Evaluating your EDMS Deployment and Scanning Options

EDMS Implementation & Scanning Options Appraisal

1. Context

If you are considering embarking on a Hospital-wide Electronic Document Management System (EDMS) programme there are several different implementation approaches to be considered. We hope that this brief introductory guide will help you to evaluate the optimum approach for your organisation.

We understand that the strategic drivers may be significantly different between organisations. Most organisations recognise that continuing with paper case notes is unsustainable and may be struggling to meet service demands. Some may have run out of physical space or are looking to realise cash releasing benefits through the closure of a record library. Regardless, the overriding consideration will be to ensure that the EDMS will:

  • identify and deliver the efficiency savings at departmental level that support the ROI objectives;
  • provide measurable improvements to patient safety and clinical efficiency – allowing clinicians to mine information easily from scanned case notes and associate documentation with patient encounters;
  • be deployed without having a detrimental impact on departmental

Hopefully, this guidance will help you to consider the relative advantages and disadvantages of each of the options, evaluate and make recommendations on the best approach for your organisation – taking into consideration your own business drivers, organisational capability and infrastructure and affordability.

The IMMJ Systems team have helped many healthcare organisations to navigate the many complex issues and can recommend a solution to fit most budgets and would be happy to facilitate a discovery workshop at your own premises. For more details, please contact us on….

Your EDMS programme can be split into two sub projects, albeit with strong inter-dependencies:

  • Deployment of an EDMS for accessing patient records in a clinical context;
  • Implementation of a scanning service to digitise existing patient case notes and ongoing capture of new patient

2. Deployment approaches for EDMS

2.1 Summary of options

The implementation approaches considered are:

1.      “Do Nothing”

Do not implement EDMS

2.      Phased deployment

Deploy EDMS on a specialty by specialty basis using outpatient clinics as the trigger for scanning.

3.      Big bang approach

Deploy the EDMS across all clinics in all specialties from the agreed go live date.

2.2 Evaluating the options

Option 1: Do Nothing

Advantages

  • No requirement for additional investment in the short term (or until additional physical library capacity is needed);
  • Challenges associated with managing organisational change will not be

Disadvantages

  • Fails to address the needs of clinicians. Immediate access will still not be available to essential patient information when & where needed;
  • Continued risk to security and confidentiality;
  • Physical space constraints will remain at the health records library;
  • Still gives rise to fire and health and safety risks;
  • Not a cost-effective option – resource time is being spent ‘firefighting’ rather than being using efficiently;
  • No significant opportunity to realise benefits with regard to Patient Safety Clinical/Information Governance, Health Records department or across the administrative establishment; Fails to address any recommendations of the NHS Information Strategy, Connecting for Health initiatives or meet the Trusts strategic ICT aims;
  • Contrary to the concept of the modern NHS and 2023 paper-less target.

Option 2: Phased deployment

Advantages

  • A phased deployment allows the organisation to be flexible to ensure scanning services can meet agreed Service Level Agreements (SLAs). Specialties can go live one after the other or a few at a time depending on scanning and transformation capacity. In the event of any concerns, pulling for the next set of clinics can be paused;
  • Clinical engagement and transformation activities are focussed at specialty level enabling concerns to be identified and addressed;
  • Process changes are tested, proven and embedded prior to introducing them in another specialty;
  • Fewer resources are required simultaneously to implement/support a phased deployment;
  • It is still recommended that transformation activities take place across all specialties ahead of go live to understand the impact of taking physical notes out of

Disadvantages

  • The deployment time (between first and last specialty go live) is greater than with a big bang approach;
  • It may take longer to realise all the associated benefits with a phased deployment;
  • Patient records scanned whilst attending a live clinic may be required if the patient attends a non-live specialty.

Option 3: Big bang approach

Advantages

  • Enables a rapid deployment if the transformation and support resources are in place to cope with simultaneous demands on implementation, training, scanning and IT support activities;
  • Benefits can be realised sooner than with a phased deployment;
  • All users will be familiar with the EDMS Solution from go live. This will result in a reduced support requirement if scanned patients move between

Disadvantages

  • There is a concentrated resource requirement to support a big bang deployment;
  • The scanning throughput for forward scanning could be significant from go-live, SLA’s will need to be closely monitored;
  • If either scanning team (back and forward scanning) fail to meet SLAs, patients could be seen, referred on or followed up without key information being available to This could cause significant patient safety issues;
  • As a big bang deployment is not confined to a particular specialty it is more difficult to pause the on-demand scanning in the event of any issues. This could have a detrimental impact on clinical acceptance and result in loss of confidence in the programme.

3. Options appraisal – Scanning

3.1 Summary of options

When identifying different scanning options, it is important to understand that there are two distinct functions:

  1. Archive or ‘back scanning’ – the digitising of existing patient case notes
  2. Day forward scanning – the digitising of new patient documents that are generated as a result of a patient encounter

The strategic options that have been considered are:

  • Which patient records will be scanned? Whether to archive scan all patient case notes, selectively back scan presenting patients or retaining physical records an only scan new material associated with patient encounters;
  • Who will provide the scanning service? Whether to outsource scanning or bring the function in house. A common compromise is to outsource back scanning and take responsibility for day forward scanning in house;
  • Where should primary scanning function be located? Location of the bureau is a key consideration, particularly when considering SLAs for making information available quickly to clinicians on the Keeping the scanning function on site may minimise the risk that case notes which have entered the preparation and scanning process are unavailable if required by clinicians at short notice. If clinical activities take place across geographically dispersed sites, consideration could be given to a distributed scanning service;
  • If back scanning, how will records be prepared in advance of scanning? Discussions around how to prepare case notes for scanning, whether to tidy, discard are also vitally important as the majority of scanning effort is actually pre-scanning preparation. Equally there needs to be an understanding on how the case note will be presented to the clinician and how many variants of key documents exist.

3.2 Which patient records will be scanned?

Scan new patient documentation only & make paper case notes available until no longer required

This is the least expensive option as no archive scanning costs will be incurred.

The existing patient case notes would continue to be stored until the minimum retention period has been reached and the medical records staff would need to continue to manage the library for the foreseeable future and make patient records available for clinics for an agreed period. It is recognised that this may vary according to specialty specific demands.

There is a clinical risk that must be managed to ensure that the physical notes are used for reference purposes only and not updated with additional patient written notes or documentation during the patient consultation.

Back scan presenting patients only (scan on demand)

It is difficult to calculate a precise cost for scanning only those patients presenting for clinics (‘active’ records) but for the purpose of estimating costs, the number of unique patient attendances over the past three years has been used.

From a scanning perspective there would be a gradual increase in numbers of records to be scanned if a phased implementation is preferred. This means that the new scanning processes (back and forward scanning) can be fully tested both for quality and ability to meet service levels before volumes increase. However, if the scanning function is being outsourced a flexible contract will need to be

negotiated as there will be peaks of demand as outpatient activity will not remain constant resulting in fluctuating throughput levels (i.e. number of sheets to be scanned daily).

From a health records department perspective there will still be a requirement to keep a limited health records service and continued storage of patient records until either the retention period has expired or the patient has presented and therefore the patient case note becomes digitised.

Back scan entire record library (i.e. back scanning plus scan on demand)

From a scanning perspective this is the most expensive option but delivers higher cash releasing benefits such as the ability to close the health record facility and eliminate the management overhead of paper case notes more quickly.

It would also be possible to achieve a more constant scanning throughput as archive records could be pulled in addition to presenting patients’ records to ensure that the demand is ‘flattened’ rather than fluctuating as would be the case with on demand scanning only. The risk here is that the scanning of ‘non-active’ notes will result in digitised patient records being viewed in specialities which have not become officially live.

Another consideration to be taken into account is record retention. It would not be an efficient use of resources to scan patient records that are close to the end of the natural retention period.

3.3 Who will provide the scanning service?

Whether outsourcing or insourcing, adherence to agreed service levels is critical. For the ‘on demand’ scanning service, physical case notes will be pulled in advance of clinics for digitisation. It would be catastrophic if the digitised patient records were not made available in advance of the patients booked slot and cancellation of patient appointments would be a likely outcome.

Urgent requests for case notes that have been despatched for scanning will also need to be considered. Depending upon the agreed service levels, it may be necessary to either interrupt the process and return the case notes in physical form or scan them as a priority.

New material generated from outpatient and inpatient encounters will also be required promptly. There may be instances where patients are seen in follow up clinics within 24 hours or their case might be discussed at MDT meetings which will need to refer to the digitised notes. If the forward scanning bureau is failing to deal with the volume of new material generated, the clinical risk will invariably result in a decision to delay the roll out into further specialties.

Outsource scanning (back and forward scanning)

Scanning health records is a very specialised service and managing high volume scanning is not a core competency for most hospitals and is typically outsourced.

Whether obtaining a quotation or tendering for a competitive price it will be necessary to create a detailed specification of the service required. Typically, a hospital would seek to find either a local provider or one with a local presence in order to meet critical SLAs.

The contract will need to be carefully negotiated to ensure costs and quality can be controlled and that a flexible relationship is in place. As the roll out of EDMS progresses across the organisation, it will be necessary to scale up or ramp down the volume of scanning required, keeping in step with the agreed implementation approach. Hospital activity levels (outpatient attendances per day) coupled with the specialty roll out plan will determine the scanning throughput required.

As part of the contract will include the destruction of the original case notes post scanning, the scanning supplier will need to be able to demonstrate compliance with quality standards (e.g. BS10008 compliance).

Run all scanning functions with Hospital resources

In this scenario the Hospital takes on the responsibility for the entire overall risk for scanning strategy which is unlikely to be an area of expertise on a large scale.

The Hospital would therefore be responsible for the recruitment and training of the specialised resources required to run the service.

Compared to the cost of outsourcing, creating an in-house scanning function is not necessarily a cost- effective option as the Hospital bears the overhead of training resources, finding suitable accommodation and purchasing the specialised scanning equipment that would be required to scan large volumes of paperwork of variable quality and sizes.

Outsource back scanning and Hospital manages forward scanning in-house

A major consideration here would be whether there is suitable accommodation to situate a forward scanning bureau on site. Another key consideration is whether health records staff can adapt to the substantially different roles that would be required to run an efficient scanning bureau.

To counter that there are several advantages for the Hospital to manage the processing of day forward patient documentation.

Firstly, it provides opportunities for the skills transfer and re-deployment of medical records staff – the alternative being finding other suitable roles for health records staff in the hospital or, worst case, redundancy. Secondly, it puts the Hospital in full control of the ongoing cost of scanning bureau and incentivises the introduction of efficiencies (such as e-forms) that can progressively reduce running costs. Another significant consideration is ensuring that the health records team remain motivated during the transition towards complete digitisation of patient records. They will continue to be responsible for running a critical service to the Hospital throughout the programme and the prospect of transitioning to a new role in the forward scanning bureau may provide an incentive for key members of staff.

It also provides a platform for better integration with hospital services. Adherence to the stringent service levels that will be set for forward scanning will be easier if the Hospital has responsibility for the end to end service. The forward scanning function is inextricably linked with clinic preparation and the timely release of new patient documentation from the outpatient department and wards. A forward scanning bureau can only be responsible for meeting turnaround targets after the patient documents have been booked in. It is the responsibility of all Hospital staff handling patient documents to ensure they are presented in a timely manner and according to agreed standards and procedures.

3.4 Where should primary scanning function be located?

Location of the ‘back scanning’ service is a key consideration and there are some precedents for a supplier to provide resource to work ‘on site’ if there is sufficient office space. This minimises the risk that case notes which have entered the preparation and scanning process are unavailable if required by clinicians at short notice. It also allows for the development of a close relationship between supplier and health records staff and the increases the possibility of skills transfer.

Sending case notes off site to scanning supplier

The location of the supplier must be considered in terms of impact on service levels and typically Hospitals will look to work with a provider that has a base within close proximity or is willing to establish a local bureau. However, an established supplier will already have trained team in place and should be able to quickly respond to the demands of the implementation plan.

Embedded scanning team on site

If the Hospital has suitable accommodation on site, it may be an option to consider establishing an embedded service. For the Hospital this may mean incurring the cost of setting up temporary accommodation.

Although there will be a slower start up due to the local recruitment challenges the supplier will face, the advantages are:

  • It negates the need to move large numbers of case notes;
  • There will be more flexibility to interrupt the scanning process to access paper notes in emergency;
  • It encourages close working with health records staff (the local experts).

3.5 How will case notes be prepared prior to scanning?

The most time-consuming part of the scanning process is in the preparation of case notes prior to scanning. Typically, staff engaged in pre-scanning preparation will outnumber scanning staff fivefold and it is in the hospital’s interested to make this process as efficient as possible to ensure that it does not create a ‘bottleneck’ that slows down the scanning process by introducing too many decision points.

To counterbalance this there must be consideration for how the digitised record is presented to the clinician to enhance accessibility.

Regardless, there are certain basic rules of case note preparation that must be observed to ensure that the scanning process is efficient and meets quality and legal admissibility standards.

The other key consideration in the preparation process is whether any documentation can be removed and either treated as a ‘discard’ (removed and securely destroyed) or stored and retained in line with record retention policies. Any such decisions must be taken under clinical leadership with input from a broad range of disciplines as there will be different demands placed upon the notes.

There may be certain documents that need to be retained but are difficult or not practical to scan such as CTG traces and X-rays. In this situation they may be substituted with patch pages during the preparation phase and can be recalled from deep storage if and when required.

It is critical that any preparation process is clearly and unambiguously documented. The ‘rules’ must

be simple enough that they can consistently be followed by suitably supervised clerical staff.

3.6 Scanning Options Appraisal

3.6.1 Scope of patient record digitisation

Option 3: Day Forward Scanning only (deploy EDMS and scan new patient documentation only & make physical records available until no longer required)

Advantages

  • Least expensive option as no back scanning required;
  • With rapid procurement, an EDMS could be deployed relatively quickly and no archive scanning would be

Disadvantages

  • May be subject to clinical adoption challenges if clinicians still need to refer to the physical patient records as well as the EDMS for the foreseeable future;
  • Risk of clinical rejection of the EDMS due to incomplete patient history;
  • Risk to patient safety that new documentation may be added to the historic patient general record as opposed to being presented as forward scanned material;

Cash releasing benefits will be realised much later due to associated administrative costs with the continued storage and distribution of physical records for a few years until no longer requested.

Option 4: Scan live health records on demand (deploy EDMS and scan ‘active’ presenting patients only)

Advantages

  • Reduced scanning costs as only records for presenting patients will be scanned;
  • Realises most of the quantifiable benefits associated with e-health records, i.e. reduced health records costs, reduced administration cost etc;
  • Digitised patient records will be available across Trust;
  • Is the most widely used option of those Trusts researched;
  • Would greatly reduce the need for physical storage space (although some space would still be needed for non-health record material and dormant/deceased health records);
  • Addresses the needs of clinicians by providing immediate access to essential patient information when and where needed and in a secure and reliable way;
  • Reduces the risk associated with security and confidentiality of health records;
  • Will alleviate the physical space constraints within the Health Records Library;
  • Reduces the number of fire and health and safety risks;
  • Addresses the recommendations of the NHS Information Strategy, Connecting for Health initiatives and meets the Trusts strategic ICT aims;
  • Is aligned to the concept of the modern

Disadvantages

  • A flexible scanning contract will need to be negotiated as it will be more challenging to predict throughput levels due to variable daily clinic attendances (i.e. number of sheets to be scanned daily) and the supplier may experience ‘peaks and troughs’ of demand for scanning capacity;
  • Requires significant investment predominantly in the first year;

There will still be a requirement to keep a limited Medical Records service and continued storage of patient records until either the retention period has been reached or the patient has presented and therefore the patient case note becomes digitised.

Option 5: Scan all health records (full archive scanning)

Advantages

  • Would greatly reduce the need for offsite storage and realises the associated cost savings, e.g. staffing reduction, pay & non-pay costs etc;
  • Digitised Patient record will be available across Trust;
  • Addresses the needs of clinicians by providing immediate access to essential patient information when needed, where needed and in a secure and reliable way;
  • May be the most financially beneficial option over the longer term. Electronic storage of dormant and deceased records can be cheaper than the storage of hard copy records in the long term;
  • Reduces the risk associated with security and confidentiality of health records;
  • Will alleviate the physical space constraints at the health records library;
  • Reduces the number of fire and health and safety risks;
  • A higher volume of information will be available to review electronically with the use of tools such as optical character recognition;
  • Significant opportunity to realise cost saving benefits in the Health Records department and across the administrative establishment;
  • Addresses the recommendations of the NHS Information Strategy, Connecting for Health initiatives and meets the Trusts strategic ICT aims;
  • Is aligned to the concept of the modern

Disadvantages

  • Requires the most significant amount of initial expenditure for scanning;
  • Scanning dormant records may not be cost effective where records are due to reach the end of their retention period;
  • The return on investment period is longer than for the other options
3.6.2 Scanning Resources

Option 6: Outsource scanning operation to an external provider

Advantages

  • Scanning company would have more high volume scanning experience than the Trust
  • Scanning supplier will be responsible for the procurement and maintenance of specialist equipment e.g. scanners for oversized documents;
  • Risk would be limited, g. scanner breakdowns, would be met be the Supplier although the Trust would still retain ultimate responsibility;
  • The Supplier would inherit costs and issues related to employment, e.g. staff turnover, performance management, sickness, leave cover, pension expenses etc;
  • The Supplier would be able to facilitate record storage & destruction requirements if required;
  • The Trust would not be required to bear the costs associated with setting up a new bureau, which will in turn reduce the overall costs of scanning;
  • The size of external scanning bureaus means that they are more flexible in managing variations in demand at less cost;
  • Less upfront capital expenditure required leading to improved cash flow;
  • Financial penalties could be imposed upon the supplier if they failed to deliver to the agreed SLA.

Disadvantages

  • Patient health records will not be located on the Trust’s premises;
  • Risk of the Trust not retaining direct control over the quality of the scanned image;
  • The Trust would be bound into a contract should any issues arise in the project;
  • Reliance would need to be placed on the ability of the external provider to deliver;
  • Would require provision for emergency returns out of hours if not scanned locally

Option 7: Scan health records using internal resource “In house bureau”

Advantages

  • The quality of scanning is within the Trusts control;
  • The Trust would not be bound to a contract with an external supplier;
  • Patient health records would remain on site;
  • Having the health records located on site makes it easier to revert back to the paper process should any issues arise with the EDMS rollout;
  • Less risk of confidentiality / security breaches;
  • Less risk of damage or loss to patient case notes during transportation to third party location.

Disadvantages

  • The Trust would carry the significant risk associated with the project;
  • Would require significant investment in staff and, to a lesser extent, technology;
  • The Trust would inherit the costs and issues related to employment, e.g. performance management, sickness, leave cover, pension expenses, staff turnover etc;
  • The Trust would be required to manage the peaks and troughs in demand with less flexibility than an externally scanning company with economies of scale;
  • Would require an initial set up period whilst scanning equipment is procured and staff are recruited and trained, which could introduce delays;
  • Would need to create space within the existing medical records library to house individuals and scanners which may require additional cost;
  • No contingency or remuneration would exist if project fails.

Option 8: Outsource back scanning and Hospital manages forward scanning in-house

Advantages

  • Scanning company would have more high-volume scanning experience than the Trust;
  • The Trust would not bear all of the costs associated with setting up a new bureau, which will in turn reduce the overall costs of scanning;
  • Medical Records staff can be retrained to work in the new Forward Scanning bureau which will alleviate potential redundancy costs;
  • The size of external scanning bureaus means that they are more flexible in managing variations in demand at less cost;
  • Potential for reimbursement through contract should project fail;
  • Less upfront capital expenditure required leading to improved cash flow;
  • Financial penalties would be imposed upon the supplier if they failed to deliver to the

Disadvantages

  • Patient health records will not be located on the Trust’s premises;
  • Risk of the Trust not retaining direct control over the quality of the scanned image;
  • The Trust would be bound into a contract should any issues arise in the project;
  • Reliance would need to be placed on the ability of the external provider to deliver;
  • Would require provision for emergency returns out of hours if not scanned locally.

4. Evaluating the options

Whichever implementation/scanning approach is adopted, it is recommended that silos of key patient information stored electronically in other clinical systems are fed into the EDMS where possible. This will encourage users to access the system regardless of their specialty or department to view key information ahead of going formally live. In addition to ensuring users are familiar with navigating the solution, this will also provide a more holistic view of the patient’s health.

An analysis should be performed on key clinical systems currently being used across all specialties to determine whether documents can either be imported into the EDMS with patient and (ideally) episodic context or accessed via an embedded link into the native application using patient context.

To evaluate the vast array of options, senior stakeholders must be consulted and each of the above options discussed and prioritised according to:

  • Meeting strategic objectives
  • Clinical usability
  • Cost
  • Organisational capacity and capability
  • Risk

IMMJ Systems have extensive experience of implementing EDMS solutions and can provide an independent advisory service on the most advantageous and cost-effective approach to implementation and scanning for your organisation.