Progress towards a paperless NHS
Is the NHS on track to become paperless by 2020, or is it heading for a paper jam?
The NHS has set itself the target to be a paperless service by 2020. Health secretary Jeremy Hunt is fully behind the plan and has committed £1.8bn (€2.1bn; $2.3bn) towards it as part of a £4.2bn cash injection to improve the uptake of new technologies in the NHS.
This money will support plans in NHS England’s Five Year Forward View to provide better, more cost effective care through electronic records and interoperable systems within five years. But with less than four years to go, experiences on the ground suggest that there’s a lot of work still to be done to realise this vision.
“I feel like sometimes I’m stepping back in history when I’m at work,” says Rhys Davies, a foundation year 2 doctor at Western Sussex Hospitals NHS Foundation Trust, currently working in general practice. “I think a paperless NHS would be a very good thing for everyone concerned. But I have trouble believing it when we’re still using fax machines in 2016.”
A few months ago, a new patient was repatriated to Davies’ ward. When the patient arrived with incomplete paperwork, Davies asked a colleague at the patient’s previous hospital to fax over his drug chart. But as it was after 5 o’clock, all the secretaries had gone home and locked up the offices.
“It took me an hour and a half until I found a fax machine that I could use out of hours,” says Davies, 27. “If we had a more paperless system, [the drug chart] could have just been emailed.”
Efficiencies and paper trails
It is estimated that junior doctors spend up to 70% of their time on administrative tasks, often using outdated and paper-based systems, which are a source of inefficiencies and errors.
In 2015, most data breaches reported to the Information Commissioner’s Office related to paper records, not electronic data. Human error makes fax machines particularly culpable. Last year, Northumbria Healthcare NHS Foundation Trust mistakenly sent five faxes with confidential patient care information to a member of the public by dialling the wrong number.
Electronic formats provide an audit trail and encryption that paper cannot replicate. They also have the potential to collate different sources of information digitally and better integrate patient care and centralise research data across settings.
However, electronic systems have their own security problems. Data on paper can be breached only by the limited number of people with access to the physical document, whereas electronic records are susceptible to hackers from any location. They are also prone to system crashes or electronic malfunctions, and external storage systems are needed to back up records.
But it’s not just a shift from paper to digital that’s needed. Improving interoperability between existing and new digital systems will also be crucial for achieving a paperless NHS.
Rupini Perinpanathan, a clinical manager at a general practice surgery in Lewisham, says her practice continues to use several programmes to complete simple tasks.
“What seems to have happened is that something better has come along and succeeded it, and you’ve ended up having to use various programmes to be able to carry out one or two tasks,” she says.
There has been modest progress in this area, however. In 2015, the two leading general practice software suppliers in the United Kingdom—EMIS Health and TPP—agreed to set up data sharing between their core clinical systems. Months later, frontline clinical information leaders issued the “Newcastle Declaration” —a call for a radical change on interoperability to give health and care professionals access to all the available information needed to provide care.
A break from the past?
Government initiatives to digitise patient records have often failed. The care.data patient information sharing scheme was closed in July 2016—three years after it was announced—after a review by national data guardian Fiona Caldicott. The review recommended new ways for patients to consent to and opt out of how their information was used that went far beyond the original plans. And last year, the General Practice Extraction Service data sharing project for general practices was found by the National Audit Office to be over budget and behind schedule, and being used by just one organisation nationally.
However, these shortcomings pale in comparison with the biggest NHS information technology project of them all. The National Programme for IT was reported to have cost nearly £10bn (£9.8bn) before it was terminated in 2011. Ironically, the same figure was cited as a potential saving through NHS digital plans by 2020 by Tim Kelsey, the former national director for patients and information.
The potential for improvements is there. One in 10 patients is affected by a serious medical error or harm in hospital, half of which prove fatal. Research indicates that electronic prescribing can reduce drug errors by half, but it had been commissioned in only 12% of hospitals in 2014, according to Kelsey. He said that improved use of information and data analytics could save the NHS between £16.5bn and £66bn a year through better collaboration between hospitals and investment in data skills, which would help create a more proactive, personalised care model.
Barriers to implementation
Mahiben Maruthappu, who as senior fellow to the chief executive officer of NHS England advises him on £100bn of health spending focused on innovation, technology, and prevention, believes updating paperless systems is sometimes overlooked for more immediate concerns.
“Sometimes people use the approach ‘if it ain’t broke, don’t fix it,’” he says. “If there’s substantial financial stress, tech isn’t where some people would put their money. They’re just trying to get on top of their books, manage unnecessary attendances, and manage agency costs.
“If people are looking for within year improvements in efficiency or costs, especially given that they’re working on a year by year financial cycle, technology doesn’t always offer that.”
In 2012, the Department of Health estimated that electronic records would cost £1.3bn over the next decade and that the benefits would not be immediate. But the resulting savings could hit £6.3bn. In the long run, an underinvestment in technology could increase overheads, reduce staff time and data security, limit information access, damage data security, and harm patient care.
Research by the Health and Social Care Information Centre suggests that a gradual adoption of a new system can prolong the adjustment for staff compared with a single uptake, such as the electronic record system launched at Cambridge University Hospitals in 2014, which saw 2.1 million patient records uploaded overnight.
But progress and implementation vary. At one former workplace, Davies could order blood tests and radiographs electronically, while patients’ flow charts and observation charts were still on paper. At another, observations and drug charts were electronic, but forms for blood tests had to be filled in manually.
“Both trusts are trying to innovate and modernise but have gone in completely different directions,” says Davies.
Despite the substantial efforts of many individual institutions, meeting the national target of a paperless NHS by 2020 seems a long way off. The success of a paperless NHS largely depends on the medical profession and the public buying in to the benefits of digitising patient information.
According to the European Commission’s EHR (Electronic Health Record) IMPACT study, successful electronics records systems need the involvement of clinicians, a strong political commitment, and consistent investment in systems that are original conceptions, not just replacements for paper processes in digital formats.
Staff require training on the technical skills, strong leadership, open and intensive communication, recognition and rewards, support from information technology experts, effective project governance, clear objectives, and attention to local circumstances.
The public also need convincing. One of the biggest criticisms of the care.data project was that patients would have to opt out actively if they didn’t want their information to be shared. This led to suspicion from the public that their data could also be accessed not only by any healthcare professional but commercial companies too.
A paperless NHS has the potential to make doctors’ working lives more efficient and facilitate the sharing of data between healthcare settings to improve patient care. It remains to be seen whether the NHS can successfully deliver this on a national scale, or if locally or independently developed solutions are the way forward. The barriers seem to be manifold and complex.
Investment must be delivered alongside interoperable systems and reliable, trustworthy technology to convince doctors and patients that they can rely on a digital NHS.Thomas Macaulay, freelance journalist
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
- England NHS. Local Digital Roadmaps. 2016. https://www.england.nhs.uk/digitaltechnology/info-revolution/digital-roadmaps/.
- Fox M. Digital recommendations for the NHS. 2015. https://doteveryone.org.uk/blog/2015/12/martha-lane-foxs-digital-recommendations-for-the-n/ .
- Care Quality Commission. Safe data, safe care. 2016. https://www.cqc.org.uk/sites/default/files/20160701%20Data%20security%20review%20FINAL%20for%20web.pdf.
- Information Commissioners Office. Fax errors lead to data breach at Northumbria NHS Trust. 2015. https://ico.org.uk/about-the-ico/news-and-events/news-and-blogs/2015/05/fax-errors-lead-to-data-breach-at-northumbria-nhs-trust/.
- Times TPP. TPP and EMIS announce direct data sharing. https://www.tpp-uk.com/files/2015/05/Times-75_LR.pdf. 2015.
- IT system for GP records criticised. BBC News 2015, July 2. http://www.bbc.co.uk/news/health-33354824 .
- NHS IT system one of “worst fiascos ever,” say MPs. BBC News 2013, Sept 18. www.bbc.co.uk/news/uk-politics-24130684.
- Nuffield Trust. Will technology save the NHS £10 billion. 2015. www.nuffieldtrust.org.uk/node/4208.
- Choices NHS. One in twenty hospital deaths preventable. 2012. www.nhs.uk/news/2012/07July/Pages/One-in-twenty-hospital-deaths-preventable.aspx.
- National Information Board. Martha Lane Fox sets out her digital proposals for the NHS. 2015. www.gov.uk/government/news/martha-lane-fox-sets-out-her-digital-proposals-for-the-nhs .
- Jee C. NHS must improve use of data or go bust, health boss warns. ComputerWorldUK 2014 Sept 17. www.computerworlduk.com/news/data/improve-use-of-data-or-go-bust-kelsey-tells-nhs-3572522/.
- Department of Health. The power of information: Putting all of us in control of the health and care information we need—Impact assessment. 2016. www.gov.uk/government/uploads/system/uploads/attachment_data/file/213691/dh_134185.pdf.
- Oxford University Hospitals. Electronic patient record (EPR) Benefits realisation case study. 2016. www.ouh.nhs.uk/patient-guide/documents/epr-case-study.pdf .
- Bawden J. Recent pressures in the Cambridge and South Cambridgeshire health system. 2014. https://ehrintelligence.com/images/site/articles/2014-12-01-Recent-Pressures-in-the-Cambridge-and-South-Cambridgeshire.pdf.
- Impact ERH. Interoperable eHealth is worth it. Study report 2010. www.ehr-impact.eu/.
- Godlee F. What can we salvage from care.data?BMJ 2016;354:i3907. http://www.bmj.com/content/354/bmj.i3907 doi:10.1136/bmj.i3907.