Presentation from the International Congress of the Royal College of Psychiatrists 24-27 June 2014, London

1. The Electronic Patient Record (EPR)
in Mental Health
Speakers:
Dr Mike Robson
Lancashire Care NHS Foundation Trust
Laurie Beed
Dr Ashimesh Roychowdhury
St Andrew’s

2. Service user and carer perspectives – some reactions
How long will my electronic record be kept?
Will it be stored in more than one place, to make it secure against loss?
Why can’t apparently easy things be done, such as sending the diagnosis to my GP
following a consultation?
How do I get access to my record? Will I see it in a patient-friendly format, without jargon?
Will people without computer access or skills be able to see their record?
Will my record be portable if I move?
Do other local services have access to my record? Do commercial organisations have
access?
Will doctors be trained so that they are experts in using these record systems?
Is an electronic system being brought in as a money-saving exercise, or for the convenience
of health staff, not as a quality improvement measure?
Laurie Beed, May 2013

3. Some patients will welcome
online access to their records,
booking appointments and
ordering prescriptions, because
it will give them ready access to
their records, improve their
understanding and help them to
manage their health better
Some patients will not use
online access to their records
because of cost, difficulty of
understanding the technology,
an assumption that it’s always
breaking down and in any case
they just like to see the doctor
Some patients will welcome
online access to their records,
booking appointments and
ordering prescriptions, because
it will give them ready access to
their records, improve their
understanding and help them to
manage their health better
Some patients will not use
online access to their records
because of cost, difficulty of
understanding the technology,
an assumption that it’s always
breaking down and in any case
they just like to see the doctor
Laurie Beed, May 2013
Service user and carer perspectives - opposing views

4. Service user and carer perspectives – possible responses
• If new systems work well, are easily accessible, and
produce benefits in care, confidence about them should
grow
• The Royal College of Psychiatrists might produce a leaflet
about Electronic Patient Records, allaying some of the fears
about EPRs

5. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (‘The Francis Report’, 2013)
Recommendation number 244
Theme: Common information practices, shared data and electronic records
Service user and carer perspectives – remember it’s about safe care
There is a need for all to accept common information practices, and to feed performance
information into shared databases for monitoring purposes. The following principles should
be applied in considering the introduction of electronic patient information systems:

6. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (‘The Francis Report’, 2013)
Recommendation number 244
Theme: Common information practices, shared data and electronic records
Service user and carer perspectives – remember it’s about safe care
There is a need for all to accept common information practices, and to feed performance
information into shared databases for monitoring purposes. The following principles should
be applied in considering the introduction of electronic patient information systems:

7. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (‘The Francis Report’, 2013)
Recommendation number 244
Theme: Common information practices, shared data and electronic records
Service user and carer perspectives – remember it’s about safe care
• Patients need to be granted user friendly, real time and retrospective access to read their
records, and a facility to enter comments. They should be enabled to have a copy of
records in a form useable by them, if they wish to have one. If possible, the summary care
record should be made accessible in this way
• Systems should be designed to include prompts and defaults where these will contribute
to safe and effective care, and to accurate recording of information on first entry
• Systems should include a facility to alert supervisors where actions which might be
expected have not occurred, or where likely inaccuracies have been entered
• Systems should, where practicable and proportionate, be capable of collecting
performance management and audit information automatically, appropriately
anonymised direct from entries, to avoid unnecessary duplication of input
• Systems must be designed by healthcare professionals in partnership with patient groups
to secure maximum professional and patient engagement in ensuring accuracy, utility and
relevance, both to the needs of the individual patients and collective professional,
managerial and regulatory requirements

8. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (‘The Francis Report’, 2013)
Recommendation number 244
Theme: Common information practices, shared data and electronic records
Service user and carer perspectives – remember it’s about safe care
• Patients need to be granted user friendly, real time and retrospective access to read their
records, and a facility to enter comments. They should be enabled to have a copy of
records in a form useable by them, if they wish to have one. If possible, the summary care
record should be made accessible in this way
• Systems should be designed to include prompts and defaults where these will contribute
to safe and effective care, and to accurate recording of information on first entry
• Systems should include a facility to alert supervisors where actions which might be
expected have not occurred, or where likely inaccuracies have been entered
• Systems should, where practicable and proportionate, be capable of collecting
performance management and audit information automatically, appropriately
anonymised direct from entries, to avoid unnecessary duplication of input
• Systems must be designed by healthcare professionals in partnership with patient groups
to secure maximum professional and patient engagement in ensuring accuracy, utility and
relevance, both to the needs of the individual patients and collective professional,
managerial and regulatory requirements

9. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (‘The Francis Report’, 2013)
Recommendation number 244
Theme: Common information practices, shared data and electronic records
Service user and carer perspectives – remember it’s about safe care
Systems must be capable of reflecting changing needs and local requirements over and
above nationally required minimum standards

10. S W
O T
A Strengths, Weaknesses, Opportunities and Threats
(SWOT) Analysis of Electronic Patient Records

11. Helpful to achieving
the objective(s)
Harmful to achieving
the objective(s)
Attributes
of the
Project
(internal
factors)
Attributes
of the
Environment
(external
factors)
S W
O T
Strengths Weaknesses
Opportunities Threats
A method for
making a
structured
analysis of a
project, plan
or
development

12. S W
O T
Strengths Weaknesses
Opportunities Threats
(Internal
factors)
Identifying the SWOTs of an Electronic Patient Record (EPR)
What are your thoughts?

13. Strengths of an Electronic Patient Record
• 24 hour a day access, improving out of hours
continuity of care
• Availability of information means less asking of
the same question over and over again
• Remote access to information facilitates sharing
by users who are geographically separate
• The record is legible and can be standardised
• Can include automatic processes, such as
calculating assessment scores
• Records can populate dashboards, giving
clinicians feedback about the progress towards
reaching standards or following care pathways
and helping to focus clinical time where it is
needed most
• Records can be searched, filtered, viewed in a
variety of different ways
• Records can be made portable
• Information is more securely held than on paper,
with backup copies being made automatically

14. Weaknesses of an Electronic Patient Record (1)
• Access to a computer and network are needed
• Overall usability of systems is poor and
developments are slow to happen
• Downtime may be needed for updates and
system may fail entirely
• Systems may not be intuitive to use, so extensive
training for users will be required
• It is time-consuming to enter the clinical
information, which is frequently duplicated,
copied and pasted, and ‘dumbed down’ (loss of
richness, tendency not to update, just to copy)
• Gaps in systems cannot easily be worked round,
unlike on paper
• Too much inconsistent / over-inclusive data and
not enough information?
• Highly structured records may mitigate against
formulation and explanatory description

15. • Information, once entered, can sometimes be
very difficult to find - potentially creating clinical
risk. Legacy records will often be in a different
system
• Information may be entered long after the clinical
event
• They often don’t reflect (and therefore don’t
support) clinical processes
• Opportunities for connectivity and information
sharing are frequently not taken. Primary and
secondary care systems don’t communicate, for
example. Opportunities for mobile working are
lost
• Systems in neighbouring areas may not be
compatible – how can the record be shared if a
patient moves?
Weaknesses of an Electronic Patient Record (2)

16. Opportunities created by an Electronic Patient Record
• Connecting up the records held by various
organisations such as primary and secondary care
• Clinical records can be created collaboratively by
professionals, patients and carers, with the record
becoming richer as time goes by
• Structured information can be collated and
harnessed for audit and research
• Standardisation facilitates information sharing
• Information about local patterns of disorder can
be used to commission appropriate services
• Automatic analysis and display of information can
help clinicians to comply with guidelines and
assess the patient’s progress through pathways
• Patient safety can be improved through
information sharing and the use of decision
support – improved governance
• On-line services for patients, such as repeat
prescription requests, booking of appointments
• Money-saving in the long term?

17. Threats related to an Electronic Patient Record (1)
• Task-shifting can occur – for example, a higher
proportion of clinicians’ time is spent creating the
record
• Users may create ‘workarounds’ for deficiencies in
the record, meaning that information is entered in
various ways, or the display of the information may
be generally poor, potentially creating clinical risk
when trying to find the information later
• The processes of commissioning, specifying and
purchasing systems have long-term consequences.
Contractual arrangements made are difficult to
alter and once a system is being used it is difficult
to contemplate moving to another system even if
the replacement would be better
• Information may be held in ‘silos’ and not shared
appropriately across organisations, creating risk
• If clinicians are not competent in using systems,
patients may lose confidence in them

18. • Systems are ? used to monitor staff, rather than
concentrate on patient care
• Sensitive information may be too easily available /
exportable – or service users won’t trust it’s secure,
not hacked and not shared – Care.data
• Clinicians may decide not to enter sensitive
information, in case it’s too widely seen
• Patient narrative may be lost in ‘tick-box’ systems
• Information may be assumed to be accurate or up
to date when it is not
• Systems may become obsolete, paper never will
• Patient access may create complaints
• Perceived need to ‘fill the boxes’ and not assess
and treat the patient
• Commercial interests may mean systems are
designed to create profit rather than fit a need
Threats related to an Electronic Patient Record (2)

19. Strengths Weaknesses
Opportunities Threats
• 24 hour a day access
• fewer repeated questions
• shared record
• standardised
• automatic processing of
information
• clinical dashboards
• searched easily
• portable
• secure
• connecting organisations
• collaboratively create records
with patients and carers
• enhanced audit and research
• standardisation facilitates sharing
• reactive local commissioning
• compliance with guidelines and
clinical pathways
• improved patient safety
• on-line services for patients
• money-saving
• equipment needed
• usability is poor
• downtime
• training requirements
• time-consuming to enter the clinical
information
• gaps in systems
• inconsistent / over-inclusive data
• against formulation?
• important information is difficult to retrieve
• clinical processes not reflected
• delays in making entries
• separate systems don’t communicate
• Information in one system cannot readily be
exported into another
• task-shifting
• clinical risk created when information cannot be
found
• choice of system can have long-term negative
consequences
• information held in ‘silos’
• perceived lack of competence
• staff feel monitored
• handling of sensitive information
• clinicians censor their entries
• loss of narrative
• spurious accuracy
• obsolescence
• generates complaints?
• box-filling without thinking
• commercial interests affect system development
Summary of the SWOTs

20. Strengths Weaknesses
Opportunities Threats
9
9
13
15
Summary of the SWOTs

21. Electronic Patient Records
A Patient Perspective
Laurie Beed

22. Questions and Concerns
Affordability
Reliability
Sustainability

23. Affordability
• Will equipment be affordable for those on low income, or
even relatively higher income?
• First/Second/Third class or Economy/Premium/First
class access options are not acceptable in healthcare.
Full access or better quality and download speeds can
be offered at higher charges. This can lead to
disincentives for patients to use the electronic records
• Will access to records, initial outlay on equipment and
system operating access, start cheap but, due to
creeping cost inflation, gradually become unaffordable to
too many?

24. Reliability
• Secure, accurate, understandable
available and user friendly?
• Changeable without notification. This can
lead to confusion or lack of confidence by
the general public
• Trustworthy? Can I trust the records
always to be there and available?

25. Sustainability
• Will the facility always be there?
• In for the short or long term? Permanency is important
• Sustainability will be dependent on Affordability and
Reliability
• Impact on Telecare and Telehealth
• How much faith do we have in the system
• How easy will it be to maintain and deal with upgrades?
• What is the situation on standardisation. Agreed national
standards in Healthcare throughout the country will be a
positive contribution to quality and Sustainability

26. The Future/Predictions
• The hope/expectation is that it will work
successfully, save money and improve quality.
But will it?
• Implementation problems should be expected
and must be resolved efficiently to maintain
credibility. This is achievable
• Significant cost savings are less likely.
Healthcare improvements are likely to be more
achievable and this may not be readily
identifiable on certain balance sheets

27. Extra points
• Are GPs up to this? What are their views and
problems with electronic records?
• “I am more interested in my GP being able to
access my records than I am accessing my
records.
• I want a GP to access relevant data quickly not
searching through a long list. Everything in date
order has no important priority listing and is time
wasting searching.” My daughter 39, mother of
2 children

28. The record
• What is a patient record? We talk about a Patient
Record as though we all know what the record is and we
all have the same view. Do we?
• Thinking about how the Record will appear to the patient
- will the Record be displayed in date or medical
conditions order. Other subdivisions could be hospital,
consultant or GP
• Will patients be able to submit comments or correct
errors?
• Will allergies or other severe life threatening conditions
be prioritised and highlighted?
• Relevant/important family histories – will or can this be
available in the Record?

29. Communication hazards/problems
• Sensitive information and bad news – how will this be
handled?
• Examples: terminal conditions especially when
conveying that news to parents of a child
• Also disappointing and upsetting news e.g. a lady unable
to conceive (there are male parallels) and disability
conditions
• Possible stigma or embarrassing conditions. Husband
and wife, after numerous attempts, the wife found unable
to conceive so they legally arrange the services of a
surrogate mother. I know of a case where the child is
now four. Making this public at the wrong time could be
difficult

30. Final comments
• Mistake/error can be more likely to get through
and be believed in electronic recording causing
more problems
• Paper records containing errors and mistakes
can often be noticed and more easily corrected
• Direct debits and online banking I suggest are
less likely to be checked by customers than
when we received paper accounts from banks
• Implementation and applications must be
considered and patient access to their records
must be an available facility not a requirement

31. The objectives of the project to create and deploy an
Electronic Patient Record
Having considered
the Strengths,
Weaknesses,
Opportunities and
Threats, objectives
for the project can
be determined
The objectives
should have
reference to the
SWOTs in order
that they are
realistic

32. Achieving the objectives
Whether the objectives have been clearly defined
Whether the objectives are achievable
Whether everyone agrees about the objectives
If some groups have justifiably different objectives, whether the project can
accommodate their objectives too
Whether the objectives have face validity or are supported by evidence or
experience
Whether the benefits of achieving the objectives are clear
Whether the objectives have been communicated effectively at the start of the
project
Attributes affecting the satisfactory
achievement of the objectives could include:

33. Achieving the objectives
Whether the objectives have been clearly defined
Whether the objectives are achievable
Whether everyone agrees about the objectives
If some groups have justifiably different objectives, whether the project can
accommodate their objectives too
Whether the objectives have face validity or are supported by evidence or
experience
Whether the benefits of achieving the objectives are clear
Whether the objectives have been communicated effectively at the start of the
project
Clearly defined
Achievable
Everyone agrees
Accommodating /
flexible
Valid or evidence-
based
Clear benefits
Effective
communication
Some related questions could include:
Have we clearly defined the objectives of the project to create and
use an Electronic Patient Record (EPR)?
Can we assume that improving patient care and safety is the main
priority and it should be achieved if clinical records can be created
efficiently and made available so that they facilitate communication
and information sharing and provide a basis for evidence-based
practice, audit and research?
Does everyone involved have the same shared objectives, or do we
at least understand the overlaps and gaps?
Is there flexibility - can the objectives be changed in order to allow
the EPR to develop in response to clinical need and national and
local policies?
Can the most up to date technologies be harnessed via agile
developments to create a modern EPR, compatible with other
systems?
Are local and national contracts negotiated effectively?
Attributes

34. Achieving the objectives
Professionally agreed record standards
‘Anywhere’ access through mobile working initiatives – bring / choose your
own device – but ensure their security
Intuitive interfaces appropriate to the device being used, eg touchscreens
Offline working
Data warehouse solutions allowing information from different sources to be
collated
Electronic prescribing systems
Fast log on solutions – fingerprint recognition / swipe cards / proximity devices
and smooth roaming
Integrating clinical process redesign and system design
Near to care inputting with rugged tablets, etc
Task-based apps – no need to open a whole record to enter specific
information
Forced fields / error trapping and conditional logic to improve data quality
Key enablers and ways to minimise problems could include:

35. Achieving the objectives
Describing some of the key enablers:
Implementation of standards for referral, admission and discharge documents, approved by the PRSB
and developed by the AOMRC. This drives integration beyond just seeing other record systems from
your system
Anywhere access and near to care inputting: e.g. roll out of ruggedised tablet devices to wards, mobile
devices to community staff and using software to enable staff to input information into applications, at
the point of care, that then send securely to the healthcare record via wifi or mobile networks
Offline working solutions allow clinical data entry with sending once a wifi or other network is next
available. The data can be encrypted and secure whilst on the device
Use of data warehouses: extracted and cleansed data from the clinical system can be used to populate
dashboards, improving clinical care and guiding the use of resources to where they are needed
Intuitive interfaces : older systems developing mobile UI
e-prescribing: to deliver improved safety and cost savings (especially from formulary costs), which
would then encourage the digitization of the rest of the record and drive primary and secondary care
integration
Fast log on- e.g. use of biometric readers on keyboards in secure areas where swipe cards cannot be
taken
Task based applications: developing interfaces for tasks e.g. outcoming of therapeutic activity, recording
of physical health signs on a ‘round’ without the need to log in and out of each individuals record and
then find the correct form to input into, saving significant time

36. Attributes of the project and the environment
The project to create and use an EPR will take place in a context
Internal
factors
Project
objectives
External
factors

37. Attributes of the project and the environment
(internal and external factors)
These factors could include:
The resources made available for the project
How widely there has been consultation about the project
The political will to carry the project through
Whether the funding of the project is guaranteed
The commercial drivers which pertain to the project
Whether appropriate expertise is being used to achieve the objectives
Whether an appropriate, up to date, technological framework is being used
Whether contractual arrangements support the project appropriately

38. Some related questions could include:Factors
Attributes of the project and the environment
(internal and external factors)
The resources made available for the project
How widely there has been consultation about the project
The political will to carry the project through
Whether the funding of the project is guaranteed
The commercial drivers which pertain to the project
Whether appropriate expertise is being used to achieve the objectives
Whether an appropriate, up to date, technological framework is being used
Whether contractual arrangements support the project appropriately
Resource allocation
Wide consultation
Political will
Guaranteed funding
Commercial drivers
Expertise
Technology
Contracts
Have we considered how best to make use of local
and national expertise, as well as learning from past
experiences – both successes and failures?
Have the needs and view of patients, carers, clinicians,
providers and commissioners all been taken into
account – has the thinking about the project been
broad?
Have we considered how general economic conditions
may affect the project?
How do the contracts and relationships with system
suppliers affect the project?

39. Strengths Weaknesses
Opportunities Threats
• 24 hour a day access
• fewer repeated questions
• shared record
• standardised
• automatic processing of
information
• clinical dashboards
• searched easily
• portable
• secure
• connecting organisations
• collaboratively create records
with patients and carers
• enhanced audit and research
• standardisation facilitates sharing
• reactive local commissioning
• compliance with guidelines and
clinical pathways
• improved patient safety
• on-line services for patients
• money-saving
• equipment needed
• usability is poor
• downtime
• training requirements
• time-consuming to enter the clinical
information
• gaps in systems
• inconsistent / over-inclusive data
• against formulation?
• important information is difficult to retrieve
• clinical processes not reflected
• delays in making entries
• separate systems don’t communicate
• Information in one system cannot readily be
exported into another
• task-shifting
• clinical risk created when information cannot be
found
• choice of system can have long-term negative
consequences
• information held in ‘silos’
• perceived lack of competence
• staff feel monitored
• handling of sensitive information
• clinicians censor their entries
• loss of narrative
• spurious accuracy
• obsolescence
• generates complaints?
• box-filling without thinking
• commercial interests affect system development
Putting
it all
together
Clearly defined, achievable, widely agreed,
clear, flexible, valid objectives . Key enablers in place
Resource
allocation
Wide
consultation
Political will
Guaranteed
funding
Commercial
drivers
Expertise
Technology
Contracts

40. Questions,
answers and
discussion