The UK’s National Health Service (NHS) provides health care free at the point of delivery and although it faces a constant battle for funding and skills it is nevertheless a body of which its clinicians and its patients are proud. As a large and complex organization it is constantly seeking ways to improve patient outcomes and reduce costs. In these efforts, electronic patient records (EPR), also known as electronic health records (EHR), play a central role.
NHS England is responsible for purchasing primary care services but most hospitals are managed by NHS Foundation Trusts and are free from central government control. As self-governing organizations they are free to determine their own future. At the local level, general practitioners (GPs) act as the first point of contact for most patients. All of these elements must integrate to deliver an effective EHR program.
In a booming IT healthcare sector, the UK has Europe’s largest EHR market having spent the equivalent of £2.1bn on these systems in 2015 alone. The NHS has great purchasing power as a monopoly provider of care to more than 55m people, so why have its EHR investments delivered only limited success?
The answer to this question may come from a review of computer systems across the NHS led by IT expert Professor Bob Wachter, who is examining every facet of NHS technology infrastructure including EHR. His findings will inform the path of the NHS towards its goal of becoming a paper-free health and care system by 2020.
The NHS has already acted on some of Wachter’s early recommendations by announcing key appointments to drive NHS technology and information modernization. New Chief Clinical Information Officer, Professor Keith McNeil, focuses broadly on systems strategy and Chief Information Officer Will Smart handles the underlying technology elements. On behalf of the NHS they will provide strategic leadership and act as commissioning ‘client’ for digital programs.
“There is a range of initiatives to increase the digital maturity of the NHS and to improve patient outcomes through the aggregation and analysis of data. Electronic patient records are the mechanism by which the interaction between patient and clinician is captured, so they improve the quality and availability of data. That business intelligence improves productivity. You might see, for example, a reduction in acute care admissions. There is a broad cultural shift that comes with this technology,” says McNeil.
“One advantage is cost reduction. You can drive standardization and efficiency in clinical practice because you end up avoiding duplication, which increases process efficiency. Much of the efficiency gains will also come in terms of safety and quality. You transform the way that work is done and then you see cost reductions over the next four or five years,” adds Smart.
Stories of success galvanize the UK
The UK’s journey towards technological maturity in its national health program has not always been smooth. The Department of Health ran the NHS National Program for IT (NPfIT) until 2010, which improved many areas of infrastructure but delivered only £3.7bn of benefit at a cost of £7.3bn.
“To be fair, the UK has a mixed history but the introduction of electronic picture archiving eight years ago was very successful. Now, there are no non-digital images used in radiology. There has also been a lot of success in EPR systems in GP practices, though there has been less success at the level of foundation trusts. At that level, the United States is ahead of us but it has been working on it for decades. We are behind the curve,” remarks Smart.
“The complexity cannot be underestimated,” adds McNeil. “In banking, for instance, there is a linear progression of processes, but in health things are much more complex. It is like building the plane while you are flying and there are always unanticipated problems, but there is also an opportunity to transform working practices.”
Since the demise of NPfIT, individual NHS organizations have been able to choose their own approach to technology implementation. The eHospital initiative at Cambridge University Hospitals (CUH), which is the first digital program of its kind and scale to ever be implemented in an NHS trust, has been a notable success (Figure 1, below).
Using a purpose-built EPR system from EPIC and supporting IT infrastructure from Hewlett Packard Enterprise its aim was to improve patient care, safety, and quality, while maximizing efficiency. The EPR system went live across all aspects of care at Addenbrooke’s and The Rosie—the two CUH hospitals—in 2014 and spanned all major clinical areas: A&E, wards, critical care, outpatient clinics, surgery, pharmacy, laboratory, and radiology services.
EPIC was selected as the EPR provider because of its high level of integration and its proven track record in the United States. It allows clinical and administrative staff to configure and adapt the system to align with NHS processes. Today, the system typically has 3,200 concurrent users at peak times.
The outcomes from providing real-time access to comprehensive patient records are impressive. Delays to patient care have decreased significantly; the time required to prepare discharge medications has halved from 90 minutes to 45 minutes; electronic prescribing has resulted in a 100% reduction in sedation-related prescribing errors in paediatric intensive care, which saves at least 50 intensive care bed days per year and at least 100 regular bed days per year; and the ability to review notes and x-rays virtually has freed up 4,500 clinic appointments.
Furthermore, the use of handheld and mobile devices at the patient’s bedside allows clinicians to spend more quality time and improve patient experience. Those devices integrated with the EPR system have delivered staff time equivalent savings of £1m annually, almost £1m is being saved each year through a reduction in adverse drug reactions, and the list goes on.
As with any change of such a large scale CUH inevitably encountered some challenges at launch. These were, however, quickly resolved and since the system went live it has been able to share the lessons it learnt in the early stages with other Trusts that are implementing digital programs as they work towards the target of a paperless NHS.
“Interoperability is always a challenge because there are multiple actors in the delivery of care. Electronic records, however, help with that. They drive benefits for all parties involved,” remarks Smart.
A key question is whether digital transformation is simpler within the context of a single, state-operated organization compared to a more fragmented system such as in the US. Dr Zafar Chaudry, Chief Information Officer at CUH, is very clear on this matter.
“Each healthcare system has its unique challenges in terms of EPR implementation. Change management is still the major issue in both systems and I don’t believe it’s easier in the NHS. I believe the opposite—in the US, organizations can mandate adoption and link it to performance; in the NHS we cannot,” he says.
The Next Step in the Digital Journey
The success of eHospital marks only the start of CUH’s digital journey. It already has plans to provide more joined-up healthcare with other trusts through EPIC’s Care Everywhere and EpicCare Link functionality. EPIC’s MyChart patient portal, which enables patients to securely view aspects of their medical record, has also performed well in the pilot phase. This is a key element in the UK’s strategy to encourage patients to become more involved in and informed about their care.
As the eHospital project shows, EPR is just one element of a much broader process of technology transformation that the NHS as a whole must undergo.
“EPR won’t happen in isolation. It must align with other systems priorities and the forward view that takes into account the challenges facing the NHS. As well as EPR, we must also look at interoperability, sharing data, educating the workforce to use digital capability well, patient engagement, and linking the technology to social care. We need to integrate horizontally as well as vertically,” remarks McNeil.
“The ability to do things on a national level means we can get a lot of standardization and make bulk purchases, but we don’t want to dictate to our stakeholders or stifle regional and local innovation,” adds Smart. “We need to leave room for people to act on their own in bespoke areas. The US, for example, may not have the national co-ordination but we have nowhere near the level of funding that national initiatives have over there.”
For the UK as a whole, much depends on how clear the long-term strategy is for the NHS, but projects such as eHospital and the open source OpenEyes EPR in place at Moorfields Eye Hospital are good indicators of the value that well-designed systems can provide.
“The journey to a paperless NHS and EPR implementation is a slow process. It’s the change management aspects that slow things down. It’s never about the technology, but more about people and the redesigning of processes. Even the best technology won’t have an impact unless there is standardization of clinical practice and a reduction in variations in clinical practice by speciality,” notes CUH’s Chaudry.