Research points to serious issues in EPR acceptability

‘Few would dispute that the vision for the Electronic Patient Record (EPR) is acceptable. The majority of clinicians and clients would welcome the use of EPRs in the ways ‘Information for Health’ depicted them. The reality is very different, however, and current EPRs are far from fulfilling the high expectations of the policy makers and the users. Nor is it simply a question of time before the nirvana of new and better systems arrives. Our work suggests that future EPRs (whatever they are called) are unlikely to be significantly different to, and significantly more acceptable than, current EPRs unless some fundamental changes take place in the way EPR development is being taken forward.’

(Jones, Hart, Henwood, 2003 p 240)

This is the main conclusion of a recently-released research report to the Department of Health, Policy Research Programme by Andrea Jones, senior research fellow, Dr Angie Hart, principal lecturer, and Chloe Gerhardt, research officer at the Centre for Nursing and Midwifery Research, and Dr Flis Henwood, reader, Social Informatics Research Unit, all at the University of Brighton.

Entitled ‘The Use of Electronic Patient Records (EPRs) in the maternity services: professional and public acceptability’, the report argues that there is a large rhetoric-reality gap in relation to ICT policy and practice in the NHS and makes a number of recommendations about what makes the use of EPRs more and less acceptable to the NHS staff and patients/clients expected to use them.

The findings are based on research that was undertaken over two years (2001-2003) using quantitative methods (survey of English maternity services, response rate of 74%) and qualitative methods (detailed case studies in four NHS trusts).

The report does not make easy reading for those framing ICT policies and it warns those charged with implementing ICT policies in the NHS of the uphill struggle ahead. For example, it is critical of the way policies have raised the expectations of NHS staff and patients beyond what is likely to be achieved with EPR systems over the next few years. The authors conclude that NHS staff are likely to be disappointed by the EPR systems being developed in NHS trusts, and a high risk that past cycles of inflated expectations leading to cynicism will be repeated.

Another key finding is that whilst senior IT professionals leading EPR developments in NHS trusts talked of clinical ‘ownership’ the actual organisation of procurement processes and other ICT related activities showed that IT professionals were really in the driving seat and the involvement of, or consultation with, clinicians was very limited. In one case study site, for example, IT professionals undertook the roll out of new PCs to the maternity service as part of ‘Project Connect’, with no consultation with clinical or managerial users.

There was also evidence that, at an NHS trust level, virtually no thought had been given to patients as ‘users’ of record systems. Those leading EPR developments in NHS trusts anticipated the role of patients/clients to be a passive one, as ‘beneficiaries’ of new EPR systems, despite countless policy papers encouraging patient involvement.

More common information system implementation problems were also identified in this research. Clinicians – in particular – having the time to get involved and have a constructively critical voice in EPR developments was one of the biggest problems in the case study sites, with the exception of one, which the researchers named the EPR ‘high flyer’ site. Knowledge and experience amongst NHS staff responsible for project managing procurement and implementation processes within clinical departments was also a problem, with most of these staff having no prior experience of this work, and little learning taking place within or between NHS trusts.

High levels of duplication arising from the continued use of paper systems was another finding that echoed previous research, though, on the whole, clinicians were not found to be resistant to changing practices as is commonly assumed. Observations of clinical practice showed that clinicians valued paper records mainly because they provided a more flexible, reliable form of record-keeping than existing EPRs. This was especially important in maternity where the paper-based Client Held Record (CHR) is used in all services to ensure continuity of information and encourage patient/client involvement in their care.

One particularly interesting aspect of maternity services experience was the conflict generated in our EPR ‘high-flyer’ site between the EPR system designed to support day-to-day clinical practices, such as discharge reporting, or prescribing (the Hospital Information System), and specialist EPR systems designed to support clinical research and audit (the Maternity Information System). This conflict had significant implications for the acceptability of the trust-wide EPR system by senior doctors and senior midwives within maternity.

A lynch-pin role in relation to this conflict, and other clinical governance issues, was that of the ‘IT Midwife’ (or ‘System Manager’). This post was found to be crucial for the on-going maintenance of EPR systems, for sustaining the quality of data, motivation and understanding of midwives entering data, and for the ability of systems to produce meaningful clinical data. Clinical managers’ support for such roles was, however, variable across NHS trusts.

All-in-all the report provides a very comprehensive picture of the current issues raised by EPR development in a service like maternity, and a detailed picture of the reality of NHS staff and patients/clients experiences.

For further details contact Andrea Jones at:

Centre for Nursing and Midwifery Research, University of Brighton, Faculty of Health, Mayfield House, Village Way, Falmer, Brighton BN1 9PH

Telephone 01273 644109

Electronic copies of the Executive Summary and full report are available from www.inam.brighton.ac.uk/eprproject.htm