Below is the story of why IM& T works so well at Trafford General Hospital in Manchester. These are four of the lessons:
- Be in control of your IT suppliers. Too often in the public sector it’s the other way around.
- Don’t buy from suppliers that seem excessively secretive and talk much about their proprietary information - which may include your data. Know their systems well enough to produce the reports you want, when you want them and in the format you want, rather than wait for your information to be given to you when the suppliers want to give it, and in their format.
- Don’t impose change. Have the push come from the business users [in Trafford’s case nurses and clinicians] who understand what technology can do for them.
- Keep IT in the background - not centre stage.
Laura Slatcher dreams of forms - reducing the number of them.
She works with a small IM&T team at Trafford General Hospital that is trying to standardise and reduce the number of paper forms doctors and nurses use in the care and treatment of patients.
As is typical for a hospital of its size there are up to 70 - mostly different - paper forms on every ward. Slatcher is working with clinicians to define ways of switching from paper to electronic records - which they are doing with alacrity.
“We have to standardise here,” says Steve Parsons, Head of IM&T at Trafford Healthcare NHS Trust in Manchester. “The doctors and nurses welcome that. They want to work better and more efficiently because they are under pressure themselves to do that.”
Trafford General bought its main systems outside of the £11.4bn the National Programme for IT [NPfIT]. The hospital, though, is one of the most technologically-advanced in the UK says Peter Large, Trafford Healthcare NHS Trust’s Director of Planning.
There has been no risky “Big Bang” implementation of a Whitehall-bought patient administration system. Rather, Parsons’s approach has been step by step progress over 10 years: implementing systems, learning from what went well and not so well, and integrating hardware and software from a range of suppliers. This strategy could help to explain why the clinical staff we spoke to at Trafford hold the small IM&T team in high regard.
In 2000 the hospital had rudimentary technology - isolated systems in some departments. Now the IM&T team is able to give clinicians what they have asked for; and at Trafford it’s the doctors and nurses who say what they want. Systems are not imposed on them. Here the technologists are in the background, not centre-stage as in the NPfIT.
Trafford and the NPfIT
Says Large “We found ourselves in the position of being ahead of the game. When we were asked to commit to the National Programme we held back because we needed to know we would be committing to a better solution than was already available to us."
Parsons adds “Some trusts didn’t really have anything at all so were desperate to be in the first wave. From their perspective the national programme was a brilliant step forward. But the right products never arrived.”
One reason for Trafford’s success is the integration of the hospital main and departmental systems. Before electronic patient records, patients could come into hospital without their paper notes being available. Now doctors across the hospital’s departments and clinics can access at the hospital’s XML-based electronic patient records at any time, day or night - and from home if they have remote access.
Doctors can view x-rays and assessments of them from the patient record; and from system alerts and patient tracking, operational managers can see how well individual doctors and nurses are coping with the numbers of patients on their daily lists.
No black-box technology
The hospital’s three main systems are an electronic patient record from Graphnet, software to schedule and manage appointments from Ultragenda, owned by iSoft (now acquired by CSC), and the “Ensemble” integration engine from InterSystems.
What sets these and the hospital’s other systems apart is that they are not black boxes, impenetrable to Trafford’s technologists. Parsons insists that Trafford’s suppliers make their software transparent so that it can be understood by the hospital’s IM&T staff and integrated with other systems, at database “field” level if necessary. That way Parsons can produce any report clinicians need and usually in real-time.
When a supplier keeps its software opaque for reasons of proprietary and commercial confidentiality, Parsons is restricted in the type of medical and administrative reports he can ask the company to supply - and may have to wait hours or a day to get them. He wants none of that.
It’s this level of control that Parsons believes he has a right to expect - and he seems a little surprised that CIOs don’t always require openness from their software suppliers.There again Parsons is a civil engineer. It's a world in which openness is allied to safety. Parsons designed buildings and pumping stations in the water industry where managers don’t tolerate unnecessary secrecy from their suppliers. From there he became involved in managing IT-led change and came to Trafford General Hospital in 2000.
He says that hospital data belongs to the hospital, not the supplier. “There are people working in the health service who will say: ‘we are the system supplier. It is our data.’ But ours is patient data. This is client’s data, not the supplier’s.”
To an outsider - one who doesn’t work in the NHS - the most surprising thing about seeing the IM&T engine rooms at Trafford General is the complexity and the different ways each ward works. These complexities have to be managed to give doctors and nurses a seamless view of what is happening with each patient.
Could the NPfIT ever have worked?
It’s remarkable, given these complexities, that anyone thought a national system - the National Programme for IT in the NHS - could ever have worked. It’s hard enough to integrate IM&T within a single hospital let alone on a regional or national scale.
Parsons and Large consider it lucky that Trafford went live with the Graphnet patient record technology as early as 2003, several months before the tenders for the NPfIT systems were awarded.
It meant that, while some in the NHS were waiting in eager anticipation for NPfIT systems that never arrived, Trafford’s technical staff were learning in precise terms what clinicians wanted and converting this knowledge into working systems. At no point did the promised national systems offer more than Trafford’s.
How patients benefit from Trafford’s IM&T
In a room close to each ward is a 46” screen known as the “whiteboard” which shows lists of every patient, whether in a bed or visiting outpatients. Allied to the patient’s name are relevant details including colour-coded alerts to warn if a VTE [thrombosis] check hasn’t yet been done, an observation is overdue or an x-ray has not been assessed. In A&E the icon turns red if a patient has waited for three hours, and purple if more than four hours.
Also on the whiteboards, breaches of Department of Health guidelines on waiting times are shown clearly for each patient. The screen also shows which doctor is responsible for any breaches of waiting times.
If nothing else, these system alerts and icons - which include ticking clocks - show how technology can make treatment and care safer for patients.
Why doctors keep their smartcards at all times
Clinical staff must use smartcards to access the system, and they are unlikely to forget them because they also allow access to the car park.
In trials of NPfIT systems, some doctors were reluctant to use smartcards because of the time taken to log on each time they returned to the computer. At Trafford log-on takes a few seconds, and Imprivata’s single sign-on means that holders of smartcards do not have to remember different passwords. Take out the smartcard and the screen goes blank.
Says Parsons “We are dependent on EPR now. A year ago one or two consultants refused to look at the EPR. Their secretaries had to print off the last letter from outpatients because they would rather not look at it on a screen. That’s changed.”
Patients give their details only once
In parts of the NHS patients give their name and address every time they visit a different part of the hospital. At Trafford General Hospital a new patient has a file created at, say, A&E. It is then available to all parts of the hospital, ready for staff to order electronically a blood test or x-ray, or book an appointment.
Links to GPs
Through Sunquest's Anglia order communications system and using the HL7 messaging standard, GPs can from their desks order hospital blood tests and x-rays, and get the results in their inboxes. The orders and test results are recorded in the hospital’s Graphnet EPR.
If the local GP has authorised it - and so far about half in Trafford’s catchment area have - A&E doctors will soon be able to see a synopsis of the GP-held patient record which would show any treatments outside the Manchester area as well as medications and significant medical events. The synopsis comes into a hospital server that is controlled by GPs, using their local Emis or Vision systems. In return, GPs have access to their own patients within the hospital-based EPR where they can see all the records related to a patient’s episodes of treatment .
Real-time view of free beds
On the whiteboard, staff can see when beds are due to become vacant, doctors having given the system an estimated time and date of departure for each inpatient. If a doctor fails to give an estimate the system shows an alert.
Says Slatcher “Doctors are restricted with what they can do with the patient’s record - cannot make referrals, cannot update whiteboards - unless the estimated discharge date is kept up to date. Doctors will complain that they cannot get on because clerks or nurses haven’t kept this administrative information up to date.”
The estimated discharge date is also useful to ensure that the system has alerted district nurses if the patient, after leaving hospital, needs physiotherapy, dietary monitoring or help from social services.
Bed management is a module now removed from the “Lorenzo” system as part of the Department of Health’s plans to cut the costs of NPfIT contracts.
Duplicated patient records are rare
Parsons and his team have done much to tackle the bane of hospital administration: duplicate patient records. Says Parsons “We have a central patient index which is updated nightly from all GP practices. If you say your name we check date of birth and previous addresses, maybe from the GP - you may still get two people with the same name living in the same house.
“Once we have updated John Jone to John Jones, the central system will update all other related systems to the new spelling. One single ID for everyone avoids having duplicates which could end up with patients having the wrong records. That’s critical to get right.”
Medical Director Dr. Simon Musgrave says “Duplicates are a fairly rare event now.”
Staff in A&E can create duplicates very easily from patient provided information but “we have systems in place to track those in the following 24 hours and merge them back to the correct record", says Parsons.
The hospital’s old iSoft patient administration system had 150,000 duplicate files in a database of 460,000 patients. That was typical for an acute hospital says Parsons.
Trafford dispensed with its patient administration system - it doesn’t have one, having replaced it with the Graphnet's EPR and Ultragenda from iSoft [now owned by CSC].
EPR goes beyond Trafford
Many doctors are sceptical of the need to make electronic patient records available across England, which was one of the main - and ultimately unsuccessful - aims of the NPfIT. The sceptics say it is very rare for patients to need treatment outside their locality.
Trafford has 250,000 patients in its catchment area but its EPR has 1.4 million records which includes most people in Manchester.
Trafford adopted the Department of Health’s pre-NPfIT strategy in the late 1990s which called for hospitals to install, incrementally, six levels of EPR - electronic patient records. Level one was a patient administration system and departmental systems. The highest, level six, was a full multi-media EPR online.
Says Parsons “I have been fortunate of having the support of the Trust Board throughout the 10-year period of staying on a strategy that said: ‘we will continue to build that six-level EPR and all that went with it until an equivalent and better came from the National Programme for IM&T through Connecting for Health’.”
Reporting, accountability and safety
Trafford publishes hundreds of reports to operational managers: how long patients have been in their bed or how have they waited, how many patients have had certain types of forms filled in such as VTE forms. Every morning emails to consultants tell them the number of patients they had admitted the day before and how many have not had, say, thrombosis assessments.
Standard reports from some suppliers to the NHS may be too limited for Trafford’s demands, says Parsons. “Some of the questions we are asking require difficult algorithms. On bed occupancy for example doctors get credits for the numbers of patients they are caring for. The standard unit for care is one day or night in hospital. If somebody is in for six hours, if you work in units of one day, nobody gets credits for that. We want to break IM&T down to parts of days and look at trends.”
Ensuring patient safety during the transition from paper to computer needs careful management.
Says Musgrave “When you ask for an x-ray [on paper] you fill out a form, get the x-ray done, and the x-ray report is written on a piece of paper which comes back to you so your secretary gets a bit of paper that says “cancer” on it. That’s the end point, the safe point, and you do something about it.
“If you order it on a computer and you do not have a paper record, you have to have some other different system for making it safe. How do you know the x-ray has been ordered, has been done, and been reported? And what is the report? There is no back-stop there unless you invent one via the computer.”
“Will we ever do entirely without paper?” asks Parsons. “Hmm.”Some of Trafford's further challenges include:
- Securing the agreement of all GPs in the area to share a synopsis of their records. About half have agreed so far.
- Scanning in all paper notes to the EPR. At present about 50% of patient notes have been scanned and are available to clinical staff as “PDF” files, normally with chapter headings. They include diagrams, charts and handwritten text.
- Dealing with any uncertainties that arise when the Trust is acquired - in all probability by Central Manchester Foundation Trust .
- Maximising the IM&T opportunities that the acquisition will bring both Trusts in terms of modernising systems and extending the concept of the shared electronic patient record across a wide area of Manchester.
Trafford has 14 people working on IM&T and IT infrastructure related matters who handle support, infrastructure and integration. The total yearly cost, including salaries, is about £1.5m in capital and revenue which covers the spend with all of Trafford's IM&T suppliers.
This compares with costs of between £23m and £31m for each NPfIT installation at acute trusts in London and the South - and these sums do not include the costs of running a hospital’s IM&T and associated infrastructure. Neither do the NPfIT costs include the salaries for an acute hospital’s IT and IM&T staff.
Says Parsons “This is bargain stuff”.
If Trafford can do so much for so little, can centrally-bought NPfIT systems costing many times more - for less - still be justified? The Department of Health argues that NPfIT systems offer more than non-NPfIT. But how much more could Trafford offer its clinical staff, in terms of proven technologies and integration?
Asked where he’d put Trafford in a league table of UK hospitals with systems that clinicians need and want to use, Large says with a slight smile “Let's be modest - in the top 10%."
He's probably not joking.
**Since writing this article Parsons and his team have been short-listed by the eHealth Insider Awards for the trust’s electronic whiteboard project, in the category of “innovation in healthcare interoperability”.