• The survey found that EPRs are in widespread use, with 83% of respondents saying they now use them as part of their job in the NHS. On balance, the NHS staff we surveyed were positive about the impact of EPRs in several areas and felt these systems are already improving both patient care (75%) and patient safety (73%).
• Yet 37% of staff also felt EPRs are not currently working well in their organisation. The survey points to a mix of frustrations and barriers to the effective use of EPRs, including having to use multiple EPR systems every day, a lack of real-time support and limited opportunities to give feedback on how they are working.
• An area of particular concern is training. Only around half (49%) of survey respondents had received training on how to use the EPR system for their role, and less than a third (28%) had received training on how to fix or troubleshoot problems.
• Unlocking the full value of EPRs will require coordinated action across the NHS to improve the integration of systems, training and support for staff. Without this, there is a risk that many of the potential benefits for productivity, safety and quality of care will remain unrealised.

Related reading on the hub:

• HSSIB Investigation Report: Patient safety issues associated with electronic patient record (EPR) systems – a thematic review
• Patient safety and electronic patient record systems: Patient Safety Learning’s response to HSSIB report
• Electronic patient record systems: Putting patient safety at the heart of implementation

EPR systems are a way of managing clinical information with the intention of making this information more easily accessible for use by healthcare professionals. In A plan for digital health and social care published in June 2022, the Department of Health and Social Care set a target that all NHS Trusts should have an EPR system by March 2025.[1] In November last year, NHS England announced it was on course to meet this target, stating that 90% of NHS trusts have now introduced these new systems.[2]

When implemented safely, EPRs can support and improve care and treatment by:

• Enabling staff to have a complete overview of patients’ care in real time.
• Removing the need for patients to have to share the same information multiple times.
• Freeing up healthcare professional time and resources.

However, there are also a number of patient safety risks associated with their implementation and use, as highlighted in a blog by our Chief Digital Officer Clive Flashman in January.[3]

In their investigation, BBC News found from a Freedom of Information (FOI) request sent to all acute hospital trusts in England (of which 116 responded) that:[4]

• 89 trusts confirmed they monitored and logged instances when patients could be harmed as a result of problems with their EPR systems.
• almost half recorded instances of potential patient harm linked to their systems.
• nearly 60 trusts reported IT problems that could affect patient care.
• more than 200,000 letters were not sent across 21 trusts.
• there were 126 instances of serious harm linked to IT issues, across 31 trusts.
• and three deaths across two trusts related to EPR problems.

Commenting the findings of this FOI request, our Chief Digital Officer Clive Flashman said:

“Poor implementations of EPR systems can lead to direct and indirect harm to patients. Often this is not associated with the IT system and goes unreported, so we have no data to show the true scale of the issue.

We need more transparency in reporting and sharing knowledge so we can avoid patient safety problems and harm. This is a priority issue that must be addressed by those leading EPR implementations.”

At Patient Safety Learning we believe that patient safety needs to be a core purpose of health and social care. Patient safety considerations need to be embedded through each stage of the process when organisations introduce EPRs:

• Development – patient safety must be at the heart of the initial creation and development of EPR systems. Consideration should be given to interoperability (the ability to work with other computer systems or software used by the organisation to exchange and make use of information).
• Rollout – it is vital as EPRs are introduced into organisations that the appropriate training is provided to staff. There also needs to be sufficient usability testing (testing how easy these systems are to use with a group of staff who will ordinarily be using them).
• Implementation – once an EPR is in place, monitoring how these are operating in practice and learning and acting on any incidents or near misses that take place relating to this.

Reflecting on this, our Chief Executive Helen Hughes said:

“We must invest in proper implementation so that the benefits of EPRs and health technology are realised and do not lead to avoidable and unintentional harm. Actively involving healthcare professionals is essential to ensure we are designing for safety in often very complex workflow processes, so we better understand and respond to risks and manage the mitigations.”

References

1. Department of Health and Social Care. A plan for digital health and social care; 29 June 2022.
2. NHS Digital, 90% of NHS trusts now have electronic patient records; 16 November 2023.
3. Clive Flashman, NHS England warns electronic patient records could pose ‘serious risks to patient safety’: what can we learn?, 10 January 2024.
4. BBC News, NHS computer issues linked to patient harm, 30 May 2024. 

Electronic patient records (EPRs) are a way of managing clinical information with the intention of making this information more easily accessible for use by healthcare professionals. In A plan for digital health and social care published in June 2022, the Department of Health and Social Care set a target that all NHS Trusts should have an EPR system by March 2025.[1] In November last year, NHS England announced it was on course to meet this target, stating that 90% of NHS trusts have now introduced these new systems.[2]

Although EPRs have the potential to significantly improve patient care and information handling, there are also a number of patient safety risks associated with their implementation and use. In a recent blog reviewing the recurring themes identified through their safety investigations, the Health Services Safety Investigations Body (HSSIB) identified a number of these:[3]

• Interoperability – problems stemming from EPRs being unable to exchange or make use of information from other IT systems used by trusts.
• Usability testing of software – EPR systems being introduced without appropriate testing of how easy or difficult healthcare professionals tasked with using these find them to operate.
• Standards and standardisation – EPR systems in use not incorporating human factors engineering principles in their design to ensure they are the best they can be.

The themes listed above have been highlighted in recent media coverage, including recently a number of patient safety incidents and a patient death related to the introduction of a new EPR at the Royal Surrey Foundation Trust and St Peter’s Hospital Foundation Trust.[4]

Patient Safety Alert

Euroking is an EPR provided by Magentus Software. According to an NHS England National Patient Safety Alert issued on the 7 December 2023, the Euroking EPR has been found to process information incorrectly — overwriting the existing record with new information and incorrect storage and display of safeguarding information, which could lead to “incorrect management of the pregnancy and subsequent harm”.[5]

The Euroking EPR is used in the maternity departments of at least 15 NHS trusts according to information held by HSJ.[6]

NHS England has said there is “currently no evidence of actual harm being reported as a result of these issues" and the Trusts involved have 6 months to deal with it.

The alert tells Trusts to review their data within the system and consider if Euroking meets their maternity services requirements and is safe, looking at replacement systems if deemed necessary. However, what is unclear from this Alert is whether NHS England had already spoken to the vendor and asked for a fix to be created and pushed out as soon as possible. Commenting in response to the Alert, Euroking have said that they were working with NHS England on issues concerning the data fields in the system and have provided their customers with ”support and information”.

More robust response needed

At Patient Safety Learning we don’t believe this is an adequate response to the issues raised in this Patient Safety Alert.

A more robust response could have involved NHS England having been clear about the changes that were needed from a patient safety perspective and, subsequently, having worked with Euroking to make these changes and then push out this fix to all existing users as soon as possible. If that had been done, this Patient Safety Alert could have looked quite different, focused on the need to update the software first by a certain date, then check each data field and add back in any overwritten data if still available. This would also mean that the need to potentially consider moving to a new system, a potentially expensive and disruptive change, could then have been a lower priority.

Although this issue and subsequent Alert relates to a specific vendor and system, we also believe it would be useful for all trusts to check that the same issue is not affecting similar systems (all EPRs, not just their Maternity one) from other vendors. It would have been helpful for NHS England to have annexed their alert with a testing process to support trusts in this.

References

1. Department of Health and Social Care. A plan for digital health and social care; 29 June 2022.

2. NHS Digital. 90% of NHS trusts now have electronic patient records; 16 November 2023.

3. Helen Jones. Electronic patient record systems: recurring themes arising from safety investigations. HSSIB; 19 December 2023.

4. Alison Moore. Patient died and 30 harmed after new IT system launch. HSJ; 11 October 2023.

5. NHS England. National Patient Safety Alert: Identified safety risks with the Euroking maternity information system; 7 December 2023.

6. Joe Talora. NHSE warns widely used EPR could pose ‘serious risks to patient safety’. HSJ; 8 December 2023.

• Principle 1 - Justify the purpose(s) for using confidential information.
• Principle 2 - Don't use personal confidential data unless it is absolutely necessary.
• Principle 3 - Use the minimum necessary personal confidential data.
• Principle 4 - Access to personal confidential data should be on a strict need-to-know basis.
• Principle 5 - Everyone with access to personal confidential data should be aware of their responsibilities.
• Principle 6 - Comply with the law.
• Principle 7 - The duty to share information can be as important as the duty to protect patient confidentiality.
• Principle 8: Inform patients and service users about how their confidential information is used.