Forget the big bang approach to EPR implementation – the financial constraints on NHS trusts make it risky to rely on the two big suppliers. By Rachael Fox

At Rewired, earlier this year, I was talking to a junior doctor who was disenchanted and burnt out and had a desire to forge a career in the digital health space. Naturally, our conversation touched on the junior doctor pay dispute, which is still some way off being resolved. The net cost of pay restoration for junior doctors has been calculated at approximately £1bn, or the equivalent of a handful of big bang EPR procurements, it was pointed out to me. This is, also, not far off the figure by which the NHS tech budget has been reportedly cut.

The conversation left me considering the viability of spending such huge sums of money on inflated, monolithic EPR deployments that take years to implement, as well as the impact on the wider NHS and the future of the clinical systems market, should a duopoly be allowed to develop.

However, the announcement that Tim Ferris is to leave his position as NHS England’s director of transformation in September presents an opportunity to re-evaluate what is best for the NHS and potentially plot a different course, one that encourages competition, innovation, and the best use of taxpayers’ money.

Unfortunately, it looks increasingly unlikely that the government’s target for 90% of trusts to have an EPR in place for December this year is going to be met. The frontline digitisation programme has admirable aims, but the already ambitious target has been made much more difficult following the news that the NHS tech budget has been slashed. For the less digitally mature trusts I’ve spoken to, it means many won’t be able to see through their implementation plans in the timescales set.

Deployment within months

Looking further ahead, if all trusts are to meet the target of core-level digitisation by 2025, set in the Long-Term Plan, they need to achieve greater speed to value from their system suppliers. From my experience there’s no reason why a hospital following a phased departmental deployment plan shouldn’t be up and running within months of signing a contract. As long as the contract does not run into hundreds of millions, deployment should not take years. Often, delays are caused by the time and money wasted on procurement, and decisions to implement being drawn out.

What also hinders speed to value for trusts is the piecemeal and incohesive way clinical system development has been approached. But, by taking a modular approach to go-lives, starting with the areas that will see the greatest value in the shortest time, digital maturity can be accelerated.

The patchwork of legacy technology and capabilities within any given region has had a knock-on effect in terms of joining up systems and the sharing of information. We have to get to a point where there are more common standards, so clinical systems can feed the information needed to deliver person-centred care.

Standardisation doesn’t need to be at the expense of localisation and customisation, and nor is wholesale rip-and-replace a viable solution. We’ve seen excellent examples of organisations such as Gloucestershire Hospitals NHS Foundation Trust starting with a trusted blueprint, and customising where required, to accelerate digital transformation.

Importance of competition

Few organisations can achieve the big bang approach to EPR implementation pushed by some of the international suppliers. With reduced national funding for EPR projects, big bang has become a more unrealistic, or risky, proposition for trusts who may find their funding withdrawn or reduced. They need to consider a different approach at the outset.

The financial constraints most trusts operate within make it dangerous to rely on the two big suppliers. A duopoly, as we’ve seen in primary care where two organisations share 90% of the market, is not in the interest of the NHS – not from a financial or innovation perspective. Nor does it motivate suppliers to provide the best possible systems at the most sustainable price.


To move quickly and at scale, there needs to be an environment where all organisations—on the care provider and supplier side—can get involved, because the elephant is too large for one or two organisations to eat alone. I was pleased to hear that techUK’s newly formed Interoperability Working Group has recognised that the biggest barriers are not technical, but the need to get everyone to play their parts, as the flow of information is only as effective as the weakest link.

Future clinical systems market

Despite being two to three years behind hitting the government’s targets for digital maturity, I believe the ambition and the end game is right. However, if a duopoly in secondary care EPR systems is allowed to evolve, I fear the horizon will continue to be just out of reach.

Clinical information systems’ value, for healthcare professionals and patients, relies on shareable, actionable content. Once we have this information from all care settings being shared efficiently, then I believe the next big push will see greater focus on real-time clinical decision support. In addition, real-time, up-to-date views of capacity and demand will also be crucial.

As we move forward, the desire for patients to manage more of their own care will increase. This will lead to a consolidation of patient-facing portals as more functionality is built into the NHS app. This standardisation will be increasingly important for clinical system providers to deliver repeatable integrations at scale. And for trusts, it makes sense to continue using their established patient portals, rather than adding to the financial and resource burden of replacing when procuring an EPR.

As a clinical information system provider, Altera has a responsibility to focus relentlessly on the speed, usability and affordability of our solutions to help NHS trusts meet the targets expected of them.

From a trust’s priorities perspective, improving patient care, delivering efficiency savings, and achieving HIMSS Level 5 does not have to require you to spend two years and risk organisational chaos by unnecessarily replacing your PAS.

At the core of each of these priorities is openness: being open to understanding what hospitals need to speed up their processes, now and into the future; listening to clinicians to ensure every action we take makes technology easier to use; and remaining open to working with every other provider, preventing costly rip-and-replace programmes that take years to realise value.

Rachael FoxRachael Fox is executive vice president, Altera Digital Health, EMEA.