Panel discussion: how to take a pragmatic approach to digitising NHS records

One of our recent panel discussions focused on the topic of how to take a pragmatic approach to digitising NHS records, and we were joined by panellists including Dr Tamara Everington, chief clinical information officer and haematology consultant at Hampshire Hospitals NHS Foundation Trust; Emily Lucas (innovation facilitator) and Dr Julia Dawson (innovation lead) at University Hospital Coventry and Warwickshire NHS Trust; Stefan Chetty, director of public sector services at Restore Records Management; and?Matt Sim, head of IT design Restore Digital.

The conversation revolved around projects and programmes from our panellists, what to consider for successful transformation, what is working well and why, and what is key to achieving future NHS transformation aspirations.

Tamara started by sharing insight into her role and remit as well as where Hampshire Hospitals is in its digital journey. “As a trust we became part of the national GDE programme and that was helpful in accelerating our digital journey. We made a huge amount of progress through the pandemic and we are now a largely digital organisation, which has been based on a ‘best of breed and integrated’ approach.”

The trust is currently in the position of trying to procure a shared PAS and EPR with core functions across the acute provider footprint within the integrated care system, Tamara added.

“In some ways, some of the things we are doing are really forward-thinking and exciting like our patient engagement portal, which is part of the NHS App Wayfinder Programme, and we’ve got digital prescribing sorted out. But we are still on our journey to scanning in our documentation, and there are other areas that we need more focus on.”

Julia and Emily highlighted their work at University Hospital Coventry and Warwickshire (UHCW), explaining how the innovation team is responsible for bringing innovations into the trust and also supporting staff with their own innovative ideas. In terms of the wider trust, Julia shared that UHCW will be implementing its first trust-wide EPR this summer, and the innovation team is about to start a project exploring what digital consent might look like and how it fits into the wider health inequalities ambitions and language services.

Next, Stefan shared context around Restore Records Management: “Ultimately, we are responsible for supporting organisations in all areas of the document lifecycle. For the NHS in particular, that can be the creation of new notes where that is still happening, but really it focuses on the future for the NHS – offsite storage, ongoing retrieval of records, the outsourcing and management of administration functions like clinic prep and loose filing, and so on, in order to help the NHS improve patient care. We aim to help customers transition into a digital future in the way that is most appropriate for them.

“Digital transformation doesn’t begin and end at scanning physical patient files,” Stefan added. “There are many more facets to that. How information is created and used is part of a bigger picture, it’s not just about tackling legacy paper. However I do think it’s important that we don’t lose sight of that legacy paper as part of the solution.”

Whilst there are some NHS trusts that are “very successful” digitally, he acknowledged, there are many trusts with lower levels of digital maturity. “The levels of variance within that middle bracket are quite significant. Whilst paper is often seen as part of the problem, I think there’s an opportunity to look at it as part of the solution if it is looked at in the right way.”

Matt introduced himself by sharing that he has worked within the Restore group for around 20 years. “Over that time, we’ve probably taken on three or four NHS-driven projects every year, spanning those 20 years. We’ve had a broad range of experiences, both helping trusts to digitise their physical records but also providing solutions and systems. That might mean providing scanners onsite if customers want to get hands on with their documents, or providing that as a managed service. We work outside of the NHS too, but I think we’ve been able to bring experience from all the different sectors and apply that to how we can support transformation, digitise records, and really help the NHS to get some real value out of them.”

The challenge of physical patient files…?

Coming back to the challenges that trusts with lower levels of digital maturity can face, Stefan said: “One of the challenges is less of a tactical, practical thing and more about perception, in that digital transformation in the NHS tends to focus on the outcome of being digital. But there’s the process to getting there – for example, if legacy paper is required as part of the solution for trust’s new EPR, the practicality of getting those physical patient files into the system likely won’t have been fully considered in many cases, because it’s not seen as a major outcome.”

There are natural challenges that present themselves with a paper solution, Stefan added, such as the obvious problem with space to store the physical files; the cost and productivity factor in terms of requiring staff to deliver that service onsite; the standardisation of processes; and the efficiency of whether those processes work.

“In a paper world, there are associated challenges such as note availability too,” Stefan pointed out. “If a note has been moved to a certain place in the hospital, it’s not immediately available afterwards and retrieving it for a future appointment can be a challenge. We’ve seen that up to 30 percent of notes that are required for clinic are actually located somewhere around the hospital. That leads to the creation of temporary notes, duplication, and more paper means more loose filing and a question of where that goes.”

Multiple locations within a trust and transferring physical notes between those locations can also pose a challenge, Stefan added, pointing out: “There’s transport, costs and time to take into account here.”

Ultimately, Stefan said, there are things that a trust can do now to make digital transformation over time far more practical. “There are steps that can be taken that tackle those very hands-on problems that mean the future digitisation programme is far more cost effective, and likely to happen sooner. But if these factors are detached from a digital solution, then the switchover to digital can be more of a challenge. That leaves you facing a big bang with a huge amount of culture change, and a legacy paper challenge that has not been honed for transformation. Also, if the trust’s digital strategy involves scanning all of those legacy physical files and you haven’t taken steps to organise and manage your paper files, that scanning is going to be a particularly costly exercise.”

… and the challenges of transformation

“There’s a bit of me that hates the word digital,” Tamara reflected, “because ultimately we are working in the context of the national health service, and our objective shouldn’t be to be more digital, it should be to be providing a better service for patients. In order to do that, we need to be freeing up time for our staff to do the jobs that they were trained to do.”

Picking up on the point about training, Tamara shared that she recently completed a paper for her board in which she was asked to provide assurance on the fact that staff are capable and competent to use the digital solutions within the organisation, with particular focus on business-critical systems. “I can provide no such assurance, and in fact the more we looked into this, the more we realised that even senior figures in the organisation receive training on digital systems but are then reluctant to use them, often out of worry that they will somehow break the system,” she said.

“We are working with people to make systems and processes better, and we need to understand the problem that we are trying to fix and respond to that in a really positive, structured way. We need to do that hard work to plough through all the little questions that come up about digital around things like multiple case notes, as Stefan mentioned. People need to know what to do or expect in all the scenarios they might face within their roles, and that’s the nitty gritty work that needs to be done in order to take forward your digital solution so that it delivers, at the end of the day, something that improves care for patients and for staff.”

Digitally mature organisations

Whilst digitally mature organisations can face similar to issues to those at the lower end of the spectrum in some ways, Matt reflected, each organisation presents in its own way with its own challenges.

“Digital maturity is a journey,” he said, “and for some organisations, they are dealing with legacy technologies that they need to integrate in order to maximise their value. Just removing the physical patient files is a step along the way – the next step is getting systems to talk to each other, to gain efficiencies – because that’s what we are trying to do.”

For more digitally mature organisations, Matt said that a challenge can be the pace of evolution when it comes to technology. “An organisation might have a five-year strategy, but when you look at how much technology can evolve in five years, you can quickly see that the challenge isn’t about what you are doing; it’s about how you can keep up.”

When you look at what Restore tends to place focus on now, “so much is emphasis is placed on new technology,” Matt said. “We are promoting a lot of cloud-based technologies and improvements that we gain and provide to our customers, for example through AI extraction and content enrichment of documents. But the problem is, if you don’t have a platform that evolves with that and you can’t utilise with that new technology, you can very quickly end up with a platform that is legacy before you’ve even fully implemented it.”

What makes a project successful?

From Julia and Emily’s perspective, when delivering a successful project as part of the UHCW innovation team, has there been anything that stands out as a reason for that success?

Bringing along staff and senior stakeholders with a project is always key, Julia commented. “It’s also the number one reason why projects fail – it’s a ‘do or die’ situation.” She came back to Tamara’s point around the implementation of technology needing to ultimately free up time for clinicians. “It’s got to make their lives easier and you’re not going to achieve that unless you bring them along with you. They’ll be the first to tell you if something isn’t going to work because they don’t work in a particular way, or because the technology will complicate some aspect of their work.”

She emphasised that it is all about communication. “It means something different to everyone – for example, people tend to assume that if they email someone, they can communicate easily. But looking back to my days as a clinician, you would never find me on my emails. You would need to bleep me or find me in person. It’s about having that understanding, and also about using the right language. ‘Innovation and transformation’ can just sound like an anxiety that people are going to have to deal with down the line. You need to really explain the benefits it can bring.”

Tamara raised a new point: “I’m a fan of failure. One of our most successful procurements recently has been getting a new ED system in, and the reason it went so well is because we had a previous attempt at it where we didn’t do very well. We got some time-limited funding, COVID complicated matters, we didn’t manage to develop it well and everyone walked away feeling demoralised. But we did a very honest and open reflection on everything we learnt from that failure and as a result we went into the new procurement with a very clear vision of what we wanted to get out of the solution. A key part of that was the need to have a very strong relationship with our vendor. That has been the most important thing, it’s almost like going into a marriage. There are things that we thought we wanted that they have been able to guide us on, and vice versa, things that they thought worked for us that we weren’t so keen on.

“I think they are the three key things – stakeholder engagement, as Julia said, learning from failure, and a positive relationship with your vendor.”

Stefan added in a point about engaging with stakeholders, noting that sometimes the people who oppose change at first can “end up being your biggest advocates, if you communicate with them in the right way and understand what is important to them. They are usually the voice of a much bigger group of people. I would actively advocate the same thing – as part of any big transformation, you need to engage with the most outspoken clinicians or affected departments. Let them test and challenge every element of an implementation.”

You also need a “true understanding of the current state,” Stefan added. “Those senior stakeholders especially need to know what that looks like. There can be challenges in practice within the current state of play that aren’t recognised as such, if the senior leaders don’t realise that they are in fact challenges.”

What does good look like?

“The key thing is visibility. You need to go back to the start and understand what the ‘problem’ is,” said Stefan. “In saying that, I want to add the caveat that records management isn’t just a problem, it’s also part of the solution, and it’s important to bear that in mind. It comes back to knowing the current state; if you don’t know that, you might not address the right things. If you don’t know what your design outcomes are, you won’t know what is important to that particular trust or hospital, what the non-negotiables are.”

You need a staged plan, he continued; to engage with the vendor in steps, and to understand what immediate benefits you can get onsite and offsite. Then you can build in a solution that leads towards the ultimate digital vision.

“From a clinic prep process for example, you can put in the standardised, formalised processes whereby you can manage the size of the paper record over time. If it gets above a certain thickness, you would create a new record, so that when it comes to digitisation you would only be scanning in the most recent information. You’d merge all loose notes and filing at the point of prep, so that if you do need to scan as part of your digitalisation, it’s far more cost effective. You’d also start introducing standardised forms at that point to support your future efforts.”

Ultimately, he added, wherever it may be, good for records management would look like space within hospitals being optimised for patient care. According to the ERIC (estates, return, information, collection) data, over 200,000 square metres’ worth of space is taken up by medical records within trusts across the UK. Based on a private room being 16 square metres, that’s over 10,000 bed spaces.”

Additionally, Stefan said, good would look like everyone being engaged in what digital means for a trust; recognising that it is not just about scanning all of your paper; and managing the process over time so that end users are engaged in what decisions are made by the trust in order to deliver a better outcome for them and for the patients.

Matt shared his view that good looks like “having a measurable outcome of a project – sometimes you can get to the end of a project and everyone can be a little bit confused as to what was done and whether it’s even been successful. So I think having that very clear remit is key. Regardless of where you are on your digitalisation journey, at every stage you need to be measuring progress and have very clear outcomes.”

In terms of the technology sitting behind all of this, Matt also raised a need for more open standards. “Every time that you come onto the next legacy platform that you need, it can’t a case of starting from scratch all over again and asking the same questions. We need a good framework early on with a long-term strategy and open technologies.”

Hopes for the future

Over the next three years, what would Tamara like to see in this space?

“We’re in the new hospital programme, looking to build a new hospital in 2030. We’ve chosen to do that as part of a ‘Hampshire Together’ approach, rethinking the model that we want, because we know that the care we deliver today will look very different to how it will look in the future. It comes back to Matt’s point earlier: how are we going to keep up with all of this? We need to always be keeping our eye on where we are going – as Stefan said, freeing up space from medical records is definitely on our agenda.

“Another part of this is having a very clear understanding of what the plan is, based on what the wider NHS plan is for the next few years. What we are doing needs to align with what the NHS needs over the next few years. Also, very importantly, what specifically is needed to enable those plans, and how are we going to pay for it? It’s about thinking through strategic, costed development.”

Tamara added: “We also need to make sure we maximise our opportunities for the future – for example, one of the things we’ve done is take the real-time data from our systems and feed it into a power BI platform which helps staff to see what they might be able to expect in the next 24 hours. It tells them where they need to focus to improve patient flow, which is one of our priorities at present.”