For a recent HTN panel discussion, we explored how organisations are tackling the challenges of paper and digital records, with the help of expert panellists including Stacey Sutherland, clinical digital documentation lead and change lead for trust-wide division at University Hospitals of Derby and Burton (UHDB) and Chesterfield Royal Hospital; Caroline Holmes, deputy director of patient data and records, digital services, at Mid and South Essex NHS Foundation Trust (MSE); Stefan Chetty, director of digital services at Restore Information Management; and Andrew Robertshaw, implementation manager at Restore Information Management.
Panellists shared their progress, their approach, insight around overcoming challenges in this space, and what worked well; before moving on to discuss data protection, governance, compliance, and the future of records management.
Starting out with some introductions, Stacey highlighted how her role involves creating assessments in the EPR and helping to reduce reliance on paper; whilst Caroline explained her remit looking after health records and access to those records, clinical coding and data quality across MSE.
Joining us from Restore Information Management, Andrew introduced himself as implementation manager and NHS specialist, with more than 20 years of experience working in information management, the majority of which has been spent working within the NHS, before moving into his current role developing processes and solutions to support customer requirements.
Stefan offered an introduction to Restore Information Management, outlining how the company works with organisations on all elements of the document lifecycle, including in creation, data capture, storage, retrieval, transport, and the management of physical records. “Our primary focus is on helping trusts create and execute a plan for going digital, delivering services around the standardisation of content prior to digitisation, scanning of paper records, right through to the secure and compliant destruction of physical paper in line with retention periods.”
Stefan also moved on to present an overview of some key insights around tackling the challenge of paper records, pointing to some of the issues trusts often face within the process. “The Estates Returns Information Collection (ERIC) is published by the NHS every year, and tells you about some of the costs and space used by trusts. What the latest figures show is that there is still a significant spend on storing medical records, typically paper records, with a cost of £178 million onsite and £66 million offsite across all non-ambulance trusts.”
As well as cost challenges, there are also challenges relating to space, Stefan shared, with 220,000 square metres taken up by medical records on sites at hospital premises. “That figure has grown at a time when arguably space is more premium than ever for the NHS,” he said, “and the data also tells us that the vast majority of trusts are in some way still reliant on paper – there are only four trusts bold enough to say they have gone fully digital.”
What that scenario highlights is the potential for cost savings, Stefan continued, allowing for the prioritisation of capital projects linked to patient care and the redeployment of resources to frontline care. “Restore Information Management can help with that by immediately releasing space savings and costs through offsite storage, even prior to going digital. Whether it’s the scanning of newly created paperwork, standardisation, digital delivery or transforming the reliance on paper.”
Being system agnostic means the potential to integrate with a trust’s chosen EPR and EDRMS, Stefan went on. “We do also integrate with PAS systems to create auto-ordering systems, so where you may have an admin overhead relating to requesting physical files from an outsourced provider or your own internal health records team, we can provide an interface with your PAS system that automatically delivers physical or digital files at the right time for the clinic in advance of appointment, all underpinned by strong governance and compliant with DSPT.”
Journeys to date
Stacey told us about UHDB’s journey to date, including the launch of a paper-light project within the trust’s health records team a few years ago, and ongoing work with teams across UHDB to reduce workloads and increase scanning. “My role is focused more on our Paper2Pixels events, which we held at the end of 2023 to invite clinical teams across all five of our sites to bring us their paper to be processed, letting them know we can’t put their paper into the new system if we don’t know about it.”
That process involved a lot of information, and proved to be a “huge challenge”, according to Stacey, “but now the challenge has become processing all of that paper and making sure the right forms are processed in the right way before being put into the right system at the right time”. The team gathered over 3,000 documents, she went on, including more than 1,000 individual forms, which was more than expected, “but the biggest shock was that 70 percent of those were not trust-approved documents – that’s like 700 individual documents that are going into patient’s paper notes that nobody knows about”.
The cost implications are huge, Stacey continued, “not only of storing the paper, but also of printing and ordering the paper – it really was a massive shock to everybody that that was the amount, because as a nurse I sit with one piece of paper and think that’s fine, but when you look at thousands of people at once, that’s a huge impact”.
UHDB existed as two separate trusts up until 2017, Stacey shared, and is starting out on its single EPR journey, trying to consolidate systems. “The way we’ve looked at it has been dictated by the EPR as to what we can deliver, at what point, and how things flow,” she stated. “Some of it has been dictated by the different systems we’re turning off, because that means they will then take priority, so we don’t regress, because we want to keep our HIMSS level as high as possible.”
Looking at it from the patient’s point of view is also important, Stacey considered. “Anything like cannulas, chest drains and that sort of thing is high priority for the patient to make sure we’re recording things properly and that they’re auditable, but equally, from a patient’s point of view, they want one person to know their entire story and they don’t want to keep retelling it – if we did have that one record, that is what matters.” It’s a balance, she continued, “between trying to be very much patient-led but equally looking at our clinical teams that are the most reliant on paper, and almost starting at the beginning of the patient journey – that really helps when selling it to our teams, too”.
“We’ve done similar work,” said Caroline, “and just as COVID happened we merged three acute organisations into a single organisation, with over 300 electronic clinical systems including three legacy PAS systems, so there’s a lot of information that’s held electronically, but also a lot still on paper across the trust”. While the health records department itself has a single management structure, each individual site still has a legacy PAS system and therefore separate patient IDs and different processes across each site, she explained.
One of the sites has had about 95 percent scanned for about ten years, Caroline shared; one of the sites has had all outpatients scanned for a number of years but has only scanned about half of inpatients; and the third site only recently embarked on its scanning journey standing at around 50 percent scanned. “Scanning is not getting rid of paper, it’s just the storage of it,” she said, “and that’s the myth, because it’s still very much relying on paper.”
The trust has begun work on its EPR, according to Caroline, which is due to go live in around 18 months time with a neighbouring mental health and community trust, resulting in a single EPR across both organisations. “A lot of the work we’re doing with the scanning is a precursor to us going live with that EPR,” she said. “We’re trying to standardise the approaches across the three legacy organisations, which is challenging given the legacy electronic systems to store the PAS data and the legacy scanning systems. Knowing we’ve got the EPR coming, we’re choosing not to change that process at the moment.”
MSE is focusing on standardising documentation, particularly across nursing, maternity and AHP documents, Caroline stated, “and like Stacey said, we’re finding lots of forms that nobody else knows about”. Using an external scanning company to do the legacy scanning has been working well, she went on, “and as far as storage, one site has very little activity on that actually on site, one site did have about 12 months worth of activity that’s reduced as a result of the scanning, and one site has got a huge warehouse eventually with about five or six years’ worth on once we don’t have any more space”.
Once that happens, MSE sends the records to Restore’s storage facility, Caroline told us, where they are managed offsite. “When we call them back now, we’re starting to scan those rather than send them back to deep storage, and once we scan the actual record we’re destroying it after a month.” The main focus remains the standardisation and accessibility, however, not only for within the organisation, but also for its acute care portal, “an in-house written piece of software that clinicians within and beyond the organisations can view – in one portal a lot of the 300 different clinical systems are visible, and that includes scanned health records”. GPs and colleagues in the community have access to that, so information is visible for patients moving between sites.
“It’s been really interesting listening to Stacey and Caroline, because a lot of their approach mirrors the kind of approach we take,” observed Andrew. “There are four key areas I’d like to touch on for successful delivery, whether it’s managed in-house, outsourced, or like Caroline has described, a bit more of a combination. There’s planning, which is understanding where you are now or what you currently do with medical records and where you want to get to, considering timelines and approaches, and planning how you’re going to phase those changes in.” Critical to that, he said, is producing a gap analysis and a project plan.
The second area mentioned by Andrew is communication, not only with medical records teams, but in terms of early engagement with clinicians, which is “really key to get these projects going”. Whilst some might be reluctant to change, in Andrew’s experience getting them on side means they will go on to share that with their colleagues and drive that forward, rather than hindering the project. “My third thing is standardisation,” Andrew continued, “and I’m pleased that’s been talked about a lot already. For me it’s getting your current medical records in a good state, ready to go digital, which could mean the physical size and layout, or the reduction or standardisation of forms.”
There can often be differences in how medical records are being used within the same hospital, Andrew shared, so it’s integral to consider exactly how those are being accessed and used, how far ahead of an appointment they are being delivered, and how things like referral letters are attached. “If you can stop the production of paper in the first place, that’s great, so consider things like new paperwork and e-forms.” The final point is around working with a trusted partner, he concluded, whether that is someone else from inside your organisation, another hospital that has already completed something, or a supplier. “Don’t work in isolation – somebody has already probably done what you are planning to do – talk to those trusted partners and get their advice, ask them what has gone well and what hasn’t, so you don’t fall into those same traps.”
Changing approaches to managing paper records
In terms of what the change in approach looks like so far at MSE, Caroline talked about the actual delivery of the physical health records, saying: “We’ve got people that deliver those records around the trust for outpatient appointments, and we still have deliver what we call orange wallets, which are essentially blank paper and labels to the outpatient departments, but those are a lot smaller because they don’t contain the historical information.” At present, particularly for the site transitioning at the moment, “it’s still a mixture of patients with physical health records and those with scanned health records”.
Tracking is a weak point for the trust, Caroline told us, “and sometimes it’s a challenge because you have to play detective to find out where they might be located around the hospital”. Now, it’s often more of a challenge because they can be going between hospitals, as patients are seen between sites and not everybody has access to the host PAS system. “So yes, we’ve got lots of challenges around the moving of physical health records around the organisation,” she stated.
“I’ll pick up on that, because that is a huge benefit in looking at where we are today and moving to a digital solution,” Stefan said. “We see that sort of challenge a lot, and in some cases up to 30 percent of notes required for clinic have been somewhere that wasn’t the medical records library; then you get the challenge of temporary files being created, so you’ve got two versions of the truth, and if your clinic prep processes don’t merge the two you could end up having the most important information in a record that isn’t seen as the primary.” Then there’s the inter site transport, “which typically does have an agreed SLA but sometimes not”, which all factors into making it difficult to ensure records reach the end user at the right time.
These sorts of challenges aren’t very often discussed, Stefan highlighted, “but a lot of trusts are dealing with them nonetheless. Standardisation of processes, but also content of a record, can be done even if you’re not ready to go digital, and it will help you to get to that point”. Putting certain things in place now to control how information is used and managed, and looking at what goes into the file, means that “when you do come to digitalise, scanning is far more straightforward”.
Also key is executive buy-in, and UHDB’s patient safety group, Stacey explained. “We’ve got a 68-page booklet that is purely assessments and care planning for our patients – how are we taking things out of that and letting people know that this is now on our electronic system and not in this booklet? That’s not my decision to make. That’s our chief nurses that need to make those decisions, and so having good relationships with all of them has been key – I think getting that buy-in right at the beginning, when we’re generating excitement about choosing our new EPR, is essential.”
Data governance, data protection and compliance
Stefan talked about the data governance, data protection and compliance angle. “It’s a big subject, but the foundations are there,” he said. “You’ve got the NHS DSPT which outlines many of the elements to be considered, but if we’re talking about paper records it’s a lot of the things we’ve already spoken about, the data capture, consistency in metadata, audit trails, and so on. All of that is much more of a struggle in paper format than it is in the digital world.”
There are also things to consider for compliance around physical security and the condition in which files are stored, Stefan went on, as well as business continuity, training, awareness, and so on. “The way we’ve done it is that we’ve developed a certified information governance framework based on DSPT and taking into consideration the NHS Records Management Code of Practice.” This essentially helps Restore Information Management to understand current state, objectives and timescales of organisations, he said, “to then produce a gap analysis and help the trust with an action plan on how to bridge those gaps”.
Included in that is a stakeholder management plan, which is a key way of making sure you have that governance and buy-in across the trust, Stefan shared. “Ultimately that’s also a key part of you achieving HIMSS level seven, which is the utopia for a trust. The foundations of it are in place within the NHS, it’s just the practical applications of those things that sometimes trusts might struggle with.”
“There have been lots of challenges,” Stacey noted. “Just trying to get buy-in and agreement from everybody is a huge thing, but I think it depends what you class as governance, because to me governance is the process around how decisions are made and how we store and record that information.” One of the EPRs at UHDB has been in place for 30 years, she shared, “and trying to find out how those decisions were made 30 years ago has been quite a challenge – now we’re lucky that if we’ve got Teams we can click the record button and it gives us all these AI-generated notes, but back then, if the note-taker didn’t write that down then we haven’t got that anymore”.
A big part of the process has been getting clinical colleagues to realise that forms they may think are bespoke to them are actually 90 percent the same as elsewhere in the trust, Stacey said. “We’re asking the same questions, and having that one form will make life so much easier for everybody. We’re looking at it and seeing how we can condense things, maybe adding one extra question for a certain specialty, and then making sure those decisions are recorded in a really suitable way.”
Sometimes there are differences that exist between Chesterfield and UHDB, Stacey considered, “and although rewording can be very helpful, we have to accept that we are different trusts, with different legal teams, different requirements; some things might always be different”. UHDB is also working as part of the East Midlands Acute Providers network, she went on, “and it turns out quite a lot of East Midlands are now choosing the same EPR, so now we’re looking at why we are all documenting different things; if I transfer my patient to a neighbouring trust, I want to be able to send the paper with them – I don’t think nurses should have to restart care plans, and if we start from the same place we might be in a position to do that”.
One thing to add to the compliance debate is around the ability to audit who has viewed a record, Caroline stated. “When records are paper-based we can’t see who has looked in that record, and we have had examples where a patient wants to know who has accessed their health record, so when it’s electronic and there’s an audit trail, that’s another benefit.”
Another difficulty is in identifying and indicating which patient records need to be kept and which need to be destroyed, Caroline considered, “because that varies depending on so many factors and is really intensive – I once worked out that if we were to try and destroy everything within our organisation, it would take one person 60 years to go through and make decisions about what to destroy and what to keep”. Instead, MSE takes the approach of scanning it, she said, “and I think that’s the key thing around EPRs as well, as just because the information is electronic, how do we put in automatic destruction criteria to follow the rules and retention policies?”
This scenario is “pretty typical” of what a lot of Restore Information Management’s customers report, Andrew noted. “They’re struggling to make those decisions about what can be destroyed and when. We are starting to see small pockets where destructions do take place, but typically not for most organisations.” Choosing what to scan comes down to individual organisations, he continued. “Our auto-ordering system can take a live feed out of your PAS systems into our own system and use that to make decisions about what should be scanned. Some choose to scan to appointment, while others choose to scan by speciality or clinic code. Part of my job is figuring out with trusts what has worked in the past and what best practice is, so we can work together to find out the best approach.”
Coming back to that decision-making, MSE started out scanning by specialty, Caroline explained, “but it quickly became more time consuming trying to identify the records from within the health records library that should go offsite, doing patients that were new to a specialty who were very quickly coming back to another specialty, so it was spreading across the organisation so that clinicians were dealing with paper and electronic records”. The decision was then taken to try to do it by terminal digit number, she went on, “and we run a report each day that lets us know whether patients have a scheduled appointment within the next 30 days, and pull off about 1,000 per night at the moment to be sent to offsite scanning”.
If those records are then needed urgently, they can be scanned within a couple of hours, Caroline said, “but it was just easier for us to pull off files from a block of storage”. Certain pockets of the organisation have struggled with this approach and the fact that records are scanned as they are received, without having the time to go through them and make sure they are all in order, she added, “so at the moment we’re getting a lot of people coming to us saying they can’t find things, but there are search functions to search for certain things, and it’s about the training on the electronic system they’re using to access that information as well”.
Getting physical processes right can have a huge influence over how effective the scanning process ends up being, Stefan agreed. “Making sure everything is in the right place, and even file size management is important, because if you haven’t managed standardised file size over time, maybe by creating new volumes when you get to a certain thickness, then what to scan can be a completely different decision, as you don’t want to scan all the legacy paper that isn’t current – if you’ve managed your records over time, those scanning decisions are easier to make.”
Key takeaways
Summing up her key takeaways from the session, Stacey talked about the importance of aiming for the big picture, while remaining realistic. “We need to make sure we have all the right people involved in the decision-making,” she said, “and remember digital isn’t aways the answer; we may need to make sure we have the right process in place to get the digital system right. Sometimes paper is the answer, and if that’s right for the process, then that is what needs to stay.”
“I’d just reiterate my point about working with a trusted partner,” said Andrew, “because there’s an absolute wealth of knowledge and experience out there – use that and other people’s experiences to support your project.”
Caroline agreed with Stacey’s point about not completely getting rid of paper, but ensuring there is the ability to combine that paper or scan that paper into the digital record. “Try where possible to make sure things are entered at source so we can start removing the paper, because it makes information much more accessible to everyone involved, including the patient. We’re trying to improve the patient’s accessibility and visibility of their own health record, and that’s much easier in the digital world.”
“Make sure that paper is part of the decision-making,” Stefan advised, “so it’s part of the solution rather than part of the problem, and then frame it that way. If you are struggling to get the complete paper record to the end point of the clinician, then you will struggle to do that in a digital world, as well. Make sure your processes are right prior to digitisation, so that when you do digitise the information is complete and standardised.”
We’d like to thank our panellists for joining us to share their insight and experience.
