Associate feature: The usability conundrum of electronic patient records

At a time when the NHS is struggling to keep up with demand and patient waiting times are growing ever longer, all eyes are on the technology sector to provide solutions for a more sustainable future.  

A report assessing the burden of clinical documentation in NHS England trusts, released by technology company Nuance Communications, revealed that nurses, doctors and allied health professions (AHPs) spend an average of 13.5 hours a week on clinical documentation – an increase of 25 per cent over the last seven years.  

Building on this data, Holyrood gathered professionals from across the industry at the Waldorf Astoria in Edinburgh to discuss the challenge of clinical documentation and to explore how the situation looks north of the border. 

Setting the tone for the issue, Simon Wallace, chief clinical information officer at Nuance Communications, said: “Documentation is really important. It’s the jewel in the crown for good quality decision making.” 

Addressing further the “illuminating” findings the company had gathered, Wallace explained that most participants also felt the burden of clinical documentation was a significant contributor to burnout. 

Emphasising the importance of time, David Lowe, a consultant at Queen Elizabeth University Hospital in Glasgow, explained that the power of artificial intelligence creates the opportunity  for a more “value-added conversation” between the doctor and the patient. 

“The inherent distractions and the requirement for us to document means you don’t have that conversation so, ultimately, we need clinical workflow automation,” he said. “Consultants having that human conversation and thinking about productivity and efficiency within that period allows us more time to do the tasks we are good at …such as… decision making and communication, not documentation. And recognising that is critical for improving the quality of the patient’s journey.” 

Sam Patel, e-health clinical lead at NES (NHS Education for Scotland) Technology Service, described how current technology had moved the admin load onto the clinician with it being exacerbated by having multiple disparate systems.  

‘‘You’ve got the front door,” he said. “You’ve got decisions you’re making. There’s a huge governance aspect. You have to record things because you’re very much aware that the scrutiny is there. And this bureaucracy adds and adds and adds.” 

Attendees also discussed how it is not only the recording of information that is time-consuming but also the verification process at the back of it. It is a constant back and forth of corrections between the secretary and the clinician, Lowe explained. 

“A cardiologist sees a patient and writes a scribbled note,” he said. “Then, at the end of the clinic, they do all the dictation. That then goes to the secretary who types all that dictation and sends it back to the cardiologist to review and edit it, who then sends it back to the secretary to print it out and send. So that means that the diagnosis of heart failure from the point of seeing somebody to the letter going to the GP to initiate therapy, could be more than a week.” 

Stunned by the impact the documentation burden can have on operational standards, even host Pennie Taylor, an award-winning freelance journalist specialising in health and social care, drew attention to the impact this situation has on patient safety, opening the discussion on how voice-recognition technology could tackle the threat of potential mistakes currently embedded in the system. 

Brian Corr, a senior advanced clinical nurse specialising in urology at Raigmore Hospital, agreed and explained how voice technology had significantly lifted a weight off his shoulders and how “going back to the old way would be horrendous”.

Speech recognition software automates the documentation process as clinicians convert words into text in real-time, directly into electronic patient records as well as other clinical systems. 

He told attendees about a trial of the technology he is involved in and how it had significantly speeded up their department’s workflow by reducing the turnaround time of clinical documentation by over 90 per cent. For one of his colleagues, speech recognition reduced her average turnaround time of documentation from over a week to just 10 minutes.

Corr also highlighted a special case where he used the technology to dictate his consultation in real-time with a deaf patient. It helped his patient to understand while also dramatically cutting the consultation time.  

The current crisis in hospital waiting times across Scotland means more than 1,500 people have been waiting a minimum of three years for medical procedures, according to data from NHS Scotland. First Minister Humza Yousaf wants to reduce the waiting list by 100,000 by 2026, with investment in technology expected to help. 

Continuing the discussion, Patel who is also a consultant respiratory and general physician at NHS Lanarkshire, stressed that the key to success is not data capture itself but rather how the captured data is used. “We carry lots of different clinical hats,” he said. 

“When seeing inpatients or outpatients, my requirements for information are slightly different. Capturing this information gets you a more comprehensive view of the clinical interaction and this is a hugely powerful thing”. 

Agreeing with him, James McPherson, chief executive of Voice Technologies, said that as this technology is not “tied in itself”, it can be applied across different clinical systems, adapting to the multi-faceted responsibilities practitioners may have. 

However, as with most technological breakthroughs, cost was a concern for most in the room. Despite that, there was a consensus that when balancing the investment opportunity, there was a need to look at the “long-term” advantages of adopting this new solution. 

“It is a way of being able to have that cognitive overhead lifted,” said Patel. “I did 100 per cent clinical and then 20 per cent technology before. I now do 20 per cent clinical and 80 per cent technology and I have remembered what a privilege it is to see patients.” 

Moreover, if speech recognition was used more widely in Scotland, the technology’s ability to free up time could bring significant cost savings per doctor, he said. 

However, Patel noted that money was not the solution to every issue as it is people that make the “difference in quality”. He discussed how “resources and variation go together,” highlighting how a site that has fewer staff cannot dedicate as much time to the use of the technology or the trial of a project. 

Agreeing with Patel, Philip Korsah, consultant in anaesthesia and intensive care medicine at NHS Ayrshire and Arran and national associate clinical director at the Centre for Sustainable Delivery, said: “One of the barriers that we’re coming across is that not everyone can work in the same way. For example, one of the challenges at the moment is that the infrastructure each board level has is not equal hence the level of support that they need is not the same.

“So, unfortunately, although a small board would need it the most as it would be revolutionary for their system, they simply can’t get it done because one person is multitasking three jobs”. 
The roundtable also agreed that getting permission from health boards for a project can often become a barrier for progress. 

However, participants said they recognised that denials to move forward with a programme can sometimes be traced back to clinicians asking the wrong questions. 

In other words, as Wallace pointed out, boards need “their clinical teams to revisit and challenge the present state of workflows in different specialties” so they understand how a ‘transformation’ that incorporates new digital technology would make it more “efficient” and to carry out due diligence on any potential drawbacks. 

Louise McTaggart, head of digital strategic delivery at NHS Tayside, also called out the need for a more detailed explanation of the benefits the technology can have over other potential investments. 

“It is about investment and who makes the case for the benefits,” she said. “It’s very much cherry-picked. Devolved boards compete internally and they have to discuss whether they should be using that funding to buy something like MRI technology, which can also add lots of benefits for everybody. So, it’s about that balance.” 

Addressing this further, Wallace said there was a need for clinical specialties to have a recognised “clinical champion”. “Such an approach gives their peers confidence that this ‘new way of doing things’ is centred on delivering high-quality care to their patients, as well as making the workflow more efficient”, he explained. 

When discussing the obstacles the digital revolution is facing, the panel addressed key topics including language, fear and weak collaboration.

Fear has long been an issue associated with the rise of artificial intelligence, with many people believing the automation journey will leave them out of a job. 

However, Corr called for a change in mentality as he explained that advances in technology will actually free up staff to do what they were initially hired for. 

“You speak about this to some consultants, and they get very protective of their secretaries, and if it would mean that they are going to be sacked? Absolutely not,” he said. “Their priorities are compiling clinic lists and the technology lets them do that. Although that was always their priority, the letters took a backseat and took three weeks to actually get done. So, they can now concentrate on their actual job.” 

Marie Richmond, head of digital strategic delivery at NHS Fife, called for the need to frame training in a more appealing manner.

“So, we changed our language, we named it digital enablement instead of training,” she said. “Because when you’re talking about enablement, you’re saying, ‘we’re actually here to support you and enable you to be able to work with digital systems on an ongoing basis’.” 

She also addressed the need for nationally driven projects but how it was important to understand local concerns and needs for the national approach to work well.

Patel also discussed how change will not happen “overnight” as he called for more synthesis within the chain of supply and demand. 

“I think we need to be realistic about this and recognise that one of the constraints is that the systems we work with were designed in the nineties,” he said. “We can adapt them to an extent, but the workflows we’re talking about just now are what they are. It’s that interplay between the systems that we have, and the expectations of transformation. And I’m not one for saying buy new every year, but there has to be a recognition that you sweated that asset enough and then you need to get on to thinking about how you’re going to plan that [upgrade]. Hence the reason why strategic changes and partnership with our suppliers is important. We need to be working together and thinking about a new way of doing things.” 

Discussing what the future will look like, Lowe said: “In five years’, time? Well, voice technology will be ubiquitous for all of us, just like it is already in radiology. It’s coming, it’s just how we support its adoption.” 

in association with Nuance, a Microsoft company