Case Study Site D

Background and Methods

This Trust provides acute care for ~3,000,000 patients in an urban setting. It started implementation of a partially integrated ePrescribing module in 2009. Data were collected at the site between May 2012 and April 2013. We conducted 21 interviews with users (including pharmacists, nurses, doctors of varying levels of seniority) and implementers, and four observations (nine hours) of strategic meetings and system use. In addition, we collected notes from a recruitment meeting and three documents relating to anticipated/planned changes associated with the implementation (e.g. work process maps, implementation plan, business case).

At the time of data collection, the system was implemented in all inpatient wards except paediatrics. Functionality included prescribing of all medicines except: variable dose insulin, patient controlled analgesia, and intravenous hydration fluids. Some other medications such as warfarin were only partially supported. In terms of decision support, the Trust used order sentences, order sets, allergy checking, and some locally customised pop-up warnings. They had not switched on drug-drug interactions, duplicates, or contra-indications functionality. Clinical noting was not implemented, but users had the ability to see laboratory and pathology results on the system.

The Trust is planning to implement a fully integrated EHR from the same supplier across the organisation.

Key Challenges / Findings

Our work showed that, years after the implementation, information was still distributed amongst many different sources as the integrated system was not fully implemented. Full potential benefits were therefore not realised as yet. We also found that on-going work over extended periods of time after the initial implementation was required to customise existing functionality (particularly in relation to tailoring the system, which was developed in the USA, to the UK context); learn the extended range of functionality available; refine decision support systems; and implement increasing modules of the wider integrated system. This required a dedicated implementation team, who was gradually learning the complex skills associated with these activities. A challenge in this context was the expertise needed to manage increasing functionality and data generated by the system. For example the increasing amount of data available for secondary uses, resulted in complex considerations surrounding which data to extract and focus on.

Lessons Learnt / Key Messages

On-going work is required to implement and customise an integrated system of great complexity and this is likely to take place over long time-frames. These activities and associated resources, relating to staffing and organisational capacity, therefore need to be planned for in advance. Appropriate refinement of systems is likely to help hospitals realise the significant benefits associated with the more sophisticated functionalities of systems, including secondary uses of data and clinical decision support.

NIHR Programme Grant for Applied Research, Principal Investigator: Professor Aziz Sheikh
Collaborators' logos The University of Edinburgh Harvard University The University of Nottingham University of Birmingham University Hospitals Birmingham
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