Re-imagining clinical documentation in outpatient services

Out with the old

Clinicians in outpatients had been reliant on handwritten notes and using medical secretaries to type and edit letters. Letters could take up to 17 working days to reach patients. Budget constraints meant that recruiting more medical secretaries or using agency staff was not an option. An alternative method of quickly and accurately producing clinical documentation was required.

The transformation team implemented Nuance Dragon Medical One
cloud-based speech recognition integrated into the Cerner Millennium electronic patient record (EPR). Clinicians now use their voice to capture the patient consultation more naturally, efficiently and on their own terms.

Paul Adams, Head of Clinical Information Systems said: “The roll out of Dragon Medical One to our clinicians was quick and simple and limited only to the speed at which we could introduce clinicians and their teams to the new ways of paperless working.”

In with the new

Within weeks, turnaround time of clinic letters dramatically reduced from 17 days to just two. The trust estimates it is saving in excess of £150,000 per year and bank and agency costs have been reduced culminating in a one third reduction in spend on the medical secretariat

Furthermore, during outpatient clinics, clinicians can now enter their own notes into the electronic patient record at the point of care and these notes can be immediately sent to the GP. Clinicians create clinic letters and give them to their patients before the patient has left the clinic.

Outpatient services re-imagined

Resulting in positive change for everyone:

• Patients receive faster, personalised communication.
• Medical secretaries can now focus on patient contact rather than typing backlogs.
• Clinicians know they are providing a better level of care to patients and no longer have to spend extra time after clinics catching up on paperwork.

Dr Rob Fearn, Gastroenterologist, said: “Change always causes some anxiety, but that isn’t a reason not to make the changes. The way to make it work is to really understand the problem that the change is trying to solve. By bringing together clinicians, admin staff and operational management from the Trust I think we’ve been able to do that well.”