Highland Marketing advisory board: EPR debate

Digitising hospitals was the focus of NHS IT policy for twenty years. The job is still unfinished: so what are the options for trusts – and the integrated care systems that are planned to take over health tech strategy and funding next April? The Highland Marketing advisory board asked three leading chief information officers for their views.

Covid-19 and the latest reforms of the NHS have focused attention on health tech to an unusual degree. The first few months of the pandemic saw a rapid roll-out of remote working, virtual clinics and digital-first primary care and triggered a lively political and media debate about their future role in healthcare.

Meanwhile, the health tech market has been focused on integrated care systems and the shared care records, data platforms, and apps they will need to join-up services, introduce population health management, and create a new ‘offer’ for places and citizens.

In the middle of all this, the digitisation of hospitals seems to be in danger of being overlooked. Which is odd, because for 20-years it was the focus of NHS IT policy, and it is still far from complete.

In comments to the HETT show at Olympia, reported by the Health Service Journal, NHSX chief executive Matthew Gould around 10% of trusts remain “largely paper-based” while there are “a whole lot more that are only semi-digitised.”

With the global digital exemplar programme wound down, the Unified Tech Fund planning to allocate the last of Jeremy Hunt’s tech money by March, and ICSs due to take over IT strategy and funding in April, it doesn’t look like there’s a central strategy to improve things.

Yet, as the ‘What Good Looks Like’ document for ICSs acknowledges, there is a need to ‘level up’ trust electronic patient record provision, if hospitals are to work efficiently, support their staff, and feed into those shared care record and data platforms.

So, the Highland Marketing advisory board asked three leading chief information officers what their trusts are doing, to inform a debate about the challenges and opportunities ahead.

Big box? Best of breed? Ecosystem? Or new thinking?

Adrian Byrne, the chief information officer of University Hospitals of Southampton NHS Foundation Trust, started by challenging some of the terminology that is used around hospital systems.

Traditionally, he noted, people have contrasted ‘big box’ or single supplier with ‘best of breed’ models for rolling out EPR functionality, such as patient administration, order comms, e-prescribing and, more recently, e-noting and e-observations. But this may be unhelpful and outdated.

Unhelpful, because even the biggest of ‘big box’ EPRs don’t do everything, so trusts are going to have to integrate them with other systems at some point; and the real question may be how much integration they want to handle.

“There seems to be an idea that it’s ‘go with one of the big boys’ or ‘let chaos reign’, but I don’t subscribe to that,” Byrne said. “We are said to have a best of breed approach, but we want to integrate where we can and get down to as few systems as possible.”

Outdated, because most of the current discussion about EPRs is focused on how they are evolving into platforms that can collect and then flow data into different systems, including patient-facing apps.

“I spoke to Will Smart [the former CIO of NHS England, who now works for Dedalus] a couple of weeks ago,” Byrne said, “and he didn’t want to talk about EPRs anymore. He wanted to talk about platform, flowing data, and patients: and I think that’s right.”  (Highland Marketing also spoke to Will recently, and there’s more on his views here).

Hospital IT is like an onion…  

In practice, the basic distinction is well understood. Martin Sadler, the chief information officer at Sandwell and West Birmingham NHS Trust, said his organisation “put in an EPR 18-months ago” and “it has given us a platform to say: ‘this is what we have done to the patient’ and ‘this is where they are in our system’.”

Whereas Neil Perry, director of digital transformation at Dartford and Gravesham NHS Trust, said that in 2017, when his organisation refreshed its IT strategy, it first “decided what it wanted to do” and then decided that “best of breed was the way to get there, fastest.”

Since then, his trust has adopted a modern approach to integrating data from its different systems and re-exporting it to apps that ‘fill gaps’ in its EPR functionality, working with an open platform from Alcidion.

However, there was agreement between presenters and advisory board members that an EPR, however, developed, is not enough.

Sadler said that while his trust had deployed Cerner Millennium, this was not the end of its IT strategy. Perry showed a slide that set out his strategy as an ‘onion’ with core functionality at its centre, and open, innovative systems for e-prescribing, analysis, and remote patient monitoring in the outer layers.

“An EPR is important, but to my mind, in our onion, it will be doing the core stuff and around the edge will be all the really exciting stuff: and that’s more or less what Will says,” he said.

Options, pros and cons

Bearing this in mind, the presenters and advisory board members felt there were pros and cons to the two approaches that less mature trusts will need to consider. A single supplier approach can get trusts a long way fast: one vendor pitches its system as “HIMSS 4/5 out of the box.”

There is a perception that this makes ‘big box’ the preferred option for NHS England, which picked a lot of single supplier trusts for the GDE programme, and NHSX, which has structured the digital aspirant funding and the UTF around a PAS plus EPR modules approach.

It’s also understood by boards. Neil Perry said one of his challenges was getting new leaders to understand his strategy. “You get the board asking why we don’t have an EPR, or why we don’t go and buy Cerner or Epic,” he said. “Regulators can also be a challenge.”

On the other hand, a single supplier approach is expensive. Sadler said his trust chose to retain its patient administration system and running Cerner Millennium still costs half his IT budget.

There is also a danger of trusts deploying their ‘out of the box’ EPR functionality and getting stuck at its level. The GDE programme was set up to take trusts in this position to the top of the HIMSS EMRAM maturity model and to create a ‘blueprint’ for others to follow.

It worked for the trusts involved; but many of Gould’s “semi-digitised” hospitals will be running systems they got around the time of the National Programme for IT, with a bit of e-prescribing and e-observations, for which there has been national money.

So, perhaps the biggest argument for ‘best of breed’ these days is that it can encourage innovation. Perry said that as part of its 2017 strategy reset, his trust decided that “we didn’t just want to be an early adopter, we wanted to be right on the left-hand side of the adoption curve, in the red zone, working with start-ups and innovators.”

Byrne’s team has developed its own technology, including the My Medical Record personal health record that is being quite widely adopted, particularly for prostate cancer follow-up (the Highland Marketing advisory board has been following the progress of MyMR, and there’s more information here).  

Challenges and opportunities

Parking the current lack of national focus, why haven’t more trusts made similar progress? Board-level support and funding are definitely issues. Sadler said that in his previous CIO role, at young fashion website Missguided, his IT budget was 22% of turnover. The three presenters estimated their budgets at 2-4% and said they needed 6-10%.

But it’s not just money. Cindy Fedell, a former NHS CIO who now works in Ontario, said people were also an issue. “You need a good CIO, who can understand strategy and understand their options,” she said; arguing that more should be done to support professionalism and certification initiatives.

Then, there’s local politics. James Norman, another former NHS CIO who now works for Dell Technologies, said when it comes to collaboration across a health economy, two of the potential reasons trusts go out to tender are that they’ve been formed in a merger, and it’s easier to pick a “compromise” system than it is to get people to work with each other’s IT, or they want to be on a different system to their neighbour/s to stop a merger happening.

Although Sadler said he’d have been happy to use a neighbour’s technology; if they weren’t trying to charge so much that it wasn’t an option. “All of that needs to stop,” Norman argued. “We should be working together as one NHS and sharing ideas and skills and systems.”

ICSs: a chance to level up to where the best are now, not where the GDEs were five years ago?

In the absence of a national strategy, one of the questions for the future is going to be how integrated care systems approach the job of drawing up IT strategies for their trusts and patches.  

Byrne argued there is a danger that some could be tempted to bring in management consultants who will advise buying a new kind of ‘big box’ – a single EPR for trusts, with a health information exchange / analytics package / patient portal attached.

Which, he argued, was likely to be a bad idea because it would mean swapping out one v1.0 system for another v1.0 system. As an alternative, he outlined a three-pronged approach.

First, a proper evaluation of the level of digital maturity that trusts have achieved for the money they have spent, to identify best-practice and where best to allocate ‘levelling up’ funds.

Second, ICS or ICP-led, system-wide procurements in areas where these make sense: pathology, imaging, areas like maternity that are not covered by EPR functionality and have a strong patient component. And third, system-wide integration of existing IT, so organisations can exchange messages with each other and with patient facing technology.

“I think it has to be an evolutionary approach,” he said. “If people have some digital maturity, they should keep going, and keep thinking about how to build on those foundations. And it has to be clinically-led.”

Nicola Haywood-Alexander, the CIO for the Lincolnshire integrated care system, said she was hoping to develop a strategy around this kind of idea. “I want to build up an architecture across the ICS,” she said. “Instead of asking: ‘does this hospital need an EPR’ I want to ask: ‘what do we need across the system?’

“That way, we can use investment to support new kinds of thinking. A lot of work that is done in hospital at the moment is going to be done in the community or homes in the future. So, we need to look at what works in hospital and ask how we can get it into the community or homes.

“Then, with a bit of luck, we can get the aspirants to where the best people are now, and not where the GDEs were five-years ago.”