Paperless ahead of schedule?
With the development of the new Royal Liverpool University Hospital well under way, the Trust set a slightly more challenging target date of this year (2017) for paperless working, ahead of the governments 2018 target.
There will be no facilities to store health records in the new state of the art, digital hospital which has been designed to operate within a paperless environment so it is imperative that processes are put in place now to support this way of working. Fortrus Ltd are working in partnership, to provide the Trust and the citizens of Liverpool with a Paper Free Health Record (PFHR) solution.
RLBUHT had to find best of breed digital technology to pioneer best practice knowledge and digital expertise, whilst also increasing efficiency, decreasing costs and improving patient care. Like many, the Trust is operating in a challenging financial environment and needed to look at how they could continue to meet customer expectations, whilst having tighter control of budget expenditure.
The scope of the project was to develop a bespoke Paper Free Health Record that would be an organic EPR replacing and/or rationalising existing legacy systems. This is all being provided by Fortrus Ltd under a fully managed service agreement that includes 14+ other suppliers, it is also implemented with the view of being a Liverpool-wide integration, engaging clinicians, non-clinical users, and external organisations who require access to the PFHR.
Fortrus has developed the bespoke software application specifically for the trust - The Royal Paper Free Health Record (PFHR). The PFHR will enable clinicians to access digital medical records that consist of structured and unstructured data. The trust currently hold hundreds of thousands of paper medical records and many thousands of paper forms. The scope of the project enables the trust to transition from paper-based working methods to digital ways of working in line with the target date and well in advance of the move to the new Royal.
Key to the success of this programme is the resultant user experience, put simply; the users experience must be intuitive, and easy to understand. Fortrus engage users through a research and development approach whereby user research is conducted at the point of care. Inefficient processes will be identified and innovation used to design the software in such a way as to improve the users access to information as well as their ability to record information about a patient.
The approach taken is a continual process that enables the PFHR to evolve over time and constantly meet the needs of future changes, whether that be NHS compliance regulation changes, or meeting the needs of the business drivers for RLBUHT and its clinicians. The Managed service contract provided by Fortrus was signed in July 2015 and the scanning project commenced in April 2016, with the UNITY system, clinically live on the 18th October 2016. There are currently 6,500 users using the UNITY solution provided by Fortrus, across two sites.
There have obviously been some challenges faced throughout the process, some of which are typical of such managed programs and those that always need to be considered when digitising patient records. It is essential that an effective scanning strategy was developed and implemented at the outset of the project, all clinical (paper) processes had to be reviewed and clinical engagement was an integral and ongoing process throughout all phases of the project development and implementation. Key to the success of the project was also the willingness of third party suppliers to integrate and the information exchange included a number of suppliers.
By working in partnership, Fortrus set up a dedicated scanning facility in Oldham, which meant that it would be designed and set up to meet the Trusts specific needs, which include the following:
- 96 million pages over 5 year programme
- 350,000 case notes in total
- 91 million pages scanned in the first year, 152,000 pages scanned per day - this target has consistently been hit every day since the start of the legacy file scanning.
- In year one the trust will be approx. 10-15% over the target where it is expected that 41,000,000 pages will have been scanned.
Fortrus has implemented our 'UNITY' solution in many NHS Trusts and taken a number of unique approaches using technology to best fit the Trusts scanning requirement, whilst ensuring at all times that users can find documents easily and quickly. We have seen some tremendous results from the RLBUHT scanning operation and the overall volumes that have been scanned since April 2016.
We believe that by working together with RLBUHT we have achieved a first in terms of the volume of patient records that have been scanned to date, whilst all key deployment target dates have also been met.
Outlined below is a breakdown of the file numbers that have been scanned since the start of the project, with a soft go-live in July and full solution go-live in October last year (2016).
|Number of Deceased Legacy Files ingested into UNITY since April 2016||21,000|
|Number of Live Patient Legacy Files ingested into UNITY since April 2016||82,000|
|Number of Legacy casenotes scanned from August go Live to current Date||76,400|
|Number of Thin Folders scanned from August go Live to current Date||30,400|
|Number of emergency Pulls since August 2016||149|
|Percentage of emergency pulls within SLA since August 2016||100%|
|Casenotes Ingested in August 2016||16,018|
|Total images scanned in August 2016||6,004,362|
|Casenotes Ingested in September 2016||20,338|
|Total images scanned in September 2016||7,449,342|
|Casenotes Ingested in October 2016||31,975|
|Total images scanned in October 2016||9,405,294|
|Casenotes Ingested in November 2016||48,887|
|Total images scanned in November 2016||10,290,674|
|Casenotes Ingested in December 2016||41,900|
|Total images scanned in December 2016||4,272,329|
|Casenotes Ingested in January 2017||47,201|
|Total images scanned in January 2017||4,505,426|
|Casenotes Ingested in February 2017||47,594|
|Total Images scanned in February 2017||9,021,200|
|Total Documents scanned in February 2017||316,024|
|Total Pages scanned in February 2017||4,510,600|
Six months into the 15 month contract, we are almost at the halfway point for year one, which means that we are already tracking ahead by approximately 6 weeks, however the scanning volumes are now starting to recede to the levels they should be at and we are on target to hit approximately 152k per day, every day.
Timescales and funding for the programme were tight and so Fortrus worked in close partnership with the Trust to create effective work packages under the managed service framework, ensuring the project stayed on track with the go-live deadline dates that had been set.
For the programme to run in the most efficient way possible, a cultural change was required within the IT department. The IT department and PFHR programme team were refreshed and all the initial project team have now moved on This was identified as a key requirement for the success of the project. In addition to the PFHR project team, Fortrus also provided one full time technical person onsite for the duration of the project from day one, this had a significant impact on the success of the project implementation as it meant that any issues were dealt with immediately.
There are a number of other areas that have contributed to the success of the programme to date and a fundamental step in the change management programme for it to be successful was working closely with all stakeholders, gaining their feedback and commitment as well as keeping them informed on decisions. Monthly management meetings took place, which helped, not only to manage stakeholder expectations but to resolve any issues that occurred at the time in which they occurred, the stakeholder group involved a wide range of personnel from management to end users, to clinicians and nurses.
Classroom style training was adopted initially, but the Trust soon moved to training in the clinical environment as it proved to be far more effective. Providing training in the Clinical environment meant that floorwalkers and training staff could go through the system in situ with the users, meaning that the training was always in context with the role the users perform.
The floorwalkers were an integral part to the success of the roll out and at their peak pre-go live and during go live there were 25 floorwalkers providing support across the two Trust sites. They were employed purely for training support purposes and were on hand 24x7 across both sites, via mobile phones, ensuring that users could call them at anytime, in addition to this a WhatsApp group was also created for the whole project team, which included all floor walkers, this ensured that all appropriate staff were kept up to date at all times.
The floorwalkers were such a success in supporting other areas that they transferred from being ‘Paper Free Floor walkers’ to Trust wide ‘Digital Support Officers’. There are currently 17 (over time this will reduce slightly) but the digital support officers will remain an integral part of the programme, which is testament to the success achieved through their introduction to the programme.
The Trust also had an extremely effective communications strategy and Fortrus also provided support in this area, by working closely with the trust pre go live to ensure consistent and frequent messaging and updates were shared on a trust wide basis. Newsletters with project updates and relevant training communications were produced and distributed on a weekly basis to all staff, in the months leading up to go live of the UNITY solution.
There are a number of benefits that will be realised over the course of the PFHR programme, which include reduced storage costs, no more lost case notes and more efficient access to data. The main records library is in centre of Liverpool, with Storage facilities, also at Broadgreen hospital and a number of smaller satellite sites where records are currently held All of these sites will soon be closed and the case notes stored there will have been legacy-scanned and deep-stored in line with BS10008 compliance in 2017 the case-notes will then be destroyed in line with the Trusts destruction policy.
The Medical Records library staff will gain immediate efficiency savings in tracking, pulling, re-filing, preparing, auditing and locating the health records. The automation of this file tracking process will also release clinic-side staff from this administrative chore and thereby make more patient-facing time available.
A learning process
There has been many lessons learnt throughout the project to date and no doubt there will be many more. Fortrus and the project team at the Trust had to reassure information owners of the benefits that would be realised and convince other stakeholders that sharing would be of benefit, whilst also understanding access paths to simultaneous records by multiple clinicians.
Becoming paper free involves huge organisational change, it involves bringing new technologies together alongside new ways of working to meet a defined strategic outcome that delivers a wide range of benefits; including improved patient safety and experience through an increased quality of patient data, whilst also allowing real time clinical data capture to support clinical improvement, especially by the reduction of duplicate data collections and increased support enabling collaborative working between clinicians.
Peter Khalil - Fortrus Programme Director at RLBUHT commented, “Over the past 10 months the Fortrus team have worked with our partners in the PFHR project team to establish and deliver the ambitious Phase 1 of digitising Legacy patient records and establishing suitable business and technological processes for handling ‘day-forward’ patients notes though electronic noting, e-forms and day forward paper scanning.
"This is the culmination of strong collaboration, that has brought together several workstreams and suppliers. We have worked through some complex challenges as one team to support the design and implementation of a bespoke medical records viewing platform – Unity, for theTrust. Now that we have achieved Phase 1, we will continue on to the next stages of this project which include integrating other systems so that information is brought together and made available within Unity, whilst also focusing on the use of technology to allow users to quickly find the information they need in their day forward records within Unity.”
He concluded: "By working closely with the PFHR team and other colleagues at the Trust we have demonstrated the successes that can be achieved in a short timescale regardless of the complexity of the project.”
Ian Gilbertson, Senior IT Project Manager at RLBUHT commented, “The move to Paperless working has transformed the way RLBUHT deliver health care and has made some massive improvements to patient safety which includes:
- No more lost paper records - Everything is now backed up digitally so information can no longer be misplaced
- Access to records are fully audited - Improving safety mechanisms around breach of data protection
- Multiple disciplines can access records from anywhere 24/7 - This was certainly not possible with paper and can therefore also, improve the time in which patients are diagnosed and cared for
This has been a positive step in the right direction for the Trust to not only modernise their delivery of health care, but more importantly to improve patient safety”.
There has also been positive feedback from a wide range of users:
- No need to carry heavy case notes
- Can now read the associated notes, they are easy to use and all in one place
- Audit-able, can be accessed from anywhere and saves time
- Eliminates duplication
- 24/7 floor walking support was invaluable
Through implementing the PFHR a patients' information will be available almost instantaneously. This is surely a positive thing, not only in enhancing patient care and their experience, but also improving staff working lives by cutting down on paperwork, and drudging through paper files as the exact document can intuitively be searched in just a few clicks.
Increasing efficiency by going paperless
- There will be no more waiting for paper files to arrive when patients are admitted or transferred to a ward, or from a records department.
- No more waiting on information from other teams or departments.
- Staff can simply log onto the system and with a simple search, locate a patient and have an array of knowledge available regardless of their physical location.
- No more booking additional appointments because staff are still waiting on certain paperwork to be reviewed, consequently freeing up extra appointments for outpatients.
- There is no backwards only forwards, and there are more positives than negatives to be gained from the implementation of the PFHR at the Royal………Paper Free is here.
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