25 October 2023 Articles

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



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?

Why EDM?

An EDM essentially functions as a digital library for hosting scanned copies of paper medical records. Once scanned into an EDM a record becomes instantly available to any authorised user from a trust device. Additionally, once digitised, solutions such as Optical Character Recognition (OCR) allow documents to be searched, driving further improvements in efficiency.

An EDM is a 24/7 solution, accessible to all appropriate users and without the well understood operational costs and issues associated with paper – from reducing the logistics of moving large volumes of records to reducing human error.

EDM projects have a duel aspect: a software deployment (the EDM) and a digitisation exercise (usually in collaboration with a professionally accredited scanning partner). Most EDM projects would constitute a medium level of investment (typically £3-5 million in capital investment), both in terms of finance and time: a typical deployment would last about 2-3 years from sign-off of the business case to completion of digitisation. These are not solely software projects; the EDM can go-live in under 12 months, but the operational and logistical challenges of sorting and corralling the records themselves can be intricate and time consuming.

The benefits associated with closing a library are substantial and, crucially, tangible: entire Medical Records departments (in a large acute Trust, often north of 100 personnel) can be redeployed to other important and skilled roles in the organisation. At a time when recruitment and retention of NHS staff is a major challenge, this can help considerably. The space allocated to the labyrinthine of corridors of shelving racks are also released: often prime real estate for Estates teams. This represents tens of millions of pounds in value across the NHS, to say nothing of the lost opportunities to do something else useful with the space.

A recent EDM deployment in North West London which Apira supported, successfully emptied its library entirely in 2022: the floorspace allocated had been 1,500m2, all precious real estate in a London Hospital, which has now been repurposed for clinical support services. Conservative estimates on the NHS’s space allocation for medical records has been put in the region of about 20 football pitches’ worth.

On a recent EDM project, a patient surveyed prior to the go-live caught sight of a trolley overflowing with notes for the clinic. They expressed surprise that such records even existed in the NHS (“I thought they moved to computers ages ago!”). She was partially correct: the Trust in question did have well-established digital solutions in place, and yet the paper problem had persisted until it was clear an EDM would be necessary.

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.

“An EDM deployment is a drastic measure for limited clinical gain”

Unlike EPRs , EDMs have a focussed, narrow scope of functionality. At their core, EDMs are archiving tools: a pile of scanned copies of paper documents. Intended to replicate the experience of handling a paper folder, it’s easy to assume they do the exact same job except with the intervening step of a complex project at the Trust’s expense. Moreover, instead of asking clinicians to navigate a paper record, a medium humans have thousands of years of experience with, they must now be trained to use a more complicated digital solution just to replicate the same result? An organisation may ask: why bother?

This is to wholly undersell the user benefits a modern EDM can offer. EDMs on the market are intuitive and extremely fast, offering numerous tools to navigate a record that could previously only be flipped through a page at a time. A clinician using an EDM for the first time on a recent deployment Apira supported encountered a record containing 8,000 sheets of paper. They wanted to know whether the patient had been prescribed a specific drug previously: historically, this would have meant either combing over the entire physical record by hand, or (more likely) not bothering. With the new system, they were able to find the answer in seconds.

Relatedly, post-successful deployment of an EDM, clinicians occasionally report a tendency to make more regular and more thorough inspections of the paper record once it has been digitised, due to the ease of navigation. Anecdotally it seems that digitising a record enables more informed, and more timely decisions making; clinicians quickly adapt to the technology, and soon find themselves flipping to the right page in the document more quickly than they did with paper.

The focus on direct improvements to delivery of care also tends to obscure the profound secondary benefits of digitisation: records can be accessed by more than one person at more than one location, vastly improving the efficiency of care delivery. Risks of cancellations due to missing records are drastically reduced. Possibilities for large scale auditing, research, and in an era of rapid AI advancement even deep mining are all opened up once records are digitised. And paper records, which have no reliable method for controlling who views them and when, can now be protected by a fully auditable electronic system.

“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.

Final Thoughts

In the 21st century, much less its third decade, the persistence of paper record keeping in the NHS should be both shocking and should stimulate immediate action. There exist, at time of writing, several well known NHS trusts with best-of-breed EPR solutions already deployed, that nonetheless manage libraries containing multiple millions of paper medical folders.

The costs associated with continuing to operate in this way are wholly unnecessary and easily avoidable. But both the investment strategy and cultural zeitgeist in the Health and Care Service continues to view the only proven method of addressing this issue as, at best, an afterthought, driving up operational costs and adversely impacting patient care every day.

Patients certainly recognise the problem. When patients enter a hospital for the first time and discover that a large portion of their care is reliant on a paper folder being wheeled into clinic on an overflowing trolley, any image they might have of the NHS as a modern, cutting-edge organisation providing world-leading care is going to take a heavy knock. Irrespective of the quality of other digital infrastructure.

If the NHS is ever going to fully embrace the digital age, then EDMs are not an optional extra: they sit at the core of how modern healthcare needs to operate.

The loft is not going to tidy itself.

Author: Tom Moody

Tom has dedicated his efforts to digital projects for the NHS since 2018, with a primary focus on Medical Records digitisation. In this role, he has been involved in the comprehensive end-to-end process of transforming the NHS’s digital aspirations into reality within various healthcare trusts across the country. He deeply values the diverse range of scales, complexities, and organisational character inherent in the entities he has had the privilege to collaborate with.

Tom takes great pride in his work with Apira and derives immense satisfaction from the valuable contributions they consistently provide to the NHS on a daily basis.