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HTN Feature: Paper free at the point of care

In our latest feature we focus on technology projects that have replaced a previous paper based system. We spoke with industry experts to hear their views and to hear about various projects across health and care delivering cost and time savings. Here we have curated a series of comments and case studies.

Contributors include: TPP, InfoFlex, CCube Solutions, Taunton and Somerset NHS Foundation Trust, University Hospital Southampton NHS Foundation Trust, Royal Papworth NHS Foundation Trust, The Mid Yorkshire Hospitals NHS Trust, Bolton NHS Foundation Trust and Cambridge University Hospitals NHS Foundation Trust.

We spoke with Matthew Stickland from TPP to understand how using mobile devices is increasing efficiencies in hospital care:

The role of mobile devices, phones, and tablets in providing hospital-based care is a hot topic for Trusts nationwide. There have been many stories about the widespread use of WhatsApp – and other messaging platforms – in use across NHS hospitals. These stories have highlighted clinical staff’s need for immediate methods of sharing information, as well as some of the limitations of existing clinical software in place. It also raised questions about data fragmentation and security. TPP has worked with Airedale NHS Foundation Trust over the last year to develop and roll out a secure, mobile e-observations app that paves the way for secure data to be updated and shared in real time and form part of the integrated patient record.

The Android and iOS app that has been rolled out across inpatient wards at Airedale enables clinicians to fill out patient observations on tablets at the patients’ bedside. This data is immediately added to the patient record on the Trust EPR, TPP’s SystmOne, and therefore is instantly available for other doctors and nurses to view and act on. The team at Airedale started by doing the NEWS2 score via the app and immediately saw data quality improvements, compared to paper. Equally, the automatic scheduling of observations on admission or at the point of transfer enables clinicians to meet their CQUIN indicator targets and NICE guideline CG50.

In addition to bedside data capture, SystmOne’s e-observations platform supports automatic alerts and escalation procedures to improve response times to patients whose condition is deteriorating. Using decision support such as a sepsis alert protocol within the app, clinicians are prompted to consider rapid interventions and escalation of care when necessary. The observations, alerts and escalations, alongside being filed to the individual patient record, also feed organisation level dashboards. These dashboards give an overview of hospital activity as a whole and users can drill down to ward-level locations to check response times and number of escalations at a more granular level.

Using mobile apps that are directly integrated with the clinical system addresses the questions of data security and fragmentation. With the patient data stored in one secure place, everyone works with the same information and is better informed as to the story of each patient’s hospital journey.

This functionality shows how apps that directly address staff needs can become an integral part of the technology for care teams. The e-observations success is just one part of TPP’s strategy to advance hospital care. Improved data capture in hospitals is unlocking the door to advanced decision support and automation. This data can power algorithmic and machine learning models to provide clinical assistance at the point of care, help reduce pressures, and improve care quality and safety. Whether inside or outside the hospital, mobile technology is set to transform the way healthcare is delivered.

University Hospital Southampton NHS Foundation Trust

University Hospital Southampton NHS Foundation Trust is utilising Sample 360 a digital sample tracking system that allows blood requests to be actioned at the patient’s bedside. The Trust said to HTN the process of the initial ordering of the blood test to sample receipt in the laboratory is a fully digitised and closed loop system.

The system enables the nurse or phlebotomist to scan the patient’s wristband, which the displays all outstanding requests and ensures the correct patient is bled every time. Once the blood sample has been obtained, the Sample 360 handheld device prints off a label to attach to the blood sample matching the patient’s details. The sample is then tracked through to the laboratory and the results are sent digitally back to the requester.

The Trust currently use 110 Sample 360 devices across 41 live wards and 9 care groups. To date 160,000 orders have been actioned via Sample 360 and since the introduction of Sample360 there has been zero wrong blood and tube events – a milestone for patient safety, when compared to the previous statistic of 1 per week.

Since introduction Sample 360 has highlighted to staff when a wrong patient wristband has been scanned over 700 times. The project has reduced human error, improved auditability and communication. It has improved turnover time in the laboratories meaning requesters receive results sooner and has seen a reduction in overhead costs associated with paper request cards.

The Trust has also introduced ‘DiAppBetes’ a Diabetes smartphone app co-created by Dr Mayank Patel which can be accessed via desktop applications in clinical areas, and allows medical staff rapid access to concise diabetes guidance.  The app is highlighted at the junior doctor’s induction each year.

Dr Jonathan Hinton, cardiology research fellow, said: “Diabetes is so common in hospital and diabetic control is frequently upset by either the clinical conditions or the hospital set up. The Diabetes App seems to cover every diabetes related issue that I come across, whether it be just looking up how a particular drug works or how to manage challenging diabetes problems and emergencies it always seems to have the answer. It is an invaluable tool that I frequently make use of and I have no doubt that it helps improve the clinical care and outcomes of patients with diabetes at UHS.”

Looking forward, UHS is planning to introduce a Closed Loop Drug Administration system, which will work in the same way as Sample360 whereby patients will be scanned at point of care, with the ambition to reduce drug adverse events for patients.

Vijay Magon, CEO, CCube Solutions

The need for an efficient and effective information management system manifests itself across all levels of modern healthcare provision. It encompasses everything from consultants and surgeons accessing x-rays and scans from workstations across a hospital complex, ending the need for cumbersome transfer of paper records from site to another, with the incumbent risk of them being misplaced or lost or misused; to administration staff using systems that help automate selected processes, saving time and money. Add a dose of security and audit, and suddenly, the prospect of a system that mandates governance and eliminates un-scrutinised misuse, becomes quite real.

The implementation of an electronic system turns around the culture of information. Much like the NHS’ founding principle, the modern information management system provides a ‘cradle to grave’ auditable trail of legacy documents such as patient records and correspondence. Implementing an electronic information management solution delivers the proverbial ‘double whammy’ of improving accessibility, whilst ensuring that healthcare providers like NHS Trusts and CCGs are fully compliant with their legal obligation in storing and sharing healthcare records.

Once existing paper and electronic repositories are captured and managed,  it is important to ensure that systems no longer feed storage sub-folders, ie. new patient information can be captured at source, managed, and delivered without resorting to paper. Integration between multiple IT systems and devices that generate patient information must be mandatory to ensure that patient information is accessible and usable regardless of where it is held. This includes medical devices that record vital signs – a key area of concern as currently, most medical devices work autonomously, ie. data from medical devices is (manually) transcribed and re-keyed into IT systems for reuse, or simply printed and saved on paper, adding to the scanning volumes.

We have worked with trusts across the country to ensure instant access to information is provided at the point of care. There are significant cost and time savings with sophisticated electronic document management, but a key component in ROI analysis to consider is to truly understand the time saved for healthcare professionals. Document management is a lot more than taking a process and making it digital, any successful project needs to ensure the information is available in an instant, particularly when a clinician is with a patient. This is something that needs real consideration when embarking on a project to digitise information.

On a project with St Helens & Knowsley Teaching Hospitals, a requirement was to remove its paper medical documents to ensure they were available when and where healthcare professionals needed them. The projected utilised CCube Solutions EDRM to digitise 155,000 medical records. This meant the organisation stopped 7,000 letters being hand delivered each week. They opted for a scan on demand model so they only scanned what was needed. Over a staged roll-out of over 22 months the organisation reported £1.4 million in savings.

We also worked with Milton Keynes Hospital who approached the whole 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, to do the back scanning. The in-house bureau is used for day-to-day scanning and The Trust has scanned 287,000 records equating to 57.4 million pages. The overall saving are over £1 million a year!

The cost savings can be significant and if properly delivered the time savings huge.

Andrew Raynes, director of digital and chief information officer at Royal Papworth NHS Foundation Trust

The paperless target that was originally set by health secretary Jeremy Hunt has caused some debate; some people have welcomed the ambition, while others feel it is focused on the wrong things.

I can see both sides of the argument, but if you look at it through a lens of a methodology like Lean, then by examining the source of paper production, in flow or in store can help reduce waste. If you can put the information that it holds securely in the cloud or server, in many instances you can eliminate that waste. Of course, you have to maintain your systems and your files properly using a good document management system, but it gets you off that production line and improves flow while also ensuring access from multiple locations as opposed to linear single point access record management.

As part of the preparation for our move to a new hospital, we used one of our steering groups to look at paper trails in the organisation. It examined clinical flows, finance, HR as an example, to see where there were opportunities to go paperless, and where we should focus our attention while managing risk and compliance with GDPR for example.

Our deployment of Lorenzo means that we have a single, electronic patient record. We have a complete PACS, so there are no x-rays or other scans being done on film, we are 100% paperless in inpatients and we have full e-prescribing, so there are no pharmacy charts.

We have got our patient notes down to a single folder, and one of the last things left in them are consent forms, so we know we need a digital solution for that. As a specialist hospital, we have a lot of meetings, but we have given staff laptops so they can take minutes digitally; the new hospital will have a clear-desk policy.

All this means that we have gone from level one on the HIMSS EMRAM maturity scale two years ago to level five today. Being a Lorenzo digital exemplar will enable us to get to level seven within two to three years, and that is our opportunity to eliminate the last of the paper trail.

If you take a sensible, pragmatic approach, you can move towards a paper free agenda; but you need to keep focused on why you are doing it. There are massive patient safety benefits to be gained, for example, having a single electronic patient record that our staff can access at the right level when they need to, or in e-prescribing, which can reduce drug errors and mishaps.

Those are the things that you really need to focus on. It’s not just about removing faxes and printers, but if you take this approach, you will eliminate them. We had 76 faxes in our old hospital. In the new one, we have just two which are mainly to be used only as part of contingency planning.

We asked InfoFlex about their work

“The challenge of moving from traditional paper filing to online data management can be a big but critical leap as the NHS moves to systems fit for the 21st century. With IT high on the Health Secretary’s agenda it’s an issue that if it hasn’t already been addressed in your NHS trust, it will be” states Marc Warburton, Chief Executive of InfoFlex.

The rheumatology department at University Hospitals Plymouth NHS Trust did not use an electronic data management system. Patient information was stored in paper files, limiting accessibility. Following the success in installing electronic systems experienced by nearby hospitals such as Torbay, the decision was made to upgrade to a flexible electronic system, revolutionising the way the department runs today.

Improvements in safety and an increase in efficiency were the department’s main aims – how they could address these with a seamless transition to an electronic data management system were of paramount importance. Using a paper system meant that administration was time consuming, particularly when retrieving data.

Significant concerns surrounded patient safety if, for example, their data was lost, which could be eliminated through the use of electronic data as opposed to hard copies. Running a busy department, establishing how this could be addressed and sourcing the best solution that could implement a paper-free solution with ease was essential.

University Hospitals Plymouth NHS Trust partnered with InfoFlex to develop a tailored electronic information solution specifically for Rheumatology. Its’ unique modular design means the system is highly adaptable and so draws on the capabilities already in place. In the case of Plymouth – who were still to move to electronic systems – this was from scratch.

The InfoFlex Rheumatology system is now in full use at Plymouth with over 8000 patients on the system. Staff have confirmed that the system simplifies tasks that were previously time consuming or needlessly complicated, such as data retrieval or the signing of multiple prescriptions. The transition to an online management system has had significant implications and as the whole NHS moves to a more digital/paper-free outlook – good bye to the fax machine (!) – InfoFlex couldn’t be better placed to help.

InfoFlex is a leading digital healthcare solution with a different approach. Rather than imposing a rigid IT system, it models clinical patient pathways with clinicians – without the need for coding and programming – to deliver fit-for-purpose solutions that better support patient pathway management, population health strategies and the delivery of new financial and time efficiencies within the NHS.

Patient safety at Plymouth has been increased by reducing the risk of compromised data. With data more readily available, efficiency between all staff has improved significantly, with remote monitoring using tablet computers the next priority to further increase departmental efficiency in and out of the hospital.

As regards medication, the now easily accessible evidence of following protocols for appropriate drug use is significant, as is the streamlining of data retrieval and prescription signing. InfoFlex use at University Hospitals Plymouth NHS Trust has been a resounding success.

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Mark Braden, Director of Estates, Facilities & IMT, The Mid Yorkshire Hospitals NHS Trust

Our recently launched ‘MY Digital Future – Transforming Patient Care programme’, sets out our journey to further enhance our use of digital media in line with advancing technologies. We are striving towards being paperlite by 2023 to improve patient accessibility, care, safety, outcomes and experience.

The MY Digital Future programme includes digitally enhanced patient safety initiatives such as: Electronic medicines prescribing(eMeds) (to incorporate), Electronic patient record (EPR), Local Healthcare Records, Integrated end-to-end maternity system, Digital appointment letters and patient portal, WiFi to support agile working and patient access, Migrate to NHS Mail2 .net, Scan 4 Safety, Digital Pathology, RFid and GS1 Telemedicine, and,Upgrades to our PACS system to enable wider regional clinical collaboration.

As part of our digital journey we are continuing our work to ‘Axe the Fax’ and embarking on a journey for a paperlite Emergency Department. There have been ongoing improvements on our internal networks that puts us in the top 10 nationally for infrastructure. The recent move from the national N3 internet access to the Health and Social Care Network (HSCN) transitional ultra fast fibre links have been installed with work planned to further enhance these links in the summer.

The deployment of NHS Mail2 will provide enhanced security and resilience with improved accessibility and enhanced secure collaboration with NHS and other system partner organisations, as well as significantly reducing the amount of paper we as a Trust use.

This is a really exciting time for transformational change supported by digital technology across Mid Yorkshire hospitals and our community teams. The outcome of which will be a positive transformation of patient care.

Bolton NHS Foundation Trust

Autumn 2018 saw Bolton NHS Foundation Trust successfully introduce electronic observations across inpatient wards at the Royal Bolton Hospital. Patient observations were previously recorded by staff on paper charts, from which patient National Early Warning Scores (NEWS2) were manually calculated. The new solution enables care providers to record, review and store patient observations securely on a tablet device at the patient bedside, and the system then automatically calculates their NEWS2, which triggers the required alert and response.

Phillipa Winter, Chief Informatics Officer at Bolton NHS Foundation Trust, said: “The main objective of the electronic observations project is to improve patient safety and ensure that patients receive the best possible care, ultimately improving patient outcomes.”

Simon Irving, Consultant Physician and Chief Clinical Informatics Officer, said: “This is the first digitalised daily process to hit every ward and has been key to increasing staff confidence in using technology at the point of care. It should make a huge difference to patient safety and start to orientate staff to digital processes, in preparation for our EPR.”

The Trust said to HTN their Electronic Patient Record (EPR) project is well underway. Paper documents are being migrated onto the system into a more useable electronic format, ensuring the right information is being captured, and making processes more efficient. The Trust said phase one of the project will focus mainly on clinical documentation used in inpatient areas, and radiology and pathology requests and results, and is due to go live later this year.

Cambridge University Hospitals NHS Foundation Trust 

Cambridge University Hospitals NHS Foundation Trust (CUH) said to HTN: We use a fully integrated electronic patient record system (EPR) called Epic, which was configured to NHS national guidelines and clinical workflows by our in-house digital team comprising of clinical, operational, administrative and technical staff. Our EPR was introduced Trust-wide in October 2014 and connected to national systems including the NHS Spine (personal demographics service) and eReferral (electronic referral service by GPs to hospitals).

Alongside this implementation, we introduced over 800 mobile and handheld devices, integrating them with our EPR to enable real-time documentation of patient care at the bedside. All physiological monitors and ventilators in our 40 theatres and 148 high dependency critical care beds (including point of care testing devices) are also integrated to our EPR, automating the capture of physiological data directly into our patients’ electronic records.

At CUH we have transformed our clinical processes from paper-based to fully digital ways of working, primarily through digitalised health records and integrated computing devices and mobile ways of working. Our digital strategy for the future enables us to further explore and develop our use of technology to fundamentally change the way we deliver healthcare. We are keen to embrace a number of opportunities in digital healthcare, including wearable devices, mobile and remote medicine and artificial intelligence. Our aim is to also embed further digital processes across more corporate and administrative sectors of our Trust.

Dr Afzal Chaudhry, Renal Consultant and Chief Clinical Information Officer, Cambridge University Hospitals NHS Foundation Trust “As a data-rich healthcare trust, through the use of our EPR, our aim is to now move away from simply analysing data – however rich and detailed in character – to instead understanding the true value of the information that we hold in our EPR to bring profound benefits to our patients and clinicians alike. Combining clinical data with social and genomic data, for example, will generate comprehensive and actionable information that will help to support patients through the delivery of more personalised forms of care in the future; ideally moving from a principally reactive healthcare system to one where maintaining health is a proactive continuous programme.”

Simon Needham, digital project lead, Taunton and Somerset NHS Foundation Trust told HTN about their successful projects and how they did it:

The key has always been the engagement with the clinicians and administrative colleagues within each department. This helps us keep focused on making improvements for the sake of our patients, their care and their safety. For outpatients, using a phased approach and getting agreement from the department at each stage to move between phases of implementation allowed us to bring all of the staff with us.

It’s important to collect data before, during and after implementation. We were able to see the reality of how many notes were actually needed. Although we thought we needed the notes in order to look for a certain assessment or information on the majority of patients, in reality it was only needed for a minority of patients. This meant we could change our approach to either making the historic data available or getting new data into a digital format to access.

The critical care department in Musgrove Park Hospital went paper-light in October 2018, recording clinical information such as patient observations and streamlining the system by removing 92 different paper forms used by colleagues. Clinicians are spending 10% less time completing paper medical and nursing notes, allowing more time for their patients. The system links with life support machines and cardiac monitors to enable information about a patient’s condition to be available instantly to all who need to see it. This means clinicians can remotely check on their patients and plan their care from wherever they are in the hospital.

The Trust has also just launched an electronic patient record system for the ophthalmology department, which went live in April 2019. The cataract service was the first to go ‘paper-light’. The Trust said “Using technology in this specialism will offer significant patient safety improvements once completed, the software will interface with key medical equipment, removing the potential for human error in transcribing eye measurements and giving rapid access to results for clinicians.”