Digital dictation and related technology can save the NHS time and money, as long as trusts think carefully first about their needs, writes Alison Moore.
Around a third of trusts still use analogue tapes for medical letters. These can be time consuming and therefore expensive to transcribe, resulting in long delays in sending out letters and potentially making it harder to get patients through the system quickly.
Analogue tapes can also get lost, which may endanger patient confidentiality; it can be hard to find information on them; and they make it hard to judge workload and outflow.
So over the last few years many NHS organisations have moved to digital dictation, often involving the doctor dictating through a computer. This can offer very significant savings, quicker turnaround and can help even out workload and reduce bank and agency staff costs.
But digital dictation can be just the start of a process which can also include speech recognition – which can be checked by a secretary or simply signed off by the clinician – and transcription services where digital data is sent to an outside body for typing. Trusts which struggle to recruit medical secretaries may want to consider this form of outsourcing.
There are two frameworks for hardware, digital dictation, speech recognition and transcription – one produced by NHS Commercial Alliance, the other by NHS Shared Business Service. The frameworks are likely to provide useful shortcuts for trusts considering changing to these systems and which do not want to go through an OJEU tender by themselves; they were only released in the last couple of months and some organisations may be unaware of them.
Peter Akid, managing director of NHS SBS commercial procurement solutions, says the approach of aggregating trusts’ requirements could lead to greater economies of scale, as well as avoiding each one having to go through the full tender process.
NHS SBS prepares a workplan outlining trusts’ requirements before going to market: trusts need to think ahead on this to ensure their requirements are included. Sometimes it may be possible to align the end dates of several trusts’ existing contracts so they can procure at the same point.
The NHS Commercial Alliance framework accredits different suppliers after judging them against a range of criteria; some suppliers will provide all of these services while others specialise in one or more areas (for example, transcription).
The other alternative for trusts is to draw up their own specification and go to the market for a supplier of one or more services. Because of the cost this is likely to fall under European tender rules.
Procuring successfully starts from identifying the “problem” you want to solve, says Ian Gibson of Winscribe, which produces digital dictation software. Trusts rarely start from thinking they want digital dictation or voice recognition but they are more likely to have concerns over turnaround times or productivity.
One of the concerns at Barts and the London Trust, for example, was around outsourcing transcription. The trust sent some typing outside the organisation but felt it wanted more control and went to a full tender to buy in a system with digital dictation and voice recognition.
But as a starting point, trusts need to specify what they want – and that needs involvement from all sides. Medical secretaries and doctors are likely to be the end users of the system but IT also needs a seat at the table as compatibility with existing systems will be important.
IT staff should be involved from the start, suggests Viv Ryan, who project managed the introduction of digital dictation at Salisbury Foundation Trust. Once any project team moves on, they will be needed to keep the system running and ensure interfaces with other computer systems work. For all of them, there will be the question of how the digital system interacts with other computer software used in the organisation. Part of this is about how copies of letters are stored – for example, whether they can enter into the electronic patient record.
At South Warwickshire Foundation Trust, for example, an EPR system and digital dictation are being implemented side by side. Associate director Michael Cox says: “You have to think very carefully about where you are going with the EPR long term.”
He urges trusts not to rush into decisions but to think about what infrastructure they have. Interoperability with GP systems is also key: in theory, digital dictation could allow letters to be transmitted direct to GPs’ desks, offering considerable savings on postage. But there can be issues with secure delivery and with compatibility.
At Barts and the London, a multidisciplinary project team was used to specify what was needed before the trust went out to tender for a system which could handle 7 million lines of text a year. It also drew on the experience of other trusts and made site visits to some of them.
“It’s really important to get buy-in at a high level,’ says Ian Gibson. “It’s solving a problem for them – to meet their targets or not get fined for sending out letters late.”
Many trusts in the past have simply tendered for digital dictation. But over the last year or so there has been a marked change in the market, with trusts looking for “digital dictation plus” – with speech recognition or clinical correspondence modules added on to this, plus integration with existing computer systems.
But how people use computers is also changing. One emerging trend is for clinicians to use mobile devices: supplier BigHand has worked with a mental health trust to allow the use of BlackBerrys for dictation. The trust works out of many locations and mobile dictation can help turnaround times. In principle, other mobile devices (tablets and smartphones) could be used, provided data security is ensured.
This could help future-proof any system to allow for changing work patterns; cloud-based speech recognition systems are also being introduced that work well with tablets.
Whatever system is bought, back-up is important. Even with skilled users, there will be a need for support from the suppliers, the level of which is likely to be specified in any contract.
Trusts procuring digital services should also think about whether they want some form of outright purchase of the system or to rent it as “software as a service”. This latter option means digital dictating is treated as an operational cost rather than a capital investment. As trusts struggle with reduced capital budgets, this can be helpful.
Some sort of central trust funding may be essential to get all departments using digital dictation or associated services, but ongoing costs – such as additional equipment – could be devolved to directorate budgets.
The digital dictation market has developed tremendously in two years and will probably continue to. Developers frequently release upgrades and more extensive system releases. The cost of some of these may be covered by the original contract.
Some trusts will look to add to their initial purchases by adding in digital dictation or clinical correspondent year by year, says Mr Gibson.
If trusts are to get the most out of what can easily be a six-figure investment, they need to think about implementation alongside procurement.
Inevitably, voice recognition systems are seen as a greater challenge to existing ways of working than digital dictation, and which many secretaries welcome. Part of this is to do with the potential for job losses; part of it is about ease of use and resistance from some professionals.
Many of these difficulties have been overcome by improved systems – Barts already has doctors with accuracy scores in the high 90s even though its system was only introduced late last year. Programme director Anne Gorman says it only takes a doctor to dictate 20 or so pages a week for the system to recognise and adjust to their voice. Initial training time has also reduced.
Overcoming some of these fears can assist implementation. Salisbury used a system of “super users” in each department who were trained to use BigHand and then trained their colleagues. Viv Ryan says this helped build acceptance of the system; many problems can be sorted out by the super user and colleagues feel there is someone to turn to.
Implementation at Salisbury was also staged – it took around a year for all departments to come on board and be piloted in one area.
At Barts, many medical secretaries have been trained to take on a new role as patient care coordinators, providing a point of contact for patients and ensuring they progress through the system smoothly. They may still have duties around editing transcribed material but this is a smaller part of their role.
Incorporating an outsourcing option is also easy: it is largely a matter of where the data is sent. Some trusts in London and the South East have historically outsourced and may want to continue to do so. As it involves information being sent outside the organisation, security is important. Anonymisation is used extensively, with patient details inserted when the letter is returned to the trust.
Procured and implemented well, digital dictation can improve efficiency and make a contribution to QIPP savings. In Salisbury, for instance, the turnaround time for letters has halved and secretaries can now identify urgent work and workshare more effectively.