One small step for Lorenzo

The much-delayed Lorenzo has finally gone live in an acute setting. University Hospitals of Morecambe Bay NHS Trust has given the electronic patient record a “soft landing” in one ward at Furness General Hospital. Lyn Whitfield went to see if this small step for Lorenzo is a giant leap for the National Programme for IT in the NHS.

Morecambe Bay looks stunning at this time of year. As the train makes its way from Lancaster to Barrow in Furness, the Lake District’s hills appear on the right, still showing a few autumn colours, while the sweep of the bay opens up on the left, the water already bleak and wintry.

The view confirms that repeated ministerial assurances that University Hospitals of Morecambe Bay NHS Trust would go-live with Lorenzo by the end of the summer were some weeks off the mark.

Nevertheless, the trust has become the first in the country to be able to say that it is using the iSoft electronic patient record in an acute setting – albeit on a very small scale.

Ward five of Furness General Hospital, a modern, red-brick DGH built into a hill near Barrow’s famous dock-yards, is using Lorenzo in parallel with its existing paper systems to record alerts, allergies, problems and procedures, to interface with the trust’s radiology information system, and to create discharge summaries.

Eventually, the ward will move from a “soft landing” to a “hard landing” and paper orders will be discontinued. Meanwhile, a second “soft landing” on a medical ward at the Royal Lancaster Infirmary is being planned.

With this ultra-cautious approach, the trust is clearly determined to avoid some of the problems that have hit the “big bang” deployments of England’s other “strategic” care record system, Cerner Millennium, in the South and London. But a huge amount of work has gone into getting this far.

One year on

Steve Fairclough, the trust’s head of informatics, says: “We got involved [with the National Programme for IT in the NHS] fairly early, by deploying theatre, radiology and PACs systems and a replacement PAS; iPM.

“So we got to understand the national programme; its quirks and how to make it work for us. We also got interested in creating an electronic patient record and using it not just in an acute setting but across the health community.

“That got us involved in a strategic partnership programme, which got us into testing Lorenzo Release One (R1) and R2, and into doing some crystal ball gazing around the requirements for R3 and R4.

“Then, we were looking to take iCM. But when it became possible to move from that to Lorenzo R1, we decided to do it. Our early adopter programme has been running for about a year, and we went live on 24 October. We took the ‘soft landing’ approach, because that is how we would deploy any new software system.”

The trust hosts a health informatics service that serves the whole health community. Twenty of its staff have been working on the early adopter project, while NHS Connecting for Health, the agency that runs the national programme, and CSC, the local service provider, have each provided another 100 in support.

Ward ten at Furness General Hospital, which is normally used when other spaces are being refurbished, has become a hub for working on the new system.

Over the past year, Fairclough says the project has busted bugs in Lorenzo and got it to work in a “technically complex” environment. “We have the spine, we have our own integration engines… in total, there are 18 components that have to come together to make this work,” he says.

The trust has also customised elements of the system. For example, staff currently use differently coloured cards to order different types of test, and these colours are now reflected in Lorenzo. It has also written its own on-screen guides and prompts.

“We went through six cycles of end to end testing, and from step four those tests were run by clinicians to see if they could make it work or break it,” Fairclough says. “That flushed out lots of issues we had not previously thought of.”

Back in Westminster

In March, health minister Ben Bradshaw told the House of Commons that three implementations of Lorenzo were anticipated this year. Podiatrists began using the system at one of these, South Birmingham Primary Care Trust, in the summer.

But as recently as October, when the media was full of stories about the national programme stalling, CfH was unable to give a timetable for a go-live at Morecambe Bay, where Bradshaw had originally promised that Lorenzo would be in use by June, later amended to the end of summer.

Patrick McGahon, the trust’s director of service and commercial development, says its board was always clear that it would not be pushed into a go-live before it was ready. “The board’s engagement with this has been very significant,” he says.

“As a board, we are very interested in how to move services forward and in how IT can do that. But we have also been clear that these are safety critical systems and they must work. We took a very robust attitude that we would only do this when we were happy with it.”

On ward five

Sue Shaikh, a project specialist, explains that the outcome is a system that is fed by the trust’s PAS, iPM. When clinicians log on – using their CfH smartcards – they are presented with their own patient list.

Behind each entry sits a patient record, identified by a patient banner that incorporates NHS Common User Interface work on presenting names, dates and other items, and using the standards for hospital records released by CfH and the Royal College of Physicians.

“I worked on that project, so I made sure we copied it,” says Dr Sydney Schneidman, a consultant in emergency medicine and the trust’s clinical lead for health informatics.

From the record, staff can enter and view alerts, allergies and problems, order tests from the radiology system, pick up the results, and create discharge letters. The trust is currently replacing its pathology system, but it will be interfaced with Lorenzo in due course.

Although the “soft landing” means that junior doctors and other staff are having to fill in both paper forms and Lorenzo screens, Helen Thompson, ward five’s ward manger, says they “love” the new system.

“Before Lorenzo, if we wanted to know what had happened to a test, we would have to phone the radiology department to try and find out,” she says. “On Lorenzo, we can see what has happened. So I’m sure it will mean that nurses spend more time nursing.”

The trust has invested in a new nursing station for ward five to hold the computers and charging mobile clinical assistants needed to access the new system. But Thompson says staff have found Lorenzo easy to use. “I’m no computer expert, but it’s easy to work out once you get started,” she says.

Dr Schneidman, meanwhile, identifies the discharge summaries as a key benefit. At the moment, patients are given a carbon “flimsy” of the hospital’s discharge notes, but these can be “barely legible.”

The intention is to use Lorenzo to generate electronic summaries that can be reviewed by senior clinicians and sent straight to GP systems using the community of interest network.

To ward four, and beyond

Those involved in the early adopter project insist that they would not have been better investing in alternative solutions. “Perhaps because we are in such a rural area, we are really committed to a vision of a single electronic care record and sharing information across healthcare boundaries,” says Fairclough.

“We have investigated putting electronic patient records into that sort of setting, and it is very expensive and very hard to do. When the national programme came along, we felt that for the first time people were listening to what we wanted, because being able to transfer records around Morecambe Bay is massive for us.”

Dr Schneidman is also convinced that Lorenzo is a good system. “This is the fourth or fifth EPR I have seen in my career, and it is the best I have seen in my career,” he says. “And I am very confident that at the end of the journey we have been on it will do what we want it to do.

“We in this trust have been willing t take some pain, because this will allow us to engineer change and, ultimately, patients will benefit from that.”

Nobody is willing to say, on the record, when the “hard landing” for Lorenzo will take place or when it will be rolled out beyond its next “soft landing” in Lancaster. But Fairclough says: “The intention is that, when we get to the end of the pilot phase, we will learn all the lessons and then move the project team into deployment mode. At that point, we will want to do a ward every fortnight, or perhaps go even quicker.”