“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 speech
January 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
Letters Received in 4 Weeks, one Oxfordshire practice, 2010
60
50
40
30
20
10
0
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?