30th May 2008
I am leading a major process change initiative (named the eRecord Programme) at one of the biggest foundation Trusts in the UK. This programme encompasses the development of a strategy for the long term future state of clinical informatics support. Our main aim is to enable better healthcare outcomes for the people of our region and to improve on the experience of patients and staff as they journey through the healthcare system.
In this role I am often asked about the significance of press articles that question the quality of the computer applications being implemented in the “Connecting for Health” NHS initiative and I sometimes despair that, as we come close to the end of the first decade of the 21st century, so many people seem to think that it is the computer applications (electronic information systems) that will make a difference in their organisations, rather than the fundamental changes in process that are enabled by access to the right information, at the right time and in the right place.
Computerised applications are simply tools, they never, ever, in and of themselves, provide a return on investment and anyone who thinks that they will is destined for disappointment. The same sort of disappointment that will occur if one thinks that anywhere in healthcare there is a one-size-fits-all suite of products that will support all of their healthcare information management challenges.
For those that are interested this is an overview of the work that I am currently engaged in:
Why an eRecord?
In 1999 and 2003 two publications were released by the US Institute of medicine, they highlighted a shocking level of misadventure that resulted ultimately in untimely deaths in that country.
While there are no formal studies on the same scale in the UK it is generally accepted that the causes of adverse events in healthcare are effectively the same. Some of them are:
- poorly defined processes that either encourage bad behaviour, or fail to encourage good behaviour;
- ineffective communication, collaboration and inclusion across the healthcare sector; and
- paucity of reliable information at the right time, in the right place and for the right people to support effective decision making.
Further it is widely recognised that healthcare outcomes improve if duplication is reduced, information is shared effectively, and processes are standardised, measurable and understood by participants in those processes. When these things are achieved all stakeholders can, through analysis, monitoring, and identifying trends, improve their own performance or that within their domain of control.
The core of the eRecord programme that i am leading is to ensure that we know what the patients within our Trust have experienced or are experiencing on a real-time basis. What treatment have they received, who has or is providing it, and how they responded to interventions.
To do this we must ensure that the recording of information is a key part of the care process and that this occurs as and when that facts become known or change.
Our programme of change will be supported through implementation of a software application supplied by a large US based company although, in the same way that a Vauxhall will get you from A to B as effectively as a Rolls Royce, it could as easliy have been supported by any number of applications in the marketplace with a shorter or longer list of “features”. This tool will provide all users with a vehicle to access demographic information about Trust patients, the results of tests performed for Trust patients, the attendances that Trust patients have had, and their current location if they are an inpatient. It will also enable users to order clinical tests consistently, quickly and simply for Trust patients and to record who is responsible for our patients at any specific time.
The programme will also be supported through our partnership with a large US healthcare system who have completed a significant amount of work in this area before, through the support of our IM&T Department, and through the support of the Trust’s training and communication team in Human Resources.
There are two key parts to the programme, the delivery of an Electronic Patient Record for the Trust that will:
- support processes in all Inpatient, Outpatient, and Day Patient areas
- provide a definitive source of data regarding the location of the patient and their demographics
- support work order processing and results reporting for clinicians and enable access to this information ubiquitously
- support improved medicines management through standardised prescribing, dispensing, and administration processes
- support better utilisation and scheduling of theatres
- support improved emergency and trauma management processes and the processes of admitting patients to the hospitals
The second part of the programme will involve automating the capture of outputs from various electronic diagnostic devices (such as EEG, ECG, and Lung function equipment) so that they can be linked to the patient record electronically and the task of ensuring that the large number of systems that support specialist care within our Trust are effectively integrated with our core source of demographic information or replaced with something that meets the users’ needs and is integrated.
We also know that we will want some visibility of information that is kept by healthcare providers and allied health providers who are affiliated with, but not under the authority of, our Trust.
Carers need this complete view, and our first steps of capturing and recording information about major care events that happen across all of our Trust operations is a cornerstone of delivering it.
The computer application tool that we are putting in place will provide the authoritative source of data for Trust information about our patients’ demographics, encounters in the Trust, tests and results, medicines, procedures, allergies, and alerts.
The next step for us is to incorporate, for clinical staff providing care, a view of clinical information that is stored in specialist clinical systems, examples of this type of clinical information include mole maps maintained by dermatologists, growth charts maintained by paediatricians, and birthing records maintained by midwives. In the longer term the clinical history of the patient when they have not been under the care of our Trust must also be available through such a view so that information essential to providing high quality healthcare can be seen by authorised carers.
All of this can technically be made accessible and presented via a single interface to the core Trust patient record. However there are a number of challenges as we move toward the target.
The first and most significant of the challenges we face is the realisation that we cannot replace all clinical applications with a single solution. Not only are there no solution packages that cater for every specialty but there are very human issues of proprietorship which ultimately impact buy-in and support for collaborative strategies.
We must recognise the need for authoritative sources of patient demographic information and clinical history; and that these authoritative sources, to deliver benefit, must be integrated rather than “owned” or controlled. When this occurs we will be committed to a strategy of integration rather than replacement in most cases.
Integration of patient demographics held in all systems is essential, currently this information can be updated and out of synch across literally dozens of systems within our own Trust. This situation makes it almost impossible to tie-together patient information and to present a single view of that information. A program of work has begun to identify how this integration will occur, how data will be cleaned up, and to obtain the resources and tools that will be needed.
The second key tool in developing a holistic view of patient information is one that will enable a federated view of information held in systems that are not either managed centrally or even run within the Trust at all. Our partners use a product designed specifically to achieve this and this tool, or something like it, will become a key part of our kit to develop the right information to our clinicians, at the right time and in the right place.
Progress will be discernable through the achievement of critical success factors. These include enabling co-existence and managed transition from the old state to the new; and maintaining a balance that ensures the ownership and commitment of stakeholders to the outcome. The challenges inherent in both will rely on our ability to deploy the right tools, to engage and communicate effectively with stakeholders and to define a well supported path to success.
Not a destination…
This programme of work is a journey, it is not a destination that will be reached within 3, 4 or even 5 years. The development of tools that enable delivery of information to clinicians; that support decision making of the most complex and critical nature will be ongoing, as information becomes ever more plentiful, the challenges of filtering and presenting it sensible and meaningfully continue to increase.