1. “Paperless” Prof Jonathan Kay Clinical Informatics Director NHS England jonathan.kay@ndcls.ox.ac.uk

2. Overview Starting points Why it matters My experiences of trying to make it happen How to make it easier

3. Starting points Current processes and technology Secretary of State’s speech Analogies from other domains National projects: the Technology Fund

4. Current processes and technology Within organisation Old records Things the EPR can’t do Across organisations Documents printed from computers Snail-mail transport of paper Scanning in general practices Data networks in place and good enough Data transport systems not yet good enough Directory services Action on nondelivery

5. Secretary of State’s speech January 2013 Jeremy Hunt, the health secretary will launch the project on Wednesday alongside a report claiming it could save nearly £5bn a year, after the costs are taken into account. He said it should also improve patient care and save lives. "More importantly [than money] it can save billions of hours of time so nurses can spend more time with patients if they are not behind the nurses station trying to fill out forms," Hunt said. "And I think it can save thousands of lives. A lot of the safety problems in the NHS – people being prescribed with the wrong medication, and 'never events' where people have the wrong arm amputated – it's wrong to say technology is the panacea but it can make a big, big difference."

6. How does computerisation help healthcare? Lower unit cost of process Improved patient safety Reduced data burden on clinicians Data for other people Computerisation

7. Analogies from other domains Retail: commerce and entertainment Amazon, EasyJet, DVLA… Banking Utilities

8. Document management technology Generated in many ways Communicated by computer or scanned May be tagged by sender or recipient, but… Processing after receipt limited or impossible Different from electronic data interchange Widely used in many sectors Maturity of the Clinical Documents Architecture standard “Multiformat vendor-neutral”…

9. Why it matters

10. Lower unit cost of process … mostly saving staff time, but is it cash-releasing? Improved patient safety … better decision making because relevant information is available … removing discontinuities Marker for process re-engineering Marker for computerisation

11. My experiences of trying to make it happen

12. Laboratory Medicine reports Radiology reports Clinical communications into general practices

13. Laboratory Medicine reports, primary care Tens of reports per practice per day Thousands of reports per laboratory per day Switched off paper 20y after full coverage with computerised transmission Agreement with lead GPs, PCT, LMC Each practice was asked to ask the laboratory to switch-off Three rounds, with authority to complete in the third Lots of people couldn’t imagine it working Very few complaints Residual problems with workflow after receipt

14. Laboratory Medicine reports, secondary care Inpatients and outpatients Thousands of reports per laboratory per day Agreement with hospital boards Legal opinion No local choice by department or clinician Agreed exceptions after consultation Cellular pathology Blood transfusion Occupational Health

15. Laboratory Medicine reports, secondary care Response to consultation: this is going to be a big problems in outpatients. Some clinicians rely on the paper report to say that a report is available. What is safe practice? Consultants wanted to keep the nudge Experts wanted closed-loop approach Can we wait for EPR? Decided to switch off paper reports Working well Some residual complaints Made the transition to EPR easier

16. Radiology reports, primary care A few of reports per practice per day Hundreds of reports per department per day Tried to switch off paper 2y after full coverage with computerised transmission Agreement with lead GPs, PCT, LMC Followed laboratory medicine reports, and liaison committee to handle all communications Radiology department: “More expensive to switch off paper than continue to send it”

17. Incoming letters to general practices Realisation of time spent scanning Variation of technology across practices “Transfer of Information Task Force” Representation Project manager Quick count of flows

19. Procurement of middleware Cover all practices Cover high-volume senders Handle paper (by scanning) or emailed documents Middleware supplier has to manage connection to GP systems Document transfer model, with some tags

20. Progress Flows now working Emergency department letters Out of hours notifications Improving tags Content Timeliness Add more flows

21. How to make it easier

22. Form a liaison group first Get the right architecture and technology Choose the right flows to change first Implement as a series of quick, short modules Learning from others Not waiting for perfection

23. Timeliness and quality If users think that subsequent steps are slow there’s not much reason to speed up Senders don’t know recipient’s views Actively monitor timeliness and quality

24. Other issues The last 5 metres to the bedside Workflow without paper Routing Annotation Misunderstandings about information governance Neutrality about media Duty to share Caldicott principles

25. What I need to know from you How can I find out the current state of play? How fast can you deliver your changes? How mature is Clinical Documents Architecture? What do you want NHS England to do from the centre?