Lorenzo: the end of the beginning

Peruse the board papers of Norfolk and Suffolk NHS Foundation Trust and it soon becomes clear that it’s been a rough year on the IT front.

The trust deployed CSC’s Lorenzo as its electronic patient record on 20 May last year. It was hoped the new system would turbocharge Norfolk and Suffolk into the digital age, replacing paper and ageing, clunky software with a slick, adaptive platform. It hasn’t quite worked out that way, at least not yet.

In October last year, the Care Quality Commission warned the trust it needed to get Lorenzo in order, but as recently as June the trust’s board was still being told “performance issues” with the EPR were an “outstanding risk”.

Board papers reveal that 554 incidents relating to Lorenzo were reported on Datix between go-live and May 2016. Many of these issues were local; but others related to national “outages” that affected all trusts using Lorenzo.

Between November last year and April there were 11 such outages, and CSC, at least initially, struggled to get to the bottom of them. “Although reliability has improved, system outages have not been eliminated,” the board papers note. “Key actions are outside the control of NSFT [the trust] and so [there is] no timescale for remedy.”

It all started with the National Programme for IT

After Accenture quit the National Programme for IT in the NHS back in 2006, CSC became the sole local service provider for the North, Midlands and East of England – three fifths of the NHS.

It was due to roll-out Lorenzo to healthcare communities across these regions, but ran into repeated development delays and deployment issues. Eventually, CSC bought iSoft, which had developed Lorenzo, and with it a suite of older patient administration and clinical systems.

CSC offered these systems – primarily iPM, iCM, and the theatre system Ormis – to trusts as ‘interim’ solutions.  And, despite their age, they have proved popular. Offered a chance to tender for alternatives as their national contracts ran out, most trusts chose to stick with them.

Figures released to Digital Health News last week showed that of the 782 systems deployed across 223 organisations under the NPfIT in the NME, 64 % were being retained under new local contracts.

However, the number of trusts deploying Lorenzo remained small and mostly confined to ‘exemplars’ like University Hospitals of Morecambe Bay NHS Foundation Trust, which exerted a huge effort to make Lorenzo work.

In response, the Department of Health and CSC negotiated a contract reset in 2012 that removed the company’s right to be the sole supplier of systems to the NME, while making central money available to trusts that still wanted to adopt Lorenzo.

The Health and Social Care Information Centre confirmed last week that 11 trusts took up the offer; with a further four still in the pipeline.

Lorenzo in a post-NPfIT world

With the national programme drawing to what is more or less its final close, Digital Health News undertook a review of board papers for those 11 trusts.

Of these, eight have publicly disclosed performance issues. In addition to Norfolk and Suffolk, they are Derby Teaching Hospitals, Barnsley Hospital, Sheffield Teaching Hospitals, Warrington and Halton Hospital and Tameside Hospital NHS foundation trusts, and the Walsall Healthcare and Hull and East Yorkshire Hospitals NHS trusts.

The remaining trusts were Ipswich Hospital, George Eliot Hospital NHS trusts and South Warwickshire NHS Foundation Trust.

Some of the problems were minor, and many have been resolved as the system has been given time to bed in.

But others have persisted for months and disrupted patient care. The deployment of Lorenzo has been blamed for duplicating patient records, losing patient records, not registering when patients have had surgery, booking in the wrong patients for surgery, and causing problems with booking and scheduling more generally.

Two trusts have reported problems with VTE assessments not being recorded on Lorenzo. An audit at Hull and East Yorkshire Hospitals NHS Trust, reported in its May board papers, found that of 25 VTE assessments, six were never recorded on Lorenzo.

Warrington and Halton Hospitals NHS Foundation Trust reported similar issues earlier this year, informing its board that “relevant reports are not yet available and the data capture systems require refinement”. CSC says it is aware of this problem and working to resolve it.

At least two trusts have also reported problems linking child protection plans into Lorenzo. CSC says the system should not be used for accessing the plans until an upgrade in October and that trusts should know this.

The cost of change

Despite the central funding incentives to take Lorenzo, several trusts have found that fixing deployment issues have eaten into their finances.

A report to Sheffield Teaching Hospitals NHS Foundation Trust, written in February, said fixing Lorenzo performance issues was a “critical” to improving the trusts declining financial position.

In April, Warrington and Halton Hospitals NHS Foundation Trust said £2.4 million of “costs associated with Lorenzo” were the biggest single contributor to a blow-out in pay cost in the first 11 months of the 2015-16 financial year.

That was then and this is now

Only four of the 11 trusts responded to requests for comment on the issues raised in their board papers, and they were mostly more upbeat than they were in those reports.

In a statement, Norfolk and Suffolk – the trust that reported to its board in May that “Lorenzo poor performance” had had “negative impact on quality, staff morale, system confidence and finance” – said the EPR had actually led to “£1.4 million of benefits to date, mostly made up of efficiency gains.”

While there were still “some general performance issues” with the system, national outages had been fixed and the EPR was helping “patient safety by removing the previous fragmentation of the health record”.

In a statement this week, Sheffield Teaching Hospitals said there were some “initial issues with data inputting but the majority of these are now resolved” and it was “already seeing benefits, including patient flow processes thanks to an increase in real-time data collection for inpatients.”

Ipswich Hospital said in a statement that while there had been some early issues related to the trust’s "initial migration strategy" these were resolved soon after the system went live in February 2014. 

More than two years down the track, it added, Lorenzo is working well and Ipswich is looking to roll it out more widely, adding theatres, e-prescribing, and clinical notation. "The trust has found the infrastructure and system performance of Lorenzo significantly improved over its legacy environments."

“People moan about it but it does have benefit”

Mark Norwood, associate director of IM&T at Derby Teaching Hospitals NHS Foundation Trust, says there were some big data migration problems when the trust switched to a Lorenzo patient administration system in 2014, but these were “partly self-inflicted, partly because CSC was still learning.”

The trust was unable to report referral to treatment times for three months and staff had to untangle thousands of patient pathways. However, these problems had long since been resolved and Norwood says they are typical of any big bang deployment.”

“People moan about it, but it does have benefit and we are starting to see some more positive views of Lorenzo,” he says. Norwood adds that the trust also plans to transition some of its clinical system to Lorenzo later this year.

CSC’s vice president for the UK and Ireland, Philippe Houssiau, points to this kind of confidence when asked about Lorenzo’s reliability.

None of these trusts are buying, or getting funding for, a multi-million-dollar piece of IT kit without a robust business case, he points out.

At the same time, it’s not just trusts that received ‘interim’ systems from CSC that are sticking with them. University Hospitals of Morecambe Bay, the first trust to deploy Lorenzo in 2010, this month signed up for another five years.

In addition, some trusts outside the NME have opted for the system, with Salisbury NHS Foundation Trust planning to go-live in October. CSC is even planning to launch Lorenzo in Australia and New Zealand. 

“Lorenzo is deployed in some of the most prestigious trusts, and they did not make this choice based on face value,” Houssiau argues. “They are all engaged with trusts that are already using the system.”

“It requires a lot of stress and a lot of engagement”

Asked about issues that appear common to the 11 trusts whose board papers were reviewed, Houssiau acknowledges there have been some national outages, but says these have been resolved.

He also argues that many of the problems reported in the board papers were normal for an “absolutely massive” shift not just in IT but in how staff work with these systems.

“As with any new system deployment, it requires a lot of lot of stress and a lot of engagement. Some trusts are in a better position to deal with this level of change than others.”

While this is true, the demands put on IT by trusts have also increased. Just this week, the first of the four trusts still in the pipeline for the last of the NPfIT-era funding for Lorenzo, North Staffordshire Combined Healthcare NHS Trust, announced that it will deploy the system next March, as part of a transformation programme called ROSE.

Its chief executive, Caroline Donovan, doesn’t want Lorenzo to help the trust do what it had always done, but to “use digital technology to transform the way our organisation delivers services”.  

An end, a beginning

NPfIT is finally limping off into obscurity, many would argue well-deserved, but in the NME its technological legacy will endure for years to come. 

It has left behind a scattering of ageing iSoft-era systems, many of which have just been locked in for another five years, and a flagship system in Lorenzo that has yet to deliver – at least widely or consistently – on its promise of IT transformation.

Just as trusts are realising they really need that to meet the financial and quality pressures on them.