Bringing up baby

Not a single trolley overloaded with paper notes can be seen on the wards run by Liverpool Heart and Chest Hospital NHS Foundation Trust; the first sign that its Allscripts electronic patient record system has been embraced by its users.

The trust, which went live with the system in June this year, went from paper heavy to nearly paperless in a matter of days: something that has definitely has put its mark on the hospital.

Johan Waktare, the trust’s clinical lead for EPR, and an EHI columnist says: “I’m not going to pretend that everybody is using it optimally, but as a whole people are using it.

“People do see the benefit, even if there are always some who focus more on what’s still missing than what they got. Even the resisters are becoming positive.”

Throwing darts

Waktare was keen for EHI to come and see what the trust has achieved, because he has strong views on what should count as an ‘EPR exemplar.’

He has some concerns about the incremental, ‘best of breed’ approach, because of the underlying integration issues, and argues that his trust shows what can be done by running a big, well thought through programme with a single supplier.

Liverpool Heart and Chest certainly scores remarkably highly on EHI’s newly developed Clinical Data Maturity Index, which models the presence of nine administrative and clinical systems across nine levels of increasing complexity.

It is one of just three trusts in the country that the CDMI records as having all the systems in place. However, there is still a lot of work to be done as what Waktare calls its “baby EPR” grows. As he says: “Rome wasn’t built in a day.”

On the other hand, he definitely wants Rome built. In fact, he challenges the IT team to make improvements and changes so regularly that a picture of his face has been posted on a dartboard in the EPR programme office.

“My job is to push and their job is to be realistic,” he says cheerfully. The EPR team, incidentally, is led by his wife, Lyndsey Waktare, who is the trust’s EPR clinical and business change manager.

She certainly takes a pragmatic approach to the job in hand. “For me, it’s about continuing to work with the users and to get the organisation as IT enabled as we can,” she says. “I’m not sure we’ll ever be fully paperless. I don’t think we will ever take away the doctors’ notebooks and the nurses’ handover sheets.”

Two years in the planning

Liverpool Heart and Chest spent a long time preparing for its go live. When it decided to award a contract to Allscripts Healthcare in April 2012, it was the first trust in the country to do so; having been impressed by the company’s work with the Mayo Clinic in the US.

At the time, the board realised that it would take two years to get ready for the implementation, which saw the trust retain its patient administration system – iSoft iCS – but add clinical modules from the US company.

June’s go-live saw it switch on order communications, test results, clinical documentation, nursing observations, nursing documentation, patient flow, a new e-prescribing system, and electronic document management; to mention just the main EPR functionalities.

It has been a big undertaking by the IT department, which has massively improved its reputation within the trust in the process.

“We used to have an IT department with a horrendous reputation. If someone phoned up for support, they would be told to turn their computer on and off again,” says Lyndsey Waktare.

“We have made massive movements forward and I’m really proud of it. I know it’s not perfect but we’re committed to continuing to work with the end user. The system isn’t singing and dancing yet, but it will be eventually.”

Nursing obs can be a right CoW

On the Maple Suite ward, nurse Paula Cromby is busy looking up a patient’s notes on one of the many Computers on Wheels spread around the ward.

“It’s brilliant,” she says. “It’s much easier to find things such as blood results, and saves us notes going missing or being put in the wrong place.”

However, she admits that not everyone is as keen.“Some of the nurses find it a bit difficult. But it’s about getting used to it. It’s navigating around the system and finding out how to do things and educating ourselves.”

The biggest remaining problem, she feels, is nursing observations. These are done electronically on a monitor that sits on top of the CoW, but this makes the CoW difficult to navigate around the ward.

In addition, the observations do not sync automatically with the system, and have to be entered into the Allscripts EPR manually.

“We want to transfer the obs straight into the EPR – it would be great if we didn’t have to do that,” says Cromby, making an obvious hint to Johan Waktare, who is sure that this can be done very soon.

Back in the EPR programme office, Lyndsey Waktare says she is aware of what clinicians want, but that her team cannot do it all at once, and must prioritise.

“We know it’s clunky,” she says of nursing observations specifically. “We would like bi-directional observation machines where you can import information back into the system. But we have to look at our resources and priorities.”

Changing the nature of work

Another priority is to make ECGs electronic. As a specialist hospital, the trust does a huge number of ECGs every day, but for the time being, this are being scanned into the EPR by the nursing staff.

“It’s a massive impact on the scanning bureau and on the nurses,” she says, as a nurse walks past with an ECG printout in her hand, looking for the right label to put on it.

“It’s adding a good few minutes, and that’s if I can find the label right away,” says the nurse. “When we have a lot of ECGs that has an impact on how much time we can spend with the patient.”

Meanwhile, some parts of the hospital need to be brought up to speed. At go-live, staff in the critical care unit did not feel comfortable with using electronic observation charts and went back to working on paper.

“It was felt by some of the senior critical care staff that it was too much to deal with. They felt it was unsafe so we got them back on paper for now.

“We are working with them to get them back on the electronic system in a way they feel comfortable and they have gained a lot more confidence,” Lyndsey Waktare says.

Johan Waktare argues that when issues like this have arisen, they have arisen from the need to change working patterns rather than from problems with the technology.

“People asked us to do a lot of stuff the way they were doing them on paper,” he says. “They didn’t always understand that you can work differently with technology.”

Many iterations planned

Still, he reiterates, now the go-live has happened more staff want more electronic working than otherwise. The first round of additional changes will happen in December, when a service update and optimisation is planned that will address issues that either were not dealt with before go-live or that have arisen since.

“Everyone wants something doing and everyone thinks their piece of work is the most important. We are already planning things that will fit into the second, third and fourth change process,” says Lyndsey Waktare.

The EPR team believes that everything that is done should improve clinical workflows and make sure that they become more IT enabled.

But it also recognises that this needs to be done without inflicting too much change on users. “We pushed the organisation to the brink with the amount of change we can put in at once,” says Lyndsey Waktare. “We still haven’t got it 100% right, but we will never stop improving it.”