You Can’t Always Get What You Want The saga of the United Kingdom’s Connecting for Health EHR program, formally called the National Programme for IT or NPfIT, presents an important cautionary tale for the U.S. Within the U.K., major National Health Service (NHS) IT projects have a history that dates to the late 1960’s, with a number of individual NHS Trusts and hospitals introducing their own smaller scale information systems in the 1970s and 1980s. The 1992 NHS Information Management and Technology (IM&T) strategy was the first truly nationwide NHS IT effort. Ultimately this initiative failed, in part due to political battles, in part due to a lack of specificity and sufficient overall objectives and evaluation, plus a need for `better stakeholder communication`, although there were some significant regional successes. This led to a more centralized IM&T strategy, which became known as NPfIT, and launched in 2002 with an expected total cost of about $3.4 billion. We fast forward, skipping a few nasty bits in the process. In 2011, the U.K. “urgently” dismantled this futile (now) $20 billion attempt to connect patients’ records electronically, following years of well-publicized problems from a system that couldn’t even track immunization side effects. A “death knell” for the system began in 2009 because “costs were escalating without evidence of benefits, despite the programme having run for seven years already,” as per the Public Accounts Committee. A very interesting 2014 case history report by University of Cambridge researchers provides many further `juicy` details, and can be found online:

https://www.cl.cam.ac.uk/~rja14/Papers/npfit-mpp-2014-case-history.pdf.

Although the U.K. setting is hardly identical to our own, there is much to learn from this report, since several major conclusions are broad-stroked and thematic. The authors document a whole series of IT failures, including `no time to engage with users`, `failure to check progress against expectations`, `failure to test systems`, `not providing training`, and `a lack of concern for privacy issues`. We ignore the evident commonalities, and the lessons of history, at our own peril.

Epic Failure In a report very recently published (September, 2015), the United Kingdom’s Care Quality Commission (CQC) recommended that the Cambridge University Hospitals NHS Foundation Trust (CUHFT) be put on “special measures,” to a large extent because of problems the Trust had in implementing its new Epic EHR, which was implemented in October 2014. (The report is available at www.cqc.org.uk/sites/default/files/new_reports/AAAD0111.pdf). The report related that the Commission inspected the Trust, which operates Addenbrooke’s and the Rosie Hospitals, in April and May 2015, and found its performance rating “inadequate” overall, with five elevated risks and four risks on its Intelligent Monitoring system. Just five months prior, the Trust had only two elevated risks and one risk on the same scoring system. The inspection found, among other things, that: (i, p. 16) EPIC was the “root cause” of the problems with data collection within maternity and gynaecology (and inferentially, within many other specialties, as well); (ii, p. 70) the system was time consuming to use and limited engagement with patients; (iii, p. 17) EPIC created significant numbers of delayed discharges that impacted on patients receiving end-of-life care; (iv, p. 152) since the implementation of EPIC the trust had seen a serious decline in its referral-to-treatment performance, with 14 of 18 specialties not meeting the required target of 92% of patients waiting no more than 18 weeks from referral; (v, p. 152) the system did not produce accurate data; (vi, pp. 4, 118) the system generated prescription errors; (vii, p. 15) since the introduction of the EHR system, outcomes of patient care and treatment were not robustly collected or monitored; (viii, p. 124) some information seemed to disappear from patient records.

As collateral damage, the trust’s chief executive Dr Keith McNeil `unexpectedly` quit just prior to the release of the CQC report, as did the chief finance officer, Paul James.

A related article from the BBC noted that the Epic system cost £200m and illustrated one of the Trust’s `mistakes.` As the BBC News Analysis team reported, “Perhaps the most worrying aspect of the Addenbrooke’s story is not that such a world-renowned hospital has ended up in a predicament like this, but rather that it happened so quickly. A year ago, the trust which runs the hospital – CUHFT- wasn’t even on the Care Quality Commission’s radar in terms of being a failing centre. In fact, two years ago, [ …] it was among the band of hospitals considered to be the safest, according to the risk-rating system at the time. But now a hospital which can boast to being a centre of excellence for major trauma, transplants, cancer, neurosurgery, genetics and paediatrics, has been judged to be a basket case and will join the 12 other failing hospitals already placed in special measures.”

In fact, problems with Epic’s Cambridge launch were acknowledged long before this CQC report. In December 2014, just 2 months post-launch, John Naughton reported on this in The Guardian, in an article titled `The NHS’s chaotic IT systems show no sign of recovery: Paperless patient records are a necessity, but a new, US-made system at Addenbrooke’s in Cambridge is a chronic misreading of patient needs`. Naughton noted that the official hospital announcement of the switch onto EPIC on October 26 trumpeted the new system as being “on bespoke software that has been designed by and for clinicians.” He then went on to provide stark contrast given in an email one week post-launch, from a friend who had broken her foot and gone to Addenbrooke’s. “From the patients’ point of view,” she wrote, “it [the new system] is quite dehumanising. Staff now approach [while] gazing at a mobile device and trying to find you on it; then they check you in with a wrist barcode. There is no time for conversation or even often for eye contact. Some of this might improve as they get more confident with the system but they are deeply unhappy with the change in culture and they say all the real nurses will leave.”