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EPR and transforming workflows and efficiencies

Shortly after the launch of Liverpool Heart and Chest Hospital’s EPR project, it is already being viewed as a transformational event
Johan E P Waktare MD
Consultant Cardiac Electrophysiologist 
and Clinical Lead for EPR and IT, 
Liverpool Heart and Chest Hospital, UK
Patient care records have remained essentially unchanged for hundreds of years. They represent a paper-based process in a digital era. Digital healthcare has made significant in-roads into modern medicine, but the process has been very unmanaged and fragmented. In the UK, some projects, such as widespread national adoption of replacement of film-based radiology images with pure digital PACS (picture archiving and communications systems), has been relatively successful but the national initiative (NPfIT) has severely under-delivered. In 2010, Liverpool Heart and Chest Hospital (LHCH)began an ambitious project to deliver a comprehensive Electronic Patient Record (EPR), and this successfully went live on schedule in June 2013. This article will discuss the approach taken and the clinical benefits delivered, as well as exploring the challenges faced.
Status pre-EPR
LHCH is a specialist tertiary care hospital in the North West of England. It provides cardiothoracic services to the local population in and around Liverpool, North Wales and the Isle of Man, with a  total catchment population of 2.8 million. Services include cardiology (PCI, EPS, pacemakers  and other device implantation/extractions), respiratory (including adult cystic fibrosis services), cardiac surgery (including a major aortic service), thoracic and upper gastrointestinal surgery.
In 2010, the organisation had digital PACS, e-Prescribing and Pharmacy Stock/Dispensing and a longstanding PAS, as well as a variety of stand-alone systems, such as audit databases. However, these systems were fragmented and not interfaced. Electronically generated reports were almost universally printed to paper for filing in the notes.
Project and go-live
A ‘visioning’ phase of understanding needs and potential benefits was undertaken. This was clinically led from the outset, with the assignment of the author to the project and engagement of clinical staff to specify requirements. During this phase, several key principles emerged that drove the approach the hospital was to take (Table 1). In parallel to the EPR planning, a comprehensive review and update of the organisational IT infrastructure was undertaken.
The organisation chose to take a ‘best of breed’ approach to supplier engagement and system development. However, the severely underdeveloped nature of the Clinical IT System estate meant that, in practice, a very comprehensive package of functionality was required. Furthermore, the approach of releasing the OJEU tender as a single lot and a requirement for an integrated solution meant that while a potential supplier was welcome to sub-contract freely, the natural approach would be to deliver a comprehensive solution based upon limited solutions. The tender was won by a major US EPR supplier (Allscripts Inc). They tendered  to supply the majority of the required functionality from their products (predominantly Sunrise Clinical Manager/Allscripts Acute), with the significant exception of the electronic document management System (EDMS), which was to be supplied by Hyland Inc (OnBase). Table 2 shows the major components and functionality planned and delivered.
The project was delivered over a 15-month period, using a combined team of LHCH recruited analysts and Allscripts implementation consultants. Again, the ongoing strong clinical leadership and organisational engagement to create a system that was designed for the needs of the organisation was again key to this phase. This included clinical staff identifying how the system should work in terms of supporting workflows and giving clinically safe but highly productive permissions in the system.
Go-live was with a single activation (often referred to as ‘Big Bang’), and high intensity organisational support was maintained for four weeks.
Improvements and challenges
This article is written a mere six months after go-live of the project, but what is definitely evident is that the delivery of an EPR has been a transformational event for the organisation. The transformation has been challenging but it is now evident that the platform for a new way of working is in place.
The greatest area of benefit arises as a direct result the natural by-product of a virtually paper-free, IT enabled healthcare environment. While not having paper notes that can get lost, or at a minimum require co-locating with the clinician who wishes to review them is an automatic feature of introducing an EPR, its benefit must not be underestimated. Staff can review records from other locations within the organisation, or even from outside using the pre-existing access portal.
The strategy of creating an integrated surfacing of all clinical data in one user interface is also an important component of better user processes. While some historic systems did allow retrieval of care data, each one presented a different user interface and had its own log in process. This, in turn, creates higher training requirements and governance risks in terms of users having to manage multiple system credentials.
Service delivery and performance management has been facilitated. At present this is predominantly being realised as workflow improvements such as end users being able to create patient lists to facilitate ‘virtual ward rounds’. A specific example is having a list of all patients presently prescribed broad spectrum antibiotics that the infection control team can utilise to give oversight and guidance. A visit to clinically review the patient is done on a targeted basis based upon the data gleaned from the EPR. As all user activity in the EPR is audit logged, all incidents can be investigated more fully and irrefutable evidence of the sequence of events demonstrated. Clearly these data are typically used to allow users to understand the correct processes in the EPR and to identify training needs, but it has also been invaluable in investigating incidents. This audit data in itself can directly influence end user behaviour. A report identifying users who have ‘clicked past’ duplicate medication alerts to create a potentially dangerous combination of prescriptions has directly resulted in greater caution in the users with respect to system alerts.
The major area of challenge has been around training and user adoption. By design of the organisational strategy, historic processes for care delivery were made unavailable at go live and thus this has not been in the form of ongoing ‘paper’ processes. Instead the issues have centred upon proper use of the system by both users and mangers. The delivery of such a transformational project will inevitably require a significant period of embedding, and vigilance to ensure that the benefits of EPR are being realised. Examples include the choice by local staff and managers to attempt to re-create historic paper processes under the EPR, creating a workflow that was not only no better, but actively less efficient and higher risk of under-delivery than pre-EPR. This has now been addressed and a superior workflow to pre-EPR is in place. Clearly this under-delivery, and delayed delivery of improved processes, adversely effects the timely delivery of benefits and requires active management.
LHCH has undertaken an ambitious change project to deliver a comprehensive EPR solution in a short timeframe. This project benefited form careful planning and strong clinical leadership and engagement, and delivered the solution on schedule.
Through this approach, a comprehensive suite of functionality has been delivered, acknowledged in LHCH having the joint highest CDMI (Clinical Digital Maturity Index) score in the NHS. The CDMI is an evaluation of the scope of hospitals’ digital administrative and clinical systems and is NHS England’s preferred metric for evaluating the delivery of IT-enabled healthcare.
Massive workflow benefits have been delivered to LHCH clinical end user staff, and after a challenging transition, the benefits are widely acknowledged in the organisation. While already very significant, the benefits realisation is also only at an early stage. Major benefits will be delivered though full adoption of existing functionality, system optimisation and new functionality that is being planned.
IT-enabled healthcare is the future of healthcare. While the label ‘EPR’ is widely employed to describe the process outlined above, it does not address itself to the wider clinical care and process benefits that derive from harnessing the power of modern digital technology to improved clinical care processes. Highly available digital care data, with decision support processes, lead not only to more efficient and more convenient care, but also directly results in higher quality care.