There are many articles on the benefits of digitising medical records, and there is no doubt the benefits are real. They include medical records being available instantly to multiple users, reduced operating costs, released space, a complete audit trail of who has viewed every page, increased security and disaster recovery options. These benefits are well documented and I won’t expand on them here. But having led a medical records digitisation project from concept, through business case, procurement, deployment and eventual closure of the medical records library, my observation is that the literature does not explain just how tough a medical records digitisation project really is. Here are my thoughts on the challenges. The starting point for a digitisation project is often an environment where there is little or no control over template documentation used by clinicians, for inclusion in medical records. Most hospitals have a Health Records Committee or similar group with responsibility for approving document templates for medical records, but in my experience this is often bypassed. This is not surprising, as nearly everyone has access to a PC with software that can be used to create a new form. It is not unusual to find fifty to one hundred different types of referral form, all set out differently, and with some including information that would be better associated with other documentation stored elsewhere in the medical record. Template forms with no heading or description are also quite common. This causes problems as staff scanning these forms will have to make a judgement on how to index them eg are they correspondence, history, results, miscellaneous etc? Continuing to use a plethora of forms brought into use over the last 25 years whilst deploying digitised medical records will slow down the scanning operation and make it likely that different operators will make different indexing decisions. For digitising the medical records library archive the problem of non-standardised forms is unavoidable. But to stop adding to the problem an essential first step is to take control of the paper records. Standardise all new template documentation, to include barcodes containing the metadata for correct indexing and space for a standard patient specific label to be affixed, which must also contain a barcode to identify the patient. Where the technology allows, converting these new forms to e-forms takes this a stage further, and removes or reduces the requirement to scan new material. Frequently the starting point also involves lack of certainty about how many records exist and how many pages are within them. This is because there is invariably poor tracking of medical records, poor recording on the creation of new volumes, multiple sub stores within different departments and offices, and medical records that have been outside of the main library for years. Add to this the multiple temporary volumes created when the current volume is not immediately available, the lack of order frequently found within medical records due to misfiling into incorrect sections or tabs, and loose or unfiled paperwork stuffed into the back, and the starting point for a digitisation project is far from ideal! Therefore another key action before starting is to conduct a medical records audit to identify as accurately as possible, how many medical records exist, their growth rate, how many pages exist by record type or year or other relevant partition and the quality of the content with a focus on anything that will require manual intervention or slow the scanning process. A scanning supplier will do this before tendering a price, but the commissioning authority should also do this at outline business case stage in order to estimate the costs. Also at the outline business case stage, a decision needs to be made on what will be scanned, what will be indexed and what will be stored, to calculate the cost of scanning, indexing and storage. At this point there are different approaches to scanning that need to be considered. There is no right or wrong answer here, as it depends on the starting point and the investment objectives. To explain the options, here is a simple one page reference document that defines the different approaches that are available.
Be aware that there is a clear tension between indexing and cost. Clinicians want as much as possible indexed on important document types, which requires manual intervention and therefore increases cost (eg indexing ‘To’, ‘From’ ‘Date’ and ‘Specialty’ on correspondence). The lower cost route is minimal manual indexing such as tab section identifiers only, with all patient details taken from the barcode on the medical record cover (or manually entered where barcodes are not used) and supplemented via an interface to PAS. An automated approach to indexing, often called smart indexing, has become popular in the last two years and is available via many suppliers. This is based on optical character recognition (OCR) but is not 100% accurate. This is because some clinicians tend to write over printed words making them unrecognisable to OCR, or because forms get damaged or torn over time, also leading to OCR failures. This can introduce a clinical risk, as if a search for ‘diabetes’ returns no forms with this word, this can be taken as factual whereas in reality there could be a form where the word has not been recognised. Another obstacle is that removing paper forms breaks existing workflows that rely on pieces of paper moving around an organisation (or across organisations) before eventually being filed in the medical record. It is therefore necessary to process map the current state in each department to understand these workflows, and then design a future state that supports the necessary workflows without paper. It is sensible to do this department by department, and go live with digitised records in each department as the work is completed while it is fresh in everyone’s mind and before there is time for paper based workflows to change. But here is where it gets really difficult, because once a department has gone live with digitised records, its patients will pop up in other clinical services due to consultant to consultant referrals, new GP referrals and emergency admissions, and these other departments will not have been fully process mapped. There then follows a process of fire fighting, as the project team are called to resolve problems associated with the mixed economy of records that starts to develop in other departments. Most hospitals consider a big bang approach to the roll out of digitised medical records to be too high risk, but a phased approach leads to a gradual loss of control as patients move between departments. Perhaps the biggest issue though is that taking paper away from clinicians by digitising medical records drives a culture change that many embrace but some resist. Those that embrace it become frustrated by wanting their service to be the next to be digitised, but some resist and I’ve even come across a consultant that got his secretary to ‘print screen’ every page of his patients’ records in advance of a clinic! The culture change comes from information being available instantly. No longer can patient enquiries, complaint responses, audits etc be put on hold while waiting for the medical records to arrive. Strong and credible clinical leadership is essential. The issues I’ve raised may sound very negative, and to some extent that is intentional as I wanted to put the other side of the story to the usual reports of benefits and successes. But despite these challenges, digitised medical records is definitely a prize worth the effort, just don’t go into a project like this thinking it will be easy. The physical transformation looks like this. Please do not hesitate to contact me or High Resolution Consulting Limited if I can offer any support with your plans for digitising medical records, particularly making the business case, conducting a records audit or producing a scanning strategy.
Copyright © 2015 Magrath Consulting Limited, all rights reserved.
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Mark Magrath MBAI am a management consultant with 12 years experience as an executive director in an NHS Foundation Trust, including 10 years as Deputy Chief Executive. I only write blogs on projects and assignments that I have personally led. My aim is to write amazing content that combines real world experience with insightful advice. Categories
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August 2021
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