GP practices are having to cope with frequent IT faults, with clinical software systems going down on a regular basis. Rhiannon Jenkins looks at the effects on patient safety and workload
The UK Government’s entire strategy for general practice appears to focus on improving telephony systems, while the Labour Party is talking about the use of AI to reduce waiting lists. But on the ground, the NHS can’t even get the basic technology right.
Practices all over the country – particularly those using the clinical system EMIS Web – are facing regular IT outages that can sometimes last for days. Not surprisingly, this poses serious problems: GPs are reporting near misses, patient anger and – inevitably – an increase in workload. They find themselves resorting to pen and paper at the surgery, having to duplicate the work later and, in some cases, even cancelling appointments.
‘It’s not good enough,’ says Hampshire GP Dr Neil Bhatia, who has a special interest in IT. ‘This is the 21st century, GPs are at the forefront of IT and medicine, yet we’re being provided with software that isn’t fit for purpose half the time. When it works, it works quite well. But the problem is, you’re just waiting for it to crash.’
A snapshot report obtained by Pulse of NHS outages between April and June suggests around 25 in general practice in two months – all from EMIS. And statistics from Pulse’s latest survey show how practices are being affected; they are having to deal with an average of almost two outages a month.
The impact
When an IT system crash – or outage – occurs, practices typically lose access to everything until the system is restored. This can include email services, appointment books, medical records, and the ability to manage prescriptions and test results. The consequences are worrying.
First is the patient safety aspect. An EMIS outage in May left practices with no access to their clinical system for around four hours, after an error by a member of the software development team. Dr Bhatia says he and his practice staff were unable to access patients’ medical records, which can make prescribing medication risky: ‘If you don’t know what their medical history is, or what they’re allergic to, then you’re just guessing, so it has the potential to be very dangerous.’ Dr Bhatia says he now keeps a list of patients’ prescription requirements on paper and only issues them once the system is back up and running – but this of course has workload implications.
As well as the problems with prescribing safely during an outage, any delay in receiving urgent blood results could also put patients at risk. ‘There may be something really urgent there – someone with no neutrophils or very low platelets, or something that might require them to go into hospital,’ Dr Bhatia says.
Naturally, the degree of risk to patients depends on the severity and duration of the outage. In March, practices across Kent and Medway raised serious alerts about patient safety when their internet connection went down for five days. Practices were unable to access Accurx or Docman, which is used for clinical letters and discharge summaries. The local Document Organisation, Referral and Information Service (DORIS) was also unavailable. Bromley GP Dr Mark Essop told Pulse: ‘It was on a scale that I’ve never seen before and it left some practices with only one or two users being able to log in, and some with none… it crippled practices on the cusp of a bank holiday.’
On top of patient safety concerns, an outage can cause chaos by disrupting the appointment system. ‘If patients can’t book an appointment because we can’t open their records to book one, it’s a total disaster,’ says Dr Bhatia. ‘Those patients don’t give up; they’ll just try again later. Then, that afternoon or the next day, there is twice as much to do. Nothing disappears, it just gets delayed.’
A recent Pulse survey revealed GPs only cancel appointments as a last resort. Only 6% of respondents said they had done so as a result of IT issues yet they still face the wrath of patients. Kent GP Dr Zishan Syed says ‘angry confrontations’ with patients are common and are ‘distressing’ for all practice staff.
‘People have this expectation that it’s your job to fix it [the outages], but it’s not,’ he adds.
Around 30% of GPs surveyed said they now print off appointment lists as a back-up in case there is an outage. Dr Hamid Iftikhar, a GP partner in Birmingham, says his reception team takes this step when they suspect the system could go down. But this represents additional workload they can ill afford. ‘It just adds more pressure and more responsibility,’ says Dr Iftikhar. ‘We need to see who is entering the building but if patients can’t sign in on the system then no one knows who is here, so someone has to stand on reception.’
And it is the extra work caused by IT problems that affects practices most. Around 80% of respondents said they write notes by hand and enter them into the system later on, and arrange deferred prescriptions. This effectively doubles workload as each consultation takes place as usual but needs to be recorded twice.
‘Crashes two to three times a week’
Dr David Coleman is a GP at Conisbrough Group Practice in South Yorkshire. Until September 2021, the practice used EMIS but decided to switch to another clinical system following an 18-month period of frequent outages, which was like ‘death by a thousand cuts’.
The outages would take place two to three times a week and involve the system crashing – usually in the mornings when staff tried logging on to the system, but sometimes during consultations. ‘We would lose at least 30 minutes of computer time each time,’ says Dr Coleman. This had a knock-on effect on appointment capacity as many of them were booked on the day.
The impact wasn’t restricted to capacity issues, though. Dr Coleman estimates that the outages led to a financial loss in the high five figures. This was mainly down to paying locums when the system was down, and then having to book them again later in the week to help catch up with appointments.
The lack of support from EMIS left Dr Coleman and his colleagues feeling ‘intensely demoralised’. He claims that the company pointed the finger at the network, while the network blamed the clinical system.’We felt, in retrospect, that we’d been pretty much fobbed off because nothing else changed but the clinical system and the problem was immediately solved,’ says Dr Coleman.
What is behind the problems?
There are two main types of IT outage: those due to problems with the network, such as the connectivity issue in Kent and Medway in March; and those that result from problems with the system supplier, such as the EMIS outage in May. Both were serious incidents, but equally distressing for GPs are daily glitches, usually down to supplier failures.
These regular faults include software lagging and freezing. Dr Syed gives the example of searching for a keyword in a patient’s record using the EMIS search bar. ‘You literally just type, and it crashes; the whole thing shuts down,’ says Dr Syed. ‘That means for the rest of today, I can’t search any records as it will cause the system to crash.’
The worst hit are those that use EMIS – around 4,000 general practices in the UK. Pulse’s survey reveals that practices with EMIS systems on average face outages 2.19 times a month.
EMIS expects to complete a new system, called EMIS-X, by 2026. In the meantime, it has had support from NHS England to fix its bugs. A spokesperson said: ‘We have had some issues recently with EMIS Web and we are truly sorry for the impact this has had on some of our users.
‘Getting EMIS Web back to a high standard of performance is our top priority. We will continue to update customers on our improvement programme.’
Those with other suppliers fare better. Sheffield GP Dr Vivek Patel, who has used EMIS in the past, says his current SystmOne software ‘is generally more reliable’. TPP users are not immune to their system going down, however – they report one instance a month. Dr Patel says he experienced a network outage in May that disabled access to the clinical system: ‘Any outages, even one, is enough because it throws everything,’ he says.
TPP says it hasn’t had a software outage in 26 years, and the failures encountered by users are local network issues. Director of technical operations Kev Sanderson says practices should call at once if there is an outage: ‘We are network experts and liaise directly with local IT teams to help them fix any network problems.’
Solutions
While frequent IT faults are frustrating for GPs, shopping around for an alternative supplier is no simple option. NHS England is responsible for commissioning the software suppliers, so practices have limited choice. However, contrary to popular belief, practices do have the right to choose a different supplier from the NHS portfolio. But this is by no means straightforward; the transition period, around a week, can be particularly challenging.
NHS Digital has long-term plans to develop the GP IT market through the GP IT Futures framework. For now, TPP has taken matters into its own hands. In June, it launched a Twitter campaign, making it easier for practices to migrate to its SystmOne. It promises to waive the £3,000 migration fee and offer practices £10,000 to cover migration costs.
Meanwhile, EMIS is hosting a UK roadshow to promote its new system EMIS-X. GPs will hope all these efforts are more than just clever marketing.
What to do if you face an IT system outage
- Ensure your business continuity plan is accessible. It should contain your operating plan, which should assume the loss of all IT infrastructure and contain essential information, such as key phone numbers and guides for staff.
- Communicate! Ensure patients are aware of the problems as this will minimise the risk of their becoming frustrated and making complaints.
- Contact your ICS primary care team. They can help escalate unresolved issues, assist with communication and alert other clinical units.
- Clinical activity can continue without access to the full clinical record as long as it is safe to do so. This is down to the clinician’s judgement.
- If continuing clinical activity, ensure robust manual record-keeping systems are in place. Your operating plan should contain a template for this, as well as a mechanism for transferring the information back to the clinical system.
- Once the system is back up, reflect on what went well and what you could improve.
Dr Jonathan Inglesfield is a GP in Surrey
Pop up comes up on Systmone that I have seen that anyone who refers a EMIS practice to Systmone may be able to claim £10,000= check this before switching from EMIS to Systmone and see if you can refer yourself if on EMIS and then have a practice break with the £10k to account for the stress of the switchover!
I have to laugh, don’t you? ————the police still use pen and paper when interviewing——–no problems
Our practice was on Vision which was sophisticated but needed someone to keep an eye on it. We were bullied into changing to systm one which is very simple. The problem with it is that it collects junk and trying to find old entries is a total nightmare. I wanted to find a previous consultation where I had measured a mole so in the end searched for it. 1300 entries came up because one of our receptionists was called Mrs Mole.
I pin my hopes for the future on an AI system that can summarise notes and have a tab that only selects useful clinical entries.
EMIS LV was rock solid and super fast. EMIS web is slow and crashes frequently. The introduction of EMIS web did not improve or help the basic task of note taking in a GP consultation, it made it worse. Consultations that could be finished in just a few minutes in LV take 10 in the web version. You could load up and go on LV in seconds. Web..sometimes it takes 15 minutes just to switch it on, on a bad day in a practice with poor internet connection and some system wide ‘upgrade’ underway. IT continuously promises the earth and stars and the delivers up a field of turnips. Always
EMIS Web or Docman crash on virtually a daily basis. I just accept that it doesn’t work and I’m going to have to restart my computer. It is very frustrating and really isnt good enough in a 21st century country.
But then again I have to keep telling myself, the NHS is no longer a world leading health service (and it starts to make sense).
EMIS Web has hitches/periods where it runs slow. We very rarely have significant crashes though. If you use searches in certain ways there is currently a bug that will crash it and you can get random ones too. But all solved with restarting the software, don’t even need to reboot. You don’t get repeated crashes all day if you are wise with how to use IT. You could if you just plough on doing the same thing and hitting the same glitch.
Its still better than the over-complicated, over-busy displays of System One even with the flaws.
“Dr Syed gives the example of searching for a keyword in a patient’s record using the EMIS search bar. ‘You literally just type, and it crashes; the whole thing shuts down,”
It ‘only’ crashes in patients with shared records and it ‘only’ shuts down if you do not click on continue. Yes, bug reported by us a month ago and nothing done (yet), no reply, no explanation, no updates on the fault.
Likely all the mandated links to spine/PDS, Docman, Doris, scripswitch makes me refer to EMIS as S***tware (not very good Software) but it may not all be the fault of EMIS. Previous TPP but the last practice in England to connect to PDS in 2018, as the more links the slower the system. Kent was designated EMISht region so had 10 years of bullying by health authority, to make their life easy for only needing to service one supplier.
We have to thank the GPC / BMA for negotiating away the IT supplier interest of the end user (GP’s) to that of the health authorities so we are secondary to choose and book, data collection through QOF, medication data collections, sick note data, all to feed government with data to prove the NHS is fine and dump unpaid work on primary care.