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What is standing in the way of a paperless NHS?

The number of healthcare practices using digital records is rising, yet thousands of patients are still unable to access their data

Health secretary Jeremy Hunt’s ambition is for the NHS to be paperless by 2018. As Computer Weekly has previously reported, many practices are deploying initiatives such as electronic health records in a bid to reach this target.

But while the minister has set his sights on a paperless future, NHS organisations face the prospect of digitising vast numbers of historical records, combined with the cost of implementation given the budgetary constraints the NHS faces.

When the Pennine Acute Hospitals NHS Trust embarked on its digitisation initiative, it predicted it would be scanning 100 million patient records in the first year of the project – creating up to 450 million images that would need to be stored.

At the InterSystems connected-healthcare conference in 2015, Inderjit Singh, head of enterprise architecture at NHS England, said every local area would be required to create an annual digital roadmap outlining how they plan to achieve paper-free status through an open interface which should be underpinned by key standards.

Digitising paper records is one part of a wider digitisation of business processes for the NHS. “On one hand we talk about the ability for patients to be able to access the information online, but on the other hand we still have discharges being sent through the post in a significant number of organisations,” said Singh.

“We talk about technology as an enabler, but we need to move beyond that and really translate what this means for key clinical pathways and key focus areas the healthcare service is looking at,” he told visitors to the conference.

NHS-wide information sharing has its challenges

The scale of digitisation is not the only IT issue. Joined-up healthcare in the NHS requires a cultural and technological shift to engender the sharing of data throughout the organisation.

But progress is being made. Singh highlighted work with the National Information Board to improve information sharing in four key NHS pathways – end-of-life care, complex long-term condition management, mental health and urgent emergency care – to help patients as they are moved through these areas of the NHS and reduce the amount of paper in the process.

“We know now, in terms of where citizens are in their care pathway, that information sharing needs to be supported across a number of care settings, with care co-ordination happening at a local level,” he said. “This means information sharing both within an organisation and across organisations, and the clinical governance that supports that.”

David Champeaux, managing director of health strategy at Accenture UK, says the focus needs to move away from simply digitising paper records to rethinking the whole service.

“[Just digitising records] leads to half bridges being built, for instance by people automating an electronic medical record in a hospital but not thinking about how that connects into the GP systems,” he says.

The lack of data sharing between NHS organisations has been a long-standing problem, with GPs, ambulance services and hospitals often lacking sufficient historical data on a patient’s medication, ongoing conditions or previous visits. For example, when an ambulance arrives on a scene, paramedics need to ask patients their details. Data sharing between GPs and hospitals could help save time – and subsequently lives.

Interconnected healthcare systems

In the 2013 Harvard Business Review article The strategy that will fix healthcare, Michael Porter, a university professor at Harvard Business School, and Thomas Lee, chief medical officer at Press Ganey Associates, highlighted the gap that often exists preventing clinical professionals from having access to the right data: “A simple ‘stress test’ question to gauge the accessibility of the data in an IT system is: Can visiting nurses see physicians’ notes, and vice-versa? The answer today for almost all delivery systems is ‘no’.”

As different types of clinicians become true team members, working together and sharing information needs to become routine, Porter and Lee noted.

The lack of data sharing between NHS organisations has been a long-standing problem, with GPs, ambulance services and hospitals often lacking sufficient historical data on a patient’s medication, ongoing conditions or previous visits

However, while experts agree a truly integrated healthcare ecosystem will save lives and reduce costs, doctors are finding these systems difficult to use. According to research from Accenture, 47% admit they struggle with new systems.

“Over half of doctors said the introduction of electronic health records in their hospital has reduced the time they have been spending with patients,” says Champeaux.

And while giving patients access to their records could improve how they manage chronic health conditions, the Health and Social Care Information Centre (HSCIC) has found only 0.4% of patients have accessed their healthcare records due to low promotion of the capabilities, and some GPs still do not offer patient access to their health records.

Many believe that as GPs and other healthcare providers have digitised, they have missed an opportunity to increase engagement with each other, focusing on internal transactions rather than the entire ecosystem, and in many cases the digitisation process is not taking time to remove redundant processes.

“There is a danger of investing in technology without taking the opportunity to step back and re-imagine the services end to end,” says Champeaux.

Look beyond digitisation of electronic patient records

It was announced in September 2015 that the NHS should be developing roadmaps over the next year on how it will be paperless by 2020, but Hunt’s focus on the paperless aspect of these systems has left the point of them unclear.

Philippe Houssiau, Healthcare & Life Sciences at consultation and outsourcing firm CSC, dubs the paperless initiative an “irrelevant title” for the ongoing digitisation of healthcare data.

“You really solve nothing by replacing hand-written or typed sheets with a computer screen that can provide the same kind of information, in the same place, in the same format,” he says. “That’s where a lot of the initiatives that have been taken have really missed the game.”

Read more about healthcare IT

Currently, 40% of a clinician’s time is spent waiting for relevant information, or making decisions based on information that is inaccurate or unreliable, which should be the main issue digitisation is aiming to tackle, says Houssiau.

“The whole digitisation programme has not really fulfilled that goal,” he says. “IT-enabled streamlining of processes across the board would allow those resources to shift away from managing back-office operations and doing a lot of non-value added work in a clinical or care perspective, but that shift hasn’t happened.”

Houssiau points out that the focus for digitisation should not be around “the NHS being paperless” but getting the right data to the right people to allow “optimal decision-making”.

In the future, this might even be managed by patients themselves. By putting data in the hands of patients – for example, those with acute conditions such as diabetes that require an ongoing change in lifestyle – you implement a level of self-accountability, he says.

Big data with health benefits

Providing patients with more information builds a better bridge between patient and doctor, which in turn can make the patient record more accurate, according to Uwe Diegel, CEO of iHealth Europe. Such data can then be used to feed big data initiatives.

“It’s quite easy to take a single piece of data and take it out of context,” says Diegel. “The NHS is being incredibly active about big data, it’s pushing behind the scenes of big data and it’s going to change the face of healthcare, but mostly the face of research.”

According to Diegel, those who will benefit most from this easily accessible and interpretable data will be medical researchers, as opposed to those in a GP surgery dealing directly with patients.

“Co-ordinated care really becomes population health management if you add a layer of health analytics on top,” CSC’s Houssiau adds.

Ultimately, the digitisation of paper medical records is the first step in the wider transformation of the NHS. It remains to be seen how an organisation established to provide the UK population with “cradle to grave” healthcare will evolve, and how far digitisation will enable it to maintain a UK-wide health service for all.

This was last published in September 2015

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20% of the population won't be able to access a digital NHS - many of the elderly, people with print or cognitive disabilities, foreign language speakers - what provision is being made for the digitally excluded?
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