“Paperless”

Prof Jonathan Kay

Clinical Informatics Director

NHS England

jonathan.kay@ndcls.ox.ac.uk

Overview

• Starting points• Why it matters• My experiences of trying to make it happen• How to make it easier

Starting points

• Current processes and technology• Secretary of State’s speech• Analogies from other domains• National projects: the Technology Fund

Current processes and technology

• Within organisation

Old records

Things the EPR can’t do

• Across organisations

Documents printed from computers

Snail-mail transport of paper

Scanning in general practices

• Data networks in place and good enough• Data transport systems not yet good enough

Directory services

Action on nondelivery

Secretary of State’s speechJanuary 2013

Jeremy Hunt, the health secretary will launch the project on Wednesday alongside a report claiming it could save nearly £5bn a year, after the costs are taken into account. He said it should also improve patient care and save lives.

"More importantly [than money] it can save billions of hours of time so nurses can spend more time with patients if they are not behind the nurses station trying to fill out forms," Hunt said. "And I think it can save thousands of lives. A lot of the safety problems in the NHS – people being prescribed with the wrong medication, and 'never events' where people have the wrong arm amputated – it's wrong to say technology is the panacea but it can make a big, big difference."

How does computerisation help healthcare?

• Lower unit cost of process• Improved patient safety

• Reduced data burden on clinicians

Data for other people

Computerisation

Analogies from other domains

• Retail: commerce and entertainment• Amazon, EasyJet, DVLA…

• Banking• Utilities

Document management technology

• Generated in many ways

• Communicated by computer or scanned

• May be tagged by sender or recipient, but…

• Processing after receipt limited or impossible

• Different from electronic data interchange

• Widely used in many sectors

• Maturity of the Clinical Documents Architecture standard

• “Multiformat vendor-neutral”…

Why it matters

Why it matters

• Lower unit cost of process

… mostly saving staff time, but is it cash-releasing?

• Improved patient safety

… better decision making because relevant information is available

… removing discontinuities

• Marker for process re-engineering• Marker for computerisation

My experiences of trying to make it happen

My experiences of trying to make it happen

• Laboratory Medicine reports• Radiology reports• Clinical communications into general practices

Laboratory Medicine reports, primary care

• Tens of reports per practice per day• Thousands of reports per laboratory per day• Switched off paper 20y after full coverage with

computerised transmission

• Agreement with lead GPs, PCT, LMC• Each practice was asked to ask the laboratory to switch-off• Three rounds, with authority to complete in the third

• Lots of people couldn’t imagine it working• Very few complaints• Residual problems with workflow after receipt

Laboratory Medicine reports, secondary care

• Inpatients and outpatients• Thousands of reports per laboratory per day

• Agreement with hospital boards• Legal opinion• No local choice by department or clinician• Agreed exceptions after consultation

Cellular pathology

Blood transfusion

Occupational Health

Laboratory Medicine reports, secondary care

• Response to consultation: this is going to be a big problems in outpatients. Some clinicians rely on the paper report to say that a report is available. What is safe practice?

Consultants wanted to keep the nudge

Experts wanted closed-loop approach• Can we wait for EPR?

• Decided to switch off paper reports

Working well

Some residual complaints

Made the transition to EPR easier

Radiology reports, primary care

• A few of reports per practice per day• Hundreds of reports per department per day• Tried to switch off paper 2y after full coverage with

computerised transmission

• Agreement with lead GPs, PCT, LMC• Followed laboratory medicine reports, and liaison

committee to handle all communications

• Radiology department: “More expensive to switch off paper than continue to send it”

Incoming letters to general practices

• Realisation of time spent scanning• Variation of technology across practices• “Transfer of Information Task Force”

Representation

Project manager• Quick count of flows

Procurement of middleware

• Cover all practices• Cover high-volume senders• Handle paper (by scanning) or emailed

documents• Middleware supplier has to manage connection to

GP systems• Document transfer model, with some tags

Progress

• Flows now working

Emergency department letters

Out of hours notifications• Improving tags

• Content• Timeliness

• Add more flows

How to make it easier

How to make it easier

• Form a liaison group first• Get the right architecture and technology• Choose the right flows to change first• Implement as a series of quick, short modules

• Learning from others• Not waiting for perfection

Timeliness and quality

• If users think that subsequent steps are slow there’s not much reason to speed up

• Senders don’t know recipient’s views

• Actively monitor timeliness and quality

Other issues

• The last 5 metres to the bedside

• Workflow without paper

Routing

Annotation

• Misunderstandings about information governance

Neutrality about media

Duty to share

Caldicott principles

What I need to know from you

• How can I find out the current state of play?

• How fast can you deliver your changes?

• How mature is Clinical Documents Architecture?

• What do you want NHS England to do from the centre?