For the record

As a remote observer from outside the healthcare sector, February was an interesting month for news. The first announcement was from the newly-elected US President stating that he wanted to introduce a nationwide patient records database, which sounded very much like our own NHS Care Records System (NCRS). The second announcement was a report from the UK Public Accounts Committee that suggested that since the NCRS project is running four years late, the eventual cost of the £12.7bn programme remains uncertain, and the final outcome is in some doubt.
    
The most interesting aspect is that prior to the President’s announcement, the UK and the US were heading in completely opposite directions. The NHS presents a single unified organisation that could reasonably be expected to support a common IT platform and a central connection spine, albeit that this has proved to be somewhat more difficult in practice. Healthcare in the US, on the other hand, is provided exclusively by commercial organisations, and has a much more diverse set of IT infrastructure. Overlaid on this is a health insurance system with a myriad of policies and providers.

Personal Portable Records
Based on these differences, the US had until recently adopted a completely different and perhaps more pragmatic approach. Rather than storing patient records on a centralised database, portable data records in a transportable file format would be used for exchange of information between healthcare providers. This would even extend to the point where each citizen would carry their own medical records with them on a personal storage system – a data stick or data card. When required, the patient would present the data to a medical professional who would make use of it, and store back updates as required.
    
Both schemes have major security implications, but patient distrust is perhaps alleviated when they can hold their own records in their own hand. Just how trustworthy they can be with such physical devices is, of course, debatable given the number of lost USB sticks found on trains and in taxis. Certainly “they have lost my records” might turn into “I have lost my records”. No doubt the ‘cloud’ storage operators would be happy to provide a universal back-up capability in much the same way they do for one’s photographs. For international travellers, the chance to carry your history, allergies and prescriptions with you to anywhere in the world sounds very attractive.
    
Both schemes require a common format of data to enable any healthcare provider to read and make use of the information. This format also has to be comprehensive for the present and durable for the future, and indeed, this proved to be a challenge in the early part of the NCRS project.

PDF Healthcare
The Portable Document Format (PDF) originated by Adobe has become a de-facto standard for storing and archiving electronic documents and, with AIIM’s help, has recently become an ISO open standard. PDF-Archive or PDF/A has been an open standard since 2005. Intended for long-term storage of records, it restricts some aspects of the PDF format such as hyperlinks and external font calls, and improves metadata conventions to allow better findability within a records management system. There are also PDF conventions for engineering (PDF/E) and print users (PDF/X).
    
The PDF Healthcare standard is currently at the stage of a Best Practice Guide (http://www.aiim.org/pdfh/ig) and is being jointly nurtured through the standards process by AIIM and the standards body ASTM International.
    
PDF Healthcare is best considered to be a folder, into which many different file formats and codes can be utilised to cover such data as personal documents, clinical notes, lab reports, electronic forms, scanned images, photographs, digital X-rays and ECGs. Security is obviously a major issue being addressed within the format. It should emerge in 2009, and is likely to be rapidly adopted as a very open and specific format for health applications.

Local vs Global
To my mind, the above discussion brings home the dilemma of many enterprise IT projects. Ambitions and aspirational strategies are important in order to avoid dead-ends and re-work further down the line, but there are often many simpler, cheaper and more pragmatic solutions that can be utilised as an interim or transitional mechanism. For example, the X-ray project within NCRS seems to have been a successful mini-project, which is now in widespread use.
    
The same is true for other information management projects within the NHS. Too much focus of time and money on the NCRS can detract from the day-to-day issues of managing staff, premises, procurement and safety.

Connecting documents
Despite the moves to manage core patient data electronically, paper forms are still the medium of choice for capturing data within the healthcare sector. Many are procedural, forming part of the constant train of safety checks and precautions. Others are generated to organise staff and manage their jobs. Still others are used, as in any organisation, to monitor the purchase, delivery and payment of supplies.
    
Every paper form has an associated process, and this will frequently involve a workflow based on moving the physical form from person to person within the organisation. As we all know, workflows based on physical forms are hard to run in parallel without creating multiple copies, are vulnerable to lost or mislaid forms, are difficult to monitor and expedite, present a confidentiality risk, and finally result in filing cabinets full of archived papers that are difficult to access, secure or destroy.
    
Direct electronic capture on hand-held tablets is of course an ideal, but for many forms it is simply impractical. In these cases, scanning the paper forms, capturing the data where appropriate, and routing them through an electronic process can produce dramatic returns in speed, accuracy and process management. To facilitate the process, distributed scanning stations based on departmental multi-function printer/scanners can link directly into a central workflow processing system, where the process can be picked up automatically for its next step. Specialist scanning staff are not needed, and the scanned image can be referenced immediately anywhere else in the organisation. Once trust is established, the original form can be destroyed.

Integrating paper
If the form in question is actually an invoice or delivery docket, character recognition at the point of scanning can link the invoice with the order in the finance system, and then process a sign-off workflow to authorise payment. The scanned image of the invoice will be passed around the process, but automatic matching can also take place from line items and quantities.
    
On the HR side, there are many processes that are likely to be paper-centric: holiday booking, expenses claims, job applications, appraisements. One benefit of an electronic system is that copies of potentially sensitive documents do not proliferate, and locked filing cabinets can be replaced by secure-access archives. Once secured in an electronic records system, retention periods can be set to ensure information is kept as long as is required, but no longer.

Work harder
R­­­­­eturning to our original theme, we can see that whereas a first reaction to information management is to create a central database and store everything in it, it may be more appropriate to visualise how we can mobilise data, transport it and process it in electronic format in much the same way as paper forms and case notes have always been dealt with and processed. In this way, documents have no boundaries and are available for sharing, using, processing and archiving in a much more cost-effective, compliant and service-orientated way.
    
AIIM has recently introduced a series of short online courses dealing with specific topics such as capture techniques and PDF/A at www.aiim.org/education. All of these issues are discussed and demonstrated at the AIIM Roadshow, which this year takes place 1-5 June in Edinburgh, Leeds, Birmingham, Bristol and London. 

About AIIM
AIIM is the international association for Enterprise Content Management. It represents the Information Management community and supports the interests of users and suppliers of technologies and solutions used to capture, manage, store, preserve and deliver information.
   
AIIM organises a number of events and educational programmes, including the AIIM Certificate Training Programmes, which can be taken as on-line, in-house or classroom courses. The annual AIIM Roadshow provides keynotes, seminars, roundtables and an exhibition of all things ECM. In 2009, the show will visit Edinburgh, Leeds, Birmingham, Bristol and London 1-5 June. AIIM Professional Members participate as a community of ECM practitioners.

For more information
Web: www.aiim.org.uk
­www.aiimroadshow.org.uk