Taking a look at EPRs through the lens of frailty care 

Frailty affects around one-third of UK adults aged 65 and over and is more common in deprived communities. These patients often experience fragmented services, delayed diagnosis, and avoidable hospital admissions. 

Because frailty care involves a broad multidisciplinary team (MDT) – primary care, community nursing, social care, and specialists – it’s a perfect test case for unlocking EPR potential and developing scalable approaches for other clinical models.  

Based on our experience supporting multiple systems over the last year in on frailty care, here are five moves to make EPRs true drivers of proactive, integrated and personalised care: 

1. Use EPR data to spot risks early 

EPRs can help identify frailty before acute deterioration happens. Adding tools like the electronic Frailty Index (eFI) or Clinical Frailty Scale (CFS) into clinical workflows allows systematic, consistent risk assessment. 

And by integrating predictive analytics and using population health management dashboards, Trusts will be able to see who’s at risk across a geographic region and carry out targeted outreach. 

NHS transformation leaders should invest not just in the tech, but in workflow changes that embed analytic functions. By enabling early identification and empowering teams to intervene before hospitalisation occurs, Trusts will reduce costs, improve outcomes and enable patients to stay independent for longer.  

2. Create the shared source of truth 

Frailty care spans clinical, social, and community settings and fragmented information often hinders seamless care. Your EPR must become a shared source of truth where all relevant stakeholders – GPs, consultants, community nurses and social workers – can gain the full picture. 

Systems need to be able to work together, combined with workflows that support ‘tell your story once’ principles. It should also support collaboration and collective accountability through shared care plans, joint assessments, and real-time communication. This will strengthen consistency, risk management, and evidence-based decisions. 

For NHS leadership, this means navigating complex data governance and promoting clear accountability across organisations. It also means setting clear expectations that EPRs must help teams work together and support joined-up care. 

3. Build in virtual and remote monitoring 

During the pandemic, virtual care gained real momentum but many digital innovations remain in siloed pilot projects. It’s now time for remote monitoring devices, virtual wards, and wearable technologies to be embedded into your EPR ecosystem, allowing staff to monitor vital signs or activity levels.  

Looking ahead, this integration can also lay the groundwork for more advanced capabilities such as AI-driven alerts that trigger rapid response when patients show signs of deterioration. 

NHS transformation leaders need to align virtual care programmes with core EPR capabilities and broader transformation objectives. 

Successfully scaled virtual care models reduce emergency admissions and support more people to stay safely at home for longer – a key outcome for frailty patients and other high-risk groups. 

4. Make personalised, preventative care the default 

True transformation is moving beyond reactive treatment to personalised prevention.  

Enriching EPR data with social determinants – housing, mental health, income – creates a full view of patient need. You can then use analytics to segment populations and tailor interventions based on your population’s risk and context. 

This approach aligns with wider NHS priorities to reduce health inequalities by targeting resources where they are needed most and addressing the root causes of frailty. 

5. Invest in the right people and structures 

Technology alone won’t drive transformation. You need governance that aligns digital and clinical priorities, alongside investing in workforce skills to fully leverage the EPR.  

It’s a move beyond basic training to make sure clinical teams understand not only how to use advanced EPR features but also why these features are important for improving patient care.  

It also involves creating new roles such as MDT coordinators, digital navigators, and health coaches to support these changes. 

Embedding strong change management and clinical ownership is essential, especially for complex pathways like frailty care. Coordinated efforts and sustained leadership are key to achieving sustainable improvements. 

Final thought 

Without being used strategically, EPRs fall short of their initial promised value. We urge you to take another look at your EPR - it’s so much more than a technology project - it can fundamentally change how care is delivered. 

Frailty shows what’s possible. It demands early intervention, integrated working, and personalised support, all of which EPRs can enable when aligned with clinical priorities and backed by the right capabilities, governance, and leadership.

At The PSC our mission is to make public services brilliant. If you want to find out more about how we can work with your organisation to unlock the full potential of your EPR, whether this be through using frailty as a test case or not, get in touch with us at hello@thepsc.co.uk - we'd love to talk.