Dr Bill Flatman, PhD, MBA, MSc, BA, MBCS Director of ICT Island & Portsmouth Health ICT Service

1. 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

2. 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

3. 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

4. Portsmouth Hospitals – essential facts

5. Scope of Presentation • Replacing the traditional paper health record • Not addressing EDM in other areas although many obvious applications

6. 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

7. 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

9. Why EDM & Why Now? • Problems with Paper • Clinical • Paper Management • Security • Potential Benefits of EDM • Why Now?

10. 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

11. Problems with Paper - Clinical • Misfiling of documents • Documents never filed • Records lost • Multiple records

12. 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

13. Records Related Incidents reported Jan. to Dec. 2007

14. Problems with paper - Clinical

15. 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

16. Problems with Paper – Paper Management • Filing and retrieving of paper records • Policies for Retention & Disposal • Health & Safety • Space • Transport • Multiple stores • Cost

17. Problems with Paper - Security • No auditing of who has viewed record • Records left in insecure areas • Difficult to control access • Records physically lost

18. Problems with paper

19. 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.

20. 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

21. 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

23. 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

24. Procuring an EDM solution for health records Philip Scott Head of IT Projects & Development Portsmouth Hospitals NHS Trust

25. Contents • Introduction • Portsmouth’s EDM programme • Procurement and deployment • Strategy • Governance • Lessons learned and applied • Conclusion • Questions

26. 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

27. Portsmouth’s EDM programme • Procurement and deployment • Strategy • Governance • Lessons learned and applied

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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.

34. 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

35. 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

36. 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

37. 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

38. Workforce Review Team bill.flatman@ports.nhs.uk ?