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The power of information to drive better healthcare by Dr Glyn Hayes
"Whatever the future development of the NHS we can be certain of one thing. The care of an individual patient will very often be the responsibility of many different organisations."
Communication between care providers is typically by paper, but we are moving away from this way of working as it could all be electronic. The paper can get lost or not even generated, paper which costs money to deliver, paper which has no utility except that it can be read, is now a very slow, inefficient way to work. There are a variety of systems in the secondary care community to create the document, thus an aim for interoperability is complex.
All of this paper starts as a word processed document or as the output from a clinical record keeping system. It can therefore be regarded as an electronic document which can be transferred electronically around the complex web described above. This is where EDT Hub comes in to play; the system connects to secondary systems so that documents can be quickly transferred to practices, thus enabling clinicians to have information on their patient’s instantly, perhaps before the patient reaches the door to leave the organisation. The platform enables Trusts to realise interoperable working and the benefits associated.
This immediately means that a considerable cost is removed by an electronic process, as there are no paper or postage costs which mean potential savings between 50p to £1 per document. Once the systems are set up the document always arrives where intended. The main technical requirement is a directory service which may take some time but is not rocket science. Yes, there are cost savings to be realised, but the important factor is the joined-up working to save time and deliver information to clinicians within desired timescales.
The idea of communicating patient based data on an item by item basis using structured messaging is often believed to be the Holy Grail of medical computing. Many have suggested that message structures such as HL7 and standardised nomenclatures such as ICD-10 or SNOMED CT will allow for data to be wherever it is needed around a healthcare system seamlessly and consistently. This goal is being strived for. However it is notoriously difficult to achieve the required semantic interoperability to make this happen. This is particularly so when different healthcare bodies use different software systems with different standards yet share the care of an individual. Can standardised electronic document transfer offer a practical solution to this problem?
General Practice has been using computerised patient records for over 20 years. However, other parts of the National Health Service have lagged behind. It was thus necessary to have a system which could take paper clinical documents from hospitals and other health care resources and integrate them electronically into the family practice computer records. This was done using the electronic document management (EDM) processes. Over the years this EDM process has been extensively developed to automatically scan, read, interpret and integrate any document into the clinical record and to add associated workflow features. These features allow for all the actions required by the communication, both clinical and administrative, to be handled and monitored. Scotland has adopted EDM as a national roll-out standard and they have also been recommended by the UK Royal College of General Practitioners. Further developments in providing managed services which allow for the transfer of such active documents between health providers have allowed for other sectors of healthcare and patients to receive important information when required. These are specifically health related. Standard, non health specific document management systems have not been found to be effective in this process in the UK. We now have extensive evidence of the cost savings achieved by using these facilities.
The document has the advantage over itemised structured data transfer in that it contains what the sender felt the receiver needs to know about that patient, in a form which the receiver is used to analysing and using to provide ongoing care. If well written it contains the context, the background and the opinions of the sender. None of which is likely to be in a structured data stream, yet is necessary for a clinician to interpret what is being sent. Most medical communication during the care of an individual patient is opinion rather than hard fact. Clinicians spend their lives interpreting what their colleagues say. This is not really possible with structured data.
These days with the use of Optical Character Recognition (OCR) and various forms of natural language processing, it is possible to extract standard bits of data from the document to incorporate in to the clinical record. I believe this should always be under human control.
Practices further benefit when the document is received with meta-data from the Hub (the information to quickly file the document). This removes a process of searching for information on the letter to then correctly file it to the GP system. A typical practice receiving 350 letters each week could therefore save 4 hours a week in this process alone.
Perhaps the most exciting feature of such electronic document transfer is the use of workflow attributes. Such attributes or tags were first used in the NHS in the GP path lab systems to ensure that the result could be work flowed around the practice. They were a replacement for the stamped list of actions which used to be added to paper based laboratory results. Modern systems can now extend this workflow tagging to a fine art. Documents can, at the press of one key, be circulated to dozens of disparate people in an organisation, at different times, for different purposes. These sophisticated systems can form the basis of full blown care pathways, a challenge which has defeated many complex electronic systems and yet are based on the humble electronic document. Over 5,500 GP practices use Docman to manage and workflow these documents around and be a complete store for all documents.
Connecting health care professionals through the use of IT provides demonstrable benefits, which helps many Trusts and practices towards efficiencies as described in the QIPP efficiency guide. Over 70 NHS Trusts have taken the route of PCTI’s EDT Hub to transfer these documents, ensuring a paper free environment and significant time savings that are reinvested in frontline care.