Neil Murphy, Kodak Alaris’ regional director, UK & Nordics, considers what it takes for digital medical records projects to be successful and the Trusts that have grappled with the paper-to-electronic transition
Regional director, Kodak Alaris,
UK and Nordics
Land a man on the moon and return him safely to earth before the decade is out. That was the goal John F Kennedy famously announced to Congress in May 1961 in response to the Soviet Union taking the lead in the space race. It almost sounds simple to do. The reality, of course, was rather different.
At its peak, NASA’s Apollo programme was the USA’s largest national peacetime initiative. It employed 400,000 people, required the support of 20,000 industrial firms and universities and then cost a whopping $24 billion. That’s around $109 billion in today’s money.1
Give or take a few billion, healthcare in the UK costs a similar eye-watering amount.
Latest data from the Office of National Statistics shows that the British healthcare bill in 2012 was a massive £144.5 billion.2 More recent 2013 numbers from the Kings Fund report that public spending in the NHS amounts to 8.2% of GDP. Put another way, the NHS consumes one fifth of government spending – the largest of any department and equivalent to defence and education expenditure combined.3
The UK market for healthcare has been challenged to change FAST.
Not surprisingly, the UK government is pushing the NHS to save money while meeting ever-growing patient care demands. The Department of Health launched its QIPP programme to drive improvements in the quality of care yet get the NHS to make £20 billion of efficiency savings by 2014–2015.
It’s a tough goal. One component of how this is being achieved is to cut paper out of the system with Jeremy Hunt MP, the Secretary of State for Health, challenging the NHS to be paperless by 2018. Like going to the moon, saying it is one thing, delivering is another.
Irrespective whether you believe the timeframe achievable or not, many Trusts are already well advanced with paperless projects. Some recognised early on that electronic medical records (EMR) systems enable instant access to patient information, guarantee availability at the point-of-care, improve efficiency, and reduce the costs, security risks and space associated with paper handling and storage.
Trailblazers have bitten the financially large bullet and installed fully blown multi-million pound electronic patients record (EPR) systems – one stop shop solutions from a single supplier. In contrast, many trusts have gone down the route of using an electronic document management system (EDMS) to serve up the historical and new patient information typically using a portal at the front to tie in other IT systems. Others have opted for open source software to develop their own applications or paid others to do it for them. Like everything in life, there are many options available.
And one shouldn’t conclude that records management is a problem peculiar to hospitals. GPs have to keep paper notes – so-called Lloyd George records – in their surgeries to log the treatment given prior to the use of computer-based clinical software. This places a huge administrative burden on them, too.
Right place, right time, right person
The fundamental principle of good records management is that the right patient file should be available at the right time for the right clinician. People might think this rather hum drum but ask any doctor and they’ll say the same – patient records are crucial to providing quality care. It means they can see an individual’s medical history quickly without having to order unnecessary tests which wastes time and money.
With the millions of people using the NHS each year, shunting thousands of paper records around the system each day is not practicable. Hospitals aren’t logistics operations. Their function is to treat and care for patients and make people well. But moving from a paper to an electronic system isn’t easy. It is a huge business change process not just an IT project. It is about changing working methods and culture, and getting clinicians on side many of whom have used paper records for years and can be resistant to change. It’s not because they’re luddites, rather many feel that medicine has been forced to work the way IT systems have been designed rather than the other way round.
One size doesn’t fit all
When you think of the NHS, the name itself is a bit of a misnomer. It is anything but ‘national’. NHS Trusts operate independently and have their own boards, budgets and ways of doing things. In the context of how medical records projects have then been delivered, this has led to a variety of approaches:
- Some Trusts have invested heavily setting up in-house scanning bureaus to do everything themselves;
- Some Trusts have outsourced to business process outsourcers (BPOs) the big job of back scanning their records libraries and ongoing scanning (this is because the majority of doctors still use paper in clinics which then has to be scanned and added to files);
- Others have adopted a combination of both – a hybrid model of outsourcing the back scanning to a BPO and then doing the day-to-day forward scanning themselves in-house.
BOX 1: The benefits of an EMR system
Financial and operational
- Substantial costs savings realised by not managing a records library which includes staff, building rents and rates, insurance, lighting and logistics costs.
- Space freed for clinical activities not paper storage – a huge NHS estate benefit.
- Scanning delivers 100% availability of patient records.
- Better security, back up and auditing of sensitive patient information.
- Immediate access to scanned notes improves the clinical experience and care provided to patients.
- Easy integration with other medical systems.
- Features like ‘timeline’ tools show a patient’s medical journey over time – key for chronic disease management given patients see more than one speciality.
- Enhanced collaboration among clinicians who can access notes irrespective of their location using secure remote access technology.
- Provision of all historical notes to clinicians whereas with paper only the current volume could be provided. This has helped clinicians diagnose patients who have had health issues spanning many years.
- Easier exporting of information between Trusts if patients are referred elsewhere for specialist care.
- Easier provision of medical information following legal requests as data can be provided electronically rather than via paper which has time/cost impact to process. ––––––––––––––––––––––––––––––––––––––––––––––––––––––
Getting medical records projects right: what does it take to be successful?
So how should Trusts go about designing and installing EMR systems which actually work well in practice? Clearly there are a number of fundamental things to get right, although ultimately it is all about getting technology to support how they – the clinicians – work.
1. Get clinical and the Board involvement from the start. Clinical engagement is absolutely paramount to ensure that technology deployed works in any specialty given the various needs of staff for information relevant to their jobs. Any project must start from this point and be driven by the people who will ultimately use the system. In comparison to publishing research papers, some clinicians do not see the role of CCIO (clinical CIO) as career enhancing which is worrying and needs to change given the importance of IT in an acute specialty context. Board backing is therefore a must.
2. Work hard on indexing and structuring information. In the grand scheme of things, actually scanning records is relatively straightforward. High performance production scanners will process hundreds of pages per minute and are packed with image enhancing software capabilities to ensure crystal clear scans. But it is the indexing and structuring of medical records and making them available quickly which is far more challenging. Forms recognition technology, including OCR, can help do this and automate the whole process of recognising pre-printed forms which make up 95% of medical files. This allows a system to automatically ‘find’ forms in the scanned patient record rather than clinicians having to ‘search’ for them. Some Trusts have been guilty of not focusing enough on this. They’ve just digitised the whole record but paid little attention to how clinicians will then engage with it on a computer. When faced with hundreds of pages in an unwieldy PDF, clinicians don’t – it’s just too slow to scroll through in consultations typically lasting 15 minutes.
3. Incorporate tools to make navigating the record easier. For example, a timeline function so clinicians can see a patient’s whole medical journey through a hospital and treatment given. Bookmarking also makes EMR systems easier to use.
4. Don’t try and boil the ocean. Working with the clinical team, it is important to rationalise the number of medical forms used and what will be scanned and stored in the EMR and what won’t. Also consider scanning medical records on demand. There’s little point going through the time and expense of scanning everything if paperwork will be destroyed because a patient has not presented for years and years.
5. Avoid over complicating a project. You don’t need, for instance, to scan everything in colour. Black and white will do for most forms with the exception of ECGs. This reduces network traffic and project costs.
6. Carefully assess those skills you have in-house and where outsourcing would work better. While some Trusts have successfully done the scanning internally, it should be noted that scanning is an industrial process. The right equipment has to be purchased, staff employed and trained, facilities made available, with Trusts then taking on all the project risk. Partnering is now a tried and tested route for those who don’t want to do this alone.
7. Support any EMR project by investing in IT infrastructure to ensure system usability and acceptance. For example, network performance has to be up to scratch to cope with the additional data volume, and obviously enough desktop or trolley-based PCs and large computer screens have to be available to actually read records properly.
8.Train staff thoroughly. Irrespective of whether you go for a ‘big bang’ approach where the whole hospital switches to digital records on a designated day, or whether you roll out department-by-department, training is key. Most trusts have adopted a ‘train the trainer’ approach with some making clinic time available so practitioners get personalised instruction.
9. Allow authorised remote access to the system 24/7. Clearly clinicians will derive considerable benefit from being able to review medical records remotely before coming to clinic. Also work on processes and procedures to allow your local health economy access, too. This could include GPs so that records are shared easily between primary, secondary and tertiary care providers.
10. Think about the future. Plan from the outset how your EMR system could evolve to incorporate direct entry of notes using tools like iPads or smartphones, as well as incorporating digital dictation, eforms, workflow and so on. The EMR, in this sense, is an ever-evolving database of information which needs to keep pace with how clinicians want to use it.
Clearly digitising patient records is not nearly as complicated as designing a rocket system to get a man to and from the moon. An EMR is a strategic IT solution to improve work place collaboration and ultimately a way to solve the seemingly mutually exclusive challenges of improving the quality of patient care, enhancing operational productivity while reducing cost. No doubt, NASA engineers would be impressed.
BOX 2: Showing EMR in practice: the Trusts that are digital winners
In-house bureau: Basildon & Thurrock University Hospitals NHS Foundation Trust
Basildon & Thurrock set up its own in–house bureau and installed IBML and Kodak production scanners to digitise 450,000 patient case notes. That’s around 54 million pages. All departments are ‘live’ using Mobius medical record software from Fortrus, which runs on an EDMS from Lazerfiche. Benefits have been substantial:
- £2.6 million annual savings from a £7 million investment;
- EMR designed specifically for the hospital with considerable attention paid to making historical patient information accessible and usable in the context of each medical specialty;
- The EMR also provides direct access to bloods, pathology and X-ray reports.
Outsourced bureau: Aintree University Hospital NHS Foundation Trust
Aintree University Hospital first considered creating its own scanning bureau but then decided to outsource to specialists, Capita Total Document Solutions, who use Kodak production scanners along with Capture Pro software. CCube Solutions’ EDMS was installed. Again, the ROI is significant:
- First Trust to use forms recognition technology including OCR to automate the process of recognising medical forms with three or four clicks to information;
- £1 million annual savings from £1.5 million investment;
- First Trust to use scan-on-demand with a third party with 282,000 patient files digitised;
- 30% space gained in a new £45 million building from removing paper records. A £13.5 million estate benefit;
Hybrid model: Milton Keynes Hospital NHS Foundation Trust
Milton Keynes Hospital approached the transition from paper to digital medical records by both setting up its own in-house scanning bureau and working with a third party outsourcing specialist, Hugh Symons Information Management, to do the back scanning. Unlike Basildon & Thurrock, who rolled out EMR department by department, Milton Keynes went for a ‘big bang’ approach where all departments went live on one day. The in-house bureau is used for day-to-day scanning. Just like the other Trusts listed above, returns from the project have been considerable:
- £1 million cumulative savings since the project went live three years ago from a £2 million investment;
- 35% reduction in records staff headcount;
- 287,000 patient records scanned equating to around 57.4 million pages;
- Project delivered on time and to budget with the only cost over run due to VAT increasing from 17.5% to 20%;
- Auditing and information governance improved as medical records are tracked.
Shifting medical records expertise to primary care
Located near Liverpool, St Helens & Knowsley Teaching Hospitals NHS Trust started its EMR project in 2009 and digitised records at its two hospital sites, St Helens and Whiston. Its IT resource – St Helens Health Informatics Service (HIS) – created its own in-house scanning bureau and achieved impressive results:
- First Trust in the UK to stop using paper medical files in clinical practice;
- £1.4 million annual savings from £1.2 million investment;
- 500 doctors and 130 secretaries trained after a staged rollout taking 22 months;
- Over 135,000 medical records digitised, which stops 7000 files per week being hand delivered.
Capitalising on this experience, St Helens & Knowsley HIS took the pioneering step to offer its know-how in primary care. In April 2013, in conjunction with partner CCube Solutions, it launched a fully managed service to digitise all Lloyd George records that GPs keep in their surgeries. Costing just 60 pence per record per year, the service includes collection, digitisation, hosting, training, and the software GPs then use to access the information on their desktops.
This initiative is about releasing more space in primary care, enhancing GP and practice staff productivity and removing a whole paper shuffling industry in primary care, which in itself costs millions. This makes St Helens & Knowsley HIS a true pioneer digitising medical records probably worldwide.
- ONS. www.ons.gov.uk/ons/rel/psa/.expenditure-on-healthcare-in-the-uk/2012/ind….
- The Kings Fund. www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Spending on health … 50 years low res for web.pdf.