eZ notes Project Board

From Papyrus To Digitisation and
a Full Electronic Patient Record
John Thornbury
Director of IT
Dudley Group NHS Foundation Trust
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
Medical Records – Problems with Paper
Paper Management
Misfiling of documents
No audit process
Filing & retrieving
Documents never filed
Records left in insecure
Policies for retention and
Difficult to control access
Health & Safety
Records physically lost
Records lost
Multiple records
Speciality notes
Time taken to find relevant
A requirement to re-engineer the process and wrap
a technology solution around it
Moving away from …………11 miles of files!
Page 4
Escaping from Crate Mountain!
• Data
issues associated
with transportation
of hard copy
• Significant storage
space requirement
• Carbon footprint
impact of
records across the
• A record can only
be in one place at
any one time
Page 5
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
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.
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
– What will be the paper retention policy
– How will it all look
Critical Success Factors
Key to Success is an overarching
Strategy incorporating EDM,
not left as island
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
– Classification and indexing
– Data extraction
– Validation
• Route them to relevant workflows and
– In a secure and compliant way
– Fast and in high quality
Capture Documents
at Any Location
Different Locations
• MFPs/Digital Copiers
• Scanners
Electronic Capture
• E-Transactions
• E-Mail
• Fax
Widest range of document scanners
Scales from 1 to >1,000 scanners
Deploy in remote sites
Centrally managed
Alternative input sources:
– E-mail
– Fax
• Full traceability from scan to release
• Flexible and customizable client User Interface
Records Library
• Production Scanning
Any Document Type
Automatic Classification
• Eliminates Sorting
Separation of
Multipage Documents
Data Extraction
• Eliminates Keying
Conversion of Data to PDF
Identifies documents
Index or meta data extracted automatically
Separates folders into documents
Provides advanced recognition technologies(do we
• Customizable validation and correction
• Reporting on key performance metrics
• Needs to be Highly scalable
to Any Channel
Clinical portal
Patient portal
• 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
Platform Architecture
Capture Documents
at Any Location
Any Document Type
Different Locations
Automatic Classification
• MFPs/Digital Copiers
• Scanners
• Eliminates Sorting
to Any Channel
Separation of
Multipage Documents
Electronic Capture
• E-Transactions
• E-Mail
• Fax
Data Extraction
• Eliminates Keying
Records Library
• Production Scanning
Conversion of Data to PDF
Monitor and Manage at the Process or Document Level for Complete
Reporting: SLA Metrics • Historical Performance • Tracking
100+ Connectors
• Workflow
• LOB Applications
Migrating from Paper to EDM
Postal Service
Capture & Digitize
Point of Care
Admission Forms
Assessment Forms
Fax Server
& Extraction
MRI, X-Ray
GP‘s, CCG‘s etc
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.
Case Note Structure
• When building the EDM consideration needs to be made for the case note
• 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
• 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.
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
• 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.
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?
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
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)
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
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.
• 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!
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
Do not forget
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 00081:2008
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
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
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
Be realistic about the transfer of risk

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