Opinion – Electronic Document Management: The often overlooked element of NHS digital transformation

Introduction:

In the current NHS digital transformation landscape, a huge amount of emphasis is placed on Electronic Patient Records (EPRs). From the national to individual digital strategies produced by NHS Trusts, the message is loud and clear: if you don’t have an EPR, you need one, and if you have one, you need a better one!

However, there is an aspect of record keeping in the NHS which no currently available EPR can adequately solve, and yet often goes overlooked: the stubborn persistence of paper medical records. Lingering at the edges of NHS trust operations like a messy loft everyone would rather ignore, trolleys of manilla folders continue to be core components of many trusts’ care delivery models, even in the third decade of the 21st century. A recent Times article highlighted that the NHS spent £1.19 billion over the past 5 years storing records alone; the original target of “paper-free at the point of care” by 2020 was blown past, and 12% of Trusts are reported to still be “paper-based”.

The focus on EPRs has enabled many phenomenal transformation programmes, but in many cases no plan for what to do about their old paper libraries. Like the messy loft, these libraries do not appear to be going away even as they’re ignored. There are products designed specifically to address this problem: Electronic Document Management solutions (EDMs). Yet well over 100 acute NHS trusts in England, even several with well-established EPRs, have not undertaken to deploy such a solution. Why, in an era of digital evolution in the NHS, does this core component of modern record keeping get forgotten or not prioritised?

So, what are the reasons EDMs can get left behind? Here are some common ones we hear from NHS organisations; and the reasons we think they don’t necessarily stack up.

“The paper records are redundant anyway, now that we have an electronic system in place”

This is an extremely common refrain from Trusts considering an EDM deployment. It makes intuitive sense: once proper methods for electronically noting are in place, this should render the old record a redundant, read-only folder. Over time, the paper record will be referenced less and less, until no more folders are being requested and libraries can be dispensed with, surely?

While making sense on paper (pun intended), this strategy seems not to work in practice. Firstly, many patients in the NHS suffer from chronic conditions for which clinicians require comprehensive histories to be available: a patient’s clinical history does not start on the EPR go live date. Therefore, these records at least would need to be retained as long as the patient continues to be in the care of the organisation. And the task of weeding out these records is a significant practical challenge; how would one know which records to keep and discard without pulling them open, one by one, and checking? This is a commitment of resources and time most trusts do not have.

Further, if records continue to be referred to in a clinical setting, experience shows that far from keeping disciplined to the principle of paper records being “read-only”, more paper will continue to be added to the folder, even if there is a digital record keeping system available. A complete behavioural transformation in an organisation can never be fully achieved if the means to continue old behaviours are left in place.

What organisations often imagine is that once a digital solution is in place, a natural “cut-off” point will arise when the legacy of paper will have been made redundant. But if the intention is to hold onto paper libraries until no clinicians require the paper record, trusts should expect to wait several decades. During this time the high costs of owning and managing paper will persist; despite consistent investment in EPRs across the NHS, per the recent Times article the cost of remote storage units has risen 20% in the past 5 years.

“The cost is extensive for minimal benefit”

It’s true that EDMs are usually not a throwaway expense. The solutions themselves are usually a mid-range cost where trust systems are concerned, to say nothing of the essential parallel expenditure on digitisation. Many trusts raise an eyebrow at the suggestion they should pay for a dedicated solution to replace a paper process that seems to work fine. Conversely, some trusts who enthusiastically start preparing business cases for EDMs are suddenly given a cold shower when confronted with the cost modelling for what was expected to be a quick and dirty project to scan a few records into a PDF viewer.

The most glaringly misconception there is assuming paper record libraries are free. Aside the number of resources required to manage a library (in a large acute trust, this can be over 100 WTEs), there are many hidden costs that organisations are so accustomed to they escape attention. Lost revenue from cancellations; missed opportunities to participate in research; legal costs from care delivery failures; courier costs between sites; wasted clinical time, and so on. These can add up to significant yearly cost pressures: if a brand-new software solution produced those kinds of effects, trust CEOs would be besieged with protests. But well-established paper processes don’t receive this scrutiny. Unless the problem of an active clinical library is addressed directly, costs are never going to go away. They therefore represent a permanent cost millstone around the neck of a trust. Weighed against these savings, the investment required to deploy an EDM seems paltry by comparison, which is what makes a well-drafted EDM business case and the resulting deployment so compelling.

Another important point to note is that it is extremely rare for an organisation to digitise the entirety of their library. In any medical library only a small proportion (typically about 15%-25% depending on how transient the local population is) of the records are what you might call “active” (i.e. being used, or likely to be used in future, for the delivery of care). The remainder of the library is largely records that have to be retained by the organisation for a period under records management guidance and statutory requirements but will likely never be referenced again. Understandably, a trust may balk at the cost of digitising a record that would be as much as twenty times cheaper to simply throw into a warehouse until it’s retention period expires.

This is a misconception that can kill a business case before it’s drafted: unnecessarily scoping for the digitisation of an entire library, inflating scanning costs by an order of magnitude. In reality, most successful EDM deployments instead undertake to digitise only records currently being used in the delivery of care: this can be a slower process, but the cost shrinks dramatically.