How clinical documentation has evolved in the NHS
To celebrate the NHS’ 70th anniversary, technology company Nuance has released an infographic on how clinical documentation has evolved within the NHS.
The company details the huge technological changes that have occurred over the course of the organisation’s 70 years.
It details how in 1948, staff were entirely reliant on pen-and-paper to create patient records to track patient progress and enable communication between healthcare professionals. In the early sixties, the Dictaphone brought about a change to this process, being introduced to enhance the accuracy clinical documentation. Doctors would use cassette tapes to dictate their clinical patient records for secretaries to type up, helping to reduce the time clinicians themselves spent recording patient data.
In 1998, the Data Protection Act gave patients or their representatives the right to a copy of their record, except where information may breach confidentiality. Legislation forced Trusts to develop a simpler and more efficient way of organising, securing and accessing patient documentation, arguably creating the birth of digital records.
The start of the 2000s saw the NHS ‘going digital’ with electronic patient records with some early adopters beginning to incorporate speech recognition to improve the speed, accuracy and efficiency of clinical documentation. However, with what is still a challenge today, health records of citizens were often held locally within a single NHS Trust’s IT system, meaning there was no coordinated system between healthcare providers.
At the end of the decade, the NHS migrated from tapes to digital dictation to speed up clinical document turnaround, improve data security, cut costs and reduce the potential for lost reports.
A few years later, health secretary Jeremy Hunt challenged the NHS to go paperless by 2020, a challenge which is now looking unlikely to be met.
A study by Nuance in 2015, revealed that over 50% of doctors’ time was being spent on clinical documentation. The study shows the strain clinical documentation is putting on healthcare staff. For example, it found that doctors spend on average of over 10 hours a week adding to existing clinical documentation.
Today, the NHS paints a mixed picture in terms of efficiency. Whilst some Trusts such as South Tees Foundation are incorporating AI-enabled speech recognition technology, others still rely on inefficient methods that impact upon the amount of time doctors can spend with patients.
Dr Simon Wallace, chief clinical information officer at Nuance, said: “The NHS has transformed itself over the past seven decades, with patient services evolving beyond recognition. Against a multitude of challenges – from budget constraints to an ageing population – its dedicated healthcare professionals work to deliver world-class patient services.”
“Still, too many of those are staff held back by a lack of strategic investment in technology. Clinicians are incredibly busy, and their top priority is always patient care. Clinical documentation is vitally important in tracking any patient’s journey through the care system, but it is time consuming to complete.
“However, today, AI and cloud-based solutions enable clinicians to record and share information within their own and partner organisations more reliably, flexibly and efficiently than ever before. This boosts the accuracy, completeness and timeliness of recorded data and frees clinicians to get back to what they love – caring for their patients.”