Epic challenge, Epic optimism

Exactly one month ago, Cambridge University Hospitals NHS Foundation Trust went live with its new electronic patient record system.

To say that the implementation of Epic was closely watched would be an understatement. It was clear from the moment that the trust issued a tender for a £200m eHospital programme that it would be running a marquee NHS IT project.

Then, its decision to award the EPR component to Epic gave the American supplier its first foothold in the UK (HP is providing the infrastructure and mobility component of the project).

In a presentation at EHI Live 2014, the trust acknowledged there had been issues with the go-live, which took place in the early hours of 26 October, while saying the system was “starting to deliver some real benefits”.

Now, though, a report produced by NHS Cambridgeshire and Peterborough Clinical Commissioning Group for the health committee of the local council, has laid bare the scale of the challenges faced by the trust, particularly in the first week.

The report, on “recent pressures in the Cambridge and South Cambridgeshire health system”, indicates these have ranged from a “major incident” that required ambulances to be diverted to different hospitals for five hours to ongoing issues in pathology.

Dr Afzal Chaudhry, the trust’s chief clinical information officer, told EHI he is confident the issues have been largely worked out as the trust moves ahead with the implementation process.

Pathology

Dr Chaudhry says the pathology problems were down to issues with printing specimen label barcodes; inhibiting the ability of the lab to process samples quickly, and requiring staff to work overtime in the week after go-live to keep up with demand.

The Epic system is meant to recognise where a patient and clinician are located within a hospital when a blood or tissue sample is taken, and to direct the specimen label barcode to the nearest printer.

However, Dr Chaudhry says the complexity of the system meant that labels were sometimes not printing to the correct location, causing the problems with labelling samples.

“The systems were working, the analysers were working: the problem was related to the fact that the samples were arriving in the lab with handwritten labels, and it was taking longer than usual to receive them.”

GPs were asked to stop all routine blood tests at short notice to help the trust, although Dr Chaudhry says there was not a significant reduction in the number of samples it received.

He also says the problems are now largely resolved, with more than 500 of the 539 printers now working and the lab turnaround times returning to normal from the start of the second week post- go-live.

District nursing

District nursing referrals have also been an area of concern for the trust, with workflow processes rather than IT issues apparently behind the problems set out in the CCG’s report to the council, which is looking into pressures on the local healthcare system.

In early November, Cambridgeshire Community Services NHS Trust reported concerns to its acute neighbour after receiving only four referrals over a five-day period, when it normally gets 20 referrals per day.

Before the Epic implementation, referrals were completed on paper and then faxed through. While referrals are now completed within the system, Dr Chaudhry says a referral document is still printed out and faxed through as part of a gradual change to ways of working.

However, initially, some nurses did not follow the process, so referrals were being completed in Epic and not sent on. While the issues were being addressed, the trust chose to work on paper instead of through Epic to make sure the referrals were sent through.

Dr Chaudhry says the trust has arranged a daily phone call to ensure referrals are being sent through, and has worked with nurses to reinforce their workflows.

System outage

The most serious issue with the Epic system came on the night of 1 November, when the trust had to switch to a read-only version of the software after it became unstable.

A “major incident” was declared, with ambulances re-routed to different hospitals for five hours while the trust took expert technical advice and worked with its suppliers.

Dr Chaudhry describes the outage as an instance of “transient instability”, and says the declaration of a major incident was made to enable business continuity plans to kick in.

He says the set-up of one of the trust’s servers was responsible for the instability, with “minor configuration changes” needed to bring the full system back online.

Since then, there has been one further brief period of downtime to make a configuration change. Dr Chaudhry says more may be scheduled in the coming months as the trust makes tweaks to respond to workflow problems.

However, he insists there are now no concerns about the system’s stability and functionality. Instead, he says the trust is now moving to working with staff teams on how to optimise workflow.

A programme involving eight different workflows is beings started across the hospital to look at how the system has been configured and what can be done to make it more efficient.

Winning over the staff

Winning the confidence of the trust’s staff is another area of focus. Dr Chaudhry acknowledges there have been concerns about the implementation; with senior clinicians apparently contacting the local paper, the Cambridge News, to voice concerns.

However, he says “the vast majority” of staff are very pleased with the system. “Inevitably with major change, there are people who feel concerned and others who take to it,” he says. “Most people are steadily growing, for lack of a better word, in happiness with the system.”

He mentions one consultant radiologist who initially expressed scepticism about the change. “He says the system’s now fantastic, and he wouldn’t go back to where he was before.

“My feeling is that where are is where we anticipated being and where we should be, given the scale of the change. People have worked really hard, and I’m very grateful to the staff.”

Reviewing the situation

Although Dr Chaudhry is happy with the trust’s progress, he is aware that lessons can and must be learned from what it has gone on during the implementation process.

While he says there is no “formal investigation” into the Epic outage, the trust invited the Care Quality Commission to make a visit and look at how the new system is working.

A local MP has also made a visit, while the trust is holding regular meetings with the CCG to make sure that primary care providers are kept up to date with the system. The trust is also planning to produce a number of reports on the go-live to share with the wider NHS.

Up for review

Dr Chaudhry says an American company involved in a number of Epic implementations has been providing external assurance to the trust board throughout the process, and will produce a preliminary report in December.

The trust is also planning to commission an external review of the entire Epic implementation process “not too far in the future”, with Deloitte mentioned as an example of a potential reviewer.

However, Chaudhry is keen to focus on the positive, and mentions being buoyed by a recent endorsement from an American visitor.

Daniel Barchi, the chief information officer of Yale University, made a visit to Cambridge to speak with IT staff and said the trust was “basically pretty much where I would expect you to be”, he says.

“He said that if we were one of his implementations, he would be comfortable with where we are.” That confidence will be necessary as Cambridge continues its Epic journey.