South Tyneside NHS Foundation Trust is an example of a hospital that has invested in technology to improve its business processes and make impressive cost savings.
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It is currently in the advanced stages of rolling out a wide-ranging document-scanning system that is saving what the trust says is the "equivalent of 16 bull elephants" in paper - 74 tons of medical notes each year.
The trust has a turnover of £90m and 600 beds on multiple sites. It began to look into document scanning systems in January 2004, partly motivated by government plans to modernise the NHS through IT implementation.
At the heart of this strategy is the introduction of a national Care Records Service (CRS), based on an electronic patient record system that will span five geographic clusters across England. South Tyneside believes it is in good shape to link into the records system when it eventually comes into operation.
Martin Alexander, head of information services at South Tyneside NHS Trust, says that besides governmental requirements, there were also three important business reasons for going digital.
Firstly, digital documents made good business sense on a number of counts.
The trust has 2,200 employees across a wide geographical areas, 1,200 of them medical staff who require daily access to patient medical records. The paper documents were accessible in only one place, and were prone to travel around the buildings as patients went from one department to another. Notes were even known to go missing.
Also, if photocopies of the notes were made and altered manually, it was difficult to track all the versions of a medical record and retain a master copy.
By digitising the records, the trust could make notes more accessible to more health professionals, and introduce access security and an audit trail. Digital notes could have digital rights management to protect the original versions of a document, which would be useful for legal purposes.
A second business reason to go digital was that, like all hospitals, South Tyneside had limited space, says Alexander.
Before introducing a document-management system, the trust's notes occupied 400 metres of shelf space. The hospital is required, by law, to keep adults' records for nine years and children's records for 25 years, and faced the further logistical problem of physically sorting children's paper notes from those of adults - because ostensibly they looked the same.
Data access was the third factor that led the trust to adopt a document-management system.
It was often a lengthy process to find information in the first place, because notes could be in a variety of places. But searching for electronic documents takes microseconds, and the system is far more secure, says Alexander, because nothing is physically moved around.
The trust's IT team can tell who has accessed what and can control access to the library electronically through policy management.
The first phase of the IT project was completed in February 2005, when the trust went live with a Canon Datatron scanning station, a piece of hardware linked to a PC and the hospital's server network.
The Datatron uses the Canon ADOS document management system for capturing, storing, indexing and sharing data. All documents are printed with a barcode on them, which the scanning system uses to file and manage electronic versions.
South Tyneside piloted the system in its accident and emergency (A&E) department to replace a casualty cards system.
It set about digitising the cards and has now transferred more than 160,000 records since the trials began. It eventual hopes to scan all 500,000 cards. A&E "case reports" have to be kept for a minimum of eight years and now represent most of the trust's recorded data.
Within a few weeks of trialling the new system, the trust was asked to provide information to support a legal case in court. Alexander said it was able to transfer 14,000 casualty cards onto 12 storage CDs instead of requiring a lorry to transport the documentation, as it would have in the past.
In December 2005, the trust extended the system to its executives' offices for them to scan and access documents.
A third scanning station was installed in the pathology department in January 2006. The supplies department, which is responsible for purchase orders, received a scanning station in May that year.
The next phase, currently in progress, is to extend the document system to radiology, then the contracts register in August 2008, and the finance and invoice department towards the end of the year.
The trust is currently using six Canon Datatron stations, which send data over a dedicated storage area network (SAN) and links to the hospital's Microsoft Windows Server 2003/2000 server infrastructure.
The trust procured its own SAN, a 3Tbyte Dell disc-based system, which it is now expanding to 8Tbyte.
Although the SAN is used to store patient records, most of the space is taken up by Pacs (Picture Archiving and Communications System) images, such as X-rays and scans, and by cardiology data.
The system integrates with Active Directory, and user permissions are controlled from the point when users log in on their Windows XP desktop.
"The beauty is that you are not presented with another set of passwords, and access to the ADOS appears to be transparent to the user," says Alexander. "We can also centralise administration, which saves the IT department time."
The trust's IT department is highly qualified and includes an IT manager, five technical support officers and 23 developers, and the team manages its own Unix environment and SAN. "We train our IT services staff to a very high standard, and like to have control of our underlying core technologies," says Alexander.
Patient records are kept on a Microsoft SQL Server database, and users can carry out database queries on particular extracts of data, for example to analyse a set of dates. They can access the data through a web browser and the technologies are largely based on open standards, says Alexander.
The trickiest thing about implementing the scanning system was deciding how to index the vast quantity of data that was being generated, he adds.
South Tyneside Trust was forced to reorder its indexing after a couple of months, which was difficult and affected many scanned files.
The trust now uses a unique ID, based on the exact time of the patient's visit - the minute he or she is admitted. "We had to re-index a load of records," says Alexander.
"Speaking from experience, the advice I would give someone setting up a system like this is to get your indexing sorted out early on. It seems simple to index files, but it can be very complex. You don't want too few or too many categories. Work with your users early on, and talk about how they are used to searching libraries - for example, by name or the time the patient came in."
On the other hand, records can be accessed through a web interface and so the training burden is very light, he points out.
"The system is very easy to use and people are used to using the web. Most people have interacted with Google, and this allows you to search records [in a similar manner]. You don't really need to trained - the half-hour training is mainly about how to switch the PC on."
South Tyneside's digital records system is now being used by hospital staff such as paediatric nurses interested in child protection emergency care professionals and consultants.
Demonstrable benefits of the new system include a reduction in paper and storage, time saved in finding records, and more secure and accurate information available to hospital staff and clinicians, which helps to improve patient care.
The data is more secure, and is incrementally backed up on site, with yearly disaster recovery trials. There are also multiple copies of the data on CDs, kept locked away.
Alexander says the system has reduced the medical records department's administration budget, which has helped it come in on budget for the past two or three years. "The administration of paper is difficult to predict, but IT has predictable administration costs," he adds.
In the future, it will be possible to link the hospital's digital records system into a national patient record, says Alexander, with records being made available to many more health professionals across the country via the secure NHS network.
"We are looking to develop the system in areas such as primary care, and that's really cutting-edge stuff - not many people are doing it," says Alexander. "The security of the system is essential and has to be in place, so we are doing nothing very quickly."
Trust adds intelligence
As well as its Windows Server and SQL-based electronic patients records system, South Tyneside NHS Foundation Trust has also developed a large IT system to record and analyse all types of hospital data.
The system was established in 2001 and uses business intelligence (BI) to help the trust meet performance and clinical governance requirements.
Its BI system is based on Windows NT Server, Oracle 10g databases, Silverlink software and a range of Cognos BI tools. These tools enable the trust to manage, access, analyse, interrogate and report on information across the organisation.
South Tyneside implemented the BI systems across all its major areas, including waiting-list management, accident and emergency, radiology and pharmacy. The IT system draws information from three main relational databases so analysts can gain deep insights into the hospital's processes.
Martin Alexander, the trust's head of information systems, says the BI system has helped to reduce A&E waiting lists, manage hospital processes more quickly, and achieve higher-data quality.