From the Heart and Chest

"Is this a poisoned chalice?" is what I asked myself two and a half years ago, when Aaron Cummins (our then finance director at Liverpool Heart and Chest Hospital) asked me to be clinical lead for EPR.

I had been getting more engaged in our hospital’s IT strategy over a number of months as one of the two clinical leads for IT. But up to then the focus had been on revitalising our decrepit hardware estate and re-engaging staff.

I had been to a couple of meetings about this mythical "national solution" and heard that we were going to be given a product called Lorenzo.

I didn’t know a lot about at that stage, but I knew that things were not on schedule or going to plan; hence my question to myself when I was asked to get more involved.

The fact that I am now writing this column tells you that I decided it wasn’t a poisoned chalice that I was being offered.

But becoming clinical lead for EPR was a decision that took me several weeks of careful consideration; and a good amount of assurance about how we were going to progress things before I accepted.

From an EPR to EPRedness

Fast forward to today, and my trust is four months from going live with a comprehensive electronic patient record solution; not Lorenzo, but a product from a US vendor (Allscripts).

While it wasn’t a poisoned chalice that I was handed, it was a programme far larger than I had ever imagined. I truly didn’t know then what I was taking on.

This brings me on to: what is an EPR? If you are reading this article, then I assume you have some idea, but I bet you that what you think an EPR is won’t be what the next person reading this article thinks it is.

One of the things that I did early on in my time as clinical lead for EPR was to go out and visit other sites, both here the UK and in the US, to see what an EPR looked like.

I was naive enough to ask simple questions like "what are those notes doing here if you have an EPR?" – which was my introduction to the idea that an organisation doesn’t need to be paperless – or even paper-lite – to have something that it can call an EPR.

The truth is that, as an organisation, you don’t have “an EPR”, but instead a degree of “EPRedness”. This can be measured using the framework provided by the US organisation HIMSS, ranging from stage 0 where nothing is installed to stage 7 where one has closed loop systems and full clinical decision support.

HIMSS seven levels; try not to hit a dead-end

The drawback to HIMSS scoring system is two-fold. First, organisations don’t necessarily evolve an EPR in the suggested sequence.

My trust had had a digital picture archiving and communications system for several years (which comes in at stage 5 on the HIMSS model). But it has made limited inroads into electronic direct care documentation (which begins to feature at stage 2).

More importantly, perhaps, the 7 stages give the impression of a natural progression. The reality is that to deliver stages 6 and 7, an organisation needs a limited suite of highly integrated systems – with the wrong architecture, you can end up in a dead end.

This isn’t a criticism of the HIMSS system (which I happen to regard as a helpful external validation), but more of the fuzzy thinking that I have seen around EPR adoption over the past two and a bit years.

Thinking beyond the “IT project”

Having an EPR or an EPR programme is seen as an end in itself, and it isn’t. What I and the rest of my trust’s team are doing is delivering change that will improve care for our patients, processes for our staff, and efficiency for our organisation.

The fact that it is electronic is secondary. I don’t want to be measured by how electronic we are, but instead by how much improvement we have delivered. The fact that that improvement comes in the guise of “IT enabled healthcare” is a logical choice – a reflection of the times and nothing more.

Returning then to where we are now, there is a lot done but a lot still to do. The relative underinvestment in healthcare IT for several years has, paradoxically, put us in a good position.

We were not starting from a blank canvas, but there was relatively little paint on it to either scrape off, paint over, or incorporate into the picture that we are painting.

I don’t regret our decision to simultaneously deploy clinical documentation, replace our existing e-prescribing system with the integrated Allscripts one, develop full order entry and results reporting (to replace paper based ordering and fragmented electronic results reporting) and deploy an electronic document management system (to manage our back-file and the limited forward paper scanning requirements).

However, it has been a gargantuan task. There are a huge number of work streams for the team to simultaneously manage, and I am very proud of work that they do.

Stand and deliver

So, the big question now is will we deliver on time – a near unheard of feat for an NHS “IT project”? Only time will tell.

But if we do I would like to feel that the fact that we have approached this as a project to improve patient care rather than as an “IT project” will have played no small part in our success. I can at least take solace in the fact that my hair is already grey…

Dr Johan Waktare

Dr Johan Waktare is a consultant cardiac electrophysiologist at Liverpool Heart and Chest Hospital, specialising in interventional procedures for heart rhythm disorders. He is the clinical lead on the trust’s electronic patient record project, as well as being a clinical lead for IT and the trust’s Caldicott Guardian.

A self-confessed IT geek, Dr Waktare has always been interested in computer hardware and software. His status was cemented when, several years ago, the IT helpdesk agreed to replace a user’s PC rather than look at it – after hearing that he had failed to repair it.