Special Report: Electronic Document Management

Electronic document management is no longer about ‘going paperless’. It is viewed increasingly as part of a much broader digital transformation – a shift which brings its own challenges, reports Claire Read

In building a case for electronic document management at his trust, there is one word which Bill Fawcett largely avoided.

“I don’t really talk about ‘paperless’, and that wasn’t the business case we created,” reveals Fawcett, chief information officer at Leeds and York Partnership NHS Foundation Trust.

“I don’t think electronic document management is all about getting rid of paper,” he adds. “It’s more about looking at what the technology can do to make it as efficient as possible for the clinician to do their job where and when they want to do it.”

Towards a new understanding

It’s quite the rebranding for electronic document management systems (EDMSs). For many years, such setups were inherently associated with the long-stated government aim to create a paperless NHS.

Today, however, such systems are being seen as a much broader part of increased digital maturity; part of a digital ecosystem rather than a goal in and of themselves.

According to Steve Burton, it’s a change which has been particularly marked since the pandemic hit. Burton, sales director at Civica Clinical Systems, has been in the EDM business since 2010 and in that time has observed a real evolution in how such systems are understood.

“It’s gone beyond that core proposition of ‘paperless’ which is perhaps where the market was focused 10, 12 years ago,” he suggests.

“I think now where we are [with the EDM market] is thinking about how we can play our part as part of a wider IT strategy. How we can deal with the backlog and recovery of services, but also transform services going forward.”

This might mean exploring how best to harness the data stored, using it to support population health management style approaches.”During the early phases of the pandemic, we worked with a number of our key trusts to support looking at legacy patient record data held in our system to understand who was potentially most vulnerable to covid,” says Burton.


It is also likely to involve aligning to electronic patient record (EPR) programmes. Certainly, that is the plan at Leeds and York Partnership NHS Foundation Trust, where Fawcett and colleagues are trying to create a setup in which clinicians can move “pretty seamlessly” between the EPR and EDM. “If you’re in a particular patient record, we want you to be able to move easily from one to the other natively – to be able to see all the records that go some way back.

“[With our EDM] we were looking for a tool that would give us a full digital record of the data that really matters,” he says.

For Jon Pickering, chief executive of Mizaic – the company supplying the Leeds and York Partnership EDMS – it’s all about “going paperless with a purpose”.

“An EPR [typically] is probably only storing about 30% to 35% of patient information,” says Pickering, who joined the firm last September and earlier this year led it through a rebrand from IMMJ Systems. “When you install an EPR, it’s great from the next appointment when information is being captured digitally, but what about what happened before?

“So our strategy is integrating with all those EPR systems so that we can feed the historic information into them. And I think that’s a core part of where any EDM providers need to be focused – in making sure integration into other clinical systems are in place.”

Civica’s Burton agrees. “I think over the next 18 month period in the market, we’ll see a more direct alignment between the EPR market and EDM,” he says.

An example of what that might look like in a practical sense comes from Tees, Esk and Wear Valleys NHS Foundation Trust. The organisation is in the process of implementing Civica’s Cito solution, which is designed to unite and structure clinical data such that there is a single electronic health record for each patient.

“Cito is like a typical EDRM [electronic document and records management] system in that you’ve got lots of documents in there, it’s used for viewing, and you can search documents, which is brilliant,” says Richard Yaldren, who is head of the trust’s EPR programme.

“We’re taking the full benefits of all of that. But what we’ve also developed with Civica is a patient profile. So that is an extra bit which has the entire patient record, all in one place. The goal was to build a single repository for the patient data.”

The system is also being used to create a concept of persistent data, with a view to enabling patients to tell their stories only once. There will be over 100 items which fall into the persistent data category (the likes of name, address, height, care goals) which the system will automatically fill in on any new form for a patient.

Working towards new workflows

Fundamentally, the new setup – due to go live on 1 July – is about a redesign of clinical workflows in the trust. “I’m a big believer in workflow engines, and what I wanted was a patient centric workflow,” explains Yaldren.

“In the trust’s current system, you can’t find information. There is a mixture of spreadsheets and paper. It’s one of the major bugbears of clinicians. So I took the opportunity, when we were signing a new contract with Civica, to engage with clinicians and say we were going to map out how they wanted to work clinically. We then worked with Civica to develop the Cito product and add extra functionality on. And one of the core things to that was EDRM.”

Gaining clinical engagement in such products isn’t quite the challenge it was once, according to Civica’s Burton. He speculates that, in some instances, this is because of experiences during the early waves of the pandemic.

“We had one trust in particular where there was this recognition that they needed to be paperless so they could handle virtual patient appointments, and handle staff working from home, or from different hospitals, or from different sites – that it wasn’t really possible to facilitate all that using paper-based processes. So there was support from clinicians for change, whereas previously that whole [EDM] piece had been more difficult for people.

“I think the clinical community is embracing change, whether in EDMS or other areas, so I think that traditional barrier of clinical engagement – which has been quite difficult to pass in the past – is broadly removed,” he concludes.

Show me the money (still)

Instead, the main challenge to introducing EDM is a different old chestnut: funding. “The CIOs that we’re working with, we’re helping them with their economic and business case development so they can get money from their own budgets to get these projects over the line,” says Mizaic’s Pickering.

He expresses frustration with the lack of national funding for such projects, arguing it is shortsighted in light of stated governmental priorities. “Ministers talk about data and using AI and all these cool technologies. That’s all and well and good, but most of your valuable data is sitting on paper in a store room or a basement facility.”

“My view is biased,” admits Burton with a wry smile, “but I think EDMS can add a huge amount of value. That’s not just around its traditional applications but also in other areas that are more aligned to digital maturity and improving the way services are delivered to patients.

“There are lots of great people in the market, so talk to your suppliers about developing and supporting a business case,” he urges CIOs and CCIOs.

“There are people out there that can help you in a way that is open, transparent, gives you the information you need, and enable you to make your own decisions about how the project can be aligned with your organisation’s particular needs.”

Evolving understandings

  • Electronic document management (EDM) was seen as a core part of the move towards a ‘paperless’ NHS. This aim was first enshrined by then-health secretary Jeremy Hunt, who in 2013 announced the NHS would be paperless by 2020. That timeline was soon pushed back, and it remains an unmet goal – albeit one which has since been superseded by new government initiatives.
  • EDM is now increasingly seen as part of broader digital transformation, including work to implement effective EPRs. Whereas paperless was once an aim in and of itself, many organisations are now instead seeing EDM as complementary to a broader programme of change. By making historic data easier to access, it becomes easier to – for instance – embark on new data analytic projects. By connecting EDMSs to EPRs, meanwhile, clinicians can make decisions based on historic as well as current data.
  • Those in the market say the key barrier at present is building business cases. Ironically, this may have become more complicated as the justification for implementing EDM has moved away from ‘just doing away with paper’ to ‘broad digital transformation’. But vendors say they are ready to help NHS colleagues with creating strong business cases.