For the electronic patient record team at Liverpool Heart and Chest Hospital NHS Foundation Trust, an EPR is more than just an IT system. It’s also more than a tool for a new way of working.
Clinical systems manager Lyndsey Waktare refers to the system as her ‘baby’, while her team has come up with the affectionate moniker Elsa Penelope Rose for their EPR, a suite of tools held together by Allscripts Sunrise Clinical Manager.
Elsa was conceived back in 2009, when the trust was looking to consolidate what was, at the time, something of a “basket case” of clinical systems and IT, explains Waktare.
It was also a period of uncertainty though, says Lyndsey’s husband Dr Johan Waktare, the trust’s chief clinical information officer, who has helped to lead the project from the outset.
“We didn't exactly know what an EPR was at that stage. My understanding at the start of the project was probably only a quarter what my understanding was at end of tendering process.”
Even so, the trust had several principles it knew it wanted to deliver. For example, it was determined to move all possible services to an electronic platform after visiting a hospital that was meant to be a leading EPR user – and discovering it still had paper records.
“We made it clear that if you want to maintain a paper process you need to justify why it has to remain on paper; rather than taking each individual thing and asking if it could be made electronic.”
A very big bang
Liverpool Heart and Chest was the first trust in the UK to pick the modern incarnation of Allscripts’ Sunrise Clinical Manager, which covers order entry and results reporting, electronic prescribing and medicines administration, clinical documentation and nursing workflows.
Feeding data into all these systems is a pre-existing Silverlink patient administration system, while Hyland’s OnBase was chosen for its electronic document management system and Carestream for its picture archiving and communications system.
A big bang approach taken to switch-over, and on Wednesday 26 June 2013 the trust went live with all these new systems.
Johan Waktare recalls: “The first four weeks or so was very intense. Fortunately, we had a huge amount of planning that went into it. And there was a lot of engagement and support. Far more went right than wrong.”
Two years on from go-live and the move is widely seen as a success. Touring the wards on a rare rainy day in July, it’s hard to spot a trace of a paper, while the trust is now ranked joint top of Digital Health Intelligence’s Clinical Digital Maturity Index.
Significantly, the trust also came top of a Care Quality Commission patient satisfaction survey that took place just one week after go live.
Even so, Elsa Penelope Rose's adolescence has been a struggle for acceptance. Everyone in the EPR team agrees it was tough to convince clinicians that a move towards being a paperless hospital was a step in the right direction.
Alison Tant, clinical configuration analyst, mentions that in the early days, if the system needed to be taken down for some maintenance, there would be a sense of relief from staff who could go back to paper.
Six months after go-live that mindset had completely turned around, says Tant, adding that relief had turned to disappointment if downtime was required on the system.
Johan Waktare says it has taken even more time for people to truly appreciate that an ability to use EPR effectively is a “required skill” at the trust.
“I don't mean we need everyone to be another geek. We still want good doctors and nurses but those good doctors and nurses need to be able to use IT systems to deliver their care.”
Ward manager Lindsay Marsh mentions that it is often clinicians from an older generation to have been the ones to struggle with or oppose the change, although staff are working to help each other, and there are 'super users' to provide support.
Marsh, who has been with the trust for 12 years, is a strong personal advocate of the change, mentioning that without Allscripts' system she just would not be able to do amount of auditing and data collection needed to do her job. “We can't go back to paper. I couldn't even think of that.”
The struggle to communicate
Speaking to Lyndsey Waktare and her team there are two mantras that seem to be repeated: this is a clinical project supported by IT, not an IT project, and that this is an ongoing project; the job did not end on 26 June 2013.
There's a feeling though that these have been difficult messages to communicate to the wide staff base at the trust, complicating wide acceptance of Elsa Penelope Rose.
For Lyndsey Waktare, getting those messages out there is now just as important a task as implementing Allscripts in the first place, in to support people in the necessary culture shift that is necessary when going through a “transformational change” such as this.
An important part of that is making sure that staff know that their concerns and issues with the EPR are being listened to, especially with regards to change requests.
All change requests are also debated formally at a weekly change control meeting and where they are triaged and put into a formal cycle of change. Liverpool Heart and Chest has also introduced 'change Wednesdays', which occur every second Wednesday of the month when the trust aims to make at least one change to the system.
Despite these regular updates, Lyndsey Waktare is aware that many staff members don't understand the processes for change and they can get frustrated if a request they’ve made seems to have been forgotten about.
To improve this dialogue the trust is developing a dashboard as a way for staff to track the progress of any change requests that have been made.
There is also a level of individual responsibility, according to Lyndsey Waktare, who says that staff members who don’t understand that technology need to actively listen to and try to grasp the technical explanations, or have trust in the EPR and IT teams that they are working on trying to improve the service.
Another way to get staff on board is to show the benefits the system can bring. These have focused on creating workflows that are as efficient as possible, based on Johan Waktare’s strong belief that data should only be entered once to be used multiple times for different purposes, such as audit reporting.
Examples given by Lyndsey Waktare include importing questions from WHO safety checklist into existing workflow process, rather than creating a separate document, and recording early on if a patient wants family or friends involved in their care, rather than having to have record this information at multiple stages of care.
There are also more practical things benefits, such as moving from one big paper document for recording a patient's care pathway, meaning only one clinician could access or update it at one time, to an electronic system where multiple clinicians can access the bit relevant to them whenever they need to.
Other areas where benefits may be seen are on their way, and Lyndsey Waktare is excited for the introduction of Mindray patient observations, due in autumn, while the team is also working on extending the Allscripts offering to cover its community services.
Johan Waktare is also keen for the trust to catch up on implementing services that were in the original scope but it has not yet had the chance to do, including outpatient prescribing, a patient portal and greater use of mobile technology.
As with the rest of the NHS, sharing appropriate data sharing is also on the agenda for the Liverpool Heart and Chest and the trust is an active partner in iLinks problem, which is looking to break down barriers that prevent the exchange of patient data throughout the healthcare system in North Merseyside.
Johan Waktare says that one of the things that the trust wrote into its original documents to procure IT systems was that they had to be capable of sharing data.
However, he's keen to mention that providers shouldn't be looking to share everything from the outset but should consider what data would be useful to share what is the best way to share it. “We should be targeting those things that add value rather than going for vague concepts.”
Liverpool Heart and Chest is also keeping a keen eye on the joint procurement process for a new EPR that is currently being held by Royal Liverpool and Broadgreen University Hospitals, The Liverpool Women’s and Aintree University Hospitals.
Lyndsey Waktare can't hide her hope that they will go with Allscripts and Elsa Penelope Rose will have some friends that she can play with nicely.