interviews

eHospital: An evolving system

Dr Afzal Chaudhry, chief information officer and renal consultant at Cambridge University Hospitals NHS Foundation Trust, talks to NHE about the benefits and challenges faced by the trust in implementing eHospital. David Stevenson reports.

Cambridge University Hospitals NHS Foundation Trust (CUH) has told NHE that while there have been ‘teething problems’ with the implementation of its £200m electronic patient record system, the future benefits that eHospital will bring to the trust far outweigh the initial challenges.

The system at Addenbrooke’s and The Rosie hospitals allows clinical staff to access relevant patient information wherever they are, at the click of a button. CUH is the first UK trust to use Epic’s eHospital technology, which is used extensively in the US.

eHospital went live at Addenbrooke’s on 26 October 2014, and was the culmination of a three-year process to allow CUH to start moving towards an electronic patient record.

The ‘paper-light’ system is designed to allow clinicians and frontline staff to access patient information using iPod Touch or iPad devices, instead of reams of patient notes.

Epic is the trust’s software provider, while HP is the preferred infrastructure supplier.

Dr Afzal Chaudhry, chief information officer and renal consultant at CUH, who has been overseeing the implementation, told us: “The principal clinical benefit is that whenever you see a patient, and whoever you are, you will have access to that patient’s information in a form instantly available to you.

“There will no longer be delays waiting for historical sets of notes. Because you have a more accurate and complete set of data to work with, you are more likely to make better quality decisions, which will translate into improved outcomes for the patient.”

Teething problems

However, such an extensive implementation process, which has already seen more than two million patient records from the last five years uploaded to eHospital, has brought with it some challenges. As eHospital’s own website puts it, “healthcare IT initiatives are notoriously difficult to get right”.

A report by Cambridgeshire and Peterborough Clinical Commissioning Group (CCG) highlighted areas of concern, including issues in the emergency department.

Within the first week there had been a difficulty in matching blood test results for patients, meaning some had to be checked again. On 1 November 2014, it was reported that the computer system “became unstable”. A ‘major incident’ was declared, resulting in ambulances being re-routed to other hospitals for several hours.

The system’s introduction was also associated with a 20% fall in A&E performance, but this was gradually improved towards the end of the year.

Dr Chaudhry said: “We did take a hit in the A&E numbers to begin with, which we could reasonably attribute to some effects of the transition. But in the few weeks afterwards we made some configuration changes and provided extra training and support, and we saw a week-by-week improvement in the numbers.”

NHE was told that whenever there are changes to a system in a complex healthcare environment, whether it is a small change or in the case of eHospital a really big change, it is inevitable that there will be “considerable stress” caused.

“You know from the outset that you won’t be instantly as efficient as you were. This is simply because people have to have time to adapt and transition to the new system,” said Dr Chaudhry.

He added that CUH has, unfortunately, seen some stagnation in the A&E improvement figure, and that has been superseded by additional capacity pressures on the hospital.

Capacity issues

The capacity pressures in early January this year were so severe that another ‘major incident’ was declared. On 12 January, CUH stood down from ‘major incident’ status but maintained ‘internal critical incident’ status because of the “ongoing bed pressure”.

The trust added that demand on its services remained extremely high and “we continue to contact relatives of patients who are medically fit to go home, with ongoing care needs such as feeding or personal care and asking them, wherever possible, to take their relative home while care packages are put in place, where appropriate”. 

Discussing the recent capacity issues at Addenbrooke’s, Dr Chaudhry said: “We are very mindful of the obligations that we have in achieving our regulatory targets, and we aim to meet those wherever possible. But the latest ‘major incident’ status, and the pressures that are causing that, aren’t related to eHospital but because of the volume of patients and the ability to discharge them into the community.

“In the long-term, as a system, it [eHospital] will save time. It will also, hopefully, mean we can identify things further up the care pathway in treating our patients.”

Training

eHospital training at CUH is ongoing, but the major training programme started towards the end of August, with more than 10,000 staff members trained in a period of approximately nine weeks.

“We had a series of classroom training sessions, which were running six days a week from 8am to 10pm, with individual members of staff doing the courses appropriate to them,” said Dr Chaudhry. “We supplemented that learning with ‘tip sheets’ on how to perform certain activities through the go-live process, supplemented by a team of so-called ‘super users’ and ‘floorwalkers’ available on the ground to help people if they got stuck. There was also a command centre of 150 people who were on site 24 hours a day to deal with issues as they arose.”

Feedback from users has been positive, but there have been problems, usually to do with incorrect access arrangements, or where certain activities are located within the computer system.

Dr Chaudhry said: “What we’re seeing now, over the two to three months since we went live, is that staff familiarity with the system is growing and that they are becoming increasingly confident with it.”

There are still pressure points, especially around the high-volume areas. For example, the trust’s outpatient clinics and emergency department are heavily pressured. Within those areas, “there is still work to be done to streamline the process within the electronic record to help allow staff to make sure that they can be as efficient as they can be in caring for patients,” Dr Chaudhry explained.

Within these affected areas, CUH has set up ‘stabilisation and optimisation’ workstreams to improve efficiency. “We are working with every part of the hospital to make sure each area is focused on being as efficient as it can be,” said Dr Chaudhry.

“That is then going to transition into a ‘business as usual’ function, which will start from April, whereby we will have further engagement and what we call ‘earned devolution’.

“As we engage with the clinical and non-clinical divisions, they will free-up some more staff for additional training. They will be given more authority in the system to make configuration changes for their departments to deliver best practice.”

However, if departments want to implement configuration changes that will affect wider communities within the hospital, they will go through to the core support team.

Daunting task

NHE asked if some NHS trusts might be put off from undertaking such large-scale change projects, especially with the potential challenges they can bring to already under-pressure hospitals. Dr Chaudhry said: “There is no doubt that such a large-scale change project can be daunting for everybody.

“We’ve been asked if we are under a lot of pressure from external agencies like the CCG and CQC, but the bulk of the pressure we feel comes from within. We’re very mindful of the obligations we have in wanting to look after our patients effectively.”

Dr Keith McNeil, chief executive at CUH, said eHospital has been a massive undertaking and even though the implementation has not always gone smoothly, it will enable the trust to offer a much-improved service in the future.

NHE was told that the trust is going through a process of “lessons learned” and a “post-implementation review” – the results of which will be shared with the wider NHS.

EPR Works has provided overall programme management for eHospital, managing the electronic patient record and infrastructure delivery, running the programme management office and stakeholder engagement. Another company, CTG, involved in a number of past Epic implementations, has been providing external assurance to the trust board throughout the process.

“They are in the process of doing their review,” said Dr Chaudhry. “In addition to this we are planning a complete independent review, and are in the final stages of commissioning this.

“We would hope to have that review underway by the end of January and have it complete by the end of February. It is likely to be a matter of weeks rather than months.”

Dr Chaudhry added that CUH is not saying that eHospital is the “only or best way” to move towards implementing electronic patient records, but is just describing the way it is doing things.

“If our process, implementation and experience can help support other trusts then we’re certainly very keen on this, and are motivated to share our experience with others,” he said.

Going forward with eHospital, the trust is keen to develop the system as a ‘business as usual’ function. However, NHE was told that from its own experience, and that of other Epic customers, approximately two-thirds of the configuration at the time of go-live will ultimately get replaced with refinements and developments over time.

Dr Chaudhry added that the trust sees eHospital as a constantly evolving system and plans on having its 10,000-strong staff help drive the change and efficiencies.

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