Soft launch of Lorenzo at Morecambe Bay

Tags: CfH EPR London Lorenzo PACS Pathology Quality Radiology Safety South Strategic

06 Nov 2008

University Hospitals of Morecambe Bay NHS Trust has announced a “soft launch” of Lorenzo. The trust has the electronic patient record running in one ward at Furness General Hospital in Barrow in Furness.

A small number of users on ward five – a surgical ward – are using the system to record alerts, allergies, problems and procedures, to place requests with the trust’s radiology information system and to pick up results, and to create discharge summaries. The trust is installing a new pathology system that will interface with Lorenzo once it has bedded in.

Paper forms and cards are being used on the ward alongside the new system. Eventually, there will be a “hard launch”, after which paper orders will be discontinued. A second soft launch on a medical ward at the Royal Lancaster Infirmary will take place shortly.

The trust seems determined to avoid the problems that have arisen in London and the South with “big bang” deployments of strategic systems. “We have taken a very robust attitude as a board that we will only do this when we are happy with it,” said Patrick McGahon, director of service and commercial development.

University Hospitals of Morecambe Bay NHS Trust has been working on the Lorenzo deployment – the first at an acute trust in England – for a year.

It has had a team of 20 IT staff working on the project, with NHS Connecting for Health, the agency that runs the National Programme for IT in the NHS, and CSC, the local service provider, contributing a further 100 staff each in support.

Steve Fairclough, the trust’s head of informatics, said IT and clinical staff had run multiple end to end tests of the system to iron out bugs and other issues.

The trust has also done a considerable amount of customisation; for example building in its own colour schemes for requests and other actions and writing its own on-screen guides for users. “We were very clear about what we wanted to get out of this,” Fairclough said.

The Cumbria trust covers an area of more than 1,000 square miles. It already has a community of interest network linking its hospitals, GPs and other healthcare facilities, which is robust enough to handle large files such as PACS images.

Managers involved in the Lorenzo project say its attraction is that it promises to deliver an electronic patient record that can work across the whole health community – and that this could not be achieved using other solutions.

“We have investigated putting EPRs into this kind of set up and it is very difficult and very expensive,” said Fairclough. “When the national programme came along, we felt that for the first time people were listening to what we wanted, because being able to transfer records around Morecambe Bay is massive for us.”

Dr Sydney Schneidman, a consultant in emergency medicine and the trust’s clinical lead for health informatics, also said that Lorenzo was the “fourth or fifth” EPR that he had seen in his career, and “it is the best one I have seen.”

He said that while the trust had taken some “pain” during the deployment project “we are willing to take the pain because it allows us to engineer change, and ultimately patients will benefit.”

A go-live at the trust has been much anticipated. Earlier in the year, health IT minister Ben Bradshaw indicated this would happen by the end of the summer – a deadline that appeared to come and go - with CfH able to say only that it would happen when the trust was confident in the system.

In a statement, the agency said: "We welcome the implementation of Lorenzo at University Hospitals of Morecambe Bay NHS Trust.

"The roll-out of the electronic patient record system will bring a huge improvement to the safety and quality of patient care. The experience of adopting Lorenzo at Morecambe Bay will be invaluable for informing further roll-outs of the system."

Lyn Whitfield

Readers Comments

Damage limitation

06 Nov 08 10:49

A small number of users on Ward 5 .... are we supposed to be impressed by this "milestone"?

Pathetic.

Good news

06 Nov 08 11:20

Damned if you do and damned if you don't springs to mind. If they'd done a big bang launch you'd be complaining that they were risking patient safety etc. To do it in a controlled way seems logical to me. The Trust seems happy with it. Isn't that a sign that things are being done in the right way?

Re: Good news

06 Nov 08 12:01

I'm all for testing in a controlled environment - but this sounds like a basic small-scale prototyping exercise rather than any sort of "launch".

Damned only if you don't

06 Nov 08 13:16

Lorenzo would not have been damned if it had done what it said it would do at Morecambe Bay. It has not done what it was supposed to do. Instead it has done only the minimum required to make the public launch announcement and then postpone the actual launch sine die. This is a public relations exercise without any business or clinical significance.

Did I read that right

06 Nov 08 13:28

This needed a staffing compliment of 220 people to support a go live with a handful of users?

Re: Re: Good News

lyn@e-health-media.com

06 Nov 08 13:42

The story is based on a visit that I made to Barrow yesterday. We can probably split hairs about exactly what pilot, live, etc means. But this didn't look like a pilot in the sense of something that's in development, only working in a closed environment, due to be shut down, evaluated, and then rebooted etc.

The system is live and working - albeit with just a few users and in parallel with the ward's paper systems - and the trust says that once it is happy with stability and safety it will roll this out across its wards relatively quickly.

Re the comment about a real launch being put off sine die: the trust is not putting a date on hard launch or further roll out. But it would be foolish to publicise this now and fail to proceed to either. The trust invited the press in. They know people will be looking out for further developments.

Incidentally, there will be a comment and analysis feature about the visit on site within the next few days. Lyn Whitfield (managing editor, E-Health Insider).

Pathetic Comments

06 Nov 08 13:59

Yet again, the doom mongers and the naysayers shout from the rooftops. Doomed, Doomed, we are all domed they say; yet here is a Trust begining an implementation of a new product in a clinical environment and the miserable rants of a few "know it alls but never done a thing at all" immediately scorne and attempt to mock from a postition of complete ignorance.

Is there just a chance that Lorenzo may just arrive and work? only time will tell, yes it's late but the argument surely must move one as now the product is actually here.

I would like to say well done to the Trust for doing this and well done to the team up there and shame on the ideallogically opposed and ideologically challenged.

First step to an imposed SSEPR?

maryhawking@tigers.demon.co.uk

06 Nov 08 20:00

"Managers involved in the Lorenzo project say its attraction is that it promises to deliver an electronic patient record that can work across the whole health community – and that this could not be achieved using other solutions." Managers seem really keen on the idea that a single record can work across "the whole health community" : 90% of consultations and health care is outside hospitals. The presentations on Lorenzo I have seen are incredibly hospital orientated (on their website "we have kept the tabs on the right hand side which you are all used to in your paper records"!!). Could I ask the fortunate users in Morecombe Bay what Coding they are using to enter patient data? Read (V2 or CTV3) or SNOMED? And how easy they find it to change from paper to real EPRs *with no paper notes*? My last presentation on SSEPRs at the PHCSG Annual Conference (www.phcsg.org.uk) looked at whether, in addition to the safety and clinical governance issues identified (and being examained by the RCGP) previously, they were probably not fit for purpose anyway - seeing the number of different organisations with different record keeping requirements involved! From a GP perspective, you have an EPR when you no longer need any paper entries...

Damned if you don't

rsarson@blueyonder.co.uk

06 Nov 08 21:43

This cautious approach, particularly with a bit of software which has had problems elsewhere, seems eminently sensible. But what would I know, I've only been in and around the IT industry for 55 years, and have seen a lot of Big Bang systems fail.

No bl**dy wonder ...

06 Nov 08 23:03

... that no-one else in the NW can get any help from CSC or CfH with their Lorenzo projects if, between them, 200 staff are being provided to Morecambe Bay!

So, we now have a handful of staff at Furness General plus 10 podiatrists using Lorenzo Release One - fantastic!!

two cheers...

07 Nov 08 09:28

I think this debate typifies the state that we have go to in healthcare IT, and it is a petty sorry state at that. There are things to celebrate in this announcement – the final delivery of Lorenzo into the NHS, the much improved and sensible deployment model, the supplier and users collaboration. I can see why some of these comments that look as if they come from CFH, sound pretty defensive

On the other hand, yes, it is 5 years late, small scale, devoid of the integrated functionality promised.

But more than that CFH have to be aware of the anger and frustration that they have caused through having squandered the best opportunity for a generation to bring about a sea-change in NHS IT. Sorry guys, you have no-one to blame but yourselves

half a cheer

07 Nov 08 10:13

Have to echo the comments in 11.

In 2000, I implemented an evolutionary EPR with a small budget and a team of less than half a dozen, no army of expensive advisors behind us, working with a small UK supplier, across initially 6 wards, but as soon as the juniors saw it, we quickly rolled it across the whole hospital, and ramped up the facilities.

Progress at Morecombe Bay, a sensible staged rollout, and the potential to change the system (though hopefully they have influence over more than colours), is far more in tune with successful adoption, and something to celebrate.

But as all the NME has to show for Acute care after 5 years (and contrasted against the Royal Free and other London & Southern experience) and all this funding, is a shambolic inditement of the CfH approach.

And the anger amongst Informatics staff about how local work has been stopped and frustrated by this chirade is very real.

Everybody knows...

07 Nov 08 10:37

Some NHS hospitals had order comms and limited clinical content since the 1990s - never mind the sophistication of the EMR systems deployed in all UK GP surgeries.

Time to move on?

Well it is for the staff at CSW - whose CaseNotes product (with proven functionality far in excess of that described above) has been deployed in NHS Trusts since before the advent of CfH.

http://www.csw.co.uk/products/casenotes/default.asp

As Leonard Cohen put it "The good guys lost" :-(

Congratulations

07 Nov 08 10:48

I would like to add my congratulations on the professional approach by both the supplier and the NHS in implemeting what is a new product. They have avoided the high risk big bang approach and are moving forward through a parrallel running phase to ensure that business as usal is maintained through all eventualities. They are in control, they are managing the process, they are not working in a culture of rumour, speculation and blame but in partnership.

What a contrast to what has happended elsewhere - and maybe, just maybe there is hope that one of the suppliers can deliver the vision that so many of us signed up to in 2002. We still need to see if Lorenzo can have a working PAS and provide MH support.

If so, and with the integration with TPP System 1, we might get the community wide/patient pathway system that was promised and all the associated benefits to patient care.

Of course - this will then get the data confidentiality brigade out to find a thousand reasons not to share patient data outside of organisational silos.

I agree - what a load of moaners!

sue.wilson@swbh.nhs.uk

07 Nov 08 20:57

It is absolutely unbelievable how so many people are so quick to knock any achievement or progress on NPfIT. I for one am glad to hear that Morecambe Bay and Lorenzo is live, even if it is only a pilot.It actually gives me some hope that we might just get to where we need to be.

I say only a pilot, but those of us who have experience of implementing electronic requesting, alerts, results and other functionality of EPRs, with newly developed software as well, know that you do not take ridiculous risks in deploying big bang, until you are absolutely sure it is all working well. So it is only on one ward, with a small number of users. So what? They are still using all of the functionality and sending electronic requests for probably the entire range of Imaging requests to Radiology. They are still testing out other functionality such as discharge summaries.

For goodness sake give them a break. Well done Morecambe Bay staff!!!!

I can only think that those who bleat, have little experience of deploying systems like Lorenzo, or worse still are worried that now they probably will have actually to do something!

You should perhaps get yourself a board and walk round with a sign "The end of the world is nigh!"

Re: I agree

07 Nov 08 21:58

Let's be clear. This is a trivial milestone in a programme beset with difficulties that has fallen far short of expectations in most areas. The question for most observers is not "when" or "whether" it will be terminated but"how".

So let's not celebrate at this stage but - rather - see this minor development in it's true context and await something of real significance.

IMHO the doubters are right to be cautious.

Question to the trust/CSC/iSOFT/CfH

08 Nov 08 09:53

Yes, very well done but...

As the software is rolled out to other wards what happens when the hospital network grinds to a halt or crashes, will there be a backup "mirrored" server on each ward ?

And if not, when the project reaches inpatient e-prescribing / e-administration functionality, and the hospital network is "down", how will the ward staff know who has been prescribed what and when it should be administered ?

Just a (rather sobering) thought...

Polarised views

10 Nov 08 08:05

This thread is interesting insofar as many of the comments take antithetical perspectives on what's been reported from Morecambe Bay. In my opinion, both viewpoints are valid.

Starting to implement a new clinical application (as has been done at Morecambe) is always a challenge and their cautious approach suggests that they have learned from the experiences of other early adopters within NPfIT. However, as a "micro-perspective" what they've done would not really have been newsworthy 5 - 10 years ago, before the days of NPfIT.

But then there's the "macro-perspective". Lorenzo is (was) a key deliverable of the National Programme and it's very late. Moreover, the Morecambe initiative is just the beginning of a long journey and appears to have been generously underpinned with support teams. So there are legitimate concerns about both the technical and resource scalability, and the timeframe. And the thinking around the nature of NPfIT is moving on: so this may be a small battle won in a war that - at the political level - has already been lost.

The real message from Morecombe?

keith.baldry@nhs.net

10 Nov 08 11:04

It appears to me that, from reading the article and responses, that there are a number of parallel threads here: - Morecombe Bay are taking a sensible approach to the introduction of a major new system by using it initially in a limited, controlled environment. Implementing Lorenzo is not like implementing the business SAP product - it does not have a 20 year track record and an industry of implementation consultancy built up around it. No Trust chief exec (or private sector MD) would "bet the business" on an untried system in a "big bang" implementation. - There is a school of thought that, with some justification, has labeled the Lorenzo product concept as wrong, and the product itself as a long-delayed irrelevance to 21st century healthcare IT systems. However, the underlying ideals behind facile interchange of key information on every aspect of a patient's healthcare remain valid. - The long delays and many false starts over Lorenzo in particular are a demonstration of something that long time IT professionals across a variety of industries could have told CfH from the outset. If you want a fast implementation you buy off-the-shelf, you never sign up to the vapourware and powerpoint fantasies of a consultancy marketing arm. If you want cutting edge function then you have to be prepared for failure and delay. The real argument should be whether Lorenzo should ever have been the "new" system, or whether it should have been an evolution and synthesis of the many leading edge small-scale systems that have been consigned to the rubbish bin by the juggernaut of NPfIT. - In respect of this last point, the tradition of central government to only do business with a select handful of big ticket consultancies is perhaps one of the factors most likely to guarantee failure - in the same way that military top brass are always accused of continuing to fight the last war instead of recognising that the world has moved on, so these consultancies are primarily concerned with protecting their historical business models and not with being forward thinking and innovative.

Do a Search on Royal Free

10 Nov 08 16:33

Do a search on the grand announcement of Royal Free going live with CERNER in June 2008 and the annoncement of 7 million quid losses in November. Look at the postings at the bottom of each. Its fascinating and depressing reading.

Thanks EHI, fantastic record of the collapse of reason in a public sector organisation.

And another..

10 Nov 08 17:35

It almost is as though people want the implementation to fail. Why can this not have a chance to succeed?

Part of the answer

ewan@woodcote-consulting.com

11 Nov 08 12:42

I don't doubt that Lorenzo has the potential to develop in to a capable system and I applaud the slow and careful approach taken in its roll out at Morecambe Bay.

BUT The idea that a single system, across all care-settings across a healthcare community is a desirable solution remains a fundamentally flawed idea.

The needs of different users, different care settings and different geographies are so large and diverse that is difficult to imagine any one system meeting them all and impossible that one system will meet them all well.

A single record (accessed by single or multiple systems) can't meet all needs. There are fundamental inconsistencies in the requirements of different users that mean that they will need to have their own version of some parts of a patient's record and we need to build an ecosystem that can support this "record dissonance"

Finally, if we could reach the point with just one system for the NHS (or a large part of it) where would we be in the medium and long term with no competition and no pressure for innovation.

Monolithic enterprises-wide systems are a bad idea from the end of the last century. Today we have the technology to integrate multiple systems to provide the appropriate sharing of data that we all want. Interestingly, Lorenzo was original designed to do just that and I'm sure we will see Lorenzo as part off but not the whole solution.

Ewan Davis

Sensible approach - what if this had been tried with CERNER

11 Nov 08 20:42

What a sensible PRINCE2 type approach - test, try, iron out the bugs, roll out in a small way, iron out the bugs again, expand, evolve.

Had this approach been used with CERNER, it would not have rolled out beyond the first ward in the first hospital (unless it had been tested and modified properly prior to go live).

Our Trust had had CERNER for over a year, and it has not been possible to get any useful changes implemented that might make it useful to clinicians.

I feel CERNER FUJITSU CfH might have taken some action by now if the system were limited to a few dusty unused computers in one ward ....

Re: part of the answer

sue.wilson@swbh.nhs.uk

13 Nov 08 01:32

Ewan, if you don't mind me being familiar, I am not sure that I entirely agree with everything you have said. I have an open mind about the integration with social care and other local authority organisations, but Health, not sure why you would think one single solution set across a local health community wouldn't work or even across neighbouring organisational boundaries? Or even indeed that it wouldn't have potentially greater benefits than a best-of-breed approach? Okay there will be human barriers, as certain care settings are more advanced than others in adopting IT, such as GPs and who can blame them for being cautious?

I am not saying I am the No. 1 fan of rigid standardisation, but there are merits if it is done correctly and I do put the emphasis on correctly. Let's take some examples, and with the mindset of a finished and developed product set:

1. GPs - There are only 4 leading systems on the market and GPs for years worked together to set standards on which these systems are accreditted. Are they so widely different and why did the GPs go down this route? Could one GP system replace all of these GP systems, probably. Some maybe have more frills than others, but it is really only choice which says otherwise.

2. Acute Trusts - They may not be as advanced as other sectors in many cases, but what about the paper medical record? Does that not lend itself to some sort of standardisation? Haven't clinical staff been trying to do that for years? I have in my career sat at countless Medical Records Committees, where that very subject is discussed and we spent a lot of time standardising the content and preventing any changes unless approved through the committee. So one specialty needs may differ from another in part, there is much the same in the core documents - Past Medical History, Medications, Assessment, Clinical progress, anatomical diagrams, surgery, anaesthetics, clinical obs, nursing plans, therapist records, discharge etc. Why are the Royal Colleges actively involved in producing new standards for documentation content to be introduced next year for paper records first, if there wasn't an issue now and if it did not lend itself to computerisation? I assure you that many consultants despair at the content of the paper medical record.

3. Community - are community care records so different from acute care? Therapists? District Nurses? Dieticians? Are the new care models not changing and acuity flattening, so we will see more of acute care being moved to community settings? What happens then? Will not standardised documentation aid that transition?

4. Staff - what about staff who move from one care setting or hospital to another, such as community staff, GPSIs, junior medical staff, nursing staff? Isn't it better in terms of patient care if they can just log onto a system without the need for high levels of training and support?

5. Military - they have standardised records across all of their care settings in health care. Are we going to say that is different because it is the military? I can assure you it isn't as I have experienced it, albeit on paper records, first hand.

Best of breed can actually fragment the very standard of care that is trying to be delivered, especially from the new care models. It may achieve as high as 75% of what an integrated care record could do, but is that an acceptable standard from modern enabling information technology? I am not sure it is today.

Finally, if local ownership and choice is given back to the Trusts, then I hope they have the skills to build all these forms themselves. Modern EPRs/EHRs are simply toolkits where all the forms which represent the paper records have to be built. Not only do you have to get the layout right so it flows to aid user input, you have to have the knowledge to built flowsheets, decision knowledge trees, rules within the forms, decison support alerts etc etc.

Mmm - I'll keep an open mind.

Long term strategy for CfH and Lorenzo

agledhill@lineone.net

13 Nov 08 16:52

I would like to suggest a long term strategy for CfH and Lorenzo.

Why not develop Lorenzo into a NATIONAL summary/detail (yes I know - oxymoron) care record system run on the national spine which would be fed by ALL NHS and private healthcare providers?

Best of breed GP, Private/Independent and Secondary Care information systems could feed into this via an NHS OPEN SOURCE common user interface.

The clinical data entry into the various clinical information systems would need be standardised using something like the freely available openEHR archetype templates.

The local encounter information produced could be flagged by "importance" level and only the more clinically significant data sent to the Lorenzo spine.

CfH would act as an integration and standards setting body ensuring that all accredited systems were interoperable using a "plug and play" type architecture.

This strategy would support competition between clinical information system suppliers, it would support innovation and it would support long term value for money for the NHS and taxpayer.

A week and no bad news

14 Nov 08 00:53

The comment in 5 (re: 220 staff) is a little wide of the mark - there's no suggestion that so many staff will be involved on a per-trust basis once the product is ready to roll out to those trusts waiting in the aisles.

Morecambe have never been slow to be trail-blazers for the programme which must take a special blend of vision and madness; it's clear that their enthusiasm is tempered with common sense from their eminently sensible 'soft launch' approach and the safeguards provided by paper-based backup.

Yes, "release 1" is not a panacea in its current form, but I think even the most cynical can see now the green shoots.

What we need to see now is CSC and iSOFT successfully industrialising deployment of these systems. I don't think you can underestimate the importance of getting Bradford "live" either given it's location in what was Accenture-land following the exodus of staff since CSC took over as LSP.

A week has passed without a bad news story from Morecambe. There's been precious little to celebrate recently but this is definitely worth a hearty cheer to my mind. The nay-sayers should make the effort to attend one of the demos of the next release that the suppliers are carting up and down the country - just maybe they'll see something to change their mind!

Well done Morecambe!!

Standardised care records

sleepyfox@gmail.com

17 Nov 08 14:06

Re: Sue Wilson's comment about standardisation - the military are different because they have the ability to rigidly enforce a single standard across all care domains. That is why their equivalent to the National Programme, the DMICP, cost £80 million rather than £4 billion, and has so far delivered on-time and on-budget. The last EHI post that I could find is here:

Click Here

What was plain from working on the National Programme is that NPfIT/CfH did *not* have the ability to rigidly enforce a single standard, which turned what has always been talked about as an IT project (indeed, often referred to as 'the largest IT project') into what it really was: a change management project, possibly the largest change management project.

Unfortunately the current organisational and governance structures in place in the NHS (and, to be fair, in most other branches of the UK public sector) do not facilitate such a large-scale change management project - cue litany of costly mistakes from the British government on large IT projects.

I personally found it difficult enough to get consultants in one single speciality in one single trust to agree on even the most trivial of items. I'm sure Sue and others will find it much easier to get thousands of consultants, GPs, community healthcare specialists etc. to come together and agree on a single standard for healthcare documentation to be implemented across all domains, specialities and geographic regions.

Meanwhile back at the coal-face it is not just the differing 'standards' of documentation that cause problems, but the differing information models present in domains and specialities. It is not just that the data items are different, it is that same items are used in different ways, one man's 'diagnosis' is another's 'observation' is another's 'differential diagnosis', and whilst HL7 makes a brave attempt at standardising the language used for such data items the reality is that 99.9% of health workers know (or care) nothing about HL7 and all have slightly different internal language and information models derived from their particular speciality's training regimes.

The *real* challenge to the National Programme was, and still is: to get the various information advisory groups, Royal Colleges, BMC etc. all to agree on both use of clinical language and standardised documentation. Then and only then will the centralised production of a single, national clinical record be both possible, achievable and safe.