Can a big stick deliver EPR success?

The NHS Commissioning Board is drawing up plans to compel trusts to deliver data flows to support quality and transparency; data flows that can only be achieved with electronic records.

In short, it looks as if the NHS CB is returning to the same ground on which the Public Accounts Committee and National Audit Office found the National Programme for IT in the NHS to have comprehensively failed; integrated electronic patient records.

EPRs to directly support the delivery of complex, multi-disciplinary clinical care across different providers; to deliver more data to planners and regulators; and to open up the potential for activated, empowered patients.

Hospital EPRs proved to be the rock on which NPfIT grounded, never to float again. The biggest, most high profile part of the programme was always the local service provider approach to delivering ‘strategic’ EPR systems to trusts.

And it was the part that most signally failed to deliver, even if some trusts in London and the South received Cerner Millennium and a smaller handful in the North, Midlands and East are finally getting Lorenzo.

Yet hospital EPRs remain essential to deliver any of the digital ambitions of the NHS CB.

There is also an ominous sense of déjà vu about the eye-watering deadlines that are now being floated for this to happen. When NPfIT was set up in 2002, it was supposed to be complete within a decade. Now, the NHS CB is talking about significant progress by April 2014 and completion a year later.

Carrots in the US

Rapid progress on EPRs is possible, given the right support and incentives. The US experience of the past few years is that a rapid uptake can be achieved.

The Health Information for Technology for Economic and Clinical Health Act, better known as HITECH, and its related ‘meaningful use’ and ‘accountable care organisation’ initiatives seen the adoption and use of EPRs by hospitals and primary care doctors surge.

But even HITECH programme is being run over five years, and first involved two years of planning, consultation and preparation. In addition, before resorting to the threat of sticks, it is providing $36 billion of investment.

Unfortunately, there is no immediate prospect of new money to make EPR adoption happen in England. Instead, with the billions of NPfIT money spent on systems integrators, consultants and lawyers – or returned to Treasury – a regime of penalties is now being devised.

EHealth Insider understands that the guidance the NHS Commissioning Board is considering for publication in June will be tough, and that there could be penalties for trusts that fail to get EPRs in place that, in the words of one source, will only need to be imposed once or twice.

A lost decade in England

But can the threat of a big stick succeed where giant waggon loads of carrots failed over past decade?

The details of the NHS CB’s new EPR scheme are not expected until June, so there is still time to make sure that the hard-won lessons of NPfIT are not ignored. However, there appears to be real danger that this is exactly what will happen.

The first NPfIT lesson is that time invested locally in building consensus, agreeing common objectives, and learning and spreading lessons from what has gone before is essential.

So before the NHS embarks on a headlong, NHS CB-driven dash to EPR, it would do well to first take stock of why its progress on EPRs has been so painful, patchy and slow.

Over the past decade, most NHS hospitals in England have made little progress beyond PAS and PAS+ replacements, perhaps alongside a few departmental deployments, and in some cases a portal to knit them together.

On progressing clinically rich EPRs, NPfIT was a lost decade.

Few English hospital trusts have advanced e-prescribing; fewer still have sophisticated clinical noting; and only a handful have advanced clinical decision support, complex resource scheduling, or integrated care pathway planning.

Not one is paperless.

Sticks at the ready

The skill, expertise and experience required to plan, implement and gain the promised benefits of EPRs and advanced clinical software remains decidedly patchy across the NHS and supplier industry.

Only a small number of individuals have experience running big successful service transformation projects, involving an EPR.

Too many NHS trusts and their suppliers still fail to learn the lessons of why others have run into problems, thinking that they must somehow be different. They aren’t; as our recent news about the experience of the Royal Berkshire NHS Foundation Trust shows all too clearly.

The most alarming strain of thinking coming out of the NHS CB is not the clarion call for sudden action, but the idea that it can somehow reinvent the laws of gravity, and that recent history doesn’t apply.

There’s more than a grain of truth in the adage, ‘those who don’t learn the lessons of history are destined to repeat them’.

Rocks on too many roads

Another key requirement for success is to have a direct partnership relationship with suppliers with a proven record of delivery, able to adapt over time. You need a partner you can count on when the going gets tough, as it invariably does.

Unfortunately, many NHS trusts are still almost as likely to be plunged into a financial crisis by implementing an EPR as they are likely to be able to deliver improved patient care.

The costs and disruption caused by an EPR project that goes badly wrong can be crippling, as Royal Berkshire is currently experiencing, and as trusts as diverse as Morecambe Bay, North Bristol, Royal Free, Guys and St Thomas’ and Milton Keynes have found over time.

Even when they go well, EPR implementations almost invariably take more time, money and effort than initially planned. The go-live on a ward – or even across an entire hospital campus – is usually just the first step.

Time to learn the lessons of history

So as the NHS CB gets ready to fire the starting gun on what promises to be a helter skelter dash to EPRs, the community that will have to deliver – NHS IT professionals, clinicians, managers and suppliers, plus academics and policy wonks – would be well served to spend the next couple of months distilling and sharing the hard won lessons of how to get it right.