At HTN Now we were joined by Richard Yaldren, head of EPR programme at Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV). He shared with us his team’s experience in EPR implementation over the five years since the projects’ inception using Civica’s Cito solution.
Where the journey to EPR implementation started
Richard talked about how the journey toward EPR implementation at TEWV started out, five years ago.
“We were at a stage where our current EPR wasn’t very stable,” he said. “I was in a role as head of systems, and we were at contract renewal stage. So, it was a prime opportunity to sit down with the supplier. It’s no small thing to change supplier; I think with where we were at, we were more interested in improving what we had and developing our relationship.”
With funding an initial challenge, Richard described how his team extended the contract but negotiated a new product from Civica in doing so.
“Part of the contract negotiation was to enter into a partnership where Civica would develop Cito alongside us, and we would supply all of the clinical expertise. Both parties would get something from it. We would have something that fitted our needs, and they would have a product that was better which could then be used in other organisations.”
The central idea behind the project was to have a clinically-driven EPR programme, which could be jointly led between clinical and IT.
Richard emphasised that undertaking EPR implementation is not easy, and that finding people who are passionate about it is important. Getting others on board is also essential to success.
The team started with working groups, including mental health services for older people, and took the opportunity to look at key clinical drivers and strategic deliverables such as recovery and trauma-informed care. He notes that collaboration was missing across mental health services at the time, and inefficient processes were affecting outcomes.
“At the beginning of the journey we had about 25 different referral processes. Now we have one referral process that manages all of those different variances.”
Richard and his team focused on key design principles, emphasising the need for co-production and for patients to be at the heart of everything they did. This meant that things like simple language needed to be incorporated into the solution. The solution also needed to save clinical time and be easy to use.
“An EPR is the beginning of the journey and it really has to enable that digital journey,” Richard pointed out. “So whatever we put in place forms the building blocks for that digital transformation.”
After starting out with a plan he now calls “very ambitious”, Richard explained that carrying out that plan has taken five years. He also noted that mental health is often a lot more complex and less linear than other clinical journeys, meaning that his team had a great deal of work to do. For example, they identified over 120 clinical pathways, 540 forms, and some patients had around 18 care plans. A lot of the information contained within these care plans was litigation-driven information, Richard said, that didn’t focus on the patient; this was another challenge that the solution set out to resolve.
When the EPR programme began, staff support was voluntary, Richard continued, and there were no dedicated resources for it for around three years which posed a challenge. He noted that each clinical specialty tended to want to do things in their own way, so the team faced issues regarding keeping things consistent.
In order to resolve this, Richard used tools such as DIALOG and DIALOG+, an assessment tool based on needs that can be implemented through the EPR programme as a new way of assessing patients.
Richard spoke about the difficulties changing the ways of thinking amongst clinical staff, whose go-to approach was still to think of “forms”, with a lot of disparate thinking still going on. He reflected that this improved over time, with clinicians having the chance to learn more about the new ways of working.
He explained how the breakthrough came when adult services set up their own approach, which led to competition between clinical services who then began to upscale their own efforts. The collaborative approach grew organically from this.
The new clinical care model
Richard presented the new and improved model for patient flow, tracking where referrals came in and were triaged, before covering aspects of assessment, planning, intervention and review.
“It’s not about capturing the entire life of the patient all in one go; it’s about building it incrementally and organically, in a clinical way, that has value,” he emphasised. “Patients were complaining that they felt interrogated – mental health especially is a very challenging time in your life, so to go there and feel like you’re being interrogated can be very overwhelming. So the idea is to build up over time.”
Since the new EPR tracks all changes, Richard highlighted that it helps overcome the instincts of clinicians to over-record on patients’ progress notes, in case of future litigation, since all of this information will already be available.
The patient profile presents the entire patient record, all on one screen, with tabs to navigate to logically grouped parts of their care history. The tracking of changes means it allows for continuity even with staffing or carer change.
Richard shared how the team is also working on scanning all of their documents through Cito, which will enable these to be migrated from the old EPR and for easy access.
Another exciting feature is that alerts are automated. “If a pathway is taken or someone comes in as an inpatient, the system is automatically alerted,” he said. “A lot of our alerts are manual at the moment and they go out-of-date which can be stressful for the clinician. I’ve coined the phrase ‘everyone will have their own virtual PA’ so hopefully they can relax a bit and focus on clinical care without having to worry about when things have to be done by, because the system will remind them.”
For the trust’s mental health services, one of the key features of the new system is the ability for the system to alert a change in risk.
“In all of the progress notes, a mandatory question is ‘is there a change in safety and risk?’ If there is, it pops up with a side window where you can record that. It’s very important if there’s a change in risk, that is done, particularly with vulnerable people.”
Real-time widgets enable clinicians to see the most recent activity for a patient and any actions that need to be taken, with the ability to click on a link and be taken directly to the relevant form that needs to be filled in. These get sent to the individual team members and to the team, again promoting collaboration and continuity. Actions feed into shared boards, so that teams can view actions and tasks in one place.
Richard worked out that this potentially saves around 30,000 days per year, because “every single night, clinicians are having to type all of this information up, but it’s all automatic now”.
Looking to the future, Richard stated that he and his team plan to go-live with 15 core clinical pathways, behind which there are about 80 workflows.
Challenges of EPR implementation
When it came to actually implementing the EPR, Richard and his team came across some challenges, including encouraging initial buy-in; creating common understanding; establishing voluntary teams; clinical and corporate time; and changing ways of thinking.
Speed of progress was an issue, he said, but things changed when it was recognised that the project should receive proper funding.
“Once the trust agreed with that and put some money in, I got a dedicated clinical team. These clinicians are absolutely fantastic and without them we wouldn’t be where we are today. They’re so dedicated and so passionate, and they’ve really helped. They’ve taken the brunt of the work and their colleagues listen to them – you might be saying the right message, but it’s really important who delivers the message.”
To keep things moving in the right direction, Richard’s team have put in place a number of activities to maintain engagement and secure feedback on how the process is going. An initial rehearsal has been held and Richard’s team have redesigned 120 clinical pathways. “We know that when these go live, we will have a consistent care model,” he said, adding that significant variance will be removed as a result. “We’ve got a dedicated clinical group that meets every Wednesday morning; we talk through the concepts and get that wider consultation to make sure that we’re still on the right track. We’ve also developed a new e-learning hub.”
Richard was keen to stress that EPR implementation is not an IT project, it is a clinical change programme. It affects everyday interactions with patients, not just processes happening in the background.
Making it accessible for patients was important, he said. “It’s their life, at the end of the day; it’s co-production every step of the way”.
The next phase of the programme will be a patient portal, where they will be able to view their care record, challenge what is there, and even add to it.
Many thanks to Richard for joining us.