Could we see a national deal for the Epic electronic patient record? Jon Hoeksma speculates and explores what this could mean for the healthcare system.

Speculation about a national deal between NHS England and US electronic patient record (EPR) supplier Epic were fanned last week a decade on from the end of the NHS National Programme for IT.

Rumours have been circulating over the summer that Tim Ferris, the new head of digital transformation at NHS England, is a big advocate of the system and has told colleagues it should be used by many more trusts.

Highly regarded Ferris joined NHS England from Massachusetts General Hospital, which in 2016 deployed Epic in a programme reportedly costing almost a billion dollars.

Ian O’Neil, the current director of transformation at NHS England, indicated at an industry conference in London last week that there have been recent high-level meetings with Judy Faulkner, the founder of Epic, but declined to give details of the topics under discussion.

In response to subsequent questions from Digital Health News on whether negotiations on a national deal were underway with Epic, the NHSX press office sought to play a straight bat with a ‘move along, nothing to see here’ type statement:

“In response to your questions about supplier discussions, it is standard practice for NHS digital leadership to meet on a routine basis with technology vendors currently providing services to the NHS.”

As to what any meetings covered:

“Meetings cover a range of topics, all with the aim of ensuring that vendors are working towards the vision and priorities of the NHS, particularly within the context of strategies such as What Good Looks Like and Data Saves Lives (Reshaping Health and Social Care With Data).”

The idea of procuring a single national EPR system for all hospital trusts in England was the central pillar of the failed NHS National Programme for IT (NPfIT) that ran from 2003-2011.

In subsequent reports and investigations of the NPfIT the National Audit Office concluded that the top-down national approach had failed to recognise the very different local circumstances between hospitals and failed to secure the support and commitment of local clinicians.

So far this is all in the realms of rumour and speculation. There were also said to have been discussions with Epic in recent months on whether it could potentially offer its system as a platform for use across Integrated Care Systems (ICSs)

As the NHSX press statement says, it’s perfectly sensible for NHS agencies to have meetings with all its key software and technology suppliers. And it is to be hoped that other suppliers are enjoying similar discussions and access.

Just imagine a moment

But just suppose for a moment that some kind of national deal for making Epic more widely available were under discussion, and again this is only speculation, what might it look like and what might it cost?

The cost of an EPR varies hugely depending on supplier and local organisation and there is a distinct lack of transparency on pricing. An NHSX source last week told Digital Health News that new work was being planned to get better data on pricing.

What price an EPR?

Best estimates suggest that NHS hospital EPR deals typically weigh in somewhere between £20million – £100million over ten years.

Epic is at the very top end of that scale, in the realm of roughly £80-100million (call it £90million average) over ten years, with most of the money not going to the software vendor but in infrastructure and dedicated staffing to implement, install and run the software. The split is said to be roughly thirds.

But the costs can be far, far more, Cambridge University Hospitals back in 2014 had a £200m budget for its digitisation programme as the first Epic site in the NHS.

Guys and St Thomas’ NHS Foundation Trust’s Epic project is reportedly significantly in excess of £175million.

Manchester University Hospitals NHS FT has a budget of £181million, while Northern Ireland has a budget of £275million and Frimley Health NHS FT a budget of £108million.

These types of projects are the single largest investment most NHS hospital trusts will make other than the physical buildings.

There are currently 138 acute trusts in England and Epic is in use at five of them: Cambridge University Hospitals, University College London Hospitals, Great Ormond Street and Royal Devon. A number of further NHS trusts in the process of implementing the system.

So, say for the sake of argument, and suspending all competition and procurement rules, that there are about another 100 NHS acute trusts to be funded to get the system – what would be required?

So the 100 acute trusts paying an estimated £90million would come to a total of roughly £9billion. Let’s round it up to £10billion to allow for a little contingency and modest management consultancy fees.

What about everyone else?

Of course, that doesn’t cover all the mental health trusts, community trusts, ambulances trusts, combined health and care trusts, or other specialist providers. And it doesn’t cover social care, but Epic doesn’t usually cover these areas so let’s put them to one side for the sake of this speculative ‘what if’ scenario.

Let’s also ignore the fact that there is currently barely enough implementation capability to handle the current sites.

What would be the benefits of a single acute EPR nationally?

If we instead just imagined that all of this came to pass, what would be the benefit to the NHS and the patients it serves?

Well for a start nearly everyone in the acute sector would use the same system and not have to retrain every time they moved to a different organisation. Everyone would gain experience of using the same system and how to get the most out of it.

For hospital patients there would be benefits on tight integration between orders and tests results and embedded clinical decision support tools. Electronic medicines management would be universal and part of the core EPR with some significant patient safety benefits.

One of Epic’s proudest boasts is that they have never bought another company and the entire system has been developed in-house. So that would mean no more messy interfacing of different systems for a build-your-own set of EPR capabilities.

Digitisation of the patient record and clinical workflows also opens up a whole new ability to do predictive analytics at scale, better carry out research and clinical trials, and identify patients at risk.

One of the big financial benefits that US hospitals see after implementing Epic is better coding of procedures leading to increased billing, which doesn’t directly apply in the NHS.

The world beyond the hospital car park

But all of these benefits would only apply within the boundaries of the hospital and even, within a single provider organisation, an EPR doesn’t do everything. It has to interface and connect with many other systems.

Get to the exit of the hospital car park [if you have fuel] and the familiar messy, complex heterogeneity would remain unchanged.

Move into the world of community, mental health, primary care and it gets a lot more complex and requires a lot of plumbing and interoperability between different systems. Provider digitisation is an important but sufficient part of a complex jigsaw.

And that, more than anything else, would seem to be the most telling argument about any national procurement of a hospital EPR to enable acute provider digitisation to be completed, no matter how good the solution. And there is no question that Epic is very good.

In the era of integrated health and care; of ICSs; of complex patient pathways spanning multiple organisations; of equipping patients with the tools and information to co-manage their own health; it would seem to be fundamentally backwards looking to solely focus on digitising one sector, no matter how important, with one type of system.

A decade on from the end of NPfIT does the NHS really need a potentially PFI-like scheme for acute provider digitisation that might lock it into higher costs and patterns of care for decades to come?

*Fun fact – Massachusetts General is also where the MUMPS (Massachusetts General Hospital Utility Multi-Programming System) database still used by Epic and other health software suppliers was invented back in 1966.