More and more organisations are looking to deploy Electronic Document

Management (EDM) Systems, why is this happening now, what are the business

drivers?

Dr Bill Flatman, PhD, MBA, MSc, BA, MBCS

Director of ICTIsland & Portsmouth Health ICT Service

My Background

• Clinical Scientist – Medical Physicist for 16 years working in London, Yorkshire & Portsmouth)

• General Management – General Manager / Operational Director for 6 years working for Portsmouth Hospitals leading the Clinical Support and Women’s & Children Divisions

• ICT – Programme Manager / Director of ICT of the Island & Portsmouth Health ICT Service for 6 years

Portsmouth Hospitals – essential facts

• Largest non-teaching Trust in England, serving a population of more than 550,000

• 1200+ beds on 3 main sites

• Turnover £364 million in 2006/07, 6000 wte staff

• 115,000 I/Ps, 450,000 O/Ps, 125,000 A+E attendances

• Cancer centre, regional services

• Key Issues – PFI valued at £240 million at financial close, and Foundation Trust Application

• Cost Improvement Programme - totalling £69 million by 2015/16

Portsmouth Hospitals – essential facts

Scope of Presentation

• Replacing the traditional paper health record

• Not addressing EDM in other areas although many obvious applications

Dispelling Myths – Why is EDM needed

• Danger of dual systems• It varies between specialties but some old data is

very important• In my opinion electronic systems for collecting clinical

data effectively and efficiently in all clinical situations are insufficiently developed, temporary paper is required

More and more clinical information is collected and available electronically. Won’t the traditional paper health record just wither away over time?

Dispelling Myths – CRS will provide

• The core CRS product (in the South), Cerner Millennium, does not address the historical paper record issue. EDM is an additional bundle

• Programme is late and embroiled in contract reset

• CRS programme is currently suspended in Portsmouth, Isle of Wight & SE Hampshire

• Plans B, C, D, etc. under active consideration

• Maintained active local clinical information system development programme

Electronic PatientRecord

SQL

Primary Care Systems

Electronic Document

ManagementVitalPAC

Electronic Requesting

of Diagnostic Tests

ScannerLaboratory Information

Management System

CRSRadiology

Information System

PACS

JAC Pharmacy

System

Consultant Resource

Management System

Specialty Systems

ChimeraManagementInformation

System

ISTC

Clinical Data Repository

(held at SHA)

Alerts

Alerts

eFormsDigital Pens

WorklistsWorkflow

SMS textemail

Gepmail

ElectronicDischarges

GP Out of hours,

other trusts,other?

GP Surgeries

Service Oriented Architecture,

Web Services

HL7 v3

Trust Clinical Systems

Limited CRS Scenario

ExternalSystems

PHT

Fully implemented systems

Information flow

Partial information flow

Single sign-on supported system

Some systems in group supported by single sign-on

Patient Demographic

Service

Choose and Book

National SystemsSpine

summary record

Direct booking

NHSNo.

Band covers systems regularly accessed by all clinicians

Why EDM & Why Now?

• Problems with Paper– Clinical– Paper Management– Security

• Potential Benefits of EDM

• Why Now?

Problems with paper

• How big is the problem?– Estimated 2.5 trillion printed pages a year worldwide, 45%

thrown away within a day (Smith, 2007)– UK: estimated 120 billion pages a year (about 5% world)– About 150 million paper records in NHS hospitals in

England, perhaps over 10 billion pages (Branzcik, 2003)

• Significant proportion need 25-30 years retention (maternity, paediatric, research trials, cancer and chronic diseases)

• Even with CRS eventually, the paper does not quickly go away

Problems with Paper - Clinical

• Misfiling of documents• Documents never filed• Records lost• Multiple records

Potential Duplicate Records on PAS (SE Hants)

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

01/06/05 01/09/05 01/12/05 01/03/06 01/06/06 01/09/06 01/12/06 01/03/07 01/06/07 01/09/07 01/12/07

Nu

mb

er

Duplicates

Active Duplicates

Duplicate Casenotes (SE Hants)

0

1000

2000

3000

4000

5000

6000

7000

8000

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan

2007-08

Other

C&B

MH

PHT

Problems with Paper - Clinical

• Misfiling of documents• Documents never filed• Records lost• Multiple records• Specialty notes• Time taken to find relevant information

All adds up to clinicians having to make clinical decisions based on incomplete information

Records Related Incidents reported Jan. to Dec. 2007

Documentation Misfiled 57

Documentation Delay 28

No access to Documentation 56

Failure to include relevant information 6

Record mislabelled 2

Missing, inadequate or illegible information 12

Patient incorrectly identified 32

Records missing 18

Delay in receiving test results 4

Other Record Problem 21

Total 236

Problems with paper - Clinical

Problems with Paper Clinical

In attempting to arrive at the truth, I have applied everywhere for

information, but in scarcely an instance have I been able to obtain

hospital records fit for any purposes of comparison. If they could

be obtained, they would enable us to decide many other

questions besides the one alluded to. They would show

subscribers how their money was being spent, what amount of

good was really being done with it, or whether the money was not

doing mischief rather than good.

Florence Nightingale, 1873

Problems with Paper – Paper Management

• Filing and retrieving of paper records

• Policies for Retention & Disposal

• Health & Safety

• Space

• Transport

• Multiple stores

• Cost

Problems with Paper - Security

• No auditing of who has viewed record

• Records left in insecure areas

• Difficult to control access

• Records physically lost

Problems with paper

Potential Benefits of EDM – Clinical(as integrated part of electronic patient record strategy)

• Information available when required• Available simultaneously in multiple places• Electronic records are more complete• Research• Future – better structured to aid care pathways and

decision support

“Physicians in our study who used a CPR produced more complete documentation and documented more appropriate clinical decisions, as judged by an expert review panel.”

Tang PC, LaRosa MP, Gordon SM. Use of Computer-based Records, Completeness of Documentation, and Appropriateness of Documented Clinical Decisions. J Am Med Inform Assoc. 1999; 6: 245-251.

Why now?

• Situation with dual systems is getting worse – with combination of paper and multiple electronic systems

• Technology now has the capacity in terms of storage, processing power and display capability to support EDM for health records

• Technology still has a way to go – portable devices, data input methods

Must not consider EDM in isolation but as part of an overall strategy. The Portsmouth EDM business case was agreed simultaneously

with a single sign-on and context switching business case

Why Not Now? – The Risks

• Implementation Risks:– Infrastructure,– HR issues with many A+C staff roles affected,– etc.

• Clinical Acceptance

• Impact on Clinical Throughput

• Security

Conclusion – 1st Part

• There are pressing reasons for investing in EDM now

• This is despite the fact that implementation is complex and large risks have to be managed

Procuring an EDM solution for health records

Philip Scott

Head of IT Projects & Development

Portsmouth Hospitals NHS Trust

Contents

• Introduction• Portsmouth’s EDM programme

– Procurement and deployment– Strategy– Governance – Lessons learned and applied

• Conclusion• Questions

Introduction - Philip

• Head of IT Projects & Development– Shared service but mostly hospital for clinical IT projects– Working with GPs for discharge/clinic letters– Major EDM programme for patient records

• Member of HL7 UK Board– Broad interest in interoperability– Chair NHS implementers group– Member of newly formed IHE-UK XDS technical committee

• PhD research student– MSc dissertation on electronic requesting of lab tests– Interest in effects of IT on clinical time and processes

Portsmouth’s EDM programme

• Procurement and deployment• Strategy• Governance • Lessons learned and applied

EDM programme: procurement and deployment

• May 2005: initial clinical workshops• Sept 2005: OBC approved for EDM strategy• Competitive procurement using OGC framework• Compared against LSP offering• Jan 2006: pilot FBC approved, contract awarded to

IBM• Mar 2006: pilot implementation began

EDM programme: procurement and deployment

• Dec 2006: hospital FBC approved, contract novated to acute Trust

• Spring 2007: hospital workflow analysis• Jan 2008: trial EDM-based clinics• Feb 2008: first hospital deployment• May 2008: full hospital deployment

EDM programme strategy

• Bulk scan records active in last 18 months plus selected specialties and departmental records

• Scan on demand for all other records• File preparation to sort, remove some redundant

content• Departmental records Q1-Q2 2008• Main records Q2-Q3 2008

EDM programme strategy

• Temporary paper notes for current admission/appointment for most areas initially (scanned on discharge)

• Electronic forms developed for Top 20 hospital forms, trial in selected clinical environments

• Trial use of digital pens, tablets, COWS• Constraint: Wireless on main site only; also have to

support five peripheral sites and mobile access

EDM programme governance• Programme Steering Group chaired by Trust finance director

– Reports to Transformation Board chaired by CEO• Clinical engagement group chaired by a clinical director• Full-time programme manager with two project managers• Change facilitators• Workstream leads for:

– Clinical process change– Training– Infrastructure– HR– Communications– Information governance– Logistics– Technical integration

EDM programme: Pilot lessons learned

• Scanning workload for newly created or received paper was underestimated and not properly built into revised job specifications.

• Initial clinical workshops did not elicit true functional requirements largely because clinicians were unable to visualize the system or the implied workflow changes.

• Insufficient attention was given to agreeing standard working practices, consequently the system was used inconsistently by different teams and individuals.

EDM programme: Applying lessons learned

• Hospital deployment working closely with HR

• Demo system used to help clinicians visualize

• Standard working practices being developed through clinical engagement group and information governance

• Bar-coded forms and electronic forms being developed to minimize new paper and simplify scanning process

EDM dependencies

• IT infrastructure– Utility, portability, ubiquity, mobility, security– Specifics: touch screens, voice recognition– Single sign-on and patient context synchronization

• Records management standards (content and process)– Interoperability (HL7, IHE-XDS etc)

• Avoid “islands” like current PACS and C&B– Workflow reform, job specification changes

Conclusion – 2nd Part

• One of the most extensive EDM implementations we can identify in the NHS, but several in the pipeline and we are keen to share experiences and learn

• The business case for scanning historical paper records is robust• No fixed timetable for becoming paperless• LSPs have varying approaches, disparate solutions• Contract reset may have reduced barriers to CRS integration• EDM is not EPR

Philip’s Contact Details

• Contact: philip.scott@ports.nhs.uk• Trust website: http://www.porthosp.nhs.uk/• Research website: http://userweb.port.ac.uk/~scottp• HL7 UK website: http://www.hl7.org.uk/

Portsmouth Hospitals NHS TrustQueen Alexandra HospitalPortsmouth PO6 3LY

?

Workforce Review Team

bill.flatman@ports.nhs.uk