Time to tear ourselves away from paper

Trusts' reluctance to store patient records electronically is a national scandal which is draining resources, harming patient care and limiting the potential of historical archives, argues Capita's Robert McIndoe

A few days ago, I was speaking to the head of procurement at a trust. He was planning some changes that would cut costs and, he said, increase the efficiency of management of its patient archives.

I asked him if he was planning to scan the archive, store it electronically and put the archive online so it could be searched by medical staff at any time. Would he then shred the old paper records, and reinvest the savings on physical storage and premises in patient care?

His answer disappointed me: no, electronic scanning and digitisation of the data was not part of the plan. He intended to take the existing paper records from the trust's basement and relocate them offsite. This would cost the trust up to£100,000 a year in leasing costs for the building. He would pay an outsourced provider£1.50 to retrieve each record, and£15 to run it to the hospital on a next-day delivery.

So by getting the paediatric records (which must be kept for 25 years) offsite, he might solve one of the problems facing most trusts - the medical records department running out of space - but he will incur more cost.

National scandal

I have no doubt that he is doing his best to respond to the needs of his managers in difficult circumstances. However, what he is planning epitomises the emerging national scandal that surrounds the NHS's management of historic medical records. The technology is available to digitise patients' historical records and make them available at the point of care delivery, and to index and search them on any basis from individual record to the entire archive. The whole NHS should be using electronic document records management to solve the problem of burgeoning paper patient records archives.

If it did, the effect on patient care would be immense, opening up opportunities in terms of medical research, too. Scanned archives could save the NHS an estimated£1bn a year by removing the need to manage and maintain huge and ever-growing repositories of patients' care histories.

Records could be accessed simultaneously by different staff, ensuring they would always be available when needed. Yet scanning is not happening - at least not to the extent or as quickly as it should be. To understand the problem, it is important to understand how the current situation came about in the first place.

The roots lie in the scope of the national IT programme. Delivered by NHS Connecting for Health, it has a core objective: to improve clinicians' access to patient information at the point of care delivery. To achieve this, the national electronic care record service will be available as a summary record for every person across all NHS sites in England by 2008-09.

The Treasury allocated£18.5bn to deliver the CRS, but there have been many highly publicised problems with the IT programme. If and when it is rolled out, the result will be a nationwide platform enabling trusts and GPs to communicate and share information more quickly and effectively than ever before.

However, there is a glaring gap in NHS CRS's coverage: paper records of patients' medical histories are filling hospital basements up and down the land. NHS CRS focuses on getting all hospitals on to the same patient administration system for live patient information.

It does not include the scanning, digitisation, secure physical archiving/destruction or electronic retrieval of historic patient records. This omission is all the more remarkable given that the NHS is continuing to spend huge sums of money accessing patients' paper records in hospitals nationally.

The high costs of paper

The decision to leave historic hospital records out of NHS CRS has two main effects: one is clinical, the other is financial. While the new national care record will contain information on patients' current problems and conditions, it will provide no information about their medical and nursing history. This history is absolutely crucial to high-quality, ongoing patient care. The hospital archives are, in fact, a national clinical treasure.

The other effect is financial, because it fails to address the huge cost to the NHS of the national 'cottage industry' that has built up around these records. A typical trust runs an archive management department of around 25-100 clerks or full-time equivalents tracking, locating and providing physical medical records, and filing them away again after use. Usually around 7,000-8,000 records are 'picked' in every major acute trust every week for outpatient clinics the following week.

The NHS remains saddled with huge overheads, despite having the technology available to scan the paper records and cut costs, which could help reduce the NHS deficit, and give both patients and taxpayers a better deal. Many observers have suggested that the IT programme should have started with the scanning of historical records, to lay the foundations for the NHS's information revolution and drive adoption of new technology throughout the NHS.

This approach would have shown the value of IT to all the doctors and nurses that rely on the paper case histories in clinics up and down the land every day. It is too late for that now.

Instead, the government has said trusts are free to tackle the issue of historical records for themselves, through local procurement, if they wish to go to market, or use what their local service provider has to offer. With every visit I make to trusts, I become more convinced that it is absolutely imperative that they do so.

We recently reviewed a medium-sized acute trust with a turnover of£107m per year. The review indicated that scanning the archive and then managing it using electronic data management software would save the trust approximately£1m a year.

Larger trusts might expect a saving of some£6m a year. Roll it out right across the NHS and you get an estimated£1bn a year saved - even before the other clinical and managerial advantages are taken into account.

Why is this not being done? The blockage appears to be among local NHS managers, who have three reasons for not scanning record repositories.

The first is that the crushing pressure on management across the NHS makes it very hard for them to prioritise and focus on any project without a firm deadline.

The second is that scanning does cost money up front - we calculated an estimated£1m-£3m per trust, spread over two years - and because the post-scanned archive is not a capital asset, this investment has to come out of revenue.

However, the recurring annual savings from year two can be from£1m upwards in perpetuity. Third, there are a lot of jobs involved. Our studies show that a digital repository would require about 20 per cent of the staff of a physical one at most, so it is hardly surprising that a manager would shy away from such an unpleasant decision.

The way forward

Whatever the barriers, trusts need to tackle this overhead, for the good of their patients, their staff and their finances. At first sight, you might assume that 'digitisation' would involve simply scanning each record - likely to run to 25-125 double-sided pages (250 images) - and storing it on a computer so it can be retrieved, read and even e-mailed.

For a number of reasons, simply scanning the record is not enough. To make real and effective use of the information in the new NHS, the scanned digital version must have two specific capabilities.

First, it must be electronically indexed so that information can be found quickly and accurately. Second, it must be fully integrated with the new CRS or current hospital PAS so that a clinician can refer directly to the history from within the patient's electronic CRS. This integration will give doctors the access they need both to the current care notes and the patient's historical hospital records all in one place.

Finally, I would like to highlight a further potential upside of scanned, searchable historic patient archives. The NHS's collective wealth of historic treatment data is an invaluable resource.

Optical character recognition technology for searching scanned archives - whether in one location or across the country - enables access to a wealth of statistical and trend information.

Imagine what the ability to search all the historical databases across the NHS could do for medical research. A national archive might also provide extra income to the NHS if opened up to third parties such as pharma companies.

Yet many trusts currently shred their patient records at the end of the retention period (eight years for adults, 25 years for maternity and paediatrics), meaning this wealth of clinical information is lost forever.

This is a national problem but one that can be tackled and turned into an opportunity which will serve in the nation's interest. -

Robert McIndoe is principal consultant with Capita Advisory Services (robert.mcindoe@capita.co.uk).