NSW clinical documentation digitisation strategy
A strategic review of scanning into the eMR was needed to support eHealth’s strategy towards an integrated paper-lite clinical information system
Project
The problem
There was a wide variation within NSW public hospitals in the extent to which scanning has been implemented and incorporated into clinical and record keeping workflows. A strategic review of scanning into the eMR was needed to support eHealth’s strategy towards an integrated paper-lite clinical information system for safe and high‑quality healthcare; across the State. eHealth NSW commissioned Doll Martin Associates to conduct an overall ‘scanning into the eMR’ current state assessment, future state requirements and roadmap to achieve identified targets consistent with the eHealth Strategy for NSW Health 2016–2026.
Our Approach
Based on the National and State standards and policies provided, DMA conducted further background research on scanning standards and healthcare record retention and destruction policies. DMA undertook extensive consultation within eHealth including Investment strategy and architecture, eMR Connect, Clinical Application Support, and conducted a workshop at each LHD/SHN to determine their ‘current’ scanning landscape, what worked well, and what were their needs and priorities for scanning in the future.
Results
LHDs/SHNs identified more than 600 State and Local paper-based forms in use ranging from external documents to care plans, progress notes, results, medication charts. The key drivers for scanning to eMR were identified: a clinician push for digital records, timeliness and accessibility of high-quality clinical information, clinical coder workforce shortages, a standard method to find scanned documents within eMR and hospital re-development programs allowing for little or no storage capacity for paper-based records. Doll Martin delivered eHealth a detailed current state activity, a scanning to eMR strategy, and a goal state and roadmap to support the NSW Government Digital NSW Strategy objectives of information that is digital by default, integrated, seamless, and accessible. A key focus area of the Strategy is further reduction of the hybrid medical record (use of paper and electronic records simultaneously) through expansion of the digital patient record across care settings, enabling the majority of clinical information to be created in a digital form. As the eHealth Strategy is progressively rolled out, the role for scanning residual paper records will reduce incrementally.