University Hospitals Bristol NHS Foundation Trust (UH Bristol) is one of 12 acute trusts in the UK to become a digital exemplar. The Trust employs approximately 10,000 staff across its nine hospital sites in and around the centre of Bristol. As well as providing general services to a population of patients in the surrounding area, the Trust also provides specialist services that are available to a wider catchment in the South West and beyond.
UH Bristol had an incredibly large medical records library. As the South West’s largest teaching and training Trust, the organisation recorded, stored and retained a huge number of paper-based medical records on its premises. Despite seven large libraries onsite to store these records, the Trust was still having to send archive material off-site to a secure storage facility.
UH Bristol has over 200,000 records stored securely off-site these were predominantly notes that the Trust was unlikely to need immediate clinical access to, but which need to be retained for a period of time in line with information governance standards. “Storage costs were substantial.”
Max Perry, Senior Systems Specialist explained, adding: “It costs approx. £3 per box to despatch, then there is an annual per box fee to pay. Additionally there is a charge of around 50p-£1 each time we request notes back.”
UH Bristol has been doing some form of scanning for the past decade. It set-up a small in-house scanning bureau ten years ago, initially as a space-saving exercise. However, the volumes it was scanning were quite small - the legacy bureau processed a couple of hundred sheets per week, scanning archive notes etc. into an old Trust-based system.
“To put it into context, we had about 1.5 million active patient records - these are paper records which would be pulled for clinics or inpatient episodes. Some of those patients might have had multiple volumes, and the older records were not ‘active’,” Max said, adding: “I would estimate that we had roughly in the region of another million non-active records in the medical records library that had to be retained.”
The primary driver for accelerating and extending the Trust’s digital transformation was to mitigate the risk around having separate patient casenotes for separate sites. “We have nine sites in total, and five different sets of casenotes, so our first objective was to have one core patient record, in one place, rather than a fragment of the record most relevant to an individual discipline or location,” Max explained.
The second objective of the project was around quality, making sure that when patients attended hospital, staff could immediately access their records. “We had got the response time to a request for note retrieval down to about 90 minutes,” Max said, referring to the average time between a clinician requesting a casenote and it arriving in the department. “However with this project, our goal was that if a patient presented to say the emergency department, staff would have access to all of their notes, as soon as they came through the door.”
“Any questions patients may have after attending an appointment can be answered on the spot, whereas previously, they would have been redirected or rang back days later when notes had been retrieved“… Afterwards “ we have been able to quickly and effectively roll out other digital projects“. Max Perry Senior Systems Specialist, University Hospital Bristol
UH Bristol made the decision to maintain control of its own scanning and leverage the expertise it already had in-house rather than outsourcing scanning its casenotes to a third-party bureau. The Trust conducted a competitive tender process and appointed Kodak Alaris partner, Kainos.
Working in partnership, Kodak Alaris and Kainos supported the Trust in expanding its in-house scanning capability. A new scanning bureau equipped with ten Kodak scanners was set-up and the Kainos Evolve Electronic Medical Record (EMR) system, deployed.
“The professional services support provided during those initial stages was invaluable,” Max said. “Although we did have some expertise, the scale of the task in front of us was incomparable to what we had done previously. At our peak, we were scanning about 1.5 million pages a month.”
The project’s go live strategy was shaped around the legacy practice of different sites holding separate records. “We decided to adopt a ‘site-by-site’ approach and began with the multi-discipline St Michael’s Hospital (a hospital with a diverse range of services including maternity; neonatal and ear, nose and throat), they shared casenotes with the Bristol Royal Hospital for Children, but not with the rest of our adult’s hospitals,” Max explained.
The starting point was to digitize records on-demand. Prior to a patient attending an elective appointment the information was scanned and migrated into the Kainos Evolve platform. The digital file relating to that hospital was then available to all clinicians who could access it. This allowed each hospital to have their own ‘go-live’, without impacting records at other sites. This promoted a slick and successful business change management process in each of the hospitals prior to go-live.
To date the Trust has implemented the process in St Michael’s Hospital, the Bristol Royal Hospital for Children, Bristol Royal Infirmary (BRI), Bristol Heart Institute, South Bristol Community Hospital and UH Bristol’s services provided in the Central Health Clinic. With the three remaining sites - Bristol Haematology and Oncology Centre, Dental Hospital and Eye Hospital, the plan is for them to adopt a paper-free approach in the near future and for the back scanning of paper notes to be conducted in the background.
Over the course of the project, UH Bristol invested in two additional scanners, bringing the total to twelve. Seven are now utilized full-time, conducting day-forward scanning (scanning of newly created content). The others are dedicated to back scanning old libraries. Backed by a seven-year warranty and with some of the scanners having been in use for five years, Max says that they have been extremely reliable. “We do occasionally have problems, but the support that we’ve had in terms of service and repair has been exemplary. We’ve probably not had a scanner out of action for more than a day and that’s only been on a handful of occasions.” He continued: “Image quality is really good and we’ve had no complaints, in fact, we’ve had very few issues around any aspect of the scanning. In terms of the efficiency/quality ratio, I think we’ve realized all of the potential within the project.”
With the Evolve platform, clinicians now have access to patient records from any computer, iPad or laptop. “One of the things I’m particularly proud of in our project is that, our clinicians have been at the forefront of the process, involved in decision-making and have been supportive of the project throughout,” Max said.
As an example, he cited the fact that as Bristol Royal Hospital for Children is a specialist children’s hospital, its consultants run clinics at other hospitals across the entire South West peninsula. “These consultants have a lot of experience with different EDM systems. Overall, the Evolve system at UH Bristol scores exceptionally high in approval ratings - people like the product, the look and feel and the ability to access it via a mobile device,” Max explained.
St Michael’s and the children’s hospital are now entirely paper casenote free. “We’ve back scanned about 20 per cent of their library to date and we are still actively scanning, processing around 1,000 casenotes a month. Every patient that attends those two hospitals won’t have a paper record unless it’s something exceptional like an emergency admission for a patient with a large historic record (which will get scanned following attendance),” Max said. In the Bristol Royal Infirmary library, which includes the Bristol Heart Institute and South Bristol Community Hospital, The Trust has scanned about 10 per cent of the active library to date. “These sites are not casenote free yet,” Max explained. “Around half of patients have paper notes, while the other half are dealt with in a paper-light fashion.”
"The project to go digital has improved patient safety and experience, allowing immediate access to patient records at the point of need. UH Bristol has reduced the potential for records to be misplaced, delays in care through waiting for records to be delivered, as well as the cost of storing physical casenotes, saving time and money that can be reinvested into patient care."
Decision-making can be done at the point that you would want to make it, rather than having to wait for the information to arrive. For example, any questions patients may have after attending an appointment can be answered on the spot, whereas previously, they would have been redirected or rang back days later when notes had been retrieved,” Max said.
“Another big benefit has been that we don’t lose casenotes anymore. Historically, we recorded about 200-250 sets of notes as ‘missing’ each year. As a Trust we were fairly good at recording and finding ‘missing’ notes later, but again - this would introduce delays around the Trust.”
While cost savings were not the primary driver, the Trust did expect to reduce spend on sending, storing and retrieving information, and over time that it would be able to shrink its medical records library. To give the project scale, it employs 82 staff in the medical records department. “At the peak of the project, this increased to approximately 120 people,” Max said.
In 2015 the Trust had over 1.5 million active casenotes with around 1.25 million archived notes containing non-current patient information such as old nursing charts. “We’ve all but released one of the libraries entirely. We expect the size of the remaining medical records libraries to naturally shrink over the course of the next ten years or so, and we are excited about being able to hand back the space to be repurposed for clinical use.” Max explained.
UH Bristol was spending a lot of its medical records budget on offsite storage. “This amount has significantly reduced (by around a third excluding retrieval costs) and perhaps more importantly, it’s stopped growing,” Max said.
The next stage will see the Trust prioritise scanning the main BRI notes. Additionally it is looking to run a number of additional scanning projects out of hours. Max explained: “Some of the content in our records libraries wouldn’t get picked up by on-demand scanning, so we’d like to do short bursts of activity, scanning those to release space.”
The project has also enabled the Trust to accelerate its digital transformation in other areas. “Previously a lot of work was paper-based - looking at paper, writing on paper, requesting things via paper, now more workflows are digital. Because we managed the project well and had good engagement throughout, IT has formed a cohesive relationship with clinical staff, to ensure effective outcomes for patients and staff.
“We have been able to quickly and effectively roll out other digital projects, we have clinicians that are well linked into IT, they’re used to making decisions about how their IT systems look, and they’re familiar with the way we approach the rollout” Max concluded.
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