Electronic Document Management
News and presentations form today’s conference focusing on a practical guide to delivering intelligent electronic document management and becoming a paperless organisation.
Delivering a Digital NHS: Progress and NHS England Update
Professor Jonathan Kay, Clinical Informatics Director, Royal College of Physicians
Setting the standards for EDM
Professor John Williams, Director Health Informatics Unit, The Royal College of Physicians London
Electronic Document Management (EDM) is essential if electronic records are to be organized and retrievable in the busy clinical environment. To maximize the utility and benefit the documents must be structured using national standards. There are many documents in the record that are amenable to EDM, but there is also a need for structured records containing coded data under standard headings, so that clinical data can be aggregated for analysis, enable greater record interoperability, and support future developments such as precision medicine. This presentation will discuss these issues, the work of the Professional Record Standards Body, and barriers and facilitators to progress.
Professional Record Standards Body http://theprsb.org
Professional record standards http://www.aomrc.org.uk/publications/reports-guidance/standards-for-the-clinical-structure-and-content-of-patient-records-0713/
Academy of Medical Royal Colleges Strategic view: http://www.aomrc.org.uk/publications/reports-guidance/icare-ict-in-the-nhs-1013/
Precision medicine and phenotyping https://www.ncbi.nlm.nih.gov/pubmed/2250488
EDM Security and risk management issues
Dr Graham Smith, Chief Clinical Information Officer, Frimley Health NHS Foundation Trust
Electronic transformation in healthcare provides both opportunity and challenge. In the NHS hospital setting, clinical records have traditionally been created on paper, filed in folders and stored in vast medical records facilities. This method of record keeping has not materially changed since way before the creation of the NHS, but all around us there has been rapid development as we move into the digital age.
As the world has changed around us, the legacy of these paper records has become somewhat of a millstone around the neck of many NHS organisations. Electronic Document Management Systems (EDMS) are increasingly being utilised to provide a digital record of the old paper documents as well as allowing scanning of paper created in the organisation to form an electronic record.
There are many disadvantages to paper files. Most fundamentally they are only available in a single location at any one time and as medical care becomes more complex it becomes a significant logistical challenge to manage these paper notes and to ensure they are delivered to the right place, at the right time in a secure manner.
If medical records are stored and managed electronically they then become available to all clinicians involved in a patient’s care and this removes the need to move files from location to location. Access to the records can be controlled, and particularly sensitive information can be restricted.
Transformation to EDMS is a complex process and requires organisation-wide change. IT infrastructure must be robust enough to allow uninterrupted access to clinical systems and security measures are necessary to prevent inappropriate access and cyberattack. A significant effort is required to move from the old but well understood paper records processes to new EDMS processes, and sending newly created records for scanning adds to this complexity.
There were always risks present in the old paper processes but these were usually well understood and accepted. Moving to EDMS whilst simplifying access to the medical record for clinicians does disrupt well known and understood processes and this transformation is not without risk. Risks do not just include the potential for not being able to access a record or not being able to find the relevant part of a record within a patients file. There are also significant financial and organisational risks involved in delivering EDMS, and business cases for EDMS projects include benefits such as clearing medical records libraries, reduction in staff and transport costs, and reduction in the use of paper. Realising these benefits is a big challenge and requires organisation wide buy-in, strong leadership and long-term strategy.
Future events of interest:
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New Savoy Conferences presents Disrupting IAPT: can digital pathways 'change the game'?
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9 October 2017