From Papyrus To Digitisation and a Full Electronic Patient Record

1. From Papyrus To Digitisation and a Full Electronic Patient Record John Thornbury Director of IT Dudley Group NHS Foundation Trust

2. Overview • Medical Records – Problems with Paper • The Potential Business Drivers • The Considerations • The Critical Success Factors • How to Migrate to EDM • The move to EPR • What that means? • The use of e-forms and workflow • Potential pitfalls • The Overall Picture in Dudley • The Recommendations

3. Medical Records – Problems with Paper A requirement to re-engineer the process and wrap a technology solution around it 3

4. Moving away from …………11 miles of files! 4

5. Escaping from Crate Mountain! • Data Security issues associated with transportation of hard copy records • Significant storage space requirement • Carbon footprint impact of transporting records across the trust • A record can only be in one place at any one time 5

6. The Potential Business Drivers • No one solution for Electronic Document Management will fit all • Depends on what the business drivers for the solution are; • Medical case notes storage space • Outsource model • Scan yourself • Use of bureau scanning • Move to scanning existing forms into the solution • Move to full electronic documents • Requirement for more patient information to be available 24/7 • Governments move to electronic documentation by 2018

7. Why Migrate from Paper to EDM • Access to and optimized processing of patient and health information is key to improve health care quality • Data and information are today siloed and often locked in paper files • Need to be digitized and entered into HIM, ERP and other back-end systems for immediate access by patients, insurance providers, hospitals, clinics and doctors at the point of care • Pressure from Commissioners • Transparency • Cost reduction • Capitalising on savings potential • Avoid wrong information/missing information • Reduce clinical safety issues • Meaningful use of EHR and EHR technology(US approach) • Enables improved efficiency and prodcutivity as well as cost savings.

9. EDM the Considerations • Need to consider; • Clinically led and owned • What information will be scanned • Understand what e-forms will be produced • What workflow will be required • What will be the case note structure • What information needs to be included from the Electronic Medical Record • What will be the paper retention policy • How will it all look

10. Knowledge People Process Technology Critical Success Factors Key to Success is an overarching Strategy incorporating EDM, not left as island 10

11. How to Migrate to Electronic Health Records • Capture all patient and health data at point of entry • Distributed • Any format • Scan at top quality • Transform them into process-ready information • Classification and indexing • Data extraction • Validation • Route them to relevant workflows and systems • In a secure and compliant way • Fast and in high quality

12. Capture Capture Documents at Any Location • Widest range of document scanners • Scales from 1 to >1,000 scanners • Deploy in remote sites • Centrally managed • Alternative input sources: • MFP • E-mail • Fax • Full traceability from scan to release • Flexible and customizable client User Interface • Different Locations • MFPs/Digital Copiers • Scanners • Electronic Capture • E-Transactions • E-Mail • Fax • Records Library • Production Scanning

13. Transform Transform Any Document Type • Identifies documents • Index or meta data extracted automatically • Separates folders into documents • Provides advanced recognition technologies(do we use?) • OCR • ICR • OMR • Customizable validation and correction • Reporting on key performance metrics • Needs to be Highly scalable • Automatic Classification • Eliminates Sorting • Separation of Multipage Documents • Data Extraction • OCR, IMR, OMR • Eliminates Keying • Conversion of Data to PDF

14. Deliver Deliver to Any Channel • Ensure interfaces developed • Support of ITK • Tightly integrated with trust systems to support clinical need • Full reporting and traceability • Scalable to accommodate low to high volumes • Customisable to support clinical directorates(but corporate standards • e-Mail • Fax • SMS • Network • Database • Clinical portal • Patient portal • EMR/EHR

15. Platform Architecture Capture Documents at Any Location Transform Any Document Type Deliver to Any Channel • Different Locations • MFPs/Digital Copiers • Scanners • Electronic Capture • E-Transactions • E-Mail • Fax • Records Library • Production Scanning • Automatic Classification • Eliminates Sorting • Separation of Multipage Documents • Data Extraction • OCR, IMR, OMR • Eliminates Keying • Conversion of Data to PDF • e-Mail • Fax • SMS • Network • Database • 100+ Connectors • ECM • Workflow • LOB Applications Monitor and Manage at the Process or Document Level for Complete Transparency Reporting: SLA Metrics • Historical Performance • Tracking

16. Migrating from Paper to EDM Patients Channels Capture & Digitize E H R Correspondence Postal Service Scanner Point of Care Physicians Doctors Nurses Admission Forms Assessment Forms Fax Fax Server Classification& Extraction Administration LAB Invoice MRI, X-Ray Etc. Inbox GP‘s, CCG‘s etc E-mail

17. Information to Scan • Clinically what needs to be scanned • What can be left in paper form and provided if required • Consideration needs to be made on what quality is needed for scanning, colour, black and white, dpi. • For ease of scanning there would be a set of quality standards for colour and for black and white scanning. • Scanning needs to conform to BiP0008 in order to be admissible in court under the e-gif standards.

18. Case Note Structure • When building the EDM consideration needs to be made for the case note structure. • Every form or document that is scanned has to live in a location, a document can only reside in one location • Able to work from a blank page, not restricted by the current case note structure • When recording the meta data associated with the case notes consideration should be taken to the speciality associated with the documents generated as this will enhance the viewing of information later. • The structure should be built so it does not impede how the user looks at the information that is relevant to them. • By setting up a number of clinical views it allows clinicians to see the relevant part of the case note structure.

19. Retention Policy • Finally consideration should be taken as to what information is retained and what is destroyed. • Currently there is no legal requirement to destroy paper that has been scanned. However storage may negate one of the business drivers. • As long as BiP0008 standard is used in scanning, you are able to destroy immediately. • Documents that are not scanned need to be under the existing retention policy for case notes. • Consideration needs to be made to what happens to electronic information after the 7 years of inactivity when there are also paper records for the patient. Data storage may be considered to be cheap but by destroying the paper part of the record this may impact on legal requirements.

20. The Move to EPR – What this means? • Once you have the EDM up and running, more clinical information will be required by staff. • Do you keep the two systems separate so that you access the case note through one and other information through another? • Do you go to a portal that allows you to move from one system to the other while keeping patient context? • Do you look to integrate the clinical information into the one clinical view? • Do you look to integrate the clinical letters, reporting, referrals etc directly into the EDM so that the clinician is looking in one place?

21. The Use of e-forms and Workflow • In moving to an integrated EDM/EPR consideration needs to be made for what information the user can enter direct into the system. • This can be via the use of e-forms these do not necessarily have to be a copy of the forms that are currently used. • As the information is electronic, decision trigger points can be included in the forms to order tests, alert other services, create automatic referrals etc. • e-forms can be used to allow multi-disciplinary teams to work more closely together, filling in part of a form then triggers other services

22. The Move to EPR – Pitfalls? • If looking to include information into the EDM from other sources possible pitfalls might be; • Case note Structure – you need to have flexibility to add more document types to the system so that you can grow your system • Getting e-forms and workflow built correctly to minimise data entry, there is no point replicating an existing standalone form if it can be condensed to make it easier for the user to enter data • Security models – don’t be too simplistic in access models but also don’t develop something so complex that it needs an army to administer (RA)

23. The Overall Picture in Dudley • At Dudley we are looking at the whole clinical experience of systems and how EDM, EPR, Primary Care, Secondary Care information blurs when treating a patient. • How can we get the relevant information about a patient to any clinician treating them? • We are looking at; • Full integration between GPs and Secondary Care across contracted CCGs for the transmission of electronic documentation – referrals, discharge summaries etc • Use of advanced portal technologies to provide information views to both Patients and GPs • Integration of systems into a unified view so that clinicians move seamlessly between EDM, EPR, reporting etc. • The move to a CRM solution that will allow the Trust to progress

24. Clinical Ownership • There needs full clinical ownership by the Trust in how EDM is deployed • The engagement needs to be from all clinical bodies as all staff will begin to use the EDM to view patient information. • Consideration should also be given to services that currently don’t view the case notes but would benefit from seeing the information stored. • The Trust would benefit from creating a clinical reference group that would oversee ownership and provide clinical assurance to any deployment.

25. Recommendations • Moving from health records to electronic health records is no longer an option – it’s a must • Health records are high volume, and mainly paper-based • Majority of patient data still locked in paper based departmental systems • There is a need today • to get ready for EHR • to improve efficiency • Improve data completeness and accuracy • to be compliant • to process EOBs • to process invoices • A time window from 2013-2016 • Essential for business sustainability and achievement of CIP/Patient Safety • Solutions exist today to get started!

26. EDM Delivers • One platform to streamline processes around capturing, transforming and routing medical records • Outstanding data quality • Accelerated information availability at the point where needed • Decision support for high quality health care • Increase of efficiency • Physicians can see more patients per day • Higher processing volume of claims and/or payments per day • Significant cost reduction • Automation of health care records capture and entry • Elimination of paper storage and paper mailing • Fast ROI • Proven track record

27. Do not forget

28. Legal Admissibility • A Trust which goes to court with a scanned version of a Medical Record is likely to be vulnerable if it cannot demonstrate adherence to BIP 0008-1:2008 • This Code provides a framework and guidelines that identify key areas of good practice for the implementation and operation of document capture and electronic information storage. • Complying with the code is structured into : • Information Management Policy • Duty of care • Policies and Procedures • Enabling Technologies • Audit Trails  28

29. Beyond the Record • The majority of the content of a medical record comprises forms • Forms drive every clinical process • An Acute Trust can have several thousand different forms with many obsolete and many duplicated • Good clinical governance depends on the use of the right form in the right place, every time • The rationalisation and re-engineering of the forms is a pre-requisite of moving to an EPR • Forms with embedded intelligence can be used to drive workflows and care pathways 29

30. Lessons learnt to date • At due diligence be prepared to find a disconnect between actual records and the entries on PAS • Prepare for and recognise that data quality may be poor • Define and map all processes rigorously • Be realistic about expectations for the transition of the service • Select the appropriate contracting model which meets the needs of all parties • Engage all staff about the potential impact of the business transformation • Be realistic about the transfer of risk 30