Design and Implementation of an Electronic Patient Record via Adaptation of Existing Hospital Software

With the aim of improving efficiency and addressing limitations in paper-based clinical documentation, two resident doctors developed a customised electronic system for clinical note documentation on hospital wards. Using iterative co-design and active engagement with clinical colleagues, a ward moved from paper-based ward note-taking to electronic documentation. To demonstrate the benefits, the team conducted a comparative trial, assessing the in-house developed electronic patient record (EPR) system against the traditional paper notes in terms of efficiency and impact on working conditions. Following validation, the results were presented to, and endorsed by, the specialty Clinical Governance team. An implementation plan was subsequently formulated to introduce the EPR system across multiple hospital wards, utilising a stepwise approach. Various challenges emerged, leading to further iterative refinements to address issues encountered during each rollout phase. Challenges included raising hospital-wide awareness of participating wards, distributing training materials via channels compatible with real-world work patterns, overcoming hesitation about transition from paper-based systems, and addressing logistical hurdles with IT hardware deployment, which impaired the efficiency gains of the EPR system. Despite these challenges, the intervention demonstrated significant improvement in the timely handover of care at discharge from the hospital, with delays beyond 72 hours being eliminated.