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 ICT
Island & 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
More and more clinical information is collected and
available electronically. Won’t the traditional paper
health record just wither away over time?
• 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
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
National Systems
Patient
Demographic
Service
Choose and
Book
Spine
summary
record
Direct booking
NHS
No.
Clinical Data
Repository
(held at SHA)
Electronic
Requesting
of Diagnostic
Tests
PACS
Radiology
Information
System
ISTC
CRS
Consultant
Resource
Management
System
Electronic
Document
Management
Laboratory
Information
Management
System
VitalPAC
eForms
Digital
Pens
Worklists
Workflow
Scanner
Alerts
Electronic
Discharges
HL7 v3
Gepmail
Electronic Patient
Record
SQL
Primary Care
Systems
Alerts
email
SMS text
Trust Clinical Systems
JAC
Pharmacy
System
Limited CRS Scenario
Service Oriented
Architecture,
Web Services
GP Surgeries
Information flow
Specialty
Systems
GP Out of
hours,
other trusts,
other?
External
Systems
PHT
Chimera
Management
Information
System
Band covers systems
regularly accessed by all
clinicians
Fully implemented
systems
Partial information
flow
Single sign-on supported
system
Some systems in group
supported by single sign-on
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 (SE
filed
Duplicate Casenotes
Hants)
Records lost
Multiple records
Other
100000
8000
C&B
MH
90000
7000
PHT
80000
6000
70000
Potential Duplicate Records on PAS (SE Hants)
Number
500060000
400050000
40000
3000
Duplicates
Active Duplicates
30000
2000
20000
100010000
0
0
01/06/05
Jan
01/09/05
Feb
01/12/05
Mar
01/03/06
Apr
01/06/06 Jun
01/09/06 Jul 01/12/06
May
Aug 01/03/07
Sept
2007-08
01/06/07
Oct
01/09/07
Nov
01/12/07
Dec
Jan
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
Other Record Problem
Total
4
21
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 Trust
Queen Alexandra Hospital
Portsmouth PO6 3LY
bill.flatman@ports.nhs.uk
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Workforce Review Team