Unintended consequences
When I worked in an NHS trust, my colleagues and I had to make a 5% cut to our annual departmental budgets each year.
There was little discussion about the implications for patients, intended or unintended consequences for clinical services, nor modelling of the impacts. All that mattered was that I had found a way to cut my budget and hit the cost improvement target.
I wish I had fully appreciated then, what I know now about complex systems – that each division and function is a subset of a wider whole and a change in one has an impact on the other.
A complex adaptive system
Too often digital teams are dealing with their own resource challenges in a departmental silo. As I interviewed chief information officers, chief clinical informatics officers and other digital health practitioners for the new NHS Providers' guide, Making the most of your electronic patient record system, many told me how they are grappling with the challenge of continually improving and adapting their electronic patient record (EPR) so that it creates genuine value. They are doing this within the context of NHS trusts fighting for their lives amid a workforce crisis and unprecedented demand. The context could hardly be more challenging.
An EPR should be at least part of the answer to these challenges. A comprehensive digital record holds the promise of making life so much easier for NHS colleagues. It enables a practitioner to have patient data at the point of care. It should save them time and generate insight that can be used to plan care, learn and innovate.
Paradoxically, the EPR is too often the source of additional pain and frustration for its users. Technology projects in health have a chequered history of not delivering their intended promise. So what is going wrong?
The world of make-believe
An EPR business case is typically born in the land of fantasy. Bold claims are made for benefits that everyone knows may not be achieved, even if they were to be measured (which they usually aren't). So from the very beginning of an EPR journey, we find ourselves overpromising while secretly knowing we will under-deliver.
When we treat the EPR in a silo and when we don't fully resource its implementation and improvement over time, the software ends up compounding the problems it is supposed to solve – taking colleagues away from patient care, contributing to burnout, generating sub-optimal data.
A systems approach to optimising an EPR
It is hard work to think in systems. System behaviour reveals itself as a series of events and it is easier to see them in isolation and forget about their relationship to each other. Cause and effect do not always happen in a linear way in complex systems.
We need to think beyond the obvious boundaries of the IT department if we truly care about enabling clinical services to do their job, enabled by the digital foundations of an EPR.
Leverage points for EPR optimisation in a complex system
It helps to have an understanding of why technology doesn't get adopted along with a learning healthcare systems approach that uses improvement methods and data to facilitate change.
As trust leaders, here are some points you may wish to reflect on as you seek to optimise your EPR:
Creating an EPR paradigm shift
- Create a paradigm shift from the EPR as a technology product to a sociotechnical endeavour – talk about it in this way and shift the dial on how it is perceived.
- Set out how the EPR contributes to the overall goals of the system so everyone is clear on what is expected.
- Devise a set of meaningful benefits related to the EPR's contribution to the wider system as a whole.
Resourcing & organising EPR optimisation
- Put in place the right capabilities and capacity for the social change aspects of the EPR and not just the technological components.
- Create capacity to adapt over time rather than treating the EPR as a project with a beginning and end – optimisation is a continual process.
- Organise the IT workflow to improve the EPR over time in ways which avoid bottlenecks and delays (I recommend The Phoenix Project as a way of thinking about this challenge).
- Set clear rules and parameters for EPR optimisation that take into account its place within the wider system.
Creating system feedback loops and designing with users
- Seek to understand problems and design with end users so you are meeting their needs and goals.
- Use data from the EPR to learn about what is working and not working – don't rely on the most senior person or with the loudest voice.
- Create a relationship between the EPR team and the system(s) so you get regular feedback from users – go to them rather than expecting them to come to you.
- Remember that the EPR vendor is part of your system – invest in building a productive relationship with them rather than a transactional one.
There is no single answer to how to optimise an EPR but thinking like a system with a constant orientation of learning and adapting will go some way to helping you get there.
This blog was first published by Digital Health.
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