In a recent speculative piece by Jon Hoeksma on Digital Health, he looks as what a national deal with Epic could look like for NHS. The speculation was started when current director of transformation at NHS England, Ian O’Neil, met with Judy Faulkner from Epic. Plus, Tim Ferris, new head of digital transformation at NHS England, joined from Massachusetts General Hospital which deployed Epic back in 2016 and supposedly Ferris is a fan.
Clearly, this is speculation, but the article does note that 5 NHS acute trusts already have Epic including Cambridge University hospitals. However, there are 133 other acute trusts in England that use something else. What was fascinating was to hear the reason for why a previous effort to have a single EHR solution (they call it EPR or electronic patient record) called NHS National Programme for IT (NPfIT) failed after working on this effort from 2003-2011.
In subsequent reports and investigations of the NPfIT the National Audit Office concluded that the top-down national approach had failed to recognise the very different local circumstances between hospitals and failed to secure the support and commitment of local clinicians.
Looking at this reasoning, I’d be very careful if I’m NHS to implement Epic across all of NHS. Epic has a very high quality product, but they are also inflexible with many of their approaches. If NHS hospitals like their autonomy and have different local circumstances, that sounds like a recipe for disaster to me.
I was also intrigued by their estimates for an Epic deal with NHS:
So the 100 acute trusts paying an estimated £90million would come to a total of roughly £9billion. Let’s round it up to £10billion to allow for a little contingency and modest management consultancy fees.
I’d say that $100 million feels like the very low end for a hospital to implement Epic. Shocking I know, but that’s been the reality. Plus, it was fascinating that this quote didn’t really include primary care and other ambulatory organizations. In the US, one of the things that set Epic apart from many other EHRs was its ambulatory solution. Hard to imagine NHS wouldn’t want that integrated environment. Although, the structure of acute care and ambulatory in NHS is quite different so that could be a mess of its own kind. In the US, most ambulatory practices that are on Epic are owned by the acute care organization (some exceptions like community connect) and therefore on the same instance of Epic. Would the same be possible for NHS?
What was most tenuous to me in this speculation was the benefits that NHS would receive from having all of the acute trusts on Epic. The first benefit was having all medical staff on Epic so when they switch organizations, they’re still on the same system. This is somewhat helpful, but little do they know that no 2 Epic installs are alike. You can imagine templates at one trust not being the same in another. Required forms and fields in one being different than another. Alerts in one being tweaked compared to another. They can get up to speed quicker than 2 separate systems, but it’s not quite as plug and play nice as you’d expect. In fact, someone switching is likely to get really frustrated by 2 of the same system that were implemented so differently.
Next, they talk about the benefit to the patients of having a universal record with tight integration between orders, test results, and embedded clinical decision support tools. Ironically, they already have 5 Epic installs. I wonder if they’ve checked in with those 5 to see if these benefits have been realized. My guess is that it’s not quite as seamless as one would think it would be. I don’t see one big Epic install for all 100+ NHS trusts. It’s likely one Epic install per trust. So, there are still challenges ahead.
Of course, you may be thinking that it’s all Epic so sharing should be easy. Well, it’s easier, but still not the same as one single database for all patients. Epic has Care Everywhere which will help. However, I still remember those at Stanford Health Care not being able to share patient records with Sutter Health across the street. It wasn’t even that it wasn’t possible with Epic, but there were issues with versions and bureaucracy. Maybe NHS can force them to collaborate and has less politics between Trusts. I’m not an expert on NHS Politics, but I wouldn’t be surprised if multiple Epic installs isn’t quite as interoperable as many would believe it should be.
The article also boasts about Epic’s lack of acquisitions meaning that NHS would no longer have to deal with messy interfacing with different systems. I think a careful evaluation would realize that Epic isn’t going to satisfy all of NHS’s digital health needs and that many integrations will still be needed. Just ask any Epic user and you’ll hear about all the integrations they still have with Epic.
They also talk about the ability to do predictive analytics at scale. Epic has been working on this across a number of efforts to leverage their data including some that include multiple organizations pooling their data. This may be the one area where NHS could benefit from everyone being on Epic. However, I also know many large healthcare organizations that are still using outside analytics providers because Epic’s analytics aren’t good enough. Plus, if each trust has their own Epic install with their own customizations, you still have issues with data standardization to deal with when doing any analytics.
The article does aptly point out that there’s more to healthcare than just hospitals. In fact, some would argue that the most important parts of healthcare are outside of the hospital. So, that’s a massive challenge as well. Plus, it’s why those of us in healthcare know that a monolithic EHR is great for some things, but there is a lot of data and pieces of healthcare outside of the EHR.
The sad part is that these types of $10 billion decisions often don’t care about these things. So, I have no idea of whether this speculation is just pure speculation or not. What is clear is that there’s a lot more that people need to understand when it comes to choosing an EHR and how to glean benefits from said EHR. The benefit of EHRs are quite different than what many people think they should be. Plus, poor implementation of any EHR is a recipe for disaster.
