As part of a government-wide Digital Strategy which aims to use technology to further improve the Isle of Man’s public services, Noble’s Hospital set a goal to remove paper records by the end of 2018. The ‘Digital Future’ project involved digitising the 20 ward, 314 bed hospital’s entire medical records archive - some 90,000 records - as well as conducting ongoing day forward scanning as new clinical notes are created, to increase efficiency and deliver enhanced care for all patients.
Scanning and digitising the entire medical records library formed the beginning of Noble’s Hospital’s digital transformation journey. Chief Clinical Information Officer Dr Gregor Peden said that there were two key drivers to the project. “We were using the digital records as the cornerstone of the rest of the Digital Future strategy so we needed some form of digital repository in order to feed all of our other projects into.”
He added: “All of our projects produced digital information rather than paper and we needed somewhere to store it, so we thought the best place to start would be to digitise the medical records and then land everything else into that record.”
The 90,000 medical records held in paper-based folders occupied an increasing amount of storage space, which was the other driver for change. Dr Peden explained: “We had literally run out of physical space, the records library was full and we had already expanded into a Portakabin at the back of the hospital. It was either build somewhere else to store paper, or invest to digitise that information, free up the space and hand it back to the hospital to be repurposed.”
We had literally run out of physical space, the records library was full Dr. Gregor Peden Chief Clinical Information Officer
Alaris partner MISL, a leading bureau and BPO provider, won the tender to digitise the entire medical records archive. As all records had to remain readily accessible to clinicians throughout the project lifecycle - they had to remain on the island. In order to meet this requirement, MISL appointed Alaris reseller Manx BusinessSolutions to manage the back scanning programme.
MISL specified Kodak i5850S Production Scanners and Alaris Capture Pro Software which quickly converts batches of paper into high quality images, to power through the bulk scanning of all legacy files. Kodak i3400 Scanners were supplied to carry out day forward scanning onsite.
The first step was to conduct a pilot controlled initial deployment. The hospital opted to back scan maternity records first as they are separate from general medical records. “We adopted this approach so if there were any issues they would be confined to one area,” Dr Peden explained, adding: “That first deployment went really smoothly, there were no issues.”
When the project went live, Noble’s Hospital used outpatient records as a starting point. The medical records team pulled all patient records six days ahead of their clinic appointments, these were boxed up and collected by Manx Business Solutions to be digitised, so when patients attended their appointments, the records were digital. “We made the decision to pull records a week ahead rather than a couple of days to support our training programme. We were able to train consultants in their actual clinics, enabling them to review the records they would be looking at in clinic that week as opposed to dummy files,” said Dr Peden.
Day forward scanning was conducted in parallel in-house. The medical records staff were trained to use the equipment and simultaneously achieved the BS 10008: 2014 standard which assures the authenticity, integrity, confidentiality and availability of electronic information.
The staff used scanners from Alaris to scan the paper records directly into the hospital’s MediViewer Electronic Document Management (EDM) solution. Built specifically for healthcare institutions by Alaris partner IMMJSystems, MediViewer indexes records with essential metadata, which can then be searched by patient, content type or location. Importantly, the solution is BS 10008: 2014 compliant, ensuring the patient record cannot be deleted or altered in any way, as well as providing a full audit trail.
Back scanning the 90,000 records was completed in just under 12 months, meaning the hospital achieved its goal to remove paper records by the end of 2018. “We started off slowly but the project quickly gained traction and at one point Manx Business Solutions were collecting 75 boxes a day - the number of records per box varied as some files are thicker than others,” Dr Peden said.
A business continuity element was built into the back scanning phase. “We had to work on the basis that a patient may present to A&E whilst their records were being scanned offsite, so we put a two-tier urgent recall process in place. Essentially we could recall any record the same day or next day- we didn’t use it often, but for the ten recalls that were requested, it worked efficiently,” he added.
Ongoing day forward scanning has been adopted with ease. All day forward scanning packs are received by the medical records team with a preprinted cover sheet with QR barcodes. “As the documents are scanned, the MediViewer system recognises the patient and the clinical area. The medical records team simply scan into one central area and the software accurately reads the barcode and routes the files to all relevant records,” Dr Peden explained.
One of the key SLAs set is that all documents received have to be scanned and imported into MediViewer within a 24-hour window. “Both the volume of documents - the team scan around 7,000 sheets a day - and the tight turnaround meant that robust, reliable scanners were a pre-requisite. The fact we haven’t breached this SLA in the 18 months since go live, speaks to the dedication of our scanning bureau and to the quality and reliability of the Kodak Alaris scanners,” said Dr Peden.
The hospital will shortly launch a new project giving staff direct entry into the records. “At the moment patient-facing staff place documents into temporary wallets, then at discharge or close of clinic, the records library staff collect these, once the documents are picked up the 24-hour clock starts,” he added.
The project has delivered a number of clinical benefits. Dr Peden explained: “Digitisation has afforded frontline medical and nursing staff with significantly faster access to patient information. More than one person can access a record at any one time which with paper is impossible, and the fact that multiple clinicians can discuss a patient over the phone whilst all looking at the same record, has been a complete game changer.”
Dr Peden says that the decision to scan in colour in particular has delivered a real value-add. “I strongly advocate that scanning in colour is a must. When looking at a series of thumbnail images on a screen, it’s much easier to recognise a colour image of say an ECG, a lot faster than a greyscale one.”
The hospital has enjoyed a considerable reduction in the time and cost associated with manual filing, tracking, searching and retrieving records. Five staff who used to manage records delivery have been moved onto other contract types which has realised a cash benefit. “We also have a satellite hospital in the north of the island, a 40 minute drive away – previously there was a notes transport service that would run notes over there and then bring them back to our records department at the end of the day. Now as the records are digital, we no longer need to do this,” Dr Peden said.
With more than 16 million sheets of paper being eliminated, storage is no longer an issue. Electronic storage is much cheaper than the paper equivalent, more accessible and more secure. The space previously used to house health records has been handed back to the hospital to be re-purposed. Furthermore, as new records are created at the rate of approximately 7,000 sheets per day, they are automatically scanned and inserted into the EDM, which has removed the requirement to find more space to store paper records in the future.
“We have over achieved on our initial target. In addition to digitising the entire medical records library, we have also made a significant dent in deceased and some specialty records which were stored in the loft and were originally out of scope,” Dr Peden added.
Commenting on feedback from clinicians on the paperless initiative, Dr Peden says that it’s been mixed. “It’s fair to say that most trainees now expect a degree of digital health initiatives when delivering care. Historically, paper would be used for triggers and prompts so for example, by looking at the piles of notes on their desk, a consultant would have a visual indication of how many letters they would have to dictate, with a digital record there is no physical reminder.
“With any digital transformation, you have to factor in the process changes that go alongside it. By going digital we have streamlined processes and forced a change in working practices - however looking at a screen as opposed to paper is not a new issue. As doctors, we spend a lot of time looking at screens anyway. At least now we can work on having everything in one place,” he concluded.