NHS IT projects are not noted for meeting deadlines. Strictly speaking, Cambridge University Hospitals NHS Foundation Trust’s eHospital implementation of new software, hardware and networking was no exception: “It was one day and one minute late,” says chief clinical information officer Afzal Chaudhry (pictured). It went live just after 2am on Sunday 23 October 2014, rather than early on Saturday morning as planned.
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For a £200m project which was only agreed in April 2013, going live on the weekend planned counts as a success. Cambridge’s adoption of Epic’s clinical software as its first UK customer, along with a massive hardware upgrade led by HP, is one of the biggest IT projects ever undertaken by a single NHS trust.
The infamous delays and failures of England’s National Programme for IT were partly blamed on its attempts to get different NHS hospitals, with different working practices, to use common software. The present government’s policy is to encourage individual trusts to choose their own systems. But the high cost of new IT has led many to avoid such choices.
Cambridge had previously made do with old systems, with some nearly two decades old and featuring green-screen interfaces, leading its eHospital programme director Carrie Armitage to describe them as “a burning platform”.
Cambridge University Hospitals NHS Foundation Trust – which runs the general Addenbrooke’s Hospital, the Rosie Hospital for women and maternity services and medical training with Cambridge University – is one of the NHS’s most prestigious. The trust’s board decided to spend the equivalent of a substantial new hospital building in an attempt to get the IT to match this reputation.
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Software supplier Epic trains staff
To do so, Cambridge chose a US software firm known for placing heavy demands on its customers. Epic put more than 100 of the trust’s staff through training and exams to become application analysts, meaning the firm saw them as qualified to adapt its software to Cambridge’s methods. “The working arrangement with Epic has been excellent,” says Chaudhry. “They have brought a level of rigour to the project that we might not have done ourselves, based on the NHS’s record.”
It was hard work for some of the staff involved, however. “Most people took to it pretty well. One or two did struggle,” says Chaudhry. “What’s become apparent, 18 months later, is that their skills have grown immeasurably.
“The NHS hasn’t always put the correct emphasis on getting people prepared for a role before they start it. It was good that Epic insisted on this.”
He says the trust used many of the workflows provided by Epic, developed in association with mainly US healthcare providers. “We were mindful that they had done a lot of implementations before, and we hadn’t,” says Chaudhry, adding that these applications were “reinterpreted in a Cambridge light – we didn’t accept everything blindly”.
The 18-month implementation involved every department of the trust’s hospitals. After passing their exams, the staff analysts worked with around 1,000 subject matter specialist colleagues to consider how processes would be adapted to work with Epic’s software. “It wasn’t a question of fitting our hospital to the system, but fitting the system and the workflows to care for our patients,” says Chaudhry. In some cases, the trust kept existing processes and adapted the software, or chose a mixture of old and new.
We need to handle paper coming in, and hand it to other people
The decline of paper in the NHS
General staff training started in August 2014 before going live at the end of October. Chaudhry says the system is still bedding in, but that some benefits are already clear. Internal appointments that used to go through half a dozen people are now booked by junior doctors. More generally, he says, “we’re highlighting to people what needs to be done or has been done”, with test orders highlighted. “In the emergency department, when a result comes back, it is flagged up really clearly,” he says. Outpatient results are sent electronically to the doctor who ordered them.
But despite health secretary Jeremy Hunt’s challenge to the English NHS to go paperless by 2018, Cambridge is not rushing to remove all paper from its processes. “We need to handle paper coming in, and hand it to other people,” says Chaudhry, although the trust is sending discharge summaries through the NHS’s secure email system to some general practitioners. Internally, it continues to use paper for consent forms, which are then scanned, and still uses the paper traces from older electrocardiograph machines. “It’s going to be an evolving process, something we want to work towards over time,” says Chaudhry.
The trust will continue to make old paper notes available to staff for at least a year, and then consider their use each quarter. After they are finally withdrawn, the physical notes will be stored for periods set by regulation, but will only be accessible electronically to clinicians. This should allow staff who currently handle paper notes to do more valuable work, Chaudhry says. Epic automatically performs some basic coding of records, allowing staff to improve the quality and accuracy of such codes. “You can see people’s roles evolving,” he says.
HP’s £140m input
Most of the eHospital programme’s budget has not gone to Epic, which was budgeted to receive £40m for its work, but to HP for a thorough updating of the trust’s hardware and networking, priced at £140m (with the other £20m for the trust’s own costs). HP’s work has included installing new network cabinets and a greatly improved wireless network with more than 1,300 access points, the latter allowing the imminent bring your own device (BYOD) option for staff. It has also integrated medical devices, meaning data from ventilators and heartbeat monitors can now go directly into Epic’s records rather than being entered by staff.
Cambridge has brought in more than 400 iPod Touches, embedded in barcode scanner cases, with which ward nurses can scan the barcodes on patients’ wristbands to see a list of tasks and basic information. “The nurses have found that very easy to learn with 10 to 15 minutes of training,” says Chaudhry.
Doctors can use apps for Apple and Android mobiles to access data on patients, although nothing remains on devices for security reasons. This is particularly useful for transplant surgeons such as Chaudhry, giving him more data about a case than he would receive from someone calling: “Often I’ll be phoned at night, saying can we ask you something. I can sit up in bed and look at my iPhone; that drives up the quality of the decision.” The mobile apps provide limited access to data, but Cambridge will shortly add full remote access to the Epic system through PCs.
We believe we’ve made a good choice, and it can transition to other NHS institutions
The Cambridge model
Chaudhry hopes other NHS trusts will consider similar projects. Papworth Hospital NHS Foundation Trust, a specialist lung unit due to move to a site close to Cambridge’s, is considering whether to share its IT system. Cambridge has held open days for other parts of the NHS, as well as visits from prospective Epic customers from Belgium, Denmark, Australia and New Zealand.
“We believe we’ve made a good choice, and it can transition to other NHS institutions,” Chaudhry says. “I think what’s challenging for the NHS is the model of having analysts upfront, funded properly. It’s hard to find these people, but I think having our own people doing the configuration has been phenomenally successful. If we’d skimped on people, or used people from outside, we wouldn’t have done as well.”
An advantage for any NHS trust looking to follow Cambridge would be that it could take advantage of the trust’s efforts, Chaudhry says. “All our work will be embedded back into the Epic foundation system,” he says. “They could start with the Cambridge-based model.”