Government Technology

St Helens and Knowsley Teaching Hospitals NHS Trust has installed an electronic document management system (EDMS), using C-Cube software from OITUK and Kodak i660 and i780 scanners, to radically change the way health records are distributed around its various outpatient facilities in Merseyside.
    
In a phased rollout starting with the respiratory, dermatology and ophthalmology departments, the Trust will move away from a labour intensive process to one where all authorised clinicians, medical secretaries and other staff in the local health economy will have secure access to patient files online via their networked desktop PCs. Files associated with outpatient appointments were chosen first given the volume of visits – 250,000 annually, in contrast to 10,000 actual hospital admissions.

Improved services
The new system means the Trust will be able to 100 per cent guarantee health records availability when outpatients arrive for consultations, with improved quality of service to patients and clinicians at the point of care. In addition to significant clinical benefits, the Trust expects the system to pay for itself within three years through staff, storage and efficiency cost savings.
    
The Trust’s health records library, based in a purpose-built 10,000 sq ft building on the St. Helens hospital campus, consists of one million paper-based case files each containing on average 250 pages, in other words a total estate of some 250 million documents. As 90,000 new patients per annum are registered it is forecast that this quantity will continue to expand exponentially.
    
Neil Darvill, director of Informatics, St. Helens and Knowsley Teaching Hospitals NHS Trust, explained: “The NHS is committed to continuously improving patient care. With lead times from referral to treatment reducing, and the increase in shared care across multidisciplinary patient care pathways, the need for Health Records Departments across the country to respond is vital. These departments are frequently environments in which teams of people do their best to get the right patient file to the right clinician at the right time with everything then filed away correctly at the end. As this is a paper based system, it is difficult to sustain in the long term as growth continues unabated.”

Available records
The impact of a paper-based system for patients is that historically no guarantee could be made that clinicians would have their medical files ready at the time of any given appointment, due to the logistics involved in the movement of health records.
    
Darvill said: “Prior to the EDMS project, we were operating at 98 per cent availability, which we wanted to raise to 100 per cent. Given 1,200 case files are delivered on a daily basis, it could potentially mean that clinicians may, on rare occasions, be delayed in receiving the required patient information. Even at only two per cent down, we felt that the project would give significant benefit to patients and staff alike.”
    
Two examples illustrate why medical records might not be available at the beginning of a consultation. First, a patient might attend the hospital for two appointments on the same day with different doctors. For example, if the first visit was to a diabetes clinic and the second an ophthalmology clinic, the medical secretary may not have finished typing up the notes after the first clinic, with the file returned to the library prior to the second appointment starting.
    
Darvill outlined a second scenario: ”If a patient with a long tem chronic condition deteriorates and is admitted to the Emergency Department very unwell, and the notes are, for example, with a medical secretary, this could create an unnecessary delay. Clinicians may not have the full overview of the patient’s condition at the point of care and the patient potentially may not receive the correct treatment in a timely fashion.”

The right solution
At the outset, the Trust considered scanning its whole health records library, but rejected the idea after realising that this was too time consuming and, most importantly, added no patient value. Given the 250 million documents stored, a study carried out estimated it would take ten full time staff 30 years to do it, with the only benefits being space saved and the EDMS being marginally cheaper than actually constructing a new building. Crucially, the opportunity to improve services to patients would be missed.
    
To solve these paper management issues, the Trust selected to install OITUK’s C-Cube EDMS. Darvill explained: “An EDMS was the only way we could start to take control and shrink case file growth. It’s not an electronic patient record (EPR) system, which has been much vaunted in the NHS but is still some years away. It’s a solution to manage paper that can be integrated to provide a solid base for any future EPR solution given we’d still want to access historical information electronically which the new EDMS now provides.”
    
Instead of digitising everything, a scan-on-demand approach has been adopted where medical records for patients coming into the hospital the next day or the next week are scanned with the EDMS then used as a delivery mechanism. Archie Menzies, sales director, OITUK, explained: “To make the project clinically viable, a front end portal for the whole system was required which had to be bespoke built as there was nothing available on the market to meet the Trust’s needs.”

Simple and safe access
The portal offers a single, simple and safe point of access to view and access outpatient health records so that everyone can see holistically the patient’s medical history. In addition, it is enabling the Trust to rationalise and remove disparate department-based repositories, built up over the years, inevitably containing duplicated patient information.
    
To ensure the portal met with local needs, a series of workshops were held with the Trust’s IT staff, senior consultants representing clinicians and OITUK itself – a team of 12 who met to discuss design options and concepts. OITUK then built a prototype, wrote the application, completed the technical integration and testing – a process which took just seven months to get the functionality right.
    
The portal screen displays a whole of host of information such as patient name, appointment time, last doctor’s letter, and has a range of links (in effect virtual chapters) into the EDMS so that a clinician can delve into the patients’ past medical history at a click of a button. The Trust has installed 24” LCD screens so that A4 sized documents can be displayed completely on screen.
    
Information shown on the portal is also sourced from various other IT systems, in particular the Trust’s Patient Administration System (PAS), the software solution comprising various modules such as Patient Master Index1 and Outpatients’ Module which records appointment times. This has minimised unnecessary development work or duplication of technology.

Planning ahead
Today, everyone can read files prior to a planned meeting by accessing the electronic case notes. Similarly, consultants have been given secure remote access so they can review patient files from home prior to attending their clinics, something they could never have done in the past as files would have been in transit. Equally, mobile district nurses can access the system when they need to just by popping into a local GP surgery and logging in.
    
So far, the Trust has trained 530 clinicians and all medical secretaries to use the EDMS, with two weeks ongoing support provided if necessary. Yet only ten minutes of instruction has been required in some cases such is the intuitive nature of the system.
    
The Trust has also used the project as an opportunity to standardise letters sent to patients and GPs, reducing the number of templates from 50 to 10, while allowing doctors and their secretaries the ability to customise how they work with the system.
    
In terms of project rollout, the chest and dermatology departments are ‘live’ with the ophthalmology files currently being converted – equating to about 25 per cent of all the Trust’s outpatient files. By the end of 2010, a further 20 departments, covering 30 specialities and 120 consultants, will be transitioned over.

Handling large quantities
To convert the numerous paper-based medical files into quality electronic images, three high performance Kodak production scanners – one i1780 and two i660 series machines – have been installed based on OITUK’s recommendation which can each cope with vast scanning volumes per day2. Even using a scan-on-demand approach, where only the records required by visiting patients are scanned, the Trust expects to scan over 671,800 files over a five-year period3 hence the need for high capacity devices.
    
Darvill commented: “Once we had been trained on the scanners, they proved to be reliable, fast, hassle free with excellent image quality which is key, given we have a myriad of different documents to scan. This ranges from A4 and A5 sheets, photos, ECG4 traces, which are 3“ high and 24 feet long, thick cardboard, and red paper with black type, which can be tricky for some scanners to recognise.”

Benefits all around
In the business case presented to the Trust’s board, the project team estimates that £3.2 million will be saved over 5 years using a scan-on-demand approach further to an initial investment totalling £1.205 million to cover IT and additional scanning staff. The large return on investment is derived from reducing the number of health records staff over time, and the large efficiency and cost improvements realised throughout the whole Trust as the paper shuffling process is removed.
    
Self evidently, the patient benefits are huge. Health professionals can now provide far better quality of care as they have the right paperwork in front of them, and, in turn, because they’re empowered, the patient has a better medical experience. Equally, online access to files means people can see more than one doctor per visit, with appointment times now guaranteed even if they are set up at short notice. This has advantages to both patients and the Trust – more can be done during one visit saving hassle and time for the individual, with the hospital reducing the number of patient appointments overall and keeping waiting times to a minimum.

Notes
1. Lists all patients, names and address, local GP and contains demographic information
2. Recommended daily scanning volumes for the Kodak i1660 and i780 scanners are respectively 120,000 and 130,000 pages per day
3. This figure is made up of Health Records (546,182), Casualty Cards (54,620) and Health Record Supplement files (71,004)
4. Electrocardiogram