Cambridge: big bang reality

The words “disaster” “chaos” and “confusion” feature strongly in reactions from staff to Cambridge University Hospitals NHS Foundation Trust’s implementation of a new electronic patient record in 2014.

Unison’s Cambridge Acute Hospitals Branch joint communications officer Carole Proctor found a number of staff willing to answer questions from Digital Health News about the trust’s implementation of Epic 16 months ago.

While most of the clinical and administrative staff that she spoke to say things are much improved and benefits are starting to be realised, Proctor herself describes the period immediately after deployment as “pretty chaotic”.

“Everybody had training, but that couldn’t be used in a real life situation; so it didn’t necessarily cover what we were then faced with when we went live,” she says.

Staff had to come up with work-around solutions and many of these are still in use to this day. “As we’ve gone through, people have got much more used to it and it’s got very much easier to use.

“But, personally, my view is we have been shoe-horned into a system that wasn’t designed for the NHS and the Epic people probably didn’t totally appreciate how the NHS works.”

Big plans, big problems

Cambridge’s strategy, EPR procurement, and subsequent deployment have been some of the most closely watched healthcare IT developments of recent years.

The trust first put together an eHospital programme to support the expansion of the biomedical campus that it shares with research firms, and which is due to house a new hospital for the neighbouring Papworth Hospital NHS Foundation Trust.

In 2010, it issued a massive, £200 million tender for infrastructure and electronic patient record software to replace its iSoft i.Express patient administration system, the contract for which was due to expire in 2014.

Hewlett Packard won the larger, infrastructure and hardware part of the tender while Epic won the EPR element, beating US rivals Cerner and Allscripts to secure its first UK deployment.

The trust signed a contract with Epic in April 2013, and announced that it would take a ‘big bang’ approach to implementation; which duly happened in October 2014.

But one year after the implementation, the trust was put into special measures by Monitor, following a critical CQC inspection that found shortages of staff in key areas, and breaches of key waiting time targets.

In taking this step, Monitor said the eHospital programme had caused "significant cost increases", while benefits had not been realised.

Ahead of the CQC report, the trust’s chief executive, Dr Keith McNeil, and its finance director, Paul James, resigned, saying the trust faced “serious challenges” that included a “growing financial deficit”, estimated to be at least £64 million this financial year.

The financial pressure the trust is now under is well known to staff who believe it is impacting on the development of the EPR.

While Proctor says that Epic staff still see Cambridge as “very much an ongoing development”, one consultant that she spoke to said there is “not enough resource to turn from a useable system to a remarkable system.”

Benefits

Having all patient information held in one place is the benefit of an EPR most often cited by Cambridge staff. “The ease of accessing information is a big plus over the paper records,” Proctor says.

As a specific example, she adds: “If [you were] dealing with an outreach patient in the old system, the notes would be on the ward – and you could be at the other end of the hospital. Now, you can look at everything and so can everybody else. So it’s so much easier to deal with queries.”

However, staff complain that the system is slow and complicated to use. One specialist registrar said the ambulatory care department has had to increase doctor staffing because they cannot work as fast as before the system was in place.

“Ease of use does improve with experience and practice with Epic, but junior doctors rotate every four to six months meaning that the process needs to repeat frequently – and there is only a limited extent to which this experience can accumulate in the first place.”
Another issue raised is the difficulty getting locum staff at short notice, as the pool of those trained on the system is restricted.

Issues

Other staff are struggling with more specific aspects of the software, or with interfacing systems to it. In the weeks following the implementation, there were reports that the trust was having difficulty communicating pathology results to labs and GPs and with sending out district nursing referrals.

Sixteen months on, correspondence remains an issue, with Proctor saying that medical secretaries are struggling with the lack of an effective digital dictation system, even though build technicians have spent many hours on this.

A consultant says the inability to generate a clinic letter by dictating one makes the process much more time-consuming.  The same consultant describes drug prescribing as an “ongoing challenge”, mentioning a particular problem with prescribing the anti-coagulant Warfarin electronically.

However, he also acknowledges that being able to do jobs in real time on a ward round is a plus – and that written documentation, such as the drug chart, is no longer ever missing from ward rounds.

“It is useful to be able to give a treatment and then at a distance monitor the effect of the treatment. So on a Safari Ward Round, you can check on a patient’s vitals from a distance and monitor the patient.”

The big bang and its aftermath

The biggest concern among staff surveyed by Proctor was the big-bang approach taken at go-live. This is the way Epic always deploys its system; following intensive training of key staff and ‘super users’. But at Cambridge, the feeling is that the EPR was implemented before it was fit for use in the UK context.

An administrator explains: “Launch should have been delayed until all areas were working and then properly ‘beta-ed’ by one unit to ensure there would be minimal problems when launched across the trust.

“Staff seem to have been expected just to work with it and wait for issues to resolve. [That is] doable for the administration team, but notfor a nursing team that is already stretched, as any resolution takes too long.”

Proctor feels that the big bang approach was “wrong and dangerous”, while a consultant says an unstaged process was not the way to go, particularly was there were other organisational changes happening at the trust at the same time.

“There was a lot of institutional naivety about what the impact would be and we were not prepared in many ways, for example hardware infrastructure, upskilling of staff and training was inadequate,” the consultant says.

Hope and experience

The trust has always insisted that its investment will pay off; and Epic’s founder, Judy Faulkner, has insisted that it will come to be seen as a UK reference site for the benefits of hospital digitisation.

In an exclusive interview with Digital Health News editor Jon Hoeksma earlier this year, she stressed that it was making much more in-depth use of the software than most trusts make of EPR systems, and that while there had been “bumps” in doing that “as a little time passes, [things] get fixed up.”

Unison’s Cambridge branch secretary Helen Chittock doesn’t necessarily disagree with this, but she emphasises that it is the hard work and dedication of hospital staff that has made sure that patient care has remained excellent throughout the long embedding process.

“People accept that the systems we had before were on their last legs and that change was needed. If Epic can provide everything that it promises, then people are quite positive,” she says. “But it’s still very difficult to see it as this all singing, all dancing system because there are still issues that need resolving.”