital Southampton is a large acute trust in the south east which has a bespoke EPR configuration around an open platform strategy using some procured product, some development and an integration engine. The in house developed part that brings all of this together is called CHARTS. The trust has focused on open standards and open platforms to ensure that data is owned by the NHS rather than by a supplier and can be readily accessed for primary and secondary purposes.
The trust has been working to optimise its EPR over the last 20 years since its introduction. A key focus has been designing an interface that is easy to use and saves clinicians' time. As a result of this focus on usability, the trust is in the lower quartile of total spend on their EPR but higher in terms of quality and staff satisfaction.
The platform based bespoke EPR approach means that the trust is in control of delivering new user requirements. It is however a challenge to avoid over customisation which can create a burden on development resources; instead teams have had to compromise on the specific requirements of speciality units.
The digital team has found that users don't always know what they need or the possibilities afforded by new technologies. It is for this reason that they approach optimisation by observing clinicians using technology in practice. This allows the team to interpret their requirements and test before mass rollout and means all can be confident the change will add genuine value. Southampton has learnt that it takes a number of iterations before a development is optimised.
As an example of responding to user needs, the trust recently updated the order communications functionality to give clinicians the ability to select an immediate alert in Microsoft Teams when a test result is ready. The Teams link was used during the pandemic to push Covid-19 test results out and this has now been brought into the order comms as a core function and will in some cases mean that patients can be discharged faster.
What does good optimisation look like?
Put simply, optimisation is about reaching the full potential of what an EPR is able to deliver for high quality and safe clinical care. Everyday optimisation is about tweaking and improving the EPR in small ways that make it as easy as possible to use (for example, a new field or form). It is about fixing errors and scaling what works.
There are more significant changes that may have larger costs. For example, a mature system tends to be accompanied by a patient facing portal that typically enables patients to access test results and communicate with their healthcare team. A systematic review of patient access to their data found positive benefits including self-care, outcomes, quality and cost.
Whatever the scale of change, trusts should approach optimisation by building teams rather than projects. This will enable an ongoing process of improvement and refinement by teams who understand clinical services and have built trusted relationships over time. Trust boards need to empower these teams and give them the space to identify priorities and deliver changes.
As well as having a well-designed process in place to identify and prioritise improvement opportunities, it is also crucial to have sufficient resources in place to deliver, and sound governance to ensure good, accountable decision making. This is covered in later chapters.
It’s not going to be easy all of the time - so as a programme board and for those involved it's important to keep the energy high, be sure to celebrate the wins and keep going. Put amazing people around it - it's all about remembering the 'why' and for us that’s around supporting exceptional care for our children and young people and creating a great experience for our colleagues. Our away days are held with 160 staff across the whole digital service and give space to have time together for the cultural piece, team building and to have some fun along the way.Chief Digital Information Officer, Alder Hey NHS Foundation Trust
Standardising ways of working
Regardless of whether a trust chooses a big bang EPR launch or gradual deployment, the organisation will be asking staff to change the way they work. For many trusts, this is about standardising processes and workflows across a large workforce, spread over disparate sites or working remotely.
But just because your EPR is underpinned by standardised operating procedures, it does not mean that everyone will behave in the same way. For example, it is not uncommon for there to be more than one way to record the same piece of information. Busy staff may learn workarounds or input the same data in different places and in different ways. This results in not only poor searchability and discoverability, but also duplication of effort and wasted time. Data being documented in different places also introduces clinical risk.
It is important to remember that assimilating and adapting to change is an emergent process that happens over time. The groundwork for much of this can be laid in the run up to an EPR go live, but it will then need constant attention over the life of an EPR. It will be impossible to second guess these workarounds at the outset.
With more complex EPRs there's always more than one way of doing something. Staff will find a way with less clicks that bypasses some of the processes […] but they don’t realise the downstream effects that these workarounds have.Chief Nursing Information Officer, London North West University Healthcare NHS Trust