VOL: 98, ISSUE: 49, PAGE NO: 34
Elloise Maddock, DipNMA, RN (Child), is nursing practice facilitator, North Staffordshire Royal Infirmary
When people are asked to define what nursing is, what nurses do, and what skills are required to provide holistic multidisciplinary care, few people are likely to mention the need to be computer literate.
Although it is a rapidly evolving organisation, the NHS has trailed behind in the information technology stakes. As nurses we have the ability to save lives using sophisticated equipment, yet we could not look up or share a patient’s history on a computer - until recently.
The national information strategy Information for Health (NHS Executive, 1998) has outlined two strategic objectives:
- To ensure clinicians have access to relevant information 24 hours a day, seven days a week;
- To provide every NHS professional with on-line access to the latest local guidance and evidence of treatments, as well as the information needed to evaluate the effectiveness of their work and to support their professional development.
The key to achieving the first aim in the short term is the electronic patient record (EPR). The key to achieving this aim in the long term is the electronic health record (EHR). The EPR system forms the basis for the migration from paper records to electronic records because in the future patient information will be recorded and stored electronically.
Information for Health outlines the strategy that will bring about one of the biggest organisational and cultural changes in the way health care professionals capture clinical and administrative data. It will include the use of a PC, laptop, or palm pilots by all members of the multidisciplinary health care team. Clicking on the mouse and tapping on the keyboard will become second nature to health care professionals instead of pulling out our multicoloured pens.
This article describes the implementation of an EPR system in North Staffordshire NHS Hospital Trust, an acute trust with approximately 1,300 beds.
Proposed benefits of EPR systems
The implementation of EPRs should bring benefits for patients, staff and organisations as a whole. The NHS Information Authority (2001) identifies several benefits (see Box 1), which include the introduction and use of standard approaches for health care delivery, the reduction of clinical risk, greater convenience for patients and the improvement of the patients’ experiences.
When using an EPR system clinicians can be guided and supported throughout the process by:
- The development and use of decision-support systems, which will be built into EPR systems;
- Multidisciplinary electronic integrated care pathways (eICPs);
- Protocols embedded within the EPR system.
National service frameworks (NSFs) can act as a major driving force, through an EPR system, to ensure that patient care is delivered according to a standard approach and that this can be audited.
Another benefit identified by the NHSIA (2001) is that EPR and EHR systems can support the introduction of quality and risk-management strategies, including clinical governance. This is because they have the facility to extract quality data for audit purposes as well as being able to provide access to up-to-date evidence and information about best practice at the point of clinical decision-making.
The convenience of patient care will be improved in various ways. For example, the use of patient booking services and enhanced clinic scheduling will help to improve communications and streamline care. Administrative data collected on patients will become available to all the relevant members of the multidisciplinary team, reducing the need for patients to repeat themselves or to be continuously requestioned.
The use of better information and the improvement of communication among the multidisciplinary team should reduce patients’ concerns and increase their confidence in the care that they are being given. This, in turn, should improve their satisfaction with the service that they are receiving.
Critical success factors
The EPR system is made up of six levels as outlined by the NHSE (1998) (see Box 2, p36). In order to realise the benefits of EPR systems for staff and patients at the North Staffordshire Royal Infirmary - part of the trust where EPRs were being introduced - several critical factors had to be considered during the procurement and implementation process. These have been outlined in previous evaluations of EPR systems (NHSE, 1997; NHSIA, 2001).
The procurement process involved defining the core requirements of an EPR system to meet the needs of acute trusts. It was recognised that future end users had to be consulted during the development and implementation of the EPR system, as the tool will have an impact on the development of the professions of these end users (Goorman and Berg, 2000).
Subsequently, various multidisciplinary clinical teams contributed to defining the core clinical requirements of the EPR system. These identified requirements included the attributes required for developing electronic integrated care pathways, electronic prescribing, electronic ordering and the electronic reporting of results.
The next stage of the procurement process involved short-listing potential suppliers of EPR systems. It was important to identify an EPR system that:
- Was user-friendly and flexible for clinicians;
- Allowed clinicians to record and retrieve data easily;
- Made information readily accessible.
These issues have been identified as critical success factors for the implementation of an EPR system (NHSE, 1997). Clinical teams, therefore, went on site visits to other hospitals to view EPR systems in use. Demonstrations of prospective systems were also performed in the trust to enable clinicians to review and evaluate the effectiveness and usability of the systems.
Contract negotiations have now taken place with the short-listed suppliers, and a process that involves clarifying and confirming of contracts is due to be completed shortly. Pre-implementation work has already commenced in the trust.
In response to the information strategy a nursing practice facilitator role has been developed. This person will collaborate with the IT department in the procurement and subsequent implementation of the EPR system in the trust. The role ensures there is a nursing voice on the EPR project team and that the nursing agenda can be put forward and supported throughout all the processes involved in the development of the trust’s EPR system. Several projects have been undertaken under the auspices of this role as part of the procurement and future implementation process, based on findings from previous evaluations of EPR systems and literature reviews.
A literature search was undertaken to assist the EPR project team with procurement and implementation. The EPR is a relatively new concept in this country, and due to the timescales involved in the procurement process, the majority of the literature reviewed was based on EPR procurements and implementations in other countries.
Several key points were identified that seemed to be applicable to the current model of health care being utilised. It was found that previous models of health care work embedded in EPRs may be partially to blame for clinical practice problems with EPRs in other countries. Goorman and Berg (2000) outlined that the sociological literature suggests that the models of EPR systems contain a projection of medical and nursing activities that does not match the activities of doctors and nurses as they take place on a ward (Berg et al, 1998; Kaplan, 1995; Forsythe et al, 1992).
Another key point found that nurses undertake many roles throughout the day. It has been demonstrated that in order to perform these roles effectively nurses must be supported by clinical practice environments that have been designed with a clear understanding of their roles and the kinds of support they require to make decisions (Sorrells-Jones and Weaver, 1999).
In order for the implementation to be effective clinicians need to be able to capture appropriate clinical data (Snyder-Halpern et al, 2001; Sorrells-Jones and Weaver, 1999; Turley, 1992).
These findings need to be taken into account and addressed if the procurement and future implementation of the EPR system is to be effective and user-friendly for the clinicians at the point of care. The development of the EPR system needs to recognise and reflect the activities of clinical practice and the processes involved. Clinicians must be able to collect the relevant clinical data and be supported in their decision-making at the point of care.
Procurement and pre-implementation
As a first step during the procurement phase a project was undertaken, which was based on the evidence that clinicians need to be able to capture relevant clinical data. The main aim of this project was to find out how data, which in future would need to be captured electronically using the EPR system, was currently captured on paper in different disciplines in the trust.
The first step also established which nursing models or frameworks of care were used as part of the nursing process. The project assisted in the assessment of the current use of integrated care pathways within the trust, and this could be potentially adopted for use electronically in the future.
The identification of the clinical data that needs to be captured electronically was the first stage in looking at the nurse’s role as a data gatherer and information user. This information was needed to determine the core clinical requirements of the EPR system. It will also be used in the implementation phase, to gauge the ease of use for clinicians in capturing and extracting the relevant data quickly and easily at the point of care for the EPR.
Information was captured to model nursing activities and to identify where processes may need to be changed. The EPR system contains functions for electronic prescribing and drug administration, electronic ordering of diagnostic tests and electronic referrals to members of the multidisciplinary team. These functions will have a positive impact on work processes in future.
Information was collated that identified several activities that are carried out by nurses including: drug rounds and ward rounds, the type of procedures performed, the information being accessed from the current computer system and the members of the multidisciplinary team whom nurses contact with respect to a patient’s care. The intention was to assist in establishing a model of nursing activities and to distinguish a difference in roles in different disciplines within the trust.
An analysis of the results led to further information being gathered on the process involved when diagnostic investigations are ordered for a patient and when a referral is made to a member of the multidisciplinary team. Electronic ordering and referrals are currently performed through various media including paper and telephone, but will be placed through EPR when the system is in place.
The processes were broken down to identify who initiates a request, who actually makes the request and the medium through which the request is currently made. This process will need to be supported through the EPR system, and clarification of the nurse’s role within the process is essential to ensure appropriate authority and access levels.
To ensure practice and policy are consistent, an agreement is required at corporate level regarding the ordering of various diagnostic investigations and making referrals under a previously agreed protocol. All these need to be developed prior to the implementation of electronic ordering.
Awareness-raising sessions have commenced to inform nurses and care support workers about the functions of the EPR system and how it will impact on the way in which they will work in the future.
The potential benefits of the EPR system and the proposed implementation timescales of the various functions were also highlighted. Simpson and Kenrick (1997) found that the potential benefits of computerisation are not clear to many practising nurses. Axford and Carter (1996) pointed out that nurses’ attitudes have been identified as a key variable for successful implementation of clinical systems.
Further work has begun, involving a cross-section of members of the multidisciplinary teams who will ultimately be the end users, to map the way in which patient and information flows take place now and how they will take place in the future. This will identify the need for organisational change within the trust.
The development of EPRs requires significant involvement from other disciplines as it is an extremely complex change management project requiring a multidisciplinary approach. The engagement of the prime users throughout the change management process is a critical success factor (NHSIA, 2001).
It is envisaged that the implementation of an EPR system will have a positive impact on patient care through improved communication, improved access to patient history and the streamlining of services. The end result should be improved patient outcomes through the use and delivery of evidence-based practice and clinical effectiveness. In order to realise these benefits several critical success factors need to be considered during the procurement and implementation stages.
The implementation of EPRs will have a significant impact on the way in which we currently work and capture clinical data. In order to be effective, the EPR needs to model current health care practices, allow clinicians to capture and extract clinical data electronically in a quick and user-friendly way and support their clinical decision-making at the point of care.
Organisational change is crucial to achieve the benefits of an EPR system and an effective change management strategy needs to be in place. End users need to be involved in the procurement and implementation process, as the development of EPR systems is about exploiting the benefits of technology to change and improve the clinical care delivered (NHSIA, 2001).
The lead nurse role on the project has allowed preimplementation work to begin and projects to be undertaken during procurement. It has ensured that the nursing agenda and requirements are considered and has provided the opportunity to raise the profile of the EPR system in different clinical areas within the trust.