PAPERLESS ED? AN EPIC EXPERIENCE. Adrian Boyle Cambridge University Hospitals Foundation

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1 PAPERLESS ED? AN EPIC EXPERIENCE Adrian Boyle Cambridge University Hospitals Foundation

2 We d like you to come and speak at Bournemouth Great! What on? Violence? Quality? Crowding? QIPS? QECC Update? Something really exciting like a SMACC talk? IT Implementation WTF? Pleeeeeeeeaase! Oh ok

3 Upgrading your IT is the most disruptive thing you ll ever do

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5 200m over 10 years* CUH 20m Epic 40m HP 140m * Do nothing = 110m Budget Out-turn Variance Capital 28,990,000 29,296, ,000 Revenue 36,273,000 32,897,000 3,376,000 TOTAL 65,263,000 62,193,000 3,070,000

6 Before Notes go missing Information is unavailable Results reporting is cumbersome Multiple poorly communicating IT systems (12 in the ED, which no one person knew how to use) GP communication was poor

7 winter is coming NHS England Five Year Forward mandates that the NHS should be completely paperless by 2020

8 winter is coming Part of Personalised Health and Care all patient and care records will be digital, interoperable and real time by 2020 Purpose of digitisation is not to digitise, it s to improve quality, safety, efficiency, and patient experience Professor Wachter 2016

9 The Addenbrookes and Rosie Hospital EPIC Implementation Huge and Complex Hospital, employing around 7,500 clinical staff Aimed for a Big Bang implementation on the 25 th of October 2014 ED / Ward / Theatre / ICU / OPD

10 Preparing for winter Team of around 50 clinician super-users Instructional Designers and Analysts Seconded 2 ED Consultants (50%) and one nurse (90%) Training of clinical staff: the playground Mapping IT processes onto existing pathways Simulations of extreme scenarios

11 Simplify your processes 19 different ways to refer people to an outpatient clinic Multiple different ways to request and receive a test We don t work linearly, so don t design linearly

12 Waiting room Minors Discharge nurse ENP Receptionist Secondary Assessment by Minors nurse, pick up card from box Minors nurse Patient registered by receptionist at reception. Card then placed by patient in box next to minors Presenting complaint Analgesia / ECG / Sometimes x-ray / sometimes Liaise PA SpR/ Consultant Treatments In Patient Pharmacy Medical Patient arrives at the Minors Minors Assessment ED on foot Initial Assessment by pre-reg nurse nurse Junior Doctor Infection Control Presenting Complaint AVPU assessment Decides on placement Secondary Assessment by Minors nurse, pick up card from box Presenting complaint Pre-Reg Ambulance staff Analgesia / ECG / Sometimes x-ray / sometimes Liaise PA Places card in Box Porter SpR / Porter Receptionist Resus Cubicle Consultant X-ray Ambulance nurse Porter staff Medical Nurse in Charge PAT Nurse Secondary Assessment by nurse Presenting complaint /VS Analgesia / ECG / Sometimes x-ray Liaise PA Physician s Assistant Bloods/ Assessment Junior Doctor Resus nurse Treatments Radiographer SpR / Consultant Update Jonah with x-ray request Paper back-up Co-ordinate transfers to ward and radiology Patient arrives at the ED by ambulance / police Initial Assessment by PAT nurse Infection Control Presenting Complaint Nurse in Charge Ops centre person Urinary Catheter Porter Secondary Assessment by Doctor Request bed on phone and Jonah Co-ordinate treatments Telephone handovers Arrive at an Inpatient bed AVPU assessment Check Treatments Decides on placement Ambulance Assessment Cubicle nurse Check Coding staff Patient registered by receptionist at bedside who returns to reception and then brings out front sheet back to nursing staff 1 Secondary Assessment by nurse Presenting complaint /VS Analgesia / ECG / Sometimes x-ray Liaise PA Places Card in Box SpR / Consultant Medical Assessment Junior Doctor Cubicle nurse Treatments Porter CT Check VTE assessment Check swabs HCA / Cubicle Ops centre nurse person Receptionist Physician s Radiographer Ambulance staff Nurse Coordinator Update Jonah with x-ray request Paper back-up Assistant Bloods/ CDU Co-ordinate transfers to ward and Urinary radiology Catheter SpR / Cubicle nurse Ambulance staff Request bed on phone Co-ordinate treatments Telephone handovers Consultant Medical Assessment Treatments Manage relatives Request specialty Doctors to review Junior Doctor Porter Ultrasound Assessment 2 Cubicle nurse Radiographer Cubicle nurse Secondary Assessment by nurse Presenting complaint /VS Physician s Treatments Analgesia / ECG / Sometimes x-ray Assistant Nurse Coordinator Update Jonah with x-ray request Paper back-up Liaise PA Places Card in Box Nurse in Ops centre Bloods/ Urinary Catheter SpR / Consultant HCA Co-ordinate transfers to ward and radiology Request bed on phone Charge person Medical Assessment Cubicle nurse Treatments Co-ordinate treatments Junior Doctor Telephone handovers Manage relatives Request specialty Doctors to review Blue Chairs SAT PA cubicle Nurse Time Secondary Assessment by SAT nurse Presenting complaint Analgesia / ECG / Sometimes x-ray Liaise PA Places Card in Box Physician s Assistant Bloods

13 Planning for winter Fixed Go Live date of 25 th of October 2014 Planned Major Incident OPD Activity cut by 30% Elective theatre activity almost entirely suspended ED Activity cut by 0% Floor walkers

14 So what happened? Pause for 24 hours for password problems (HSCIC)

15 Conflicting opinions about the implementation of EPIC

16 The major problems we had The Playground wasn t fit for purpose Collective underestimation of the disruptiveness of this A lot of competent doctors looked utterly incompetent

17 The major problems we had Interfaces with pathology didn t work well Manual cross matching of blood 300 GP microbiology tests of urines and sputums were not done Block contract payments Complex prescribing Warfarin and Insulin

18 The Productivity Paradox You can see the computer age everywhere except in the productivity statistics. We are 20% less productive (Patients / Dr / Shift) than we were before Nobel Prize winning economist Robert Solow, 1986

19 Rants from Consultants I will hold the executive to account for their botched and negligent implementation of the EPIC system Election statement for staff governor (successful)

20 But did it matter? No discernible increase in HSMR / SHMI VTE Recording Associated with three VTE s and one death Infection Control Recording MRSA C.Diff Frailty and Dementia Scoring

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22 Patient safety summary Harm incidents 15 incidents where patient harm had been reported required investigation/follow-up 2 incidents were removed, as investigations showed these were unrelated to Epic 9 incidents were rated as causing moderate harm, 5 as minor harm, and 1 graded as major (VTE SI see right) 3 Serious Incidents (SI) reported to CCG Business continuity No harm recorded Analyser interface Hospital Acquired Thrombosis 3 patients - pulmonary thrombosis Investigation completed / discussed with HM Coroner None solely related to Epic

23 Computers are distracting!

24 The major problems we have Training staff is a full day Wall mounted computers are in the wrong place and not used Able locums are harder to find

25 The major problems we have (2) Non standardised workflows Clinical productivity is reduced in all areas by about 20% Consent / ECGs are paper and then scanned in Our system doesn t talk to the GPs

26 Audit Standards Printing is a problem (standard 7) IT makes everything better or worse

27 Not all bad For clinicians Clinical Records much easier to review Virtual fracture clinic 4,500 appointments freed up 200k / year saving For patients Reduced repetition of history Drug errors are less Routine checking of x-ray reports and blood tests takes less than 2 hours / day

28 Then CQC came. CQC inspection visit April 2015 Report published in September 2015 CUHFT placed in special measures and rated as inadequate CEO Dr Keith McNeil resigns

29 With hindsight Engage, engage, engage Test in advance and say no, we aren t ready! Simplify your processes Referrals / Pathology / Radiology

30 With Hindsight Train on a system that looks like your real system Train shortly before go live Train again Train by peers who actually understand what you do

31 Big Bang or Phased Implementation? Big Bang Short term pain Economies of support staff Planning and support Phased Implementation May be abandoned Less disruptive

32 @dradrianboyle