HTN Now: CCube Solutions on key considerations for EDMS implementation

At HTN Now we hosted a webinar with Alistair Eaton, CEO of CCube Solutions, and Vijay Magon, founder of CCube Solutions. Alistair put a number of key questions to Vijay to make the most of his 30 years of experience in the industry, discussing key things to consider when implementing, extending or replacing an electronic document management system (EDMS).

Alistair began by highlighting a common question with EDMS: I’ve implemented an EPR, do I still need an EDMS?

Vijay said: “The growing adoption of EPR systems is an important first step to improving access to health information, but there are far too many healthcare organisations that believe that EPRs are all that’s necessary for digital clinical transformation. The fact is that as much as 80 percent of the information that exists about a patient is actually unstructured – in other words, it’s in clinical documents, in medical images, in files that actually live outside the EPR, in a number of siloed systems and document repositories including shared drives.

“Creating a true single source of patient information means capturing and consolidating this unstructured content or information, and linking it to the EPR. A comprehensive EDMS is an essential component of  the digital architecture of every hospital and ICS.”

At CCube, he added, the team believe that seamless integration between EPR and EDMS “can actually help provide a single view of all patient information, while at the same time enhancing digital workflows right across a number of patient care pathways, improving clinical governance and safety.”

Considerations for EDMS implementation

“Based on your experience working with NHS trusts and health boards around the UK, what can you tell us about the benefits of a good EDMS implementation and what sort of return on investment would you typically expect?” Alistair asked.

Vijay raised the importance of paying careful attention to the problem that you are actually trying to solve. “It’s very important to look at why a trust needs EDMS – it’s not just about procuring and implementing technology. The product’s scope must cover the entire process, from handling a paper case note stored in a library somewhere, to delivery of an electronic representation of that case note at the point of need. It should be deployed, first of all, to solve known short-term problems. Start with that, then build on that framework to cater for new and emerging requirements. The key is to ensure that project deliverables, performance levels, achievable benefits, etc., are all discussed and agreed up front, not once the project is underway.”

Once set up, he said, “EDMS support must support existing working practices and clinical processes, and must be set up and designed to deliver efficiency gains. Some of these may include patient risk, because patient risk is reduced because everyone’s medical history is available at the point of need.” As an example, he noted that he has seen situations where patient appointments have been cancelled because a case note for the patient has not been found or not been delivered.

“Admissions to A&E departments have reduced, as clinicians now have instant access to scanned notes, thus avoiding unnecessary admissions,” Vijay continued. “Appointments can be made at short notice, and patients can actually see several specialists per visit, moving from one specialty to the other. In the ‘paper world’, if I’ve gone to clinic one, my notes are sitting in clinic one. If, on the same day, I go to clinic two, my notes have not had the time to be moved to clinic two, and chances are my appointment in clinic two will be cancelled.”

Vijay also went on to note additional benefits including making multidisciplinary team meetings easier and allowing for them to be conducted remotely, since the system “will facilitate multi user access to the same document or image at the same time”, regardless of clinician location. Other benefits he commented on is the ability to gain further insight from legacy unstructured data using emerging technologies like machine learning, and trusts recording fewer complaints due to information being readily available.

“At the last count, we have delivered benefits totalling circa £15 million over 10 years, from just three of our trusts in the UK,” Vijay stated. “So the application of the technology will release tangible benefits leading to cost savings.”

The business case for EDMS

Alistair commented: “Almost every time I read case studies about EDMS deployments in the NHS, including some of our own case studies, I see a picture showing empty shelves in a medical records facility. But as we know from our own customer experience, back-scanning your entire legacy document store may not be the top priority. What’s your view on this, Vijay?”

“It goes back to what I said earlier about knowing what you’re trying to fix, what your current pain points are when dealing with legacy records,” Vijay replied. “Everybody wants to get rid of paper and stop paying for storage and handling of legacy information, but that’s not the starting point for all organisations. It’s certainly the predominant reason why people want to implement EDMS, because they’re paying to store so many millions of documents in a warehouse somewhere, and also the time and money spent on filing, retrieving and refiling records. If I turn up for an appointment, my paper record has been fetched from the store, and is now sitting with the clinician. Great – that works, and has been working for many years. Once I leave, that paper record then has to be managed and sent back to the storehouse. I turn up six months later and the whole process is repeated, which is a complete waste of time and money.”

Vijay talked about how some of the organisations CCube have worked with over the years have focused on the legacy caseload being reduced over time, making sure that before paper records are returned back to the document store, they’re first scanned electronically, and that any new paper generated for patients is scanned immediately.

Although this does work to reduce paper usage in the long-term, Vijay continued: “We notice over the years that the project cost hasn’t really changed very much, because paper is still in the loop – paper is still being handled by people, who cost money. Therefore, at some point, even after two or three years, they do attend to the legacy information and they do want to get rid of it.”

Another driver for implementing EDMS lies in patient’s travelling to different locations for treatments or appointments, he noted. “If record is stored with a hospital in London and I’m travelling up to Scotland where I need to attend a clinic or be admitted to hospital, my information is stuck in London on paper. It would be nice for the person caring for me up in Scotland to have access to my information quickly, without spending days shipping or sharing information between systems, between care providers.

“Collaboration between care providers is a key driver out there, as well. That means that paper records have to be digital, so that that information can actually be shared between systems – not just within the acute setting, but outside of the acute setting as well. The key message is to look at what your current landscape is in terms of the cost of running a paper-based operation, and let’s look at how EDMS can actually help to solve that.”

What problems are we trying to solve?

“I think a key one here is the expectation that when you take a paper record and you digitise it, suddenly you’ve got access to page-level information in the system,” Vijay commented. “We know that legacy information has been collated over many years, so some of the trusts that we work with will have compiled paper-based patient information over decades. When it started, there were few rules and regulations about how paper should be classified, how paper should be held. So what we end up with is typically a chunky medical record containing 300 plus pages. The worst I’ve seen is a 300-page case note, where other than the patient ID right at the top, there is actually no delineation or segregation of information sitting within the case note. If you want to find something, you literally have to take the case note and thumb through the pages.

“So let’s deal with that problem first – how much time are you going to spend in taking that legacy record and sorting the paperwork, putting documents into the right sections or subsections within the specialty, maybe putting them in chronological order? Not everybody has the time or money to do that, and also there are rules and regulations you need to respect. In a court of law, for example, if you present a digital copy of case notes, then the judge will need to be satisfied that that case note is a true representation of the paper case note, which may have been destroyed. It comes down to convincing the judge that the way the case note was handled, prepared and scanned, means the scanned copy is a true representation. There are rules – for example BS 10008 – which say that user intervention and user handling of the paper case notes should be minimised, so that you can literally drop it on a scanner and then from there on it’s a digital copy, that nobody’s actually touched or manipulated in any way. That means that the preparation of paper is an important part of the process, and and a large chunk of the scanning cost boils down to the time spent on making sure that you don’t change the way the physical record has been compiled over time.”

You are allowed to use separator sheets, Vijay pointed out – this means that a 300-page case note can be broken down into more manageable sections or subsections which are much easier to navigate through in an electronic system, so the end-user experience is improved.

“That’s important, because if you invest in the technology and end up delivering an electronic version of a legacy case note that is actually not better than paper, the tendency is to go back to paper,” he said. “That means EDMS has failed, and we really want to make sure that doesn’t happen.”

Over the years, Vijay explained that CCube has worked with a number of trusts to make sure that they can comply with BS 10008, and that we can “actually do more with a digital record in the system, because the expectation is that the electronic system will solve all the problems, and I’m going to have a better experience.”

Vijay shared that the methodology that CCube has developed over the years ensures that the manual costs of preparing and scanning the records is kept down, because the records are scanned the way you see them, but then technology is used to “add value to the scanned record”, for example using optical character recognition (OCR). This, Vijay says, ensures the cost of adding value to the scanned record is much smaller, compared to the cost of sorting the paper record before it is scanned. The system can also “create an index of the patient case note”, which can help end-users to navigate it more easily.


On integration, Vijay described how in the 20-25 years that CCube has been deploying EDMS, they “haven’t installed a single EDMS system that just sits in the corner looking after your documents. If it’s not integrated within the organisation – not just the IT infrastructure, but within the disparate IT systems in use – then it’s not going to work.

“Interoperability is a big word, but it has enormous benefits that ensure that different systems that hold patient information can actually talk to each other. Data has to be easily flowed between systems, so a time-pressured clinician can see it. All IT suppliers out there sign up to interoperability, and this has improved over the last 15 years, but I think it should be mandatory and enforceable – in other words, if you buy an IT system from a supplier, the way that data is held in the system must abide with open standards. It must not be proprietary, so that you are the owner of the data and you should have access to that data.”

EDMS in non-acute settings

Alistair moved on to discuss the use of EDMS in non-acute settings. “Much of the focus when we talk about the benefits of EDMS is on acute hospitals,” he pointed out, “but other care settings such as mental health and community can still benefit significantly from implementing an EDMS alongside their EPR.” In Vijay’s experience, he asked, what are the main benefits that are specific to those services?

Vijay answered: “EDMS is technology that was designed probably 45-50 years ago as part of the paperless world that that was envisaged at the time. Before we started doing a lot of work in the NHS from 20-25 years ago, we did a lot of work in local councils, local government, and so on; the terminology is different, but the problems are the same. The logistics of retrieving, filing and refiling records is universal.

“Working within clinical settings in trusts and health boards up and down the country, tangible benefits are being seen by a lot of these organisations. In terms of patient information, a number of our trusts who achieved that milestone some years ago, have actually now turned their attention to other departments within their organisation – corporate records, HR departments, financial records, and so on. Keep in mind that the underlying technology of document management doesn’t care about holding a patient record or a financial invoice – as far as an EDMS is concerned, it’s a document containing unstructured content.”

The classification on top is where the differentials come into play, he said. “A clinician’s view of the patient record has to be thought about very carefully, compared to somebody in the accounts department who wants to view an invoice. The underlying technology allows us to do both. There are very strict controls that can actually be configured to make sure that users can only see what they are allowed to see, and all user activity is strictly audited behind the scenes. So the starting point of this work for a lot of trusts tends to be dealing with patient information, but once you’ve done that you can roll the system out into other departments which are not clinical.”

Cloud-based EDMS (EDMS-as-a Service)

Finally, Alistair brought the conversation round to cloud-based EDMS.

With the NHS “moving very quickly towards a cloud-first strategy,” Alistair observed that “we do still see locally-hosted implementations of electronic document management. But over recent years, the trend has been to move towards cloud-based systems.

“EDMS systems store hundreds of millions of digital artefacts – but that’s exactly the kind of application that public cloud was created to support. When used properly, public cloud offers systems of that scale levels of reliability, performance and security that go way beyond what is easily achievable with locally-managed infrastructure. It can also do it in a more cost-effective way. If solutions haven’t been architected specifically to use the cloud, it is unlikely that they will deliver the levels of reliability and performance that you should rightly expect when you are putting that much extremely valuable data in the hands of a third party supplier.

“So our advice is, when you are adopting a cloud-first strategy, just make sure that you do your due diligence on the vendor’s solution, because the cloud is absolutely perfect for EDMS, but only when it’s used properly.”

Many thanks to Alistair and Vijay for joining us.