A friend of mine – a mid-level leader in an NHS hospital - is camping-out in his office for most of August.
His trust is going through a “big bang” implementation of a big EMR system sold to so many NHS hospitals over the last few years as part of the drive to digitise acute care. In this case it’s Cerner, but it could any of a handful of others big vendors, including Epic, Allscripts and a few others – almost all of whom are headquartered in the USA.
The expectation of the executive team is that the EMR will bring the super-sized conglomerate of several hospitals substantial benefits in improved productivity, higher visibility of key processes, better management data and improved links to patients and the community.
Perhaps.
But the expectation of my friend is that it will bring him and his colleagues to their knees. It is likely to be a war-zone, so he’s packing an air-mattress.
The dire experience of the VA – which used to be the best-digitised US healthcare system – means he may be right to be fearful.
One of his worries, is the fact that D-Day is mid-August. Granted, there is slightly less clinical activity at this time of year, but many of leadership and management staff are on holiday and so can’t provide the necessary support.
This time of year, as significant proportion of the doctors are new. Many are newly qualified. All the staff are worn out from Covid, cost-of-living stresses, strikes and decades of underfunding. It’s not a good time to force a huge change in working practices on the staff.
For many of them it sticks in the craw to realise that their employer is spending tens of millions of pounds on a new computer system and paying IT consultants thousands of pounds a day, for what seems a marginal benefit, while at the same time claiming they can’t afford to fund key services.
A big EMR implementation is for many, just another reason to abandon ship, leave the service and move to Australia.
The problem is, that experience, both in the UK and in the USA, is that implementing a big EMR rarely goes well. Changing many key processes at once, when the internal capacity and capability for change may be mediocre, risks the whole thing unravelling. Famously, there were calls for a public enquiry after an Epic implementation nearly destroyed Addenbrookes Hospital a few years ago.
But for many clinicians, the big bang is not actually the problem.
The problem is that the promised benefits are not just paltry, they are illusory – and the new EMR may actually be counter-productive.
To illustrate this, let me take an example from an ex-colleague of mine who told me about an installation that has been ongoing in another trust for five years.
As an emergency medicine physician, her complaint is that to ‘click on’ to a patient in the waiting room in order to signal that they have been seen – a process that used to take less than 10 seconds – now requires a series of clicks, scrolling, radio-buttons and then typing- in your name. It’s now takes 60–90 seconds depending on how responsive the system is. (It often hangs).
The fact that the clinician's name is now ‘“free text’” makes it impossible to monitor the productivity of doctors working in the department (and if you’ve run an ED, you’ll know this can vary substantially).
Where a paper-based prescription for pain relief would have taken a few seconds, it now takes an average of two minutes and can only be done at one of the limited number of desktop computers, not perching at the nursing station, or standing at patient’s bedside.
And the loss of paper (there is no mobile access) means that it’s not possible to consult the notes of a previous clinician or check a result or vital- sign while examining or talking to the patient at the bedside. This is a significant difficulty if you’re trying to correlate the patient’s story.
And that – in her opinion – is deeply unsafe.
So the EPR has made care for these ED patients worse: it’s less safe and it’s hobbling the productivity of the department during busy periods. All this makes the patient experience worse and the department more crowded. Research clearly shows overcrowding causes poorer outcomes.
This conforms to findings in 2017 that nearly a half of all NHS junior physician time is spent in front of the computer, rather than making decisions or being with patients.
Naturally, this also makes staff frustrated and unhappy. “We complained a lot in the beginning, but now we just put up with it,” she says. “What can you do?”
The answer of course is that there is a lot you can do. Solving this problem was part of my decision to create CAREFUL and build a beautiful, easy-to-use mobile app that integrate with such EPRs.
Instead, he tells me, the response of the trust has been to throw people at the problem. The place is better staffed than it was – but the service for patients isn’t markedly better, and it’s costing the taxpayer nearly double.
For my friend suffering a few uncomfortable nights, it’s just the beginning.