Overcoming paperless hurdles

During a speech in January 2013 the Health Secretary Jeremy Hunt issued a challenge to the NHS – that we be paperless by 2018. Official government reports of his speech record that he was proposing a series of developments linked to recording patient data and sharing this across health and social care services. To oversee this process NHS England has created a Strategic Systems and Technology Directorate – their key deliverables are stated on their website.
    
They have already published Safer Hospitals, Safer wards: Achieving an integrated digital care record – which is described as providing a roadmap for us to follow through ‘paper light’ record keeping to a paperless Integrated Digital Care Record (IDCR).
    
So where does this leave us in Secondary Care? No one should doubt that this is a huge challenge – this might be a ‘take two’ of the National Programme for IT, but this time it comes at a time of severely constrained budgets and limited external funding support. However let us ignore the funding and the available software (both are beyond the scope of this editorial) – instead let us look at experience at the sharp end and consider some of the issues faced.

Hardware
There is huge variation in the amount of hardware that is on the frontline. i.e. available for easy access and linked to direct patient care. Computers in the offices of consultants, ward sisters, matrons help but I would argue are not available for direct patient care. So how many access points are there in each ward, each outpatient clinic, in theatres and maternity units and what are they used for?  This is a real challenge going forward as I would suggest ready access is vital to success.
    
Mobile technology is an interesting area and really divides IT colleagues opinions across the NHS. There are those who advocate the use of iPads, iPods and similar rival technology whilst others say these are not suitable for the hospital environment. There is no doubt that we need suitable mobile solutions but I continue to see problems with theft, battery life, the need to consistently plug in small charging leads, providing enough electricity sockets and a lack of ruggedness. Any hospital technology has to be reliable and be suitable for 24/7 use as hospitals do not stop at night. I suggest this includes the ability for the IT department to be able to quickly change batteries when they begin to lose performance.

Hospitals have had varying success with Computers on Wheels (COWS) – for the most part these are heavy to move round, are of low performance and have battery issues with 24/7 use. Laptops on trolleys are another option and offer lighter weight and so increased mobility but again depend on people remembering to plug them in when they are finished. However they do offer the advantage of allowing the IT Department to incorporate an planned battery replacement programme.

Wireless Network
Mobile technology – whatever device you use depends on the network and I believe this continues to be a challenge. Many hospitals do not yet have a wireless network but even in those that do there can still be problems for ward staff as they move around. Single point in time network surveys might be reassuring but it is only when you have staff using mobile technology on a large scale that you can find if your system has any blind spots. Wireless networks depend on a large amount of equipment – as we move our clinical colleagues to being reliant on mobile devices then monitoring this and quickly responding to any issues is vital.

Support
Whatever system is used the entire hospital IT system will need responsive 24/7 support 365 days a year. The move to paperless (or more importantly care without casenotes) using an Electronic Patient Record (EPR) means that any down time will have a severe effect on patient care. We talk about the importance of  business continuity plans but I believe we will need to move to the next level – running actual exercises in defined high risk areas to ensure these plans are robust. Staff change, rotate or even forget and so these exercises will need repeating on a regular basis. This brings us to manpower.

Manpower
It is an interesting fact that many of those people whose involvement is important in the move to an EPR have previously had little or no exposure to IT within their hospital. Think about the registered nurses, health care assistants, physiotherapists, dieticians, specialist nurses and the many others who contribute to patient care. Each currently records valuable information on paper that is needed for the safe care of our patients. My own experience of rolling out electronic nursing assessments within my hospital has brought home the fact that many colleagues working on our wards have had little or no exposure to IT – either inside or outside the hospital.
    
The investment in training and time spent on the wards delivering this has been a large undertaking for us but I believe this has laid an important foundation for us to build on as we remove paper from the system.

Interaction/communication
This is clearly spelt out in the plans from NHS England which states there will be clear plans in place to enable secure linking of these electronic health and care records wherever they are held, so there is as complete a record as possible of the care someone receives. It also states there are clear plans in place for those records to be able to follow individuals, with their consent, to any part of the NHS or social care system.
    
I believe this remains a huge challenge. My own experience of providing access to GP systems from secondary care has been less than successful though progress is being made on access to the Summary Care Record (SCR). This however is hardly the described ‘secure linking’ or the record following the individual. This will remain an issue while what I see as artificial boundaries are placed on our records in Primary and Secondary Care. Sadly we are one NHS but not one organisation – if I were a locum doctor in a GP practice then I would have access to primary care patient records and my GMC registration would be at risk if I looked at any patient record where I did not have a legitimate reason to view it. However if I then moved to a locum post at the local NHS Emergency Department I would not be allowed to view even the patients SCR unless I asked them their permission or declared on the record that it was vital for the safe care of the patient. Personally I would argue that routine access to more than a mere summary without these steps is needed if we truly wish to promote safer care for our patients.

So what is achievable?
Providing safe patient care without using the traditional folder of patient notes is within reach in quite a number of hospitals. However many are still not even on the starting blocks struggling with patient administration systems and several departmental stand alone systems that do not talk to each other. So it is easy to suggest that we will have a number of hospitals who will succeed in being paperless for the patient record or be close to it by 2018 but many others will fail.
    
I believe that the sharing of information/records across Primary and Secondary Care boundaries will be more difficult and sharing with Social Care even more problematic. I  leave you with one thought – if a Foundation Trust were to provide Primary Care Services with the GPs employed by the Trust then would there be a block to running a single patient record for the organisation? Would the boundary which I have suggested is artificial just disappear?

Further information
www.england.nhs.uk/ourwork/tsd/sst/