The paper chase is on

Amid all the talk of hospitals moving to electronic systems and becoming paperless, one part of the process often goes unmentioned - what to do with all the paper already generated?

The answer is, of course, to scan it. But which bits of paper? Do you scan the entire archive or just the documents needed for tomorrow? Do you outsource scanning or set up an in-house bureau? Where are the savings to be made? And how to manage the clinical governance?

Document scanning in the NHS has been around for at least 15 years but despite the move to electronic document systems, strategic approaches are rare.

Scott Wilce, managing director of document scanning specialist Gateway Computing, which was recently taken over by Civica UK, says: “I would say a large proportion [of trusts] are doing it in some form or another. For some it is a large-scale operation, scanning the entire archive to do away with the costs of storage. Very few have managed this successfully. Others are doing piecemeal scanning on demand and day forward scanning.”

These last two are common terms in the document scanning business and may have nuanced meanings in different settings. But broadly speaking, scanning on demand refers to scanning documents relevant to individual patients attending specific clinics. These are scanned shortly before their appointment, and integrated into the electronic document management system.

“It means the more up to date documents that will be used by clinicians are available in real time,” explains Mr Wilce.

Day forward scanning means scanning the paper generated by clinicians in clinic within 24 hours of creation. It makes the record available electronically immediately and eliminates the need to store the paper.

Forward-thinking trusts are now looking at scanning incoming mail, and using bar codes to link paper documents to electronic records.

There is widespread agreement that documents that are most clinically meaningful must take priority over the archive. Suppliers point out that full archive scanning can cost anything from £1m. On the other hand, large savings may result. One trust recently invested £1.5m in scanning its archive but expects to save £750,000 annually.

David Bryce, managing director of scanning supplier Cleardata UK, says: “The budget is the biggest factor. Often the decision on what to scan comes down simply to a question of how much money a trust has and what it wants to be electronic. You need to take a common sense approach to whether it is cost effective.”

Scanning can be done in-house, by an outsourced supplier, or a mixture of the two - in-house bureaus run by outsourced specialists.

Mr Bryce adds that a good scanning strategy will consider the pros and cons of in-house and outsourcing.

“If you are going to do it in-house, are you going to have a centralised bureau or a fragmented service?” he asks. “Will you have the largest departments with the biggest problems running their own scanners while others with less paper use multi-functional photocopiers? There are no clear answers to this and every hospital is deciding what it should do.”

Not surprisingly, he argues that trusts should consider carefully before going in-house. “Some think it’s a good idea to use almost an entire floor’s worth of space, employ lots of people and buy hundreds of thousands of pounds worth of equipment when it is not really their core business,” he says.

The reasons for using an in-house scanning resource are not entirely financial, however - information governance plays a big part.

Steve Rudland, healthcare manager for Hyland Software, explains. Before a paper record can be destroyed, it has to be scanned in such a way that the electronic version can be used in court. “Scanning needs to be carried out to a legal admissibility standard,” he says. Some trusts prefer to trust their own IG standards rather than go to an outsourced provider.

In November 2011 the Department of Health Informatics Directorate issued a guidance paper urging trusts to get to grips with the specific standards surrounding scanning of medical records (for the anoraks out there, BS 10008:2008 and its supporting code of practice BIP 0008-1). All the scanning suppliers interviewed by HSJ said trusts must check whether an outsourced provider is accredited to the required standards.

The pitfalls

Meeting those standards is not simple. As the DHID guidance points out: “Where digital scanning of documents is proposed, it is essential that appropriate forward planning is made, and that process and quality assurance controls are properly considered, developed and tested.” Its three key principles are authenticity, storage and access, and evidence of process reliability and compliance.

There are plenty of pitfalls, warns Mr Rudland. “The thing that takes people by surprise is the sheer volume of work associated with document preparation before scanning,” he says. “Medical records are different and need to be treated differently.”

It is not just a question of removing the staples in a document but of documenting the procedures for removing staples. Documents with blank pages need to be scanned in their entirety while there need to be procedures for scanning those with sticky notes attached. The list goes on - and it all needs to be auditable and audited.

If the scanned documents are to be integrated into the electronic document management system - and increasingly this is the point of scanning - they need to be indexed properly and in a way that is familiar to clinicians, adds Mr Rudland.

Then there is the expertise in scanning. Outsourced providers argue that their staff do the job all day, every day and have considerable expertise. Mr Rudland says: “With in-house scanning, what often seems to happen is that trusts take the people who spent their lives pulling paper records from the shelves and put them in front of a scanner. That’s where you start to see some problems, as this is a discipline in its own right.”

Another piece of the jigsaw is interoperability - how will documents be made available in the trust’s electronic document management system? Increasingly providing the interfaces is the core business of outsourced providers.

Pain points

Suppliers argue it is time trusts started taking a more rigorous, strategic and project-based approach to scanning. This would involve looking in detail at what they want scanned and why, whether they want to take an enterprise-wide approach or tackle departments with the biggest problems first, how they will make electronic files available in the electronic document management system, and how they can be assured the scanning is legally admissible.

Geoff Laycock, technical director at scanning specialist MISL, says too often medical records managers are left unsupported in this. “If you are the medical records manager and you are being approached by a dozen companies, you will have no way of knowing what is a good and what is a bad one,” he says.

Mr Bryce adds: “You need a project manager, a project team with medical records, clinicians, IG, finance and IT on board. The team needs to have a budget and the ability to make decisions. You need to pick the biggest pain points and work there first and get results.”

Document scanning may not be the sexy end of going paperless or paperlite, but it is an absolute necessity.