Joining us for HTN Now in late October, Vijay Magon, Managing Director at CCube Solutions, led a discussion on electronic document and records management (EDRM) for patient records.
Vijay began by supplying some content about CCube Solutions; they have been in business for over 20 years, with 98 percent of that business with NHS trusts. “We’ve been helping trusts and health boards up and down the country to put in software solutions and digitise services to make it easier for NHS organisations to share and provide access to their patient records,” said Vijay.
“Over the last couple of years, we’ve also put in quite an ambitious programme to gain accreditation for a number of ISO and BS 10008 standards out there. I’m pleased to say that we’ve achieved this over the last year, which is a key milestone for us in terms of how we hold electronic information, ensuring that data integrity in our system complies with the established standards out there.”
The webinar, Vijay explained, would involve three key elements: the background context, the solutions available, and the benefits that have been realised by organisations CCube Solutions have been working with.
The problem
“This is a familiar problem for most hospitals and health boards out there – the amount of paper that is held,” Vijay said. “It occupies real estate. It has to be filed, retrieved, delivered in paper form, and then refiled again to repeat the cycle. It’s not just a fixed cost, it’s a recurring cost that increases over time.”
The paper files have “limited utility in the context of sharing, collaboration, and at the end of the day, patient care,” Vijay added. “If I live in the south but I end up in a care centre in Scotland, how will my information be relayed in a timely fashion so that whoever is looking after me in Scotland can attend to me using real information, accurately and in good time?”
Vijay highlighted the expanding NHS backlog. “It is a growing problem. How do we deal with that, in addition to the paper problem? How do we manage patient activity and patient flow? It’s all related to this underlying problem of information being paper-based.” It affects all NHS services, Vijay noted, and any further COVID resurgence will add to the problem.
Other issues include staff absence, recruitment and retention; having enough beds and equipment; funding uncertainty; and the age and standard of NHS estates.
“We look at the problem in two main stems,” explained Vijay. “There’s the problem to do with patient records remaining in paper form, and then the second problem is all around patient flow and patient engagement – how do we bring the patient into the fold?” If patients can access appointments in a timely fashion, they can ultimately help clear the NHS backlog.
Solutions and options
“In the work that we have done over the years, we’ve used some of the available technologies for EDRM to solve the first problem,” Vijay noted. This includes “attending to the volume of patient information that is occupying real estate and also occupying resource in terms of moving paper records between departments, locations and users.”
EDRM is all about capturing information, Vijay said. “That’s not just paper-based information, but also electronic information, both structured and unstructured. That includes documents that you create on your desktop like Microsoft Office files, but also multimedia information – photographs, videos.”
He explained how paper information comes in two forms: legacy records and new.
“As a key requirement, EDRM needs to attend to the capture of all kinds of information,” Vijay said. “It needs to manage that in the EDRM repository and then deliver the information to the right user at the right time.”
Vijay explained that different users have a different view of each case note “which has to be respected within any electronic system.” He described how people can physically flick through a paper chart to the section that they are interested in. “We need to be able to provide similar functionality in the electronic system,” he said, adding that this problem has now been solved in the EDRM system.
“Interoperability is a must,” Vijay continued. “EDRM isn’t just a system that sits in a corner looking after the patient record. It has to be knitted into the infrastructure. It has to be connected with the other IT systems in use – EPR systems, clinical portals, lab systems and so on. Without that connectivity, the gaps that are left will actually take away any benefits that can be realised through the adoption of digital platforms.”
If you’ve invested in digitising your record, Vijay said, “the last thing you want to do is hit the print button and go back to paper. We need to make sure that it’s easier to export information and share it with other healthcare providers and services.”
On data protection, Vijay added: “A lot of work has been added since GDPR came into effect, to make sure that you can share information in a visible and auditable fashion.”
Other components can be added, such as components to capture new information; workflow software can also be added to streamline the back end of operations processes out there, such as clinical care pathways.
Vijay moved on to demonstrate how to tackle a problem that is often faced. The issue is around taking a volume (or multiple volumes) of information like a legacy patient case model and converting it into an electronic document.
“The process for doing that is really well established now,” he said. “The key message is that even a physical case note has a structure – tabs, sections, subsections. They have to be respected when you convert that into a digital record. We’ve got processes that we have developed over the years to help with this, for example using barcoded sheets to make sure that sections and subsections can be segregated during the preparation part of the process. This means that when you drop that stack of paper onto the scanner, the scanner will automate the rest of the process. This leads to a structure that you will see in a typical EDRM.”
The EDRM system can also identify misfiled records or allow the practitioner to search for a given document; this works through character recognition by extracting text and recognising the tag. “Text searching has opened up other opportunities for the practitioner to find information rather than having to sit there and flick through images,” Vijay commented.
Vijay highlighted how EDRM systems can capture information and manage it over its lifecycle, including retention and disposal, but they can also make sure that information can be delivered to interfacing EPRs, clinical portals, and more. “They can then gain the benefit of having access to legacy records simply by clicking a single button,” he said.
“Developing interoperable tools is a big part of the delivery,” Vijay continued. “There are smartphone apps that can look at this information. We’re not pretending to show the entire patient case note to a smartphone app, but we can show relevant pertinent information such as who the next patient is and where the latest referral letter is from.”
Patient portal app
Coming back to the second of the two main problems he raised at the start, around patient flow, Vijay presented an important question: where does the patient currently fit into this?
“In order to get the patient to play a bigger role in the delivery of the care and put them in a position to help tackle some of the problems healthcare providers are facing, patients need to be connected with practitioners,” he said. “There are a number of patient portals out there and we’ve actually developed one ourselves – more of a patient app than a patient portal, which will allow the patient to be involved in the delivery of their care.”
Vijay described how patients should be able to easily register and use a portal on any device; they should be able to see a home page with announcement and useful widgets; they should be able to view past and future appointments, and request changes; they should be able to communicate with the care team; and they should be able to help by providing their own information such as weight or blood pressure data.
To support the provision of care, he noted that there are three key players: the patient themselves, the healthcare provider, and the use of available data.
Benefits
Vijay moved on to discuss some of the benefits that trusts have seen from working with CCube Solutions.
With regards to the first main problem – the issue of patient records remaining in paper form – Vijay said: “Some trusts actually started looking at this 20 years ago. Initially the issues that they wanted to deal with were largely to do with alleviating paper problems and stopping the paper records growing.
“In 2008, when we started working with St Helens and Knowsley Teaching Hospitals NHS Trust, they wanted to do more than that. They wanted to stop delivering paper records in patient clinics. We worked with them to develop a number of processes, for example scan-on-demand scenarios and role-based access within the software. By late 2009, they started to show savings by reducing the volume of paperwork which is retrieved and refiled in the storage locations around the site.”
Some customers simply look to turn their paper records electronic, some sought trust-wide access to records, and some pursued a fully integrated record.
The main difference between those pursuing a fully integrated record and those implementing trust-wide access, Vijay said, is that over time a number of the trusts realised that not all patient information is held in the patient case note. “There are numerous IT systems that hold electronic information, both structured and unstructured. That is part of the patient record and must be dealt with in a similar way,” he commented.
“That is part of the patient record and must be dealt with in a similar way. The second differentiator between the two is that trusts with a fully integrated record were already using EPRs and clinical portals; they didn’t want their clinicians to have to learn to use yet another application. This is where interoperability comes into play and we work with a number of the third party IT suppliers out there to open up the EDRM screens within a clinical portal or EPR, so users don’t have to log in and out of different systems to have access to legacy information.”
Vijay shared that CCube Solutions work with over thirty systems at trust and health board levels. They estimate that their systems hold around half a billion documents containing 52 billion pages, for approximately 30 million patients.
“The key message is not just the stat about the volume of information, but the average daily usage,” said Vijay. “We worked out that across all the sites, we have between 16 and 17 thousand users who regularly, every day, log in and use the system. So the message is that using digital patient records is not new. It has been done, is being done, and needs to be scaled out to make it easier for sites to see realisable benefits.”
Evidence of benefits are available from the sites that have already adopted the system and include clinical benefits such as instantly available medical history; improvements in patient safety and avoidance of unnecessary admissions.
There are also financial benefits; for example, Vijay shared how one NHS trust customer made an initial investment of £1.2 million and has saved over £15 million across ten years.
Many thanks to Vijay for taking the time to join us.
