Oncology noting direct to the Electronic Patient Record
The Bristol Haematology and Oncology Centre, part of University Hospitals Bristol and Weston NHS Trust, is a specialist non-surgical treatment centre for people with cancer and blood disorders serving people from the southwest of England. The centre treats around 5,000 new patients each year and is well known as a centre of clinical excellence.
The hospital was experiencing increasing risk with paper documents missing from the patient case note, case notes missing, and delays to GP communications, for example. Issues included:
- case notes on patients missing due to multiple transfers from one clinical area to another with inaccurate tracking
- clinic outcome forms following outpatient attendances were frequently misplaced. This resulted in a patient’s treatment being delayed or cancelled, and subsequent appointments not being correctly made, placing the patient at risk and affecting cancer performance targets
- missing systemic anti-cancer therapy (SACT) pre-assessment documents, which were used every day to drive patients’ chemotherapy treatment, causing either delays or cancellations as well as the need for multiple queries for pharmacists by phone or email
- other concerns regarding communications for outpatient attendances which were failing to meet national turnaround times and standards set by the Patient Records Standards Body (PRSB)
- inertia to change the status quo. Although suboptimal, handwritten notes can be made rapidly, and dictation for later transcription by secretaries performed in clinic is quick, easy and has been the practice for many years. However, this approach results in a time delay to transcription and a further delay until the clinician has approved and signed the letter. This often takes several days or even weeks
In the Oncology and Haematology services the aspiration was to deliver timely capture of clinically relevant information in one place that can be instantly accessed by staff across specialities. The existing system relies upon duplication on paper and local desktop solutions, with a combination of handwritten and dictated records resulting in delays to transcription.
Solution and impact
The Bristol Haematology and Oncology Centre introduced a transactional digital pathway, implementing clinical notes, workflows, and a suite of business intelligence reports with the intention to use the model as an approach for a Trust-wide transformational change.
Some of the early benefits were the reduction in time taken for clinical letters to be distributed to patients and GPs across Bristol, which improved communications and helped to provide high quality care. Patients and GPs are now receiving communications within three days. Previously, communications relating to a patient appointment could take anywhere up to 21 days, with many letters missing the seven-day target.
Clinicians are now able to record electronic data in real-time by typing or dictating with voice recognition, into bespoke structured forms within the Electronic Patient Record (EPR). The information is then instantaneously available to other staff members at any desktop PC who can access patient records about their patients securely from anywhere, at any time, transforming care delivery. The notes can be designed for direct checking and submission by the clinician or for later sense checking, and dispatch by secretarial staff. In the latter case however, the notes are still accessible for reference instantly from the time of creation, usually minutes after the patient has left the clinic, rather than days later.
The digital clinical notes also provide a structure for data capture and letters, improving consistency and clarity, meeting PRSB standards, as well as providing a resource for data analysis. Data from previous notes can pre-fill the forms reducing recurrent data entry.
Pharmacy and clinical nurse specialist teams have discovered their own use-cases, with early benefits to support their ways of working. Pharmacy are now able to prescribe, review and approve medication quicker as they no longer need to interpret handwriting, but also screen patients due for treatment who are on the wards a lot quicker as all the information required is in one place. Delays due to transfer of paper records and missing, incomplete or illegible records are minimised.
The digital chemotherapy pathway includes a number of digital solutions.
CareFlow Electronic Patient Record (formerly Medway EPR) provides a standalone advanced patient administration system provided by the British health and social care software and services company, System C. CareFlow EPR has interoperability and integration capabilities with many of the Trust’s clinical systems providing users with a single patient record. The system boasts clinical functionality, such as clinical noting and workflow, which was paramount for this project. Having the ability to complete clinical notes within the patients’ EPR in real time that can be accessed by anyone, anywhere, is what made this project so successful. One advantage was allowing the internal IT department to configure bespoke forms. Some EPR vendors do not allow this local configuration, instead relying on time consuming and potentially costly change requests. An issue which has arisen is that currently the dictation is not recorded and so cannot be referenced by secretarial staff. This means that the clinician has to take greater responsibility for checking at the time of dictation, but in turn this removes the need for further checking of communications days later.
Business intelligence (BI) reporting
Removing the dictation, transcription and document production process within the Trust’s current dictation software, and replacing the workflow using CareFlow’s business intelligence functionality introduced new ways of working for the clinical and secretarial teams. The tool set is fully integrated within the CareFlow EPR and can be used to create and manage highly-configurable reports or dashboards, pulling together information from different data sets. Using the BI technologies, the team were able to start to pull data from within the clinical notes. This aspect of the project however is at an early stage and requires significant further optimisation to generate timely and user-friendly reports.
3M M*Modal Fluency Direct speech, dictation and recognition software
Previously when clinical notes had been introduced to the Trust, concerns had been raised around the completion time due to clinical staff not having fast typing skills. M*Model Fluency Direct, owned by the science-based technology company 3M, supports clinicians by providing an all-in-one real time speech and artificial intelligence (AI)-powered solution that enables them to dictate, review, edit and sign clinical notes directly in their electronic health record. The text appears immediately on the screen and clinicians are trained to use set commands to correct dictation as they go in order to build a voice profile. In addition, as the forms are optimised many fields are completed with drop down options or radio buttons so free text is minimised. This also will assist later in data analysis. For many routine simple notes free-text content is minimal, but if longer text description or communication is required then voice recognition allows this.
- Clinical notes available for multiple users from any Trust Windows device at any location
- Multiple users can access a patient record at once simultaneously (whereas paper records can only be in one place)
- Electronic forms provide structure for noting and can encourage more consistent practice in record keeping and data collection
- Data from previous forms can be pulled through to new ones to reduce repeated data entry
- Clinicians can start a patient assessment form, a pharmacist inserts a note following screening of the prescription, and the chemotherapy nurse can add a final assessment and record of treatment administration when the patient attends for therapy. This entire note is available for immediate reference
- Safety and efficiency due to quick and easy access to clinical notes has enormously improved communication concerning patients with nursing and pharmacy staff
- A very significant reduction in the need to transport paper notes around the building
- During the Covid-19 pandemic, avoiding the need for paper notes, alongside the rise in remote consultations, meant that clinics could be performed from anywhere with access to trust IT systems - clinic rooms, offices, and even from home for some staff members who were shielding and would otherwise find it difficult to work. This was transformative
- In a clinic entering notes directly into the EPR is usually going to be slower than handwriting on paper (legible or not) and dictating an unstructured record or letter into a recording device, for later voice recognition processing and then editing by a secretary. This will add seconds, to a minute or two to each consultation, depending on the nature of consultation and the usability of the solution
- The majority of clinicians were initially unenthusiastic about the project as, until data fields start to become prefilled and forms therefore quicker to complete, the benefits are initially seen only by other staff groups such as pharmacists and nurses
- Secretarial staff may feel threatened as typing work is reduced, but this in turn may free up time for other tasks or roles
- Digital systems need to be very reliable. Any downtime when record keeping reverts to paper can be disruptive and could significantly affect hospital services
The digital chemotherapy pathway involved the replacement of historical paper and local system processes with the development of the core EPR clinical noting, allowing rapid collection and sharing of structured data, and the transformation of the secretarial role by removing the need to transcribe clinicians' dictations.
Key learning points
Three lead consultants, Dr Adam Dangoor, Dr Jess Jenkins, and Dr Laura Percy, together with one of the trust’s chief clinical information officers (CCIO), were right at the heart of the success of this project due to their commitment to designing the clinical notes and workflows. They supported communications, championed the use of the system in their own clinics and worked closely with their peers throughout the pilot period to gain feedback to ensure the clinical notes were suited for all settings. Due to some initial resistance to change from colleagues, the leadership from clinical ‘champions’ was essential. The forms continue to be iterated to optimise content and align with practice changes.
Having a dedicated pathway team working collaboratively together in an agile way was essential to ensure the project was delivered to a gold standard that will now be used as a Trust-wide transformational change process. One of the lessons learned was to keep this team small and agile with all members understanding their role and responsibility.
To roll this programme out further however will require support and engagement by the senior trust leadership team. The project requires appropriate resourcing and the clear benefits need to be articulated and shared.
“I have been delighted by how easy it is to use digital clinical notes. The digital change team have been really responsive and helpful, allowing us to make changes and tailor the notes to different clinical settings.”
Dr Laura Percy, haematology consultant, University Hospitals Bristol and Weston NHS Foundation Trust
“The changes have made communication between doctors and nurses clearer, we’re now able to sit with patients as we complete the digital form, improving the patient experience.”
Katherine Davis, senior staff nurse, oncology day unit, University Hospitals Bristol and Weston NHS Foundation Trust
“The notes are immediately available to other clinical staff in the Trust, and the letters to colleagues across the city, which is a big win for communication and patient safety. If a patient needs to be seen by another member of clinical staff, even minutes after a clinic assessment, the notes of that consultation are available at any trust PC.”
Dr Adam Dangoor, consultant oncologist and joint chief clinical information officer, University Hospitals Bristol and Weston NHS Foundation Trust
Quotes taken from the Global Digital Exemplar Blueprint on the NHSFutures platform with permission from University Hospitals Bristol NHS Foundation Trust.
Journey of paper notes for an oncology clinic (notes can only be in one place at a time).
Digital notes in Medway EPR available everywhere, immediately.
Find out more
Max Ward, head of clinical systems, University Hospitals Bristol and Weston NHS Foundation Trust
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