The Big Bang Theory of EPR Implementation –the Yorkshire experience

CHFT• Large DGH

• Acute services• Some community services

• 820 beds• Cover population: 500,000• 2 CCGs• 2 Hospital sites• 2 ED departments

BTHFT• Large Teaching Hospital • Acute services & Community services• 900 beds• Cover population: 530,000• 2 CCGs• 2 main hospital sites• 3 community hospital sites• Several satellite sites• 1 ED department

CHFT / BTHFT CERNER EPR • Where?

• Emergency Department• Inpatients and Outpatients

• What?• PAS• Medical and Nursing Notes• Ordering and Investigations• Capacity Management• Health Information Exchange• Patient Portal• ePrescribing

1 st big bang! Calderdale and Huddersfield 820 beds 29/30th April 2017

2nd big bang! Bradford Royal Infirmary /St Lukes / WWG/WWP/900 beds 23rd /24th September 2017

DOCTORS’ WORKLIST

helpNURSES’ CARECOMPASS

PHARMACY CARE ORGANISER

PATIENT SUMMARY

DRUGCHART SUMMARY

DRUG CHART

ED - FIRSTNET

ORDER SENTENCES

helpALLERGY

EPR

POWERPLANS

MED HISTORY SNAPSHOT

DISCHARGE RECONCILIATION

helpDISCHARGE SUMMARY

helpHEALTH INFORMATION EXCHANGE

helpPATIENT PORTAL

• 12 staff ( 5 WTE Drs / Nurses/Pharmacy)

• Safer Prescribing compared to paper

/Increased Visibility / Remote viewing

• Local configuration of Cerner UK Standard plus

custom build

• Drug Formulary Status to improve cost-

effectiveness/reporting

E – Prescribing Workstream

• 9000 Order sentences preset with drug , dose route

and directions to direct prescriber to correct dose

• Age/weight filtering of order sentences

• IV sets with pre- built dose, diluent , volume and

directions

• Improved Antimicrobial stewardship with clear

stop/review dates and reasons for starting antibiotics.

• Powerplans for more complex drug regimens eg.

Insulin/Warfarin

• MAJOR drug interactions alert and reasons

• Barcode wristband scanning of patient – displays drugs

due at that time

• Improvements on missed /delayed doses

• Reduced Inappropriate Drug administration

• Improved Discharge information and tracking

But how didwe get here?

OPTIONS• Phased rollout – by scope or location – can lose momentum

?patient transfer• Rolling thunder – risk of dual paper/EPR system • Big bang

- All functionality available at go-live - Efficient use of contractor support- Swiftly embeds new system- An instant ‘single source of truth’‘We’re all in this together ’

Risks can be minimised by extensive testing , rehearsalProductivity reduction 25% in first 6 weeks after golive

Teams – more than transcription

2 Docs 2 Pharmacists Lead

• 1 team can do an average of 4 wards (areas) in a 12hr shift• Teams consists of 1 prescriber/2 transcribers/1 floorwalker

• Huddersfield = 18 wards (areas) = [1 team]• Calderdale = 18 wards (areas) = [1 team]

Therefore 2 teams required over 5-7 days

• Bradford = 33 wards (areas) = [2 team]• St Luke’s = 7 wards (areas) = [1 team]

Therefore 3 teams required over 5-7 days

Rolling Thunder 5-7 days

• 1 team can transcribe 30 bed ward in 3 hours • Teams consists of 2 prescriber/2 pharmacists /1 Leader

• Huddersfield = 18 wards (areas)*3hrs = 54hrs [5 teams]• Calderdale = 18 wards (areas)*3hrs = 54hrs [5 teams]

Therefore 10 teams required

• Bradford = 33 wards (areas) *3hrs = 99hrs [9 teams]• St Luke’s/Community = 7 wards (areas) *3hrs= 21hrs [2

teams]Therefore 11 teams required

Big Bang approx 12hrs

Note: Times are based on previous go-lives at other Trusts –True timings will be identified during the trial load cycles

Fri 18:00 (approx. 5 hrs)

Fri 23:00 (approx.

6hrs)

Sat 05:00 (approx. 18hrs)

Sun 01:00 (approx.

5hrs)

Sun 06:00 (approx. 12hrs)

Sun 18:00(Approx.)

Old PAS switched

off

New PAS switched

on

Paper based ‘downtime’ patient flow system in use (see below)

Paper based system for managing patient flow during cutover include

• Presentation to ED forms – completed by ED receptionist• Admission to ward forms – completed by ED board nurse• Discharge from ED – completed by ED board nurse• Discharge/Transfer from ward – completed by ward nurse/clerk• Admitted to ward via GP/other route, not ED – Completed by receiving ward nurse/clerk• Bed management/patient flow spreadsheet – completed by centralised 24hr ward clerk/management team• All forms collected during cutover weekend and data entered by teams rotating around wards

Data Extraction Data Transformation Data Migration Trust Testing

Data Catch-up/Transcribing

Go-Live

Sunday 06:00 – 18:00 Approx.Data Catch-up/transcribing

04 06 07 09 1005 1208 13 14 15 16

Trust Testing

17 18Key activity

Patients in Beds (low turnover)

A&E Admitted Patients

DVT, Allergy, FB Charts (low turnover)

Go-Live

UptimeA&E Whiteboard

Drug Chart Transcribe (low turnover)

A&E Discharged Patients

Patients in Beds (high turnover)

DVT, Allergy, FB Charts (high turnover)Drug Chart Transcribe (high turnover)

Additional data (e.g. paper requests)

Additional data (e.g. paper requests)

Uptime

All Inpatient drug charts transcribed into EPR - except complex infusions ,warfarin, IV fluids ,TPN . Didn’t do daycase,maternity, some PRNs All charts reviewed pre-cutover –de-prescribing and errors

LESSONS LEARNED• Access issues – incorrect privileges• Lack of hardware• Training could be improved • Superusers versus friends• Floorwalkers from other EPR sites• Nurse witness passwords• Not sending correspondence to GPs• Staff not released for extra training/review SOPs

or to use play domain• SOPs not published soon enough• Drug chart cutover – EPR demands a more exacting

standard so is more than just transcription

LESSONS LEARNED• Don’t design in workstream silos– duplication of

effort – eg 2 different Oxygen assessments were build . No pharmacy support in ED workstream –incorrect doses found in testing

• Order Comms ordering “privileges” are different from Prescription ordering privs

• Importance of PAS• Dress rehearsal/timings of cutover• Bradford go-live 6 months later was smoother

than CHFT –had team of CHFT experienced staff

PHARMACY SUCCESS• Completed Dr Prescribing Training and

then pharmacy specific training • 16 super-users CHFT to support the

wider team• Protected time out with the SOPs and

access to play-domain. You tube• Pharmacists were a great wealth of

knowledge to support medical and nursing staff

• Whatsapp groups • Widely consulted for EPR prescribing help

– teaching/training• Dr survey – 80% prefer EPR to paper

Questions?