Hello, and welcome to Talking digital health, a podcast by law firm Mills & Reeve, hosted by health and tech lawyers, Sophie Burton-Jones and Charlotte Lewis.
Our aim is to discuss key topics of interest to those procuring tech in the NHS and those selling tech to the NHS.
I'm Charlotte Lewis. And I'm Sophie Burton-Jones, and we're your hosts for this episode.
And today, we're delighted to be joined by Alex Lawrence, improvement fellow in the innovation and improvement team at the Health Foundation. Hi, Alex.
Hi, Sophie. Hi, Charlotte.
In this episode of Talking digital health, we'll be talking about the Health Foundation's recent report, “Electronic patient records: Why the NHS urgently needs a strategy to reap the benefits”, which Alex co-authored. We've been working in the EPR space for a number of years, and we've seen ourselves the shift in focus from getting EPRs in place to then starting to realise the benefits of them. So we're very keen to talk to you about this today, Alex.
So let's dive straight in. Would you to tell us a little about the report, the purpose of it, and the key findings, please?
Yeah, absolutely. So this report presents findings from interviews with five acute trusts and one US medical centre where we asked them about their journey with the usage of their EPR over time. The idea driving this piece, you've basically already touched on it, Sophie, but it was the fact that this kind of milestone, this looming achievement of 100% EPR coverage is right around the corner. And I guess we were concerned that the system has rightly been so focused on this 100% target and helping the last, I think around 5% of trusts, get an EPR in place that no one's really stopped and asked, what's next? So, we basically wanted to take a moment, step back and look at what we think should come next, and the title is a massive spoiler. We think we need a national strategy. So, we had lots of key findings, but I'll try and touch on just the main ones.
I think firstly, procuring and installing EPRs is really just the starting point. I think because of this 100% target, it's kind of been viewed as the end point, but it's actually just the beginning of what needs to be a much longer journey.
Secondly, achieving meaningful use of EPRs, so where they really bring benefits, where they change processes, where they can transform care, requires significant time, investment and cultural change, and we think that that's really been underestimated.
Thirdly, again, a spoiler in the title that there's a complete absence of strategy here at the moment. We urgently need a roadmap for EPR benefits realisation specifically. So this national roadmap needs to be supported by trust-level implementation plans and, crucially, backed by funding. You can't really get away from that.
And then finally, we think that we need this strategy now. One of our findings was that, the longer systems are in place without delivering benefits, the harder it becomes to bring staff and other users on board with them. So that's why the urgency in the title.
Yeah, because I guess some of the earlier EPRs are almost coming up to re-procurement now. There's a few that have been in for quite a while, so they're not new.
Yeah, definitely. And we published a separate piece of work recently estimating the cost of digitising the NHS and social care. It was about kind of estimating the cost of fulfilling existing government promises, and a big part of that was the number of EPR systems that are going to need contracts renewing or reissuing soon and the number… I don't have to hand but it's quite staggering.
No, don't worry, we'll go look it up. I'm interested.
Thanks Alex. So in your report you talk about the need for a roadmap as you've mentioned, and the fact that that roadmap really needs to set out what trusts must do to ensure EPRs' basic functionalities are being used as intended, so base-level stuff, and then actually how to go beyond this to reap the ever-growing list of potential benefits that such systems can offer.
So we're going to take those two points in turn. Thinking about the first point, what do you feel that trusts are doing well and less well when it comes to ensuring that their EPRs' basic functionalities are being used as intended, and what are the barriers that you saw to getting the basics right?
Yeah, I think in terms of what trusts are doing well, I think that the vision and the ambition is really there. Trusts are motivated to get productivity improvements and modernised systems. That was quite clear to us. In terms of what they're doing less well, I think it's that kind of approach and mindset of continual improvement. So even for basic functionalities, it's really not a one-and-done situation. Developing EPRs further, so developing what we termed higher-order functionalities, creates these positive feedback loops for the basic functionalities.
So, for example, as you keep developing your EPR, you might understand how to code basic conditions better, or what you might understand more why that's so important. Or you might think the interface needs this tweak that would make it so much more usable, for example. And I think that mindset isn't really there in most cases yet, because of this big focus on the kind of 100% coverage that we've spoken about already.
And then I think in terms of the barriers to getting basic functionalities right, I’ll try and focus on just the two, otherwise we'll be drowning in barriers because there are a lot.
I think the first one is funding, but no surprises there. We heard from our interviewees that the initial financial outlay needed to procure these systems is just so enormous that there's no money left over for ongoing training and improvement. And that's a real barrier to getting these basic functionalities right, staff turnover, staff moving between sites - you can't just, deliver one training and then think that everyone knows how to use the EPR.
And then the second is staff buy-in and the two are really closely interlinked. At the moment, there's very rarely enough capacity or capability to undertake proper programmes of engagement with staff. And I think as well, most staff have had quite poor experiences with EPRs or with IT system rollouts in the past, so they're a bit burned from that. Then there's also this cultural reluctance to shift to this way of working, which we found, and I thought this was kind of surprising, that it's sort of viewed as American. We heard that as a direct quote from one interviewee, so I'm extrapolating here, but I think people don't see the way that EPRs ask you to work as inherent to the NHS, which is interesting.
Do you think that's because some of the big ones were originally US-focused systems and then they've been adapted for the NHS? Do you think it's something to do with that?
Yeah, I definitely think it is something to do with that. I think there'll be other reasons as well, but the US case study that we have was a big learning curve for me. I didn't know that much about why an EPR system that was developed in the US might feel strange to UK clinicians, but I've kind of learned a bit more about how the way the conditions are coded in the US is basically with a view to how the payment system there works, which is obviously so different. Clinicians in the UK will often be asked to code things that really don't feel relevant to the interactions that they're having in an NHS context, and that can feel frustrating because it takes up time. But I think it can also just feel odd.
Yeah, it's interesting that you raised the point about people culture training. We've done a podcast with Charlotte John where we talked about that sort of engagement piece in quite some detail, and the reason for that was because we were seeing it similarly ourselves, obviously. I think we talked about in that podcast that it doesn't need to be a blocker, but it's often perceived as a blocker and obviously you've picked that up as well. I think it's really important that people remember that you can throw all the tech and all the money in the world at something, but if you don't bring the people along on the journey with you, then it'll just sit there and not really be used to the best of its ability.
So we've just talked a bit about the kind of basic functionalities and getting those right, and then kind of turning to the second point and looking at optimising EPRs going forward. What do you consider to be the opportunity? How far is the NHS off taking full advantage of their EPR systems once they're in there at their 100%, and what support do you think needs to be offered to trusts, if any, to be able to try and achieve that?
Yeah, I think in terms of the opportunity with that kind of higher-order optimisation, it's really significant, but a lot of the evaluation studies that have been completed are in the US, which is really interesting, and it would be great to have more take place in the UK so that when we're making these statements about the opportunity, we can back it up with UK-based studies. But the opportunity is safer, more consistent care for patients, better data sharing between systems, the opportunity to do preventative care through tracking health over time and identifying risk factors, integrated quality improvement techniques, the list goes on and it's quite significant.
I think in terms of how far the NHS is from being able to take full advantage of these systems, these systems are going to keep getting better and better and they're going to keep integrating more and more tools, so probably that is just going to be a continual journey. But in a more practical sense, I think it's really varied, so the digital maturity assessment and the clinical digital maturity assessment help us show that those trusts furthest along the optimisation journey and those who are still getting the basics right are hundreds of miles apart. And a big point that we wanted to make in this piece is that we need to help those getting the basics right and doing further optimisation at the same time.
We can't progress one without the other. That's really important, and we need the use cases and the positive stories and the learnings from those that are further along to help those earlier in their journey. That can really help with staff buy-in, but also it's going to help us speed up the whole process. We were talking to NHS England about some of our findings and they said, the US case study shows that it took 15 years for them to build a great system. And NHS England were like, we don't have 15 years, but if you're taking learnings from the US, taking learnings from our trusts that are excelling, it isn't going to take us that long. We can turbo-charge this optimisation.
And then in terms of the support that they do need, I think it varies depending on whether you're just rolling your EPR out, trying to get the basics right, or at different stages of optimisation. But I do think the tiger teams NHS England have procured are a really great start. I think other things we need are peer learning opportunities to share those kind of use cases and best practice that I mentioned, partnerships with vendors to work together more and tailor systems to trusts’ needs. And then most importantly, more funding for training.
Yeah, I sort of get the impression on the peer learning point that a bit of it’s happening ad hoc in the background, depending on where your contacts are at which other trusts and where they are in their journey, but something more formal. We've been to multiple EPR events and summits and things that, and everybody is always so keen to understand what others are doing and what has worked and what has not. That sounds like an obvious thing, but just in everybody's busy lives, it's quite difficult to get it together sometimes.
Actually, we did a separate project looking at the state of adoption of AI in London with UCLPartners, and one of the people we interviewed for that project said that in terms of AI adoption, the EPR vendor a trust uses impacts so significantly on it, and also the stage that you're at in terms of EPR development, that they suggested in terms of AI sharing learning on what you've adopted, trusts should be grouped by the EPR vendor they use and how far along they are on their optimisation journey. So just using that point to illustrate how much it impacts the type of thing you're able to do and what you need.
Brilliant. So, interviewees indicated that without effective data extraction, EPRs are essentially digital notebooks. This extraction has proved much more challenging than trusts anticipated or suppliers had promised. What are the challenges and how might trusts overcome these?
Yeah, so I think there's a couple of problems here. The first is, how easy is the data to extract, which you touched on. Sometimes, not all the time, but in some cases, suppliers do hold trusts' data in separate data warehouses, and we heard from some of our interviewees that it can be a complete nightmare to try and get it out.
The second problem is, what's the quality of the data being extracted? Has it been input accurately and in a format that's accessible? Has it been coded rather than written in the free text? So I think that comes back to the quote I shared about someone describing it as an American approach. And the example that's most often given here in our study and in others is a smoker - despite there being a box you can tick if someone's a smoker, clinicians still would rather write it in the free text box because that's what they're used to.
And then in terms of solutions, I think probably you two will know much more about this than me, but the upcoming Data (Use and Access) Bill, I think, is a huge opportunity for the government to get data sharing right. I'm not saying that bill is going to fix both of the problems that I've just mentioned, but I think that it could make a really big difference to how EPRs are used and how the data is shared. It’s on my to-do list to study up on that bill and we'll be keeping a close eye on it.
Yeah, and I think it's not quite the same thing as well, but all the talk about the single patient record and what that's going to look like. I saw a survey where it said about 65% of the public, if you ask them if their single patient record exists, they think it already does because they just think, well, I should be able to get access to my data, I've got the NHS App, there it is - not quite understanding in the background what it actually means and how that all works. So I think whatever happens with the Data (Use and Access) Bill, I think there's just going to be a push in that direction for the benefit of everybody anyway, hopefully. I saw the FT published a piece with this really amazing diagram that shows you all the sources that would go into a single patient record and why it's so complicated.
Anecdotally, I've had conversations, friends, family members, and they find it incredibly bizarre. But the trouble is that we're not the people to go talking to about it. We're just going to give them a lecture on why it isn't the case. Maybe I'll just ping them or get on my phone, show them the infographic, because I think people don't appreciate that it's very complicated. It's not to say that it shouldn't be done.
Yeah, but also, I think in the past, some of the arguments for not having it have been based on that “patients don't want it. They're concerned about their data security”. Of course they're concerned about their data security, but it's not true that they don't want it. It's just the way in which it works needs to be protected. But people are more and more familiar with being able to look at your finances on your phone, and that all banks and pensions and all sorts feed into one thing. I know health records are protected in a slightly different way, but there is more understanding about that. A lot of people are keen on that.
So on some of the other points that were raised, there's a concept of a meaningful use programme established in the US. Could you explain briefly what that is, but also how could you see it being rolled out as part of a roadmap for the NHS?
Yeah, so the meaningful use programme is really interesting. I wasn't familiar with it before this project, and I think it's worth emphasising the significance of the US taking an approach like this, such a directive national approach. It's actually much more in the UK's wheelhouse to take this kind of approach, so it's interesting that we're looking to the US as an example of this. They had three stages of meaningful use, with incentive payments along the way, and it was incredibly successful. I think over 96% of acute hospitals had an EPR by 2017, up from 9% in 2008, so it worked fantastically.
As I mentioned, I think that it would work well with a national roadmap because it is actually an approach that we're more familiar with in the UK. The roadmap would need to set out a few different stages of EPR development and then help trusts or ask trusts where they currently are on that journey. There are things that they would need to do to try and get honest responses from trusts because at the moment, often when they're asking questions about digital maturity, there's a concern that the answer will either lead to funding or not lead to funding, and so people try and skew their answers based on that. And then providing the tailored support that we've spoken about already for these different groups.
Thank you. It's been really helpful to get that feel of flavour for that US case study that you talked about. It comes across really well in the report, but that's why we wanted to talk about it in a little more detail as well.
Final question, if we may. Several of the interviewees mentioned that digital systems often add complexity before delivering value, and your report touches on the importance of culture, appropriately skilled resources and training. We want to understand your view of what you feel the mood is within the NHS when it comes to EPRs and where it's negative, what can be done to shift the mood to one of positivity and optimism, to end on an upbeat note.
I think the first thing that I wanted to mention is it's not just with EPRs where there is a lag in productivity when you're first implementing it. I think that basically applies to almost all innovations. You have to expect that it's going to be a drag on people's time initially before you start seeing the hoped-for benefits. In terms of the current mood, I think it's a really interesting question. I would say that for this project, these interviews don't give us enough of a basis to answer this question on behalf of the NHS, but we are hoping to conduct some polling of NHS staff later this year that will give us a better idea of that, so stay tuned. I will share it with you when that’s out.
But if I had to guess, I'd definitely say that, the current mood is probably one of frustration for most people. Really significant benefits were promised, but in most cases, the funding, headspace and resources just hasn't been there to make this happen. I think in terms of what we could do or what the government could do, what the NHS could do to shift this mood to one that is more positive and optimistic, it ties into this kind of much broader argument that the Health Foundation tries to make across much of our work on innovation. We need to shift thinking, rhetoric and policy from talking about cutting-edge technologies all the time to looking at tech that is already in the system, where we've already spent so much money and how we can make that better.
If I was working in the NHS, personally, I'd be really relieved to see the government stop talking about bringing in new things all the time when the things that you already have aren't working very well. We think that, they're probably going to get better value by investing in optimisation than they are from investing in and acquiring new, cutting-edge technologies at the moment. Obviously, we wouldn't, we don't want the UK to fall behind in terms of those more exciting technologies, but, we live in the world that we live in and that it's resource-constrained and we think that optimisation is a great place to spend the money.
Then the other thing is probably, I know I've mentioned this a few times already, but sharing positive stories and use cases to demonstrate what EPRs can bring further down the line and really get staff on board. One example we touched on briefly in the report is a trust that has built exploration of EPRs into their junior doctor syllabus. One group of junior doctors basically found that penicillin allergies had been incorrectly coded, and because of that, there were a whole cohort of patients that were being kept in hospital longer than they needed to be. That was just from tinkering around in the EPR and having a look, and I think that, that will also help address these cultural issues where EPRs are felt to be not inherent to the NHS. There are some great things happening out there and every time I'm lucky enough to interview NHS staff, I'm always genuinely really inspired by the amazing things that are happening. It's just that eternal question of “why isn't it happening everywhere?” and trying to raise awareness of the pockets of excellence and help them spread.
Great. Thank you so much for your time today, Alex. It's been brilliant and definitely going to go back and have another look at that report and the other one you mentioned.
If you'd like to hear more from Alex, then you can find her on LinkedIn and obviously the Health Foundation posts a lot on there as well about reports coming out.
From a Mills & Reeve perspective, we're very happy to discuss any legal queries you might have around NHS digital transformation, including EPR procurement, as well as the procurement, adoption and expansion of any IT system and how you can deal with that within the constraints of your contract. Our individual contact details are available on our website at mills-reeve.com.
Thanks for joining this episode of Talking digital health by law firm Mills & Reeve.