Dr. Vijay Magon, Managing Director, CCube Solutions, explains how NHS Trusts, working closely with suppliers, can meet the technical objectives announced in the NHS Long Term plans and realise tangible benefits by careful use of existing technologies to successfully deliver the Electronic Medical Record (EMR).
Most NHS sites hold patient related data on a variety of different media, for example, paper, microform and digital. Although some areas have introduced bespoke databases allowing storage and audit, the majority rely on more traditional means. It is currently very difficult to identify exactly what information may be held on a given patient. Some departments compile their own copy of the patients’ medical records, specific to their department’s needs, with the main objective being access to information when it’s required. This practice has resulted in falling standards for the timely filing of patient related documentation in the patient’s acute medical record; increasing risk and leaving patients and clinicians at a disadvantage.
Is the holy grail of the single, integrated, electronic medical record achievable?
To address this, Electronic Document and Records Management (EDRM) systems offer the chance for Trusts to upscale their processes and embrace a culture of effective and compliant information management practice. EDRM should be seen is a key component of the wider Information Management framework which includes web content management, document and records management, electronic forms, process automation and management, collaboration, and compliance processes.
There is no magic bullet solution – just a common sense approach which focuses the available technologies on specific business processes to ensure that the solution delivers what is expected of it. The process is a migratory one which promotes a trust-wide information repository with newly created clinical documents being ‘born’ onto the repository whilst ‘legacy’ information is scanned and digitised in a staged manner.
Solutions based on EDRM technologies are in place and have delivered varying benefits in terms of space utilisation, efficiencies in delivery legacy records, access when required, etc. EDRM systems also provide additional benefits in terms of audit and life-cycle management. It is important to align digitisation of legacy records with specific processes within a Trust, rather than simply digitising records to alleviate problems related to storing and using paper. For example, the “scan-on-demand” approach applied to the Outpatient process has enabled some Trusts to realise very tangible benefits including year-on-year cost savings while delivering “paperless healthcare” – a good example of process mapping and application of the right IT solution.
The implementation of such systems 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 healthcare records.
A holistic approach…
We believe that NHS Trusts must adopt a more holistic approach for content management – to develop and provide integrated solutions that use EDRM as the underlying technology to capture and deliver electronic patient information at the point of care. The returns from investments in EDRM are being realised through careful application of this technology to address the needs of key users who deliver medical care rather than short-term measures to solve paper problems. Key users include clinicians, secretaries, administrators, etc. Each places specific demands on the medical record, and each of these demands must be addressed – a single record may need to be viewed by over a dozen different people, all for different reasons. A clinician will want to quickly navigate through the full medical history, whilst administrators are interested in latest information that will help them put a cost against a care activity. There are also nurses, medical legal staff, and many more, each with their own view of the patient record. An IT solution that does not acknowledge the roles of these stakeholders will provide limited utility and benefits.
Following many implementations at NHS sites, through close liaison with healthcare users, we believe that any solution must satisfy the following key requirements:
1. Document Capture isn’t just about capture of paper records to cut through backfile issues. The increasing proportion of patient information received and generated electronically mandates import of electronic content from other hospital systems to eliminate shared folders scattered across storage servers, and on-going generation of new clinical documents, including use of online electronic forms for capturing clinical data with little or no dependency on paper. It is vital to understand that simply digitising paper records is not enough – the solution must offer facilities to stop producing new paper through generation, management, and integration of ongoing (electronic) records – in order to minimise or eliminate the paper chase.
A common driver for digitising paper records is alleviating storage space. This remains the case although new requirements for delivering timely and relevant patient information are beginning to find their way to the top of the patient-care priority list. The cost models for scanning paper records to alleviate storage space are based on scanning casenotes as they are found. These have not changed. Consequently, given the poor and variable paper filing practices, the digitised casenotes add little value in delivering the electronic patient record and does not adequately compensate for the loss of the universal convenience of paper! While clever facilities within the viewing software help users to navigate through the electronic patient record, these are not seen as an ideal solution and, at worst, lead to “IT failures” due to poor user acceptance. So how can technology help?
Advances in recognition, classification and text analytics technologies are helping to deliver the capability to read free-form text in health records to discover both content and context, analysing the results and transforming those findings into usable information which can then be used for more-efficient patient treatment and to support researchers. Machine Learning and Artificial Intelligence breakthroughs are helping to unlock vital information buried in unstructured data and potentially transform it into actionable information.
Using such technologies to add value to scanned records is enabling practioners to access and view legacy casenotes in a manner consistent with how they access and view ongoing and new information, regardless of how the legacy casenotes are digitised. This process can be applied retrospectively to existing image repositories to spread the tangible benefits provided by document management solutions across all patient records.
2. Management and Interoperability: the document is the vehicle for content which must be searchable and integrated with the core hospital systems and practices. Its management has to encompass the document life-cycle which includes day-to-day record management (including security), as well as retention and destruction in compliance with legal guidelines.
Patient information also resides on many disparate systems within Trusts – information that is relevant to the patient and should be presented along with the digital record, at the point of care. The electronic medical record cannot sit in a document management system that remains un-connected with other hospital systems and processes. A key role of any solution must be to enable exchange of patient information between various and numerous hospital systems. 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 mandates use of established open standards like SNOMED, HL7-FHIR, ICD-10, etc. for generation, retention, and sharing of patient information.
3. Delivery: to be optimally effective the electronic record has to be delivered to key users when and where they need it. Each organisation will have many different user roles, each with their own specific requirements and, consequently, their specific need for patient information. A solution which offers a standard interface for all users will provide limited functionality to most users, especially those who work under time constraints and under pressure – these users care less about the back-end processes! IT solutions must recognize this and ensure that the patient information displayed on a screen is meaningful to the user and the user’s role. Such a model can be readily extended to include relevant third-parties engaged in delivering patient care, such as GPs, Social Services, etc. to share and collaborate.
The implementation approach behind any IT solution is just as important as the selected technology. Given the bad press about large scale IT implementations, two valuable lessons must be learnt:
(a) not all Trusts are ready for the top end solutions – each must accommodate the technology and its implementation gradually to suit a number of local conditions including budgets, IT infrastructure, user training, etc.;
(b) a core application cannot be driven top-down without involving the users who need it and who will actually use it.
Working with organisations across the public and private sectors, the common theme running through all these customers is their need for a robust, legislation compliant information management system, which acts as a hub for vital information which can be accessed and archived at the touch of a button and deliver information to those who need it, when and where they need it. An approach based on developing long-term partnerships has proved successful time-and-time again – to understand the objectives and requirements, and liaise closely with the key stake-holders to deign, build, deliver, and support successful IT solutions for the electronic medical record, at a pace that suits the Trust.
While it is good to see that the NHS Long Term Plan is accompanied by a financial commitment, each Trust must make its own case for improvement and demonstrate willingness to change. Simply throwing money at a problem will lead to yet another IT failure. We understand and appreciate that moving away from paper is not easy. It is a huge transformation process which radically changes the way NHS organisations work. It’s challenging. We work very closely with Trusts to overcome issues as they have arisen to ensure the system delivers exactly what records and clinical staff want so they can move away from well-understood but archaic paper-based systems, which just don’t work in today’s hospital environments.
The bottom-up approach means that the expected digital revolution in the NHS is achievable – gradually and over time rather than committing astronomical sums on large scale IT projects.
