Life on Marsland: planning for the NHS care record part 2

In his latest column, Iain Marsland reflects on some early electronic patient record system deployments in English hospitals - and the importance of taking clinical views into account.

Last month I looked at some of the components of the NHS Care Records Service (NHS CRS) and discussed how decision support can turn basic functions such as order processing and electronic prescribing into powerful change agents. This month, I want to look at options for deployment, again using acute hospital examples.

Early adopters

Over the past ten years, a small number of NHS hospitals have implemented electronic patient records (EPRs). Early adopters had access to the full capability of commercial, off-the-shelf EPR software and were able to tailor their EPRs to the local requirements of their clinicians. “Many improvements in clinical practice and patient care resulted from simply analysing and reporting on current practice.”

With these significant freedoms, they were able to explore a number of different deployment models, some of which are relevant to NHS CRS.

A traditional IM&T implementation project is often defined by three resources: time, money and skills. However, with an EPR implementation there are three additional dimensions:

1. The functional dimension: the breadth of capabilities involved, such as results reporting, scheduling, clinical documentation and electronic prescribing

2. The clinical dimension: the clinical specialties and services deploying the EPR

3. The patient dimension: the clinical pathways supported by the EPR.

Normally one or another of these dimensions shapes the deployment. For example, Chelsea and Westminster Hospital trust deployed iDX’s Lastword between 1999 and 2003 and layered EPR functions across all its specialties.

Between 1997 and 2001, Southmead Hospital implemented HealthVision’s CareVision, the precursor to IBA’s Lorenzo. In this case, individual functions were introduced on a specialty by speciality basis, creating a two dimensional or phased implementation model.

Around the same time, and using the same CareVision product, Gloucester Royal Hospital followed a third model, using all of the available functions of the EPR to support individual care pathways.

Benefits and downsides

There are benefits and downsides to each model. The Southmead and Gloucester deployments layered EPR applications onto a legacy patient administration system (PAS), whereas the Chelsea and Westminster model started with a PAS replacement. "Each planned deployment should have associated measurable benefits. These can be classified as cash releasing, cost avoiding, time saving or qualitative. The steady stream of unexpected benefits at Southmead was classified as 'serendipity.'"

The Southmead and Gloucester models were less risky. Clinicians were able to engage, to learn from each other, and to see live components of the EPR running well ahead of their planned go-live.

The Chelsea and Westminster model required all clinicians to implement in parallel. But this avoided large areas of the hospital being EPR-free, which is an important benefit where patients are cared for across specialties.

In hospitals, the NHS CRS will be implemented in four or five releases of increasing complexity. Each release is expected to be implemented across an entire hospital or even a “domain” of three or four hospitals. As such, the National Programme for IT in the NHS appears to be following the Chelsea and Westminster model most closely – although there are some significant differences.

Clinical analysts have a vital role

All of the three deployments discussed above used clinical analysts to determine speciality practices and patient flows. They then tailored their highly configurable EPR products, adapting them to clinicians’ needs and local practice.

As clinicians became comfortable with the EPR, and confident that it was safely supporting their care, the clinical analysts were called back to fine-tune protocols, pathways and order sets.

Similar changes were needed to enable the EPR to keep pace with the ever evolving science and practice of medicine. Even with a fully implemented EPR, analysts continue to add value by stimulating clinical teams to explore new ways of working, supported by the many and advanced capabilities of an EPR.

Plan for measurable benefits

Clinical analysts can deliver benefits very early in an EPR project – long before implementation. At Southmead, analysts presented their issues and findings to a weekly project checkpoint meeting attended by senior “lead” clinicians.

One of the most common exclamations from the clinicians was: “I didn’t know we did that!” Many improvements in clinical practice and patient care resulted from simply analysing and reporting on current practice. “Benefits may not be fully realised unless clinicians themselves are allowed to decide how the system works best for them and their patients.”

This also led to a new classification of project benefits. Each planned deployment should have associated measurable benefits. These can be classified as cash releasing, cost avoiding, time saving or qualitative. The steady stream of unexpected benefits at Southmead was classified as “serendipity.”

Realising benefits

Clinical analysts may not have such free rein with the NHS CRS. It has been designed as a standard build, with minimal local tailoring across both clinical specialities and entire hospitals. The enforced standardisation has not been well received by clinicians, whose practice is essentially judgement-based and continuously evolving.

The idea of an EPR is widely perceived as a positive step change in developing clinical practice and patient care. But the benefits may not be fully realised unless clinicians themselves are allowed to decide how the system works best for them and their patients. No matter which deployment model they used, the early EPR sites all understood this basic fact.

About the author: Iain Marsland has been in the NHS for 34 years, most recently as chief information officer for Essex Strategic Health Authority and previously as director of IM&T for acute trusts in Brighton, Sussex and Bristol. He is now an independent consultant.