Removing paper in favour of connected and accessible digital information is a core component of modern, high-quality healthcare. Having been about 80% digital in 2016, Imperial have since embarked on a five-year journey to become fully paper free by 2021, in part through their Cerner Millennium electronic patient record (EPR). Linda Watts, the Trust’s GDE programme manager, took some time to share the process, benefits and challenges of going paper free at Imperial College Healthcare NHS Trust.
Three years ago, in 2016, the Trust had three main record library sites, with around two million paper records of predominantly active patients’ files stored, supported by 113 full-time staff. Linda also notes that this is in addition to a huge offsite storage centre that housed 140,000 boxes, each containing between ten and 18 sets of paper case notes.
Linda is clear on the reasons for the Trust to shift away from paper – improved access to information in order to help clinicians deliver top-quality care, improve the patient experience and reduce costs as a result.
Due to clinical documentation now being digitally entered into their Cerner EPR, very little information needs to be recorded on paper. Previously, health records staff often prepared case notes, sent them to the desired clinic/ward/department, after which they were usually sent back without anything being added – meaning the effort had little gain.
Paper medical records departments like these consume valuable space and can make it difficult for clinicians to access realtime information and document the patient journey for future reference.
The Imperial paper-free project team are always looking at how to best rebuild previously paper-based forms and practices digitally within the pathway, rather than just recreating a form in the EPR, which Linda admits, “can be a little complex at times - as part of the process we’re redesigning the flow and pathway.”
The main challenge has been to get clinicians to work in a different way. Linda identifies, “they are comfortable with paper, and the physical case notes act as a prompt that there is a patient somewhere and something needs doing. Agreeing the process for what happens when we took the paper away was paramount.”
“Some areas are simple, and we were able to remove paper quite easily. However, in complex areas like cardiology, we’d work with Cerner to do a deep dive and together come up with the best approach for future digitisation.”
Working with Imperial’s clinical director of outpatients, they reached out to all of their clinicians asking if they were happy for the Trust to withdraw case notes from their clinics. Immediately, 30 percent of clinicians were happy with the change and went paper free. “These clinicians became our early adopters,” says Linda – “their commitment would help us generate some success stories to share with the rest of the Trust.”
While new information is entered into the EPR, some clinicians still require access to information from older case notes. The Trust, however, are determined to keep paper out of the workflow so are working with partners IMMJ Systems and Xerox to scan old case notes into digital format and embed a view within the Cerner EPR. This gives a more complete historical view of the patient.
Digitising the existing paper notes in store is a work-in-progress, with the Trust looking to scan the first 500,000 records – about 75 million pages – before reviewing next steps.
Clinical buy in has been essential to the project. Linda and her team worked with the clinical director for the Western Eye Hospital to run a paper-free pilot. The records library in their basement was in poor condition with water leaks and broken lighting, so the reasons to shift were even clearer. Not everyone was immediately on board, though. “When we instigated the paper-free project and conveyed the process and benefits, some clinicians expressed concerns”, identifies Linda. “We worked closely with them to understand their concerns, and assure them to alleviate the fear and gain their buy-in. Subsequently we were able to close their library, free up staff, and release a large space in their building which they can now use for other things.”
“The knock-on effect of that pilot was quick to gain pace. Ophthalmologists at Charing Cross, and others working remotely across London, saw the benefits. Being able to access information from anywhere, not physically collecting and carrying notes to clinic, and the improved information governance, meant that they really bought into the project from early on, which in turn encouraged other clinicians to get on board.”
Imperial College Healthcare NHS Trust has a number of sites around London, and has been focussed on removing paper from four main sites since 2016.
The team started with the Western Eye Hospital and St Mary’s, a larger hospital with more complicated services. The former is now completely paper free, while the latter is over 85 percent complete, with an almost-empty library. Together, this has freed up about 700 square metres of basement space.
Together, the spaces previously dedicated to paper records at St Mary’s (above) and the Western Eye Hospital are worth the equivalent of £400,000 per year.
It’s the next part that really excites Linda and her team – releasing some prime real estate at their other two sites that be better used for care. “Hammersmith have an amazing 589 square metre floor space, and Charing Cross have 635 square metres on the second-floor with lovely views over the trees. When they’re both paper free, and all of that heaviness of the paper and the racks has gone, the Trust will suddenly acquire wonderful new spaces that can be turned into clinical space in which they can deliver quality patient care, rather than storing paper.
Removing the paper records department at Charing Cross Hospital frees up 635 square metres on the second-floor with lovely views over the trees that will soon be space for patient care.
“We’re freeing up valuable central London floor space. The spaces St Mary’s and Western Eye Hospitals are worth the equivalent of £400,000 per year, and space freed up at Charing Cross Hospital already is already earmarked for a new ward.
The Trust quickly identified benefits of digitised information over paper, including:
Doing more with less is a common tenet of today’s healthcare. Through their paper-free cost improvement programme, Linda has seen a significant financial saving. “The Trust’s health records library budget in 2016 was £3.8m per year, it is now down to £2.6m/year in 2019 – saving Imperial £3.25m since we started this project three years ago, and that saving will grow.”
There are also obvious savings from printing, offsite storage and transportation. “Previously, we spent about £450,000 per year on printing, at last check that is now down by 50% – a £225,000 a year saving. That’s not including the £40,000 we are saving by not ordering physical folders.
“In addition, the annual cost of offsite storage and transportation in 2016 was £480,000 per year, in 2018 it was down to £370,000”, financial gains that are also helping reduce their carbon footprint reduction through fewer trees being required for paper, and fewer vans making the rounds to transport it.
Fewer physical libraries need fewer staff. Some of the staff had been in the department for a very long time, and Linda and her management team were very keen to support them to take new opportunities. “We had 113 members of staff in 2016 and had reduced that to 59 by 2019.” she notes.
“Importantly, we have worked with the staff to identify other opportunities within the organisation, looking at their CVs, discussing their interests and aspirations, and arranging secondments with other teams. I’m pleased that many have gone on to excel in other roles in areas including transformation, outpatients, IT and the Cerner EPR team.”
The Trust are often asked to share their approach and learning with other organisations on their own paper-free journey. “However tempted you are to start with the really small specialties, I find that these are often the most difficult. The bigger services will help to build momentum and gain wider buy-in going forwards,” Linda advocates. “We began with ophthalmology, then ENT and following that, Dermatology. My advice is be brave and target the big services where will make an impact.”
As paper becomes redundant, intuitive digital systems that support the clinical workflow and patient journey are ever more important.
“The benefits to both patients and clinicians are obvious, and the value that the organisation is seeing means that there’s a real momentum across the organisation to become paper free now. In fact, the success of this has given the Trust a better reputation for digital. Off the back of this success, services are happier to buy into other digital projects that are underway, helping the Trust to transform services and implement innovations faster.”
Charing Cross Hospital image attibution: Chmee2 [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]
St Mary's image attribution: Enric likes Funk [CC BY-SA 2.0 (https://creativecommons.org/licenses/by-sa/2.0)]