Case Study: North Bristol celebrates going paperless

In May 2014 North Bristol NHS Trust (NBT) opened its PFI state-of-the-art new hospital in Southmead Bristol. The hospital was a landmark design incorporating innovative design methods aimed at improving patient flow, reducing waiting times and improving the patient’s overall experience. The hospital was designed to take advantage of the latest improvements in IT including the use of an Electronic Patient Record to facilitate paper-light ways of working.

The trust has 9,000 employees based across Southmead Hospital, Cossham Hospital and Bristol Centre for Enablement to support the local Bristol and South Gloucestershire community.

The trust held its medical records in one central medical records store (two annexed buildings) located at the nearby Cribbs Causeway Industrial Park. The buildings were leased costing the trust c.£196,500 per annum. The medical records stores held an estimated 1.2m medical records with an approximate average page count of 150 pages per record.

The Medical Records Library employed 71 WTE staff retrieving thousands of medical records weekly for use in the hospital, including outpatients, elective admissions, research & audit, urgent and ad hoc requests. Medical records were routinely pulled 5 days before clinics or elective admissions. The trust also retrieved 800-1000 medical records 48 hours before appointments for late additions per week (this is inclusive of overall medical records pulled per week). In addition, the trust pulled on average 150-200 records per week for out-of-hours emergency admissions (7pm – 7am Monday to Friday, 24/7 weekends and bank holidays).

Digitising paper records

NBT needed to digitise its paper medical records to provide access to these documents for staff across its services within a click of a button.

It has utilised Electronic Document & Records Management (EDRM) software from CCube Solutions to remove paper, save staff time and remove costs of storing, moving and handling paper.

Neil Darvill, Director of Informatics at the trust: “We had around 1.2 million medical folders stored off-site, with in excess of 1000 being delivered to Southmead Hospital and other premises daily. In the long term, clearly this was an unsustainable way of working so we set corporate and clinical objectives to find a digital solution and ensure our staff were case note-free at the point of care.”

“Our digitisation project started in 2016 with the creation of a demanding product specification. The focus was on usability and what the solution would look like for staff. We decided to work with CCube Solutions, and chose their EDRM solution to deliver the digital medical folders and case notes at the point of care.”

“The project was an integral part of the trust’s phased Electronic Patient Record (EPR) strategy, as we sought a platform to ensure that our 6,000 healthcare professionals had instant access to patient medical records as and when needed. We were also working to NHS national strategy which set organisations the target of being paper-free at the point of care by 2020.”

“The business case for the EDRM project is predicated on a scan-on-demand model where only the patient notes for people booked to attend clinic will be processed – not everything in the library. This saves huge amount of money given the other records will be destroyed in line with our retention policies and procedures as and when they reach their expiry dates.”

Out of its total of 1.2 million paper casenotes, the trust estimated that it has c.400,000 active patients who will need their records scanning. As each folder contains on average 150 sheets, this means approximately 60 million pages are likely to be scanned in total. The massive back scanning task was outsourced to an internal NHS scanning function – NHS BSA.

Until the paper-light initiative has evolved, the so-called ‘day forward’ scanning is managed in-house. During this period of transition, the trust purchased production scanners which process up to 130 and 150 pages per minute allowing large batches of medical paperwork to be captured and indexed quickly and efficiently. The digital records are then automatically imported into the CCube EDRM.

Delivering for clinicians 

David Mitchell, CCIO, North Bristol NHS Trust. “In modern hospitals, people needed access to notes for a number of things. If a note is sat with a secretary waiting for a letter to be typed it was inaccessible to everyone, and this was having an adverse effect on clinical care. We also didn’t have space to store medical records in our new hospital building. Therefore we set off to create a digital archive of our paper records.”

“We looked at whether we could take the records and sort them. The logistics of that were complex so we only scanned in documents required for patient care.”

“What we have now got is the ability to search, and use strings to search, for letters from a particular department so you can pull out those quickly. We can see the thumbnail so we can pick out quickly what we need.”

“When we started there was a lot of searching. As we have gone forward letters are easier to find sequentially so this has made it easier to navigate.”

“We maybe didn’t need to scan in all the contents of every record, and after consideration, decided to keep this to all the contents of every record scanned. Some clinicians want all and some Specialties don’t – there is, therefore, an exercise to understand what is needed; for example, for people with long term conditions it is important to have the whole record.”

“The main benefit is that the record is available 24 hours a day, and multiple people if needed can access a record at the same time. Before it could have taken weeks to surface a document.”

“My advice would be to educate your workforce, try and make sure clinicians are aware. The quality of what goes in to be scanned affects the quality. The more the documents are consistently sorted the better.”

Before and After

The EDRM Solution

Further to clinician input, CCube Solutions created an electronic version of the medical record to mirror the format of the paper notes. All clinical correspondence is stored in the EDRM system along with colour photographs, ECGs, CTGs and reports. The system is intuitive and easy to use which has enhanced clinical acceptance of it. This helped to significantly reduce training time.

The digital record features a series of tabs similar to the paper file, along with a variety of sub sections to help navigation. For example, within individual tabs the subsections enable clinicians to find important information like consent forms and operation sheets quickly and easily – documentation they regularly need to review.

The CCube EDRM employs technologies like Optical Character Recognition (OCR) to enable users to use keywords to find documentation quicker rather than just relying on chapters within the patient record. Adding OCR capability also means that when patient records are batched-scanned, the use of separation sheets can be reduced. These are actually costly given the trust is scanning tens of thousands of documents per month in-house using high performance production scanners. OCR can automatically recognise what type of form is being processed, with it then saved into the correct chapter.

The EDRM solution is accessed throughout the hospital in all clinics, wards, offices, operating theatres, on wheeled trolleys and tablets. All authorised staff have access to it once training has been given.

The introduction of the EDRM solution is part of the trust’s phased Electronic Patient Record (EPR) Strategy, and will facilitate a more timely and extensive move towards creating a paper-light environment which also involves developing its EPR to reduce the amount of paper created daily.

This will ensure that one of the largest hospitals in the UK is paper free at the point of care – a key NHS England and Government goal. The new EDRM system will enhance clinical effectiveness, reduce operational costs, ensure compliance with CQC guidance about records and data management, and ultimately boost patient safety and care.

A partnership approach to IT delivery

Vijay Magon, CCube Solutions’ managing director, says, “EDRM in the NHS is all about transformation and presenting information contained on paper to clinicians in a much more efficient and effective way. Ease of use is crucial. Doctors have to be able to interact with the system in front of patients without it creating any unnecessary delays which could make consultations longer. Usability and effectiveness is very important which is what you get with the CCube EDRM software.”

“Key to the success of the project was a real partnership between us as a software supplier and NBT. They came to us with a real understanding of the processes they wanted to sort. We provided the technology and they brought the knowhow – such a partnership has really delivered.”

“We’ve delivered on the objective and removed the trust’s dependency on paper not just for patient safety but also commercial reasons and the associated costs – it’s all to do with very careful application of the available technology, to solve defined problems and then build on that success to tackle other problems, but at your pace.“

“The key message is that careful application of established technologies is delivering measurable improvements and benefits. These must be applied to address strategic requirements, rather than as a short-term measure to solve paper problems. The technology is not rocket-science, but has evolved gradually as customer demands, interoperability, and web accessibility have become ubiquitous.”

100% availability of records. You don’t have to ask anyone to get the record – it’s just a click of the button

Nathan Vaughan, Senior IT Project Manager: “The project aimed to alleviate the pressures of managing the day-to-day records, and being paperless would help that operationally.”

“Key to the project has been the way we approached the scanning. Go at a pace your organisation can handle. We did try to go a little bit too quick, so one of the lessons was take your time, do it properly, assess, and process map and plan – especially with the numbers of people involved and how they use and view these records.”

“This has very much been a people project, less about the technology.”

Key benefits 

  • £1.1 million yearly revenue savings
  • Information 100% available when clinicians need it
  • Securely stored and accessed
  • Removing staff costs handling and processing paper

Agata Huntley, IMT Project Manager: “In terms of clinical safety this project has been really important. There are lots of reasons not to use paper, and events beyond our control dramatically proved this after the new process was successfully in place!”

“Under the previous arrangement, trust staff would have to call the Medical Records Library and request a paper file. It was then over to the team there to find and then deliver it which could take hours. Once EDRM was in place it eradicated the need for a Medical Records facility and, as part of the project, we closed it down. Not long after, a fire destroyed the adjacent building which, had we not made the change, would have put our records library out of action for weeks at least. You only have to imagine the knock-on impact that would have had on staff and patients.”

“Overall, the project went really well and it’s great to see us move forwards.”

Handing the warehouse keys back

Neil Darvill: “The first thing is to say a huge thank-you to everyone involved in this project. It was a true collaborative effort, from the supplier to our project/IT team, medical records team, and our trust colleagues. This project involved a cultural change as much as a digital one so the involvement of clinicians here was vital, and continues to be the backbone to digital transformation at NBT. Having the agility to respond to – and act on – their needs and feedback is key to successfully transitioning from one way of working to another.”

“We have gone from an archaic costly way of working, represented by a massive warehouse full of documents, to a timely system where multiple staff can access patient records simultaneously online,  24/7, without the logistical nightmare of trying to find things and prep things, move things and find things, and all of that cycle of work involved. An inefficient and repetitive cycle has been replaced with ‘scan’. We have come a long way.”