We have completed a thematic review of HSSIB’s work to date to identify specific patient safety issues and learning related to electronic patient record (EPR) systems.
EPR systems are software for collecting, storing and managing data about individual patients. An EPR may consist of several components including management of a patient’s records, ordering of medicines and tests, and review of results. A single piece of software may provide one, some, or all these components.
HSSIB received concerns about EPRs in some settings and identified incidents involving patient harm where EPRs have potentially contributed.
The review found that EPR systems could contribute to the risks of patient care being missed, delayed or incorrect. These risks were persistent despite national recommendations and actions seeking to mitigate them.
Choosing an EPR system capable of meeting the needs of an organisation
- Where EPR systems did not have the functions an organisation needed or did not support the user (patients and staff), they had contributed to patient safety incidents.
- There were inconsistencies in the terms used in the design of health IT systems and their functions, such as usability and functionality, and limited guidance to support understanding of these concepts in EPR system design.
- Organisations did not always have a clear understanding of their requirements/needs for an EPR system, limiting their ability to match requirements to system capabilities (the things a system can do).
- When procuring EPR systems, organisations sometimes faced challenges understanding system capabilities and whether they met required national standards, such as for interoperability (the ability to work with other IT systems) and clinical risk management.
- National and regional support for organisations to identify their local requirements/needs to inform EPR system procurement was limited.
- Some EPR system procurement decisions were perceived by staff to be influenced by factors other than system capabilities, such as cost savings.
Implementing an EPR system that meets the needs of users
- Variation in governance processes for implementing EPR systems at national, regional and organisation levels meant associated risks to patient safety were not always identified and mitigated.
- Implementation of an EPR system was found to be a complex project that did not always effectively engage users to ensure it was safe and successful.
- Local configuration of EPR systems had the potential to introduce new risks to patient safety, with investigations identifying where this had occurred without the organisation recognising and mitigating against these risks.
- Factors contributing to an organisation’s ability to locally configure EPR systems included the capacity and capability of digital teams, the level of involvement of users in testing, support from manufacturers, and awareness and application of digital standards for clinical risk management.
- When users were involved in EPR system implementation they were not always representative of those using the system in practice, with difficulties faced releasing staff from clinical work to contribute to implementation.
- Several organisations faced challenges relating to the availability of working hardware and Wi-Fi connectivity to support the use of EPR systems in different clinical environments.
- Staff training in how to use an EPR system was often perceived to be limited. It did not always reflect how a system would be used in the ‘real world’, nor what to do if the EPR system failed.
Seeking feedback and ongoing EPR system optimisation
- Staff reported limited routes for raising concerns about poor functionality and usability of EPR systems, and limited action when concerns were reported that could impact on patient safety.
- Ongoing management of EPR systems, including upgrades and changes, did not always align with the digital standards for clinical risk management.
- EPR systems were not always kept up to date in line with national guidance and standards, or to reflect changes to internal care processes.
- Factors contributing to limited ongoing optimisation of EPR systems after initial implementation included the need to manage a range of local digital priorities, limited collaboration between digital and clinical teams, cost of upgrades, and limited resourcing for ongoing work and infrastructure.
- There were limited opportunities for organisations to share their experiences of implementing and optimising EPR systems for the benefit of other organisations.
HSSIB investigations include local-level learning where this may help providers/organisations to identify and think about how to respond to specific patient safety issues at the local level. HSSIB has identified learning to help consider and mitigate risks around procuring, implementing and optimising EPR systems.
Supporting safe selection and procurement of an EPR system
- How does your organisation identify requirements for an EPR system to account for organisational and user (patients and staff) needs?
- How does your organisation identify whether an EPR system can perform the tasks needed to meet organisational requirements and meet expected national standards?
- How does your organisation identify whether an EPR system meets relevant standards, such as those that support clinical risk management and interoperability?
- How does your organisation ensure relevant information is requested from manufacturers and scrutinised during the selection and procurement of systems?
Supporting safe implementation of an EPR system
- Does your organisation understand the expectations for clinical risk management of health IT systems in relation to deployment, ensuring these are met and regularly reviewed?
- How does your organisation ensure representative user engagement and involvement in all aspects of the configuration, integration and ongoing optimisation of EPR systems?
- Does your organisation have a process for carrying out effective equality impact assessments to consider the needs of specific patient and staff groups who may be users of the EPR system?
- How does your organisation manage and oversee configuration changes to EPR systems to ensure they are appropriate, safe and successful?
- How does your organisation evaluate whether all necessary elements are in place before an EPR system is implemented or changed, for example through assessment of IT infrastructure and training?
Supporting ongoing optimisation of an EPR system
- How does your organisation proactively identify new and emerging risks associated with an EPR system, and ensure these are reviewed and mitigated as far as is practicable?
- Does your organisation have routes for staff to raise concerns about the EPR system they use, with feedback to inform staff of actions taken in response?
- Does your organisation have contingency plans and processes to maintain patient safety when there are EPR system problems, and are they shared with staff?
- How does your organisation share learning from the implementation and ongoing optimisation of EPR systems to support other organisations?
