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What is the context?
Simon Noel, Chief Nurse Informatics Officer, Oxford University Hospitals NHS Foundation Trust
Health systems worldwide are complex and subject to multiple competing pressures, mainly concerning the staffing and resources available to meet the demands of ever-changing health and care goals. The place of good data and a dynamic record system is key to understanding the problems and requirements of the now and providing enough structured data to enable those who facilitate these care systems to understand the context of these demands. Whilst it is true that the use of comprehensive digital solutions is not available to all, where they are used, they potentially provide many benefits to comprehensive care and improved clinical knowledge. However, digital systems are a tool for assembling, managing and presenting clinical data. They do not replace clinical and operational accountability and are only as effective as the data they are given and the context in which they are implemented.
In the United Kingdom, the impetus for change and the optimised use of EHRs in the NHS has been repeated on multiple occasions since the early 1990s. Each attempt has been aimed at providing strategic direction, finding the right solution, and promoting engagement and uptake. In the presence of continuous clinical, operational pressures, balancing major strategic implementation with the resources required to continue business as usual is a significant challenge at an organisational, local, regional and national level. The challenges of funding, resources, and enabling the workforce to integrate digital workflows successfully have been present in every NHS initiative that has been published since 1990. Although time has moved on, these challenges have remained constant.
“In the United Kingdom, the impetus for change and the optimised use of EHRs in the NHS has been repeated on multiple occasions since the early 1990s. Each attempt has been aimed at providing strategic direction, finding the right solution, and promoting engagement and uptake.”
What do we know?
The effective provision of a comprehensive record is not an easy task. Whether the goal is to utilise a single platform or use a hybrid build, there will always be the need for some form of integration; minimising data silos and the effective sharing of data must always be considered, especially when paper workflows are still in use. Hybrid digital systems also depend on effective connectivity and interfacing, not just for local bedside devices but for differing digital systems and specialised applications. This interfacing requirement also extends to services and treatment functions, where partner providers collaborate, and effective data sharing is paramount to ensuring safe and effective transfer of care information to facilitate the patient journey through the system. Using technology to understand where the patient is in their journey and how the general patient population is being served is only possible using accurate and timely data to optimise clinical pathways to improve flow and identify the care need gaps in the patient population. This may be further enhanced through patient inclusion in the oversight of their care and treatment by providing access to their record and the function to dynamically interact with their care process and the clinical teams.
What do we need?
To facilitate effective digital systems, on an organisational and a cross-organisational level, some key themes must be in place.
• Executive engagement/buy-in is essential to ensure appropriate organisational leadership to promote organisational direction and compliance with digital strategy. Without clear guidance from the top, a digital direction may not match organisational needs and may see individual teams choose their own solutions by focussing on local needs, potentially conflicting with the overall strategy.
• A robust change and management process is key to keeping track of the organisational position, understanding requests, and conflicts of interest, and ensuring clinician engagement through the provision of appropriate functionality.
• Long-term planning for digital support and direction must be in place from the start, understanding that support doesn’t stop at the completion of implementation; ongoing maintenance, support, and development must be factored in for clinical applications and physical infrastructure.
• Effective reporting and organisational oversight; management of what is happening and how it is happening will allow the organisation to know where it stands and what needs to be done, which will help to promote planning against organisational and clinical requirement.
• Investment in a skilled technical and management team will allow dynamic operational response to clinical needs and understand how research, development, and innovation may support improved operational effectiveness and help use new technology to promote better outcomes.This may be the most important aspect ofplanning for an EHR, as rapid response to clinical need and the implementation of change will allow digital to be a dynamic tool and win the confidence of services and clinical teams.
• Investment in a digitally literate clinical workforce will allow the technology to be used effectively and reduce barriers to efficient EHR use.
What are the benefits?
Through effective investment, planning, and operational structure, an EHR can support improved clinical outcomes using clinical data to strengthen operational oversight, patient flow, and treatment information to assist clinical governance and service performance data in maintaining quality. Both quality and patient outcome measures can provide key metrics to evidence performance and investment strategies.
Good data can also be monopolised to direct treatment and advise clinical decision-making. Clinical guidance at the point of care may help raise awareness of potential clinical risks, such as Venous Thrombus Embolism or management of dwelling lines. The recognition of patients at risk allows the clinician to understand what is required for effective patient workload management and to ensure the clinical process is followed; appropriate protocols are identified and implemented. This is not necessarily AI, but the promotion of effective patient management through rules and algorithmic alerts. However, these data may then be used to provide support oversight of clinical risk in near real-time; learning from historical data can allow early flagging of patients at risk by the analysis of trends and underlying diagnostic information using an AI platform.
What is the bottom line?
The implementation of an EHR cannot be seen as a single discreet project with a finite conclusion. To be successful, it must be seen as a cultural change with multiple factors and complex interactions on a multitude of technological and organisational levels. Appropriate investment in people and technologies will allow the assimilation of data from a variety of resources to help guide care through the provision and utilisation of timely and accurate information.
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