Clinical go-live cutover approaches

Clinical go-live is the point of the deployment where clinicians begin to use Concentric with their patients. There are 2 key elements to most Concentric deployments that mean that clinical go-live cutover needs particular consideration:

• Consent is a process, ideally with at least 2 consent conversation touchpoints, meaning that some consent processes will be in progress at clinical go-live.
• Concentric is often introduced in phases, meaning that some of the organisation are using Concentric, whilst others are not.

Clinical go-live may be the first use of Concentric within the organisation, or simply be the go-live for the department/specialty/theatre suite. In most cases, for simplicity and clarity, the cutover approach is consistent across the organisation, but this will not always be appropriate – local nuances should be considered, and our experience is that there is often no clearly correct or incorrect answer in terms of approach.

As it forms the majority of deployments, this guide will discuss the context of moving from a paper consent process to Concentric, but the principles also apply in terms of moving from another digital consent approach.

Consent process structure and touchpoints

When structuring a cutover plan it is helpful to remind ourselves of the 4 main possible touchpoints in terms of the consent process:

1. Clinician in outpatient department/similar, where consent information is prepared, shared +/- signed. (Best practice but only done in around 30% of paper-based consent processes)
2. Clinician in admission unit/ward/similar where consent conversation is happening on the day of treatment. From a documentation perspective this may be a first documented consent conversation (i.e. there is no pre-existing signed consent form), or for confirmation of consent. (This process, in one of these two scenarios, is usually done. There are some scenarios where consent is documented in outpatients/remotely and not confirmed on the day)
3. Nursing/theatre staff on the admission unit/ward/similar and on the path to theatre, for example on arrival to theatre suite. Staff will check for the presence and appropriate completion of a consent form as part of pre-theatre checklists.
4. Surgical/theatre staff in operating theatres/similar. Here the consent form and details will be reviewed as part of surgical safety checklists, for example checking laterality with the patient prior to anaesthesia, and during the ‘Time Out’ check prior to starting a procedure.

Managing processes already started

There are several approaches that can be taken at clinical go-live with regard to consent processes that have been started, i.e. a paper consent form has been completed – for example in an outpatient appointment, but the treatment has not yet happened. We call these:

• I’ve started so I’ll finish
• Concentric only
• EHR consent (our preferred approach)

When considering approaches it is worth considering that it is at touchpoints 3 and 4 (as per numbering above) that most cutover complexities occur - staff involved at these touchpoints benefit less from the introduction of Concentric compared to clinicians involved in touchpoints 1 and 2, and confusion regarding consent form location can significantly increase the time taken for the consent-related elements of their role.

I’ve started so I’ll finish

This is the approach where if a consent form has been started on paper then that consent episode remains on paper, and the paper documentation is used throughout the process. Sometimes this might involve scanning in and re-printing for confirmation of consent, but essentially all touchpoints involve a paper consent form.

This has the benefit of not introducing any additional processes for these episodes.

The challenge with this approach is that those involved with touchpoints 3 and 4 are uncertain regarding whether a digital or paper consent is expected, and therefore significant inefficiencies can occur during this period of mixed economy. Waiting times are frequently many months, and occasionally years, meaning that this period of mixed economy can be lengthy with an ill-defined end point.

Concentric only

This approach is where, from the relevant clinical go-live, treatment can only occur with a completed Concentric consent episode, regardless of whether 1st stage consent had been completed on paper.

This has the benefit of clarity for those involved in touchpoints 3 and 4 – that digital consent is what is required – and that this will be viewed in the usual place for digital consent forms (either within the EHR/document management system (EDMS) or in Concentric, depending on process).

The challenge with this approach is that it duplicates work that has occurred during touchpoint 1 - and operationally is often challenging to get clinicians to duplicate this work, and also introduces the risk of inconsistent consent information being shared between the paper and digital consent process.

When the proportion of patients who have signed consent forms prior to the day of surgery is low then this approach can be palatable.

EHR consent (our preferred approach)

EHR consent is the concept of using the EHR/EDMS to view the completed consent form for touchpoints 3 and 4, regardless of the process followed for touchpoints 1 and 2, from clinical go-live.

This is an option where; an EHR/EDMS is in place; it’s possible for clinicians/ward staff to scan documents into that system; and that a document integration is in place with Concentric (most deployments) – without such integration this process generally becomes overly burdensome.

New consent forms (i.e. via Concentric) are automatically added to the EHR prior to touchpoint 3. Existing (paper) consent forms are scanned into the EHR prior to touchpoint 3. Touchpoint 1 and 2 scenarios transition to only using Concentric from clinical go-live.

The core benefit of this approach is simplicity for those involved in touchpoints 3 and 4, whilst only adding a small amount of process (with the benefit or removing the risk of losing the paper consent form).

A transition to ‘EHR consent’ can be decoupled from a Concentric clinical go-live, with all consent forms being scanned into the EPR prior to touchpoint 3 for a period of time, followed by the introduction of Concentric, meaning that there is no change in process for touchpoints 3 and 4 at Concentric clinical go-live.

Organisation-wide roll-out mixed economy

Despite introducing consistent pathways for areas that are live with Concentric, for both ‘Concentric only’ and ‘EHR consent’ approaches, during organisational roll-out there may still be some paper consent lists (departments or clinical areas not yet live with Concentric). There should be organisational clarity around this, for example by stating within the theatre briefing whether this is a digital consent list or not.

Minimising organisation-wide roll-out mixed economy time is a key driver to transition to BAU within the timeframes outlined in the delivery playbook.