From the editor

Paperless NHS hospital medical records

Paper-based case records in hospitals have been a permanent feature of medical care both before and since the inception of the NHS, while long shelves of Lloyd George files, each containing the medical record of an individual patient, were a universal feature of general practice. Medical records in primary care have evolved rapidly in recent years and are now paperless and computer based – a major achievement. Indeed the development has prompted some patients to complain that their general practitioner now devotes more time to the computer screen rather than to them.

Hospital medical records contain a great deal more data with multiple entries by numerous individuals over a short time period, particularly during an episode of acute care. Early forays into computing medical records, when electronic data storage was in its infancy, were a failure – an initiative probably too far ahead of developing technology. This early failure perhaps explains the low expectations that are commonly held for the development of an effective electronic record system for the NHS.

And yet we are surrounded by huge leaps in computer technology: online banking, internet shopping and access to a wealth of electronic information. Data storage capacity has expanded at a phenomenal rate so that complete sets of journals and textbooks are readily available at the touch of a button. The scale of the project to develop electronic records in the NHS is, of course, daunting. The data held for each patient may include several A4 paper volumes while the total number of individual medical records runs into millions.

When the national plan for electronic medical records in the NHS was first announced it struck many clinicians that a phased introduction working gradually toward a paperless system would be sensible. A short summary for each patient available to clinicians when needed was seen as a positive first step but instead ‘the big bang’ approach was adopted. The contrast between the confidence of the project's first director and the scepticism of the audience at an early presentation at the Royal College of Physicians (RCP) are still clearly etched in the memory of those present that day.

There are good examples of successful implementation of electronic records in fields outside clinical medicine. The Wesleyan Assurance Society, founded in Birmingham in 1841, began by offering life assurance with weekly door-to-door collections of premiums on pay day. Each subscriber to the mutual society had a paper file resembling a patient's hospital medical record. The society expanded their range of insurance products over time and moved into purpose built premises in 1991. In 1997, the company acquired and merged with the Medical Sickness Society, the permanent health insurance company for doctors and dentists. At that time all records were paper based with an individual file for each customer often bulging with NHS familiarity. A decision was taken to gradually convert to an electronic system. The combination of improved technology, excellent training for all staff responsible for the input of data and a conversion on a step-by-step basis from a paper-based to an electronic record over several years has created a virtually paperless environment.

Other interesting differences have emerged with the industry adopted approach. While many NHS leaders have had to support the strategy of a national programme for IT, business experts can think of no other example in industry where managers would be content to hand over control of implementing the core operational systems of their business to a third party.

The incredulity and scepticism voiced at the start of the NHS IT plan remain commonplace in the NHS today but that perception is gradually changing. External experts, while familiar with the patchwork quilt of disparate and unconnected systems and the failure of the new systems themselves with poorly functioning software and hardware in the NHS, argue that the quality of IT investment planning and strategy need further improvement and more money rather than less. They comment that the potentially confounding factor is still lack of ‘clinical engagement’. Too few doctors have been prepared to see the initiative as a real opportunity for their organisations and their patients.¹

In a recent presentation (in the same RCP lecture theatre where the national medical records IT system was launched) Declan Walsh of the Cleveland Clinic, USA, presented data on the incidence of fatigue at presentation for cancer at different sites. Almost in passing he mentioned that the data were derived from ‘our excellent electronic medical records system’. Perhaps it is time to move from scepticism to cautious optimism despite the recent announcement that the funding for this project has been scaled back due to the current economic climate.²