Freeing Royal Free London NHS Foundation Trust from paper: an interview with ‎director of IM&T Will Smart

Will Smart explains how digital documents and other technology are helping to transform patient care at Royal Free NHS Trust

The Royal Free London story starts in 1828 when William Marsden, a newly qualified surgeon was shocked that he couldn't find treatment for penniless patients. Royal Free thus became the first hospital to provide free care to patients and even stayed open during the cholera epidemics of the 19th century.

Almost 200 years later, the three hospitals that now make up Royal Free London NHS Foundation Trust are still absolutely focused on providing free care to patients, and technology plays a huge role in that process.

It's Will Smart, director of information management and technology, who is responsible for overseeing IT strategy at Royal Free London. He tells Computing that in an effort to provide a simpler, more cost-efficient service to both patients and hospital staff, the Trust, like many other NHS bodies, is in the process of digitising paper case notes.

"We went live with the EDRM [Electronic Discovery Reference Model] in November which is all about making legacy patient case notes available electronically at the point of care," Smart says.

Royal Free appointed business process outsourcing firm MISL as "scanning partners" in a project that will eventually see 750,000 documents digitised using Kodak scanners. Smart is pleased with the progress of the project so far.

"We expect that we will have cleared the library by Christmas, which is well ahead of schedule and the quality of the documentation that has been scanned has been excellent. We've not had any issues," he says.

MISL was selected following a tendering process that saw potential contractors judged against a number of categories, including security and cost efficiency.

"We needed a partner that offered value for money, but clearly medical records are highly confidential documents, so we needed people that had experience of dealing with case notes, understood their structure and were used to managing that kind of data," Smart explains.

"MISL had a track record that showed they had the capacity to do what we needed to do and could offer us good value for money," he adds.

The project is only partially completed, but Royal Free is already seeing the benefit of clinicians having access to digitised patient notes because "key clinical information is available when and where it's needed".

"With paper records, you have issues of case notes being lost and they can only be available one place at a time," Smart explains. "By digitising them we are aiming to make that unstructured patient content ubiquitously available across the organisation."

It's resulted in clinical physicians being able to access records of 95 per cent of patients, a figure "that's higher than we were achieving under paper", says Smart.

While the digitisation of documents has reaped benefits, going paperless represents "a very large change" for clinicians and how they access information because "we're all very familiar with navigating paper files", says Smart.

"It's been more of a struggle than any of us had anticipated in terms of navigating via screens," he adds, before explaining how UI changes have already fixed many issues.

"We spent a lot of time over the last few months redesigning the user interface to make it easier to navigate what can be large documents," says Smart.

Culture change

"Sometimes doing things digitally takes more time and certainly a comment clinicians have made is that actually it's sometimes just quicker to use bits of paper. But of course the difficulty with bits of paper is that they're not there for other people to use," says Smart.

"Hospitals are interesting. Paper is often the marker we use to denote process, the piece of paper is the artefact which goes through the process, so yes it's quite a big cultural change," he adds.

An expanded use of digital documents has seen a rise in mobile device use. Currently, Royal Free "predominantly" operates on Windows laptops and workstation modules on wheels. However, Smart tells Computing that the Trust is examining the potential of equipping staff with iPhones and iPads.

"We have the ability to move into an iOS mobile environment; we've not taken that step yet. We've got the entire infrastructure required to do it, but we just haven't taken that next step," says Smart. The need to ensure vital systems are available 24/7 means the trust must tread carefully, he adds.

"It's a very large change programme, so we just have to balance pace with delivery, without impacting services," he says, before adding that mobility very much is "the next big phase" of infrastructure redevelopment at the trust.

Having a digital record of all hospital documents isn't just good for efficiency, it also opens the door to tools for examining patient case notes and identifying trends in a way that wouldn't be possible with handwritten papers.

"One of the exciting parts of this process is the ability to begin to analyse that unstructured content. We can read the typed content in the record and we can begin to drive context and hopefully to derive interesting analytics around that unstructured data," explains Smart.

One way Royal Free can do this is by analysing data of patients to identify previously unknown trends about conditions.

"As a teaching hospital, it gives us the ability to identify cohorts of patients which is important for research to be able to get into that unstructured content. We can use semantic analysis to look for specific conditions," says Smart. "Using this sort of analysis would be very helpful in looking for treatment."

Smart tells Computing that when it comes to using big data in healthcare his sense is "we'll hand it to our clinical colleagues and they'll find ways of working on it in ways we can't possibly imagine".

"We want to make this data available so people can actually derive value from it themselves. One of our clinicians at Barnet did an interesting study around salt. Things I couldn't think of, we just need someone to have the idea and have the ability to do exploration," he says.

When it came to forming his own data analysis team, Smart says he plucked staff with the correct abilities from a variety of areas.

"It's about analysis skills and that ability to take data and apply it to the real world. The people I've got tend to be experienced around NHS datasets, around tools and analysis in a very specific context," he says.

For Smart, "data is an abstracted model of the real world and what you need is to understand how that abstract model relates to the real world that we're living in".

"So, sure, you can do regression analysis and everything else, but it needs that real-world insight into the absolute grounded reality of what you're doing. it's about mixing those skills together."

Looking to the future, Smart indicates that "a big digitisation agenda" continues to be the priority because "clearly the Secretary of State [Jeremy Hunt, Minister for Health] has mandated that we'll be paperless, so that's a big agenda for us".

Work on clinical applications is also something Royal Free is looking at very closely.

"We've got a large clinical programme we're beginning to roll out around electronic prescriptions, so there's a lot of work to be done in terms of really providing clinically useful solutions."

Ultimately, the mission of the Royal Free remains the same as it has been for almost 200 years; to provide efficient healthcare free at the point of demand - and IT will play a big role going forward.

"Using technology to support service transformation and improve efficiency has got to be a large part of our agenda over the next few years," says Smart.

"Because the one thing we can be certain of is that the economic climate isn't going to get better in the short term and we need to continue to drive efficiencies while continuing the best clinical outcomes possible," he concludes.