From paper to cloud: NHS transforms clinical documentation over 70-year history

Dr Simon Wallace, chief clinical officer at Nuance Communications, provides an overview of technical development in the NHS over the past 70 years since the inception of the NHS and the importance of supporting radical shifts in the way patient data is stored and communicated

In recent times, the NHS has undergone digital transformation at a grand scale to keep pace with the demands on its services and is striving to deliver better care and quality of service to its patients.

A radical shift in the way patient data is created and communicated is just one example of this digitisation.

In 1948, NHS staff were entirely reliant on pen and paper to create patient records, to track patient progress, and to enable communication between healthcare professionals.

In recent times, the NHS has undergone digital transformation at a grand scale to keep pace with the demands on its services and is striving to deliver better care and quality of service to its patients

The first change to this process came in the form of the dictaphone in the early 1960s – and then cassette tapes – which were introduced to enhance the accuracy of clinical documentation.

Cassette tapes were used by doctors who would dictate their clinical patient records for secretaries to type up. This major shift reduced the time clinicians themselves needed to spend recording critical patient data and instead freed up time for more patient care.

The Data Protection Act of 1998 gave patients or their representatives the right to a copy of their record, except where information may breach confidentiality.

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 was arguably the birth of digital patient records, with the legislation forcing trusts to develop a simpler and more-efficient way of organising, securing, and accessing patient documentation.

The early 2000s then saw NHS organisations ‘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, health records of citizens were often held locally within a single NHS trust’s IT system, with the resulting impact being that there was no co-ordinated system between healthcare providers. This is still a challenge today.

In 2009, the NHS migrated from tapes to digital dictation, speeding up clinical document turnaround, improving data security, cutting costs, and reducing the potential for lost reports. This was an important step forward for documentation, especially as just a few years later, the then Health Secretary, Jeremy Hunt, challenged the NHS to ‘go paperless’ by 2020. Such a move would ‘save billions, improve services, and help meet the challenges of an ageing population’, he said.

A significant study of NHS England trusts, conducted in 2015 by Nuance, revealed over 50% of doctors’ time was being spent on clinical documentation.

Shining a light on the strain on healthcare staff in terms of clinical documentation, the report also found that doctors spend an average of over 10 hours a week adding to existing clinical documentation.

Fast forward to today, and while clinical documentation has taken great strides – with some organisations such as South Tees Foundation NHS Trust, incorporating AI-enabled speech recognition technology – there are many that still rely on inefficient methods that impact on the amount of time doctors can spend with patients.

As the NHS celebrates 70 years, we now have technology that enables patient records to be created, secured, stored, and managed in the cloud and, in doing so, provide technology that supports clinicians ‘on-the-go’ and with a secure, quick, easy-to-deploy, and scalable solution for health organisations

As the NHS celebrates 70 years, we now have technology that enables patient records to be created, secured, stored, and managed in the cloud and, in doing so, provide technology that supports clinicians ‘on-the-go’ and with a secure, quick, easy-to-deploy, and scalable solution for health organisations.

Overall, 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.

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