For the 11th episode of our Monday Morning Healthcare IT Podcast Series, Tom sits down with Dave Lang, a Senior Program Director for HCI in the United Kingdom. Tom and Dave will be going over different areas that healthcare organizations should be looking at before deciding if they are, or are not, ready for an EPR Implementation.
For our listeners, keep in mind that an EPR, or Electronic Patient Record, is simply the term used in the United Kingdom to loosely refer to what we, here in the US, would call an EMR or EHR.
In case you missed it, make sure to check out our episode from last week, where Stephen Tokarz went over the process of developing your curriculum, using your LMS, and organizing your CTs during an EHR Training project.
Transcript
Tom: Hello and welcome to the eleventh episode of our Monday Morning Podcast Series. My name is Tom Letro of The HCI Group, and today I will be joined by Dave Lang, a Senior Program Director who works for HCI in the United Kingdom.
Dave, thank you for joining us today to go over the process of implementing an EPR. The term electronic patient record can be a bit of a red herring, because it can mean different things to different people around the world. What does an EPR implementation cover for you?
Defining an EPR and Establishing a Vision
Dave: So for me, the first thing we’ve got to be clear about is, when talking about EPRs, is what we are talking about in the UK market. Because an EPR can mean anything, and so, to some extent, an EPR can just be an electronic patient record, and a lot of organizations are doing that, just by digitizing their existing paper records, and having some software that allows you to view them. I think what we are talking about here is much more than that, in that although there’s an electronic patient record at the heart of it, it’s all the systems and decision support that goes around it. So really, an EPR is a bit of a misnomer, because most of our people wouldn’t recognize a digitized record, just digitizing the record, as an EPR.
So, I just want to be clear about that, and what we are talking about in these podcasts is the latter, in that we are talking about something that is not only an electronic patient record, but it also has all the ordering facilities, all the smart software, decision support software that surrounds the EPR to improve patient safety and support the clinician.
Tom: Thank you Dave, so a lot of this comes down to the strategic vision of each organization then I guess. Could you take us through that process if you wouldn’t mind?
Dave: Well in most cases, what would happen is that the organization would want to come up with a digital strategy, and to some extent all UK organizations need to do that, because we have got targets, government targets to be digital by 2020. So, the decision to buy an EPR will very much depend on your starting point in that some organizations will already have some EPR functionality embedded in their organizations, others will be very paper-based, very manual process systems. So to some extent, it’s developing that strategy and looking at having a real hard look at where you are, deciding what you want the organization to look like when you’ve completed this, and then that should tell you whether you need an EPR or whether you are just going to bring in some additional systems to fit what you’ve already got, or indeed, are you just going to digitize the record because you think that is sufficient for the organization that you’re working on support.
Executive Buy-In
Tom: Interesting, fitting the solution to the organization and not the other way around. But obviously any level of investment, be it to digitize records and have the ability to view them or implementing the whole range of decision support is going to need sign off from board level. I suppose that’s where change management begins in a project of this magnitude. How do you go about getting them, not just to sign off on the project, but to be really be on board with the vision?
Dave: Ok, so I think this is fairly fundamental, and this is quite key to the whole thing. At the end of the day, we’ve not got a lot of experience, although that’s starting to change a bit in the UK, of what an organization supported by an EPR looks like. So first of all, you’ve got to get the senior team, you’ve got to get the clinicians, you’ve got to get everybody excited about what you can do if you properly implement an EPR. So I think you’ve got to generate this excitement and interest within the organization, and especially at board level, and to some extent, you do that by exposing your senior leaders, your medical director, your chief exec, your director of finance, to what’s out there what’s been achieved in this country, what some of the best organizations have managed to achieve, but also start looking at examples from abroad.
The UK’s is so, probably 5-10 years ahead of us with this if not more, so I’m not suggesting we’re going to get on a plane and visit the USA, but you can certainly, and suppliers will help with this because at this stage you haven’t decided on a supplier, but suppliers will give you contacts to set up conference calls with other organizations almost anywh ere in the world, and it’s not cheap but it’s the cost of a phone call and your staff time. But basically you’ve got to generate that excitement, you’ve got to get the people that’s in charge to come to the conclusion of what they can achieve by implementing the EPR, because at the end of the day, it’s those guys that are going to lead that change from the top, so the nurses, the doctors, the exec team. Does that sort of make sense?
Stakeholder Involvement
Tom: Yeah, absolutely, and speaking of people that need to get engaged during this process, I feel like your stakeholders are going to be very important, so when should you, and who among your stakeholders, should you get involved?
Dave: It’s hard to say who isn’t a stakeholder in this, because to some extent, almost everyone in the organization will be touched by the EPR, everyone from the front line staff to the exec team who will be risking their reputations, and in some cases their jobs on things like this, the admin people, the finance people, almost everybody needs to be involved. So, obviously your senior team, and your clinicians, docs, senior nurses, are your main stakeholders, you get them involved as soon as possible in this, but you also need to start trickling out what you’re trying to do to the rest of the organization, engaging with them as well. Because at the end of the day, they’re all stakeholders.
There’s also something about your exec teams also start t o communicate with your external stakeholders, your CCG’s, your commissioners, the lot of GP’s, because they at least need to know what’s likely to be happening in the next couple of years, because again, it will impact on the whole, if you’re doing this and you’re impacting on the EPR, it will impact on the whole economy, not just your organization.
Governance
Tom: And obviously once you get them to buy in, I feel like the next step for them would be to put up a system of governance. What goes into that governance structure?
Dave: To some extent, that depends. So in the UK we have very strict rules in the NHS about what governance structure for any big project should be. So we use a couple of methodologies which is MSP and Prince. One is a program management structure, and the other one is a project management structure. So to some extent, whatever you do needs to be built around those structures because certainly the people that govern us will be looking for that when you are embarking on a project as big as this.
I think the second thing is though, when you are building a governance structure about this, you’ve got to think about what we are trying to do here. And what we are trying to do here is create clinical change, so although the structure might be fixed, you need to think about who needs to fit in to that structure. You will need senior teams, you will need IT people, but the clinicians, and some senior clinicians, are absolutely vital to that governance structure. Because at the end of the day what we’ll be looking for is not only delivering clinical change and new processes to support patients, but this thing has got to be safe. Whatever you’re doing, however you’re changing these processes, it has to be safe. It has to be clinically right for your patients.
Output-Based Solutions
Tom: Right, and whenever I talk to anybody who knows anything about EPRs in the UK or EHRs or EMRs in the US, they always tell me ‘you’ve got to remember that these aren’t just technical projects, they are clinical projects that are supported by IT.’ I think it’s a very important thing, and I’m glad you pointed that out. But talk to me a bit about OBS production now. Why is it necessary during all this?
Dave: Is it necessary? It is just another tool that you use as part of the procurement, but it can also be a great engagement tool as well, because what you are trying to describe – so, just take a step back a bit, what we used to do with suppliers, like most organizations, the NHS used to be very prescriptive about what it wanted. So “I want these 6 widgets that have to look like this and have to be this size and shape,” whatever. An OBS tries to change that a bit, and tries to give a description of what outputs – it’s an output-based specification, so it tries to describe what outputs you want from the new system, rather than how it works. So an example might be, in the old days we might have said, “well we want a letter with this, this, this, and this. It is just printed from Microsoft word from this sort of printer, we might just say well we want an electronic message that carries these characters, you tell us how to do it.” So an OBS is a description of what you want the system to do.
It’s also something, then, that you can, as part of the procurement, you can judge the suppliers response against, because these things are long, they are wordy, and dull, if I’m honest, because it is just lines and lines of questions that you are asking the supplier to describe about various things. But, the other thing about the OBS is that these sometimes are just written in back rooms by the PAS specialist or by the medical record specialist, but if you do it right, you can get everybody involved, so you can get the pharmacists involved, and the docs involved in the prescribing bay. You can get the PAS experts involved in the medical records/clinical appointments bay. So if you bring in the key people, once again you are engaging with the entire organization.
Now this takes some effort, and, you know, one of the things that we’ll have picked a few times in this podcast and in various blogs, is that you will need to have access to people in the organization, and of course, all the people in the organization have got the jobs, very pressured jobs in most cases, so getting that resource signed up to it is not easy, but by doing that, not only are you building an OBS that is right for your organization, you’re also engaging with the people in a very early stage, we’re actually going to have to make this thing work, because at the end of the day, IT people like myself aren’t going to make it work. It’s the clinicians, it’s the admin people, it’s the nurses, and it’s the senior team who is going to make it work at the end of the day. It’s almost one of those necessary evils, because to read it is flat out boring, but to generate it can be a very good engagement and thought process tool.
Existing Paper Records and Data Migration
Tom: Ok, so let's shift gears a bit here, Dave. How do you deal with your existing paper records during your EPR implementation process?
Dave: I think what you need to do is come up with a strategy, and I don’t think there is a single answer to this. So some people, what they’ll do is they’ll put in the EPR, and they’ll gradually phase out their paper records over time. Other people will have already digitized their records, and will look at how you can access that digitized rec ord from the new EPR system you put in, and in that case what you’ll do is you’ll include that in your OBS. So again, you’ll explain what you’ve got, what you’ve done, and you will ask the supplier how they are going to integrate with that from their OBS. I don’t think, in this country, there’s been in secondary care, although this did happen a lot in primary care, I don’t think there has been much appetite to transcribe those records, those old paper records, into the new system, just because: A, the quality they use is quite poor, and B, because it would just be a mammoth project that would take years and years and millions and millions of pounds.
So in some extent, it depends on what you’ve got, it depends on whether you intend to just carry on using your paper records and still say after 2-3 years you just say “that’s it, we’re retiring them now.” Or whether you intend to digitize your record, and access them from the EPR. I think that’s the only two really sensible solutions that I’ve seen, but there maybe others out there, and who am I to say that there isn’t. So again, and to be honest, that goes right back to the first question because that should be part of your strategy.
Tom: Ok, and what are some of the issues that can arise when you are migrating your data?
Dave: Well usually for us in the UK it’s rubbish. A lot of us are using 10-15 year old PAS systems, and that’s what most of our data is. Most of our data is around PAS data and some of the older coms data and stuff like that. Now the problem is, for a lot of us, we might have migrated that data two or three times already from various PAS systems, or combined it from various PAS systems. So you need a strategy for migrating your data, all the tech work is going to be useful, because every extra data item you take will cost you money, and will need to be made sure that it’s ok at the other side of it.
So, do the minimum you need to operate in a clinically safe way once you get to the other side of the EPR. Don’t take stuff you don’t need, and especially, don’t have a brand new shiny EPR and fill it with rubbish data because that won’t work. But there will be some stuff that in the UK you do want to start to take across, you probably want to take across a lot of your clinical correspondence, you’ll want to take a lot of your past meetings across, you’ll probably, in some cases, want to take across pathology results, which again, will likely be on a different system. So again, it does need, if you look at the history of implementations in the UK, there is many a delayed go-live because of data issues. That seems to cause the delays as much as anything else.
Tom: Right, and trash in is trash out, am I right?
Dave: Absolutely, absolutely.
Legacy EPR Involvement
Tom: So when you’re moving on to your new EPR, how involved are you going to be with your legacy EPR. Does it come into play at all? Is it one of those things where once you switch to the new EPR you are pretty much done with it? Do they interact with each other? Or does it basically just phase out?
Dave: So this is one of the most difficult questions for organizations in the UK, and to some extent, it depends on what they’ve already got. So because the American healthcare model isn’t quite the same as the UK’s, and so, our PAS is at the core of everything that we have been doing for the last 15-20 years, and it’s got that information in. Now some of these PAS’s are very old and falling apart, and in some cases, that could be driving the decision to move to an EPR, but in some cases, these PAS’s are quite new, and quite effective, in which case it is worth considering whether you can keep your old PAS functionality and integrate it with the EPR, build the EPR around it, which some organizations have done and been very successful, because the more you try to integrate things that are not quite the same, it just causes you difficulties.
But, at the end of the day, a lot of organizations will find moving to a United States vendor EPR that will find their PAS functionality not quite as good as what they’ve already got, if it is a fairly modern EPR. So that is a consideration. Whatever happens, you will not be taking everything across from your old PAS, so you need to find some way of archiving that data so that it can be got if needed at a future date. But, you know, that can be into your data where I’ll put the viewer on rather than the active PAS, because what you won’t be doing if you are replacing your PAS, you won’t be using that PAS to schedule anything for the future.
Key to Success
Tom: Right, and we’re running out of time here Dave, so I’ll just give you one more question. What would you say is the overall key to getting the required buy-in that is necessary to make a project successful?
Dave: I think the trick is to get your senior people and your clinicians, to actually be telling you that it’s what they want to do. So that’s the real thing, so it’s exposing them, showing them examples of how it works, showing them what you can do and how it will improve patient safety, how it will improve the organization’s status, make it easier to recruit, and then get them excited about it, and get them telling you, “we need this, and we need it tomorrow, come on what are you holding us back for? You need to make this happen!” I think it is flipping it over some so the whole senior team and clinical team, and they’ll always be nervous, and quite rightly they’ll be nervous because there are some bad examples out there. So they’ll always be nervous, and there are risks associated with it, and nobody should underestimate those risks.
But at the end of the day this thing should sell itself, I am firmly of the view that this is the right decision to make for most organizations, so let that organization come to that understanding themselves, make that decision, and then you try and make it happen for them in a way that is best for the organization, best for the patients.
Tom: Alright, perfect Dave, we appreciate your time here today. For more information on EPR, EHR, or EMR readiness, make sure to subscribe to our blog and our podcast, as well as to follow us on social media. Also, make sure to comment below with any questions, concerns, or things that we may have missed, so that we can keep the conversation going.
In addition, we here at HCI would like to thank our listeners for your continued support during the flagship year of our Monday Morning Podcast Series. We will be taking a break for the holidays, but make sure you catch back up with us when we resume airing in January. We have big plans for 2017, and we can’t wait to share them with you as they come to life.
And for Dave Lang, this has been Tom Letro of The HCI Group, wishing you a happy holidays. The HCI Group, offering a smarter approach to healthcare IT.