Wednesday, February 21, 2018
Article Published by the HSJ in November 2017. Authored by Alison Moore.
Going digital to manage clinical letters
A trust’s use of digital dictation and outsourcing typing to generate letters not just led to reducing delays and costs but wider administrative changes.
By Alison Moore
The average NHS organisation generates thousands of letters a week, many of them about individual patients and some time-sensitive. Ensuring they get processed as quickly as possible, and costs are contained, are a way for organisations to improve both quality and finances.
Getting it wrong can mean patients are left in limbo – and can suffer as a result of the healthcare professionals involved in their care not having important information. Already this year, several coroners have raised concerns about patients who died after information about care in hospitals was not shared quickly enough with their GPs. The volume of letters is driven by increases in the number of tests ordered and patients seen
In one case, a letter containing information about changed medication and physiological measurements took nearly a week to arrive and in another a GP was unaware that the patient had had an endoscope examination in hospital. In both cases, sending the information by mail had added to the delays.
Many trusts will recognise the situation where there is a backlog of letters and reports to be typed; urgent letters can be hard to pinpoint and speed through the system; and many communications are sent by mail when email would be the quicker and cheaper option. These problems are often increasing year by year as the volume of letters is driven by increases in the number of tests ordered and patients seen.
The solution can often be to switch to a digital dictating system – but as Birmingham Children’s Hospital found out reducing delays and costs associated with letters is only a small part of the change process which switching to digital can drive.
"It started off as a tech project but became about processes"
Adam Carson, the associate director for ICT, says the children’s hospital first introduced digital dictating three or four years ago, when it worked with Winscribe as a development site for a new product.
“At the time some of the challenges we had were around a backlog of letters – which was linked to a shortage in the clerical workforce and slow turnaround,” he says.
The trust was still using analogue dictating systems: “It was inefficient. The doctor would fill up a tape and then give it to the secretary. There was very little sharing of work between secretaries – there was little opportunity to do that.”
He was keen to address this and to move to a system with more transparency about how much work there was to do and where it was in the system. This would allow work to be redistributed, if necessary. But the trust was also in the process of implementing other changes in electronic records which included a document management system. Mr Carson saw it as important that the systems worked together so that staff could easily move between one and the other, and letters were available through both.
“It gave us a really good opportunity to think about our process for managing clinical letters,” he says. “It started off as a tech project but became about processes. We were able to make changes around who was doing the letters. What had not always been clear was where the delays in the typing of letters were – was it the secretaries? Was it the doctor? We knew there was a delay but we could not see where it was.”
Outsourcing the work
The changes led to faster turnaround time but another innovation has radically accelerated that. The trust has recently piloted outsourcing typing, something which is easier to do with digital systems than with analogue ones.
"There were also concerns among the admin staff about what this would mean for their jobs. So far there have been changes but no redundancies"
This has led to dramatic reductions in turnaround times – from 20 days down to 72 hours in some specialties. Urgent letters can also be quickly identified and prioritised in a way which allows them to be picked out and dealt with – something which was difficult and time consuming with analogue.
And 95 per cent of letters to GPs are now being sent electronically – reducing the time taken for them to learn of any changes to the patient. Meanwhile, staff who would have been tied up with typing letters have been deployed to other work. “We have also been able to look at the role of our band three admin staff and get them to do different things,” he says.
There were many challenges around introducing this degree of change. There were qualms from medical staff about the changes, some of which would alter their relationships with “their” secretary. There were also concerns among the admin staff about what this would mean for their jobs. So far there have been changes but no redundancies: everything has been accommodated through natural turnover of staff.
The children’s hospital has now merged with the nearby women’s hospital to form Birmingham Women’s and Children’s Foundation Trust: the women’s hospital is now looking at adopting the same technology.
Mr Carson suggests that financial savings don’t come just from using a digital dictation system, but are generated from the wider changes it can lead to – such as in how the workforce is used. “It’s completely changing our administrative processes,” he adds.
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