P Firth


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Using in-house EPR application development as an effective tool

130                                  Electronic records and change
                                                                          P Firth

Using in-house EPR
application development
as an effective tool for
managing change and
improving patient care
P Firth
IM&T Strategy Implementation Manager
Wrightington, Wigan & Leigh NHS Trust
Royal Albert Edward Infirmary
Wigan Lane
Lancashire WN1 2NN


Wrightington, Wigan & Leigh NHS Trust has been able to build applications which
seamlessly bolt into the electronic patient record (EPR) system using web
technology. This has enabled the Trust to implement important clinical applications
rapidly, and at low cost. More importantly it has enabled the implementation of
applications which have been designed and approved by the clinicians themselves,
thus ensuring maximum user buy-in.
  An EPR system for sending discharge letters to GPs was designed by clinicians,
with significant inputs from clinical coding and pharmacy. The resulting system
has provided SHOs a user-friendly way of compiling letters, recording diagnoses
and requesting take home medications. The time it takes to send letters to GPs
has been reduced significantly.

Local IM&T strategy
The IM&T strategy at Wrightington, Wigan & Leigh NHS Trust
(WWLNT) is clinician led, and senior consultants and clinical support
managers have consistently voiced a clear preference for a best of breed
  The current strategy is focused on maintaining legacy systems
(systems which work and are not in immediate need of replacement)

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and building electronic patient records via systems integration and
the use of web technology to meet strategic objectives1.
   The change management agenda is being addressed by delivering
fit-for-purpose systems to clinicians which are highly configurable to
meet local needs and changing circumstances. This flexible approach
to rolling out EPR has been enabled by the development of a very
powerful and flexible enterprise architecture based on web technology,
XML and the Microsoft .NET framework.

Application development
The WWLNT enterprise architecture for application development is
based upon the industry standard ‘N’ tier design, see figure 1, and
made up of the following layers:
  Presentation layer: This is where the specific graphical user interface
required by the unit / specialty is developed using web development
tools, such as ASP.NET.
  Business logic layer: The logic business layer has a set of re-usable
objects (eg. Patient Object) and support routines (eg. Retrieving a
Patient Object from the Data Access Layer) which enables rapid
application development of EPR applications.
  Data access layer: This layer is made up of a set of routines which
provide a controlled interface with the EPR database.

Figure 1: WWLNT enterprise architecture for EPR application

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   Data layer: The data layer is made up of a very large Microsoft SQL
Server EPR database. The EPR database includes a Master Patient
Index with 450,000 unique patient records (95% with a validated NHS
Number), a data warehouse holding departmental data (including
clinical coding, episode details, pathology results and NSF core data
sets), and an XML clinical repository holding electronic documents
(including discharge letters, ECGs, and medical images).

Addressing change management
The Audit Commission understands2 that introducing an EPR system
is a particularly complex challenge requiring a number of significant
barriers to be overcome. These challenges include failure to place the
systems development within a local vision for improving services to
patients, and insufficient emphasis on changing the behaviour of large
numbers of staff across the full range of clinical specialties.
   The steps taken at WWLNT to address these change management
challenges include:
1. assigning a roll-out coordinator to manage all the phases of
   implementing EPR
2. ongoing consultation and feedback with clinicians and support staff
3. using process mapping to reach a common understanding on
4. identifying the core cultural issues and agreeing new ways of
5. piloting and rapid application development to refine requirements
6. training and hands-on support.

Case study: developing an EPR application for discharge
An electronic discharge letter project was initiated by Wrightington,
Wigan & Leigh NHS Trust in response to IM&T Technical Schedule
(v2)3 and the need to address Target Reference 2.3 Clinical Messaging
Discharge Summaries, by March 2005.
  The project represented a significant challenge for the Trust, most
notably with respect to designing and implementing a fit-for-purpose
IT solution, providing the required training for a constantly changing
community of junior doctors and SHOs, and addressing a significant
local change management agenda.
  Staff on the Upper Johnson children’s ward were enthusiastic about
implementing EPR, and this location was chosen to develop and pilot

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a solution for generating discharge letters.
  It was noted that the first part of the Children’s National Service
Framework4 would be focussing on services in hospitals. Improved
communication with primary care via a quicker turn around on
discharge letters was seen as a definite benefit.
  The following sections contain an account of the WWLNT approach
for developing, piloting and subsequently implementing an EPR system
for generating discharge letters. It was agreed early on that letters
generated in EPR would have to be printed on paper, and sent to GP
via the post, prior to the agreement on NHS messaging and encryption
standards by the Department of Health.

Assigning an EPR Roll-out Coordinator to the unit to manage all
phases of the project
At project initiation an EPR roll-out coordinator was assigned to the
unit to manage all aspects of the system implementation, including
gathering user requirements, process mapping, helping staff to adapt
to new ways of working with IT, and training. The EPR roll-out
coordinator was also responsible to communicating system change
requests to the application development team.

Ongoing consultation and feedback with clinicians and support staff
The lead consultant specified the unit’s core requirements for a user-
friendly system which would enable Senior House Officers (SHO) to
compile discharge letters, record diagnoses and request take home
medications (TTOs) via the EPR system. This initial specification was
subsequently enhanced by involving ward staff (consultants, registrars,
SHOs, nurses, ward clerks), patient services, the clinical coding
department and pharmacy in the design process. Process mapping and
rapid application development techniques were then used to confirm
that the unit’s requirements had been fully understood.

Using process mapping to reach a common understanding on
Process modelling is a way of increasing understanding of how the
current situation works and provides a clear articulation of how the new
one is to be different5. An example process model agreed for the dis-
charge letter system on Upper Johnson Ward can be seen in figure 2.

Identifying the core cultural issues and agreeing new ways of
Prior to EPR implementation, discharge summary letters were typed
by secretaries 4 to 6 weeks after episode completion, based on the
doctor’s hand written notes and diagnosis information entered on the
patient administration system (PAS) by the clinical coding department.

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                                                                 P Firth

Figure 2: Process mapping for the required system for issuing letters
          with TTOs

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Long delays in returning casenotes to Medical Records for coding was
a major barrier in the way of issuing discharge letters to GPs quickly,
as was the length of time casenotes spent traveling round the internal
post and sitting in people’s pigeon-holes.
  Initially, doctors were not happy with taking on the new task of typing
their own letters, and ward clerks were not very enthusiastic about
the extra administration duties. The lead consultant had to make the
use of EPR to prepare discharge letters and request TTOs a mandatory
SHO task.

Training and hands-on support
The EPR roll-out coordinator spends however long it takes on the unit
to ensure that the implementation is successful. During key phases of
the discharge letter project this was more or less a full-time
  Providing the required training for a constantly changing community
of junior doctors and SHOs (a six monthly turnover) is the subject of a
paper in its own right and WWLNT has still much to learn in addressing
this core requirement effectively. The EPR implementation team is
committed to going back to the ward to re-train doctors during staff
induction. However, ways of enabling cascade training from the
outgoing to the incoming groups of doctors is being investigated.

Piloting and rapid application development to refine requirements
An initial one month pilot for the discharge letter module was an
essential first step for testing the software, and checking the system
was fit-for-purpose and user friendly. Feedback from ward staff was
used to modify the system. Other issues identified in the pilot were
documented and resolved prior to the arrival of the next group of SHOs.
A pre-implementation checklist was compiled from the lessons learnt
to aid planning for EPR roll-out to other wards.

The IT solution implemented on Upper Johnson Ward
SHOs initiate the task of producing the discharge summary by logging
into EPR and selecting a patient from the current ward list. Once the
patient is selected the required patient demographics, GP details and
episode information are loaded automatically, see figure 3. This saves
the SHO a significant amount of time in typing and looking up
information in the patient’s notes, and so allows them to dedicate more
of their limited administration time to ensuring clinical details and
TTOs are accurate and complete.
  SHOs are able to select a primary and a secondary diagnosis from a
drop down list of the top 30 ICD10 paediatric discharge diagnosis codes,
see figure 4. This list was derived by analyzing PAS system clinical

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                                                               P Firth

Figure 3: Check Demographic, GP and inpatient details

coding data for the ward over a twelve-month period. There are also
options to search the entire ICD10 coding database or simply enter an
appropriate text description.
  SHOs are able to select TTOs from a drop down list of the top 30
paediatric discharge prescriptions, see figure 5. This list was derived
by analyzing Pharmacy system dispensing data for the ward over a 12
month period. There are also options to search the Pharmacy drug
database or enter an appropriate text description for adhoc, rarely
prescribed items.
  An example copy of a completed paediatric discharge letter can been
seen in figure 6.

New working practice for sending discharge letters to GPs
When a patient is about to be discharged, an SHO will find a PC and
write the discharge letter. This can be during or subsequent to the
ward round depending on the situation. Once completed, the SHO will

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Figure 4: Add diagnoses and admission details

Figure 5: Add medications

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                                                P Firth

Figure 6: Example paediatric discharge letter

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print three copies of the discharge letter (marked as GP copy, File
copy and Pharmacy copy), and append these to the front of the casenote
   If TTOs are required the Pharmacy copy of the letter is signed by
the SHO and sent to pharmacy in the form of a request for medications.
Any changes that need to be made to TTOs will be amended in the
EPR system by Pharmacy staff. The SHO will be alerted to reprint the
letter with the revised medication details.
   The next day a ward clerk will post the letter to the GP and arrange
for the casenotes to be returned to medical records for coding.
   The EPR system has a discharge letter worklist screen which displays
all the patients ready of discharge, and all letters that have been
prepared by an SHO. Once the letter has been posted to the GP the
episode is marked as ‘Letter Sent’, so removing it from the worklist.
The discharge letter worklist screen is also used to sign-off inpatient
episodes that don’t require an SHO discharge letter, such as ward
attenders and cases where a letter needs to be typed by a consultant

Feedback from clinicians and support staff
The feedback from SHOs is that the EPR application enables ‘quick
and easy access to the all required information‘, which is ‘time saving’.
SHOs liked the new method of requesting TTOs, as this approach saves
them ‘having to trawl through BNF every time’.
  Pharmacy were very much in favour of being able to restrict the
choice of TTOs via the drop down list, and, in doing so, direct SHOs
into using a set of drugs which cover most of the cases for that unit.
Pharmacy were pleased to note that they are now having to modify
fewer medication requests sent to them via EPR. Pharmacy also
appreciated the additional information contained in the letter, including
patient demographics, weight, diagnoses and other supporting clinical
  The feedback from clinical coding is that casenotes are being returned
to Medical Records more quickly. Prior to EPR ‘it was not unusual for
notes to be stuck on the ward for upwards of six weeks’. Now casenotes
are being returned in a matter of days which is ‘enabling coding to
manage their workload better, and is saving time chasing casenotes
following discharge’.
  According to the lead consultant on Upper Johnson Ward, ‘the way
in which the summaries are done has now changed (ie the work
practices). Previously the SHOs would often wait till the end of the
ward round to do the discharge paperwork. Now there is a greater
awareness of the rate limiting effect of the discharge letter, and they
are more likely to be freed from the ward round to do the letter and
facilitate immediate discharge when that is appropriate. Some children

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may be discharged sooner now than previously. I suspect that actually
this is quite common. There is no doubt that we issue discharge
summaries faster now than previously. Days or weeks faster’.
   The feedback that the lead consultant received in relation to the
Trust’s approach to EPR application development and implementation
is that staff ‘felt they had been listened to’, and were impressed with
the roll-out team’s ability to ‘respond rapidly to requests for changes
to the system’. As a result the discharge letter project had been an
‘immensely successful project’.

I would like to thank Dr Martin Farrier, Consultant Paediatrician, for
his help and support with the discharge letter project, and his feedback
on the project outcomes.

1.           ,
     Firth P Smith M. Acute EPR system Technical architecture. NHS
     Informatics community website (http://www.informatics.nhs.uk) July 2003.
2.   Audit Commission. Change Here! Managing Change to Improve Local
     Services. 2001.
3.   Department of Health. IM&T Technical Schedule (v2). 2003. Available at
4.   Department of Health. Getting the right start: National Service Framework
     for Children. Standard for Hospital Services. 2003
5.         ,
     Iles V Sutherland K. Managing Change in the NHS – Organisational
     Change. NCCSDO. 2001.

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