Our Digital Future-Encompass: Delivering Care Together

Working as a junior doctor in Northern Ireland over the last five years I have been introduced to the interesting mix of systems we use to look after our patients.

From I first started working on wards on a F0 placement from Queen’s University, Belfast, ringing GPs to clarify patients’ medication lists, to spending an average of eight hours a week rewriting kardexes as an F1, the time consuming waste in the system was apparent. Initially I was an idealistic doctor, asking histories from patients before reviewing their voluminous chart as I was taught by senior clinicians, but the patients would often ask with disbelief ‘Have you not looked at my notes?’ Northern Ireland’s Electronic Care Record (NIECR) was opened to F1s that year (2013), helping us understand a patient’s history, medication and allergies, allowing a more informed discussion with patients and/or family where they could clarify rather than frustratingly tell anew. Although it had limitations, it was a vast improvement for information gathering and daily care, proving successful in a world where the best software can be poorly implemented.

As a junior doctor, every four-six monthly change of job is associated with weariness at the prospect of losing skills such as how to order, send and sign off investigations, what and where the local request forms and referral modes are and where to find filed notes. Not only are there expected variations between specialties but also between wards, hospitals and Trusts, which are sometimes difficult to understand. Whilst this variation may be justifiable in complex environments, for most patients and common conditions, the care pathways are similar and reduction in clinical variation tends to improve outcomes. Learning how your local clinical area works often takes more time and effort than caring for patients and it often feels that it reduces my efficacy as a doctor, despite constantly striving to gain clinical experience.

In F2 I was based on one of the first ‘electronic’ clinical areas in Northern Ireland. Now I could use clinical noting, read notes more easily, view nursing, pharmacy and allied healthcare professionals’ notes in one record, use an across hospital task list and view referred patients on the ‘take.’ However, the entire note was printed on discharge and placed into a paper chart! In this small area of innovation clinics were redesigned, with small desks and cameras permitting fast ‘single sign on’ and the previous clinic letter used for background detail. However, when I moved to another clinical area, I could see from an alternative perspective how these different ways of working with patients could lead to frustration with this system, ’enforced’ on them from elsewhere with little engagement or trial.

NIECR has enhanced the digital maturity of NI’s healthcare environment, with improving functionality reaching over 18,000 users of which >96% find it acceptable. However, it is primarily a view only portal into multiple, disparate data silos. This system hides the many complexities of redundant and aging systems and allows HSCNI to keep moving. Many of these, including our patient administration systems, urgently need replacement, whilst NIECR itself will require re-procurement and platform upgrades after 2022. It cannot currently facilitate many of the recommendations of the Bengoa report, such as e-prescribing and telemonitoring¹.

Encompass is a HSCNI programme set up to facilitate procurement and implementation of a regional electronic health and care record. We will have one core solution which will allow care providers to note, prescribe, request, schedule and communicate in order to improve patient care, from the cradle to the grave. Clinicians will be able to order any test, referral or procedure anywhere in Northern Ireland, view and sign off investigation results, track task lists and handovers, document observations electronically from integrated devices, prescribe and administer medications and fluids (by bar code) and be aided by inbuilt clinical decision support.

This paper-lite environment will incorporate both acute and community sectors, enabling mobile working. Current systems within scope, not incorporated into NIECR, include theatre management, bed management and patient flow, pharmacy stock control, Child Health and maternity, emergency department notes, anaesthetics and ICU, mental health and social care. The vision would include allowing community pharmacists, dentists, opticians and independent care providers access to up to date patient information on encompass. The consistent coding and gathering of information will allow data reporting and analytics to improve and allow population health identification, screening and reporting.

The programme will run alongside infrastructure modernising, ensuring good governance and training, support and engagement of healthcare professionals. Engagement of end users is a vital factor for success, which the encompass programme has shown it’s keen to do, including providing a fellowship post for NIMDTA’s ADEPT clinical leadership programme, involving both clinical and non-clinical professionals in inaugural Digital Care and Business Support Forums and a successful week of supplier demonstrations as part of procurement.

One of the most exciting features will be the patient portal, which will enable patient autonomy and encourage our HSCNI culture to become ever more citizen centred, consistent and cost effective. Our patients and clients will be able to manage their appointments and bookings, monitor referrals, view letters and results, manage medications, complete assessment forms and surveys, input health information from external technology i.e. blood sugars or fitness trackers. Relevant HSCNI appropriate educational lifestyle and disease-specific information will be available. Patient and public involvement has also been incorporated from an early stage in the process, including procurement, to ensure a satisfactory co-produced solution for all.

Make no mistake – this is different! This is not an optional system for the technologically interested or enabled user, encompass will be the primary solution for delivery of secondary and community care in Northern Ireland. Encompass seeks to deliver change in unison with all clinical staff in HSCNI, it is a way to accelerate the change in service delivery needed for HSCNI. Importantly, encompass is only an enabler for change, a facility with which clinical staff of all backgrounds reimagine and envision better ways to do their jobs in true partnership with engaged patients. Therein lies the challenge: encompass will succeed through direct involvement of the staff and patients who will ultimately use the system every day. We need you to help us design this system so get involved and help us in Delivering Care Together!