Special report: EDM/ Scanning.

Feature

Scanning the future

How much paper is it worth scanning as part of an electronic document management project? It's a fraught question, but the answer seems to be 'less than you might think' with legacy records and 'only what you can plan for' with new ones.

In 2018, Papworth, the renowned heart and lung hospital, will move to a new site near Addenbrooke's Hospital.

The site has no space for a paper records library; which has proved a good incentive for switching from a paper-based record system to an electronic one.

The hospital implemented an electronic document records and management system from CCube. While it decided that every new referral would be handled electronically, it chose not to scan legacy records.

Karen Thompson, ICT project manager at Papworth, says this was because it was "far too costly." Instead, she says, the decision was made to "concentrate on our development at the beginning of the patient's journey."

The starting point was to make sure all new clinical letters are created within the electronic medical record, while all referral letters are scanned in as soon as they arrive.

Each specialty has staff responsible for scanning in referral letters. Once scanned in, two workstreams are created automatically: a clinical one that enables doctors to see the letters and act on them, and an administrative one that enables the health records team to register a patient and input data into the patient administration system.

It has streamlined a previously inefficient system, says Thompson: "There's no need for hundreds of letters to be copied and transported across the trust, which is what was happening before."

Find better uses for space than paper

For a small, specialist hospital like Papworth, the decision to focus efforts on scanning in new referrals was a relatively straightforward one. But it can be more complicated.

There's no doubt that there are strong drivers for reducing a hospital's paper pile. Paper takes up space that could be used for clinical purposes or even to generate revenue: Paul Sanders, managing director for digital solutions, health, Civica, says he has seen a number of scanning business cases based on the need for car parks.

And moving paper records around a large hospital is time-consuming. At St Helens and Knowsley Teaching Hospitals NHS Trust, which has also implemented a CCube system, paper records had to be transferred frequently between two sites. Patient appointments often had to be cancelled because the record had gone missing.

Most importantly, an electronic medical record system enables trusts to realise the benefits of a more efficient clinical workflow and patient-focused care. Clinicians can quickly put their hands on the relevant record, wherever they are, and share it with colleagues on different sites. Every step of the patient's interaction with the hospital can be audited.

To scan or not to scan?

But some trusts have struggled with working out what to scan and what to keep on paper. It makes sense to scan all material relating to the patient, says Simon Hill, sales director UK and Ireland at Nuance Communications.

"It ensures that there is an accurate and electronic trail that's readily viewable to any medical professional with the authorisation to see it." Scanning documents not directly related to the patient is less likely to be worthwhile unless there is a huge cost associated with physical storage.

When it comes to choosing which patient records to scan, Geoff Broome, managing director of Apira, says there are three options: scanning all existing paper; scanning on demand; and day forward scanning.

The first, he says, can be quickly ruled out: "The cost of storage is usually 30p to 40p per record per annum, and the cost of back scanning is about £8. So there's no trust with that sort of payback period of 20 years - it's not a plausible proposition."

The day forward approach entails setting a date and then scanning every new document after that date, but leaving historic documents on paper. The advantage of this, says Elisabeth Belisle, managing director of Scandox, is that it's possible to amend the forms to include barcodes, thus making indexing much easier.

On-demand scanning involves scanning the records of patients a few days before their appointments, so that clinicians have the relevant information to hand.

Which approach to take depends on the particular circumstances of the trust, but it requires careful consideration. Elisabeth Belisle, managing director of Scandox, says that even on-demand scanning can be expensive because "there are many people who come in once and don't come in again. So you spend money scanning the existing paper record and nobody will ever look at it again."

Partial scans of paper records are also a mistake, says Vijay Magon, managing director of CCube: "If you make the decision to scan, you want to scan the whole record, otherwise you're not solving the problem. Some of these records can be huge, hundreds of pages, so if you want to get rid of the paper record, you need to scan all of it."

Start with a plan

Planning is crucial. Will the newly-scanned documents be stored as part of an electronic patient record, a document management solution or a portal?

How will the documents be integrated with existing clinical systems? Some trusts, says Belisle, make the mistake of procuring an electronic document and management system first and then scanning the paper documents.

"They should do it the other way around," she says. "They need to look at what they have first because that will drive some of the requirements in the system."

Scanning technology is now fast and highly sophisticated, but it's important to use it intelligently, says Belisle. "I've seen places where instead of scanning everything in colour or scanning everything in black and white, they stop the scanner every minute or so because they've decided that there were certain documents that they wanted to have in colour."

Other trusts, she says, have added a barcoded cover sheet in front of every form instead of redesigning the forms to include barcodes. This slows the scanning process down considerably.

Because clinicians want to be able to find information within a record quickly, some vendors use optical character recognition technology that translates image-based documents (such as PDFs) into searchable text.

Eva Weber, senior product marketing manager at ABBYY, says: "When looking for a specific patient case note or keyword, being able to search by document title and the content within makes life easier."

The bureau for change

The decision whether to scan in-house, outsource it to a third party provider, or opt for a combination of the two, can also be difficult. Requiring staff to spend time scanning is arguably not the best use of NHS resource.

And clearly outsourcing offers some efficiency benefits. As Sanders says: "Quite often there are peaks and troughs, such as 18 week-initiatives and seasonal spikes, and an outsourced provider can gear up and be in a position to deal with that."

But a lot of the important work has to take place before scanning starts. Belisle notes that most NHS trusts have hundreds of paper forms for different processes that may need to be catalogued and integrated.

Magon points out: "A paper record may contain 500 sheets of paper, and a paper record can also be segregated by specialty tabs. It's not just about taking clips and staples, it's about making sure that the structure of the physical record is simulated electronically."

Some trusts have a high proportion of errors in their paper records, Magon adds - quite often one patient's notes will be in another patient's file. Work to clean that up needs to happen beforehand.

The scanning itself is relatively easy, however: modern scanners work through large volumes very quickly and the technology is often clever enough to rotate a landscape page.

Scanners can even, notes Weber, assign an index to each document before attaching it to the EMR. Some trusts, says Magon, have opted for a hybrid approach, using outsourcers to carry out legacy scanning, while in-house staff scan incoming documents.

Trusts that use outsourcers will need to be clear about requirements, says Broome: "The important thing is that in the scanning contract that you agree, you need different turnarounds." He adds: "If I create a piece of paper in a day forward file, it's very important that that is scanned and added to my record quickly."

Working out a scanning strategy is the first, and often complex, part of a longer journey towards a fully digital set of processes. But once that strategy is in place, the benefits are substantial, says Sanders: "It starts to bring in workflow and automation and the ability to give greater efficiencies and ultimately improve patient care across the hospital."