Society at large has become reliant on technology in a relatively short space of time, and the timescale in which technology has progressed is impressive. Consider the moon landing, which was 50 years ago; today's smartphones have far greater computing ability than the computer that aided the moon landing mission (Kaku, 2011). We now live in a world where good technology is essential for good communication, creating and maintaining a community (through social media) and working efficiently, and the world of healthcare is catching up. Certain countries have been pioneers in the adoption of health technology, and have used it for many years. Denmark has been ahead of the trend for some time, introducing basic electronic prescriptions in the 1990s, and Sweden quickly followed its lead (Klein, 2010). In Denmark, clinicians across all regions are able to access a patient's health records (Danish Ministry of Health et al, 2018). In terms of telehealth, India is developing this area for its many rural areas that do not have regular access to doctors (Rao, 2018).
The uses of health technology range from storing patient records electronically and being able to communicate with other hospitals, specialties and professionals involved in a patient's care, to allowing isolated patients to access telehealth and monitoring these patients remotely.
Increasingly, healthcare technology is now also being used in the UK. As the NHS Long Term Plan (2019) demonstrates, the health service in the UK has witnessed a mammoth change in its use of technology over the past few years, and it has been found to have a positive impact on service efficiency as well as patient outcomes. Patients can now access their primary health records online and can be informed by over 70 applications that provide health information (NHS England, 2019). Some 93% of GP practices use the Electronic Prescriptions Service (EPS), with more than 67% of patients using this service (NHS England, 2019). The NHS has also created Global Digital Exemplars, which are knowledge-sharing platforms using which ambulance, acute and mental health trusts will pioneer the use of technology within healthcare (NHS England, 2019). However, these changes are only the beginning, and it is necessary to implement more digital services for the NHS to thrive in the future.
The main difficulty in adopting this plan to increase and improve health technology is that the NHS is made up of many different organisations and services that work in radically different contexts and use varying methods of obtaining and sharing information. A tech initiative that works within an acute ward cannot be replicated in community services, and vice versa. Thus, clinical areas must consider what health technology is beneficial to them.
One way of implementing health technology to benefit patient care and improve efficiency is developing a ‘paperlite’ culture. The term ‘paperlite’ represents the idea that most patient records can be kept within an IT system, accessed through both computers and mobile devices, and be shared among the various health professionals involved in a patient's care. Paperlite also encompasses the idea that, in other instances where paper is used in everyday working, such as printing referrals or having paper diaries, technology can be used instead. This is where the use of mobile devices comes in, replacing the use of paper.
The Queen's Nursing Institute's (QNI) (2018) report ‘Nursing in the digital age’ outlines how district nursing teams can use technology and implement a paperlite culture. One of the recommendations is to appoint a Chief Nursing Information Officer, who would lead the implementation of IT to ensure that the technology used is practical for clinical staff and to liaise with IT support. Another recommendation is to involve clinical staff in the choosing and designing of IT systems and keep them up to date with the process, which is key for a successful paperlite culture. The QNI (2018) also recommended ensuring that all staff are appropriately trained to use any IT systems or devices, with the knowledge and willingness of staff to learn being considered carefully.
Project background
The Greater Manchester area is undergoing a period of transformation, ever since Manchester's health and social care funding was devolved in 2016, allowing services to be shaped to the needs of the communities (Greater Manchester Health and Social Care Partnership, 2018). In 2018, Stockport NHS Foundation Trust applied for and received funding from the Greater Manchester Digital Transformation fund, as part of the Greater Manchester devolution. This funding was awarded to enable the trust to implement mobile working across adult community health services, with the aim of the trust becoming paperlite by the end of 2020.
Prior to the pilot, paper was very much the default option within district nursing: referrals were sent by fax or post, with only some services using secure email. Teams used a paper diary to record multidisciplinary meetings or individual training dates. All resources would be printed and physically stored at the district nursing base. Every morning, staff would have to come into the base to collect their list of patients, as well as any additional information, such as key codes and referrals, or equipment for the visits, such as wound dressings. Each visit was recorded within the patient's home notes, with a carbon copy being returned when each page was filled. Only discontinued care plans, out-of-date medicine authorisations or filled medicine administration sheets were removed from patients' home notes, to be placed in office notes stored securely at base. Any referrals, pictures or letters would be placed in office notes, copied and brought to the home visit. Once the staff returned to the base, they would input the visit details electronically onto EMIS Web, thus only logging bare essential information, such as who visited the patient, what care was provided and the timing of the visit. Any health professionals using the same system (apart from GP services, as data sharing is yet to be initiated across Stockport) could also view patient records as they were updated, but required access to a computer.
Unfortunately, internal processes did not support using the full electronic clinical record. For example, a visit to re-dress bilateral leg wounds would be recorded, but, because paper notes were being used, there was no need to go into the details of the visit on EMIS web. So, there might have been a lengthy discussion about why compression bandaging was required and what options the patient would have once bandaging was no longer necessary, but this would not necessarily be recorded in EMIS; therefore, the complexity of the visit was not captured. Further, any attempt at replication could lead to ambiguous or incorrect documentation, as staff would be attempting to duplicate something they had written hours ago.
In addition, many of the district nursing bases only had a small number of computers, which used outdated technology and were not cared for by staff due to a lack of IT understanding. Since community nurses are based across the Stockport community, and not at the trust's main site, it took very long for any IT issues to be fixed. These problems often caused delays in inputting data, which, in turn, raised concerns about the accuracy of the data inputted and lengthened the task of documenting exponentially. Often, it felt like the time taken to complete paperwork amounted to more than what was being spent with the patient.
The pilot
In June 2018, a pilot for the use of mobile devices in the community was introduced within one neighbourhood, encompassing two district nursing teams, and it continued for 8 months. All clinical staff were provided with a tablet equipped with the EMIS mobile app, along with many other useful apps and functions. They were also provided specialised EMIS mobile training. By using the EMIS mobile app, staff could simply sync their diary in the morning to view their visits for the day, and have any visits added or removed for any reason without much complication. The only pre-requisite was a 4G or Wi-Fi connection. Each time staff visited a patient, they could immediately input the data into the EMIS mobile app, providing real-time updates to any health professional with access and allowing the data collected to be more accurate, as it was recorded soon after the visit. Throughout the pilot, the EMIS mobile app was updated to include useful functions. For example, at first, only view a limited part of the care record could be viewed on EMIS mobile, but now, various documents, such as referrals to other services or discharge letters, can be viewed. These improvements allowed the team to become less dependent on paper. The mobile device was also equipped with other functions, such as the ability to complete a Datix, input mileage, take pictures and send and receive emails. There was also a range of reference apps available, such as the British National Formulary (BNF), Lohmann & Rauscher (L&R) hosiery selector, NHS Guide to Safeguarding and NHS Diabetes & Me apps.
In June 2018, the author was a third-year student nurse on sign-off placement and had previously been placed in a district nursing service that used mobile devices. Since the author was enthusiastic about the use of mobile devices in service provision and could assist colleagues who were less comfortable using technology, she was invited to join the first EMIS mobile training session. In September 2018, she joined the team as a registered nurse, and was asked to join a task-and-finish group, which aimed to develop and improve the existing consultation templates on EMIS Web and Mobile, as well as integrate paper-based care plans, to begin the process of being paperlite. The template in place at the time was not intuitive to the user, and did not capture the clinical data required for a paperlite system. Over the next 8 months, the task-and-finish group met regularly, carefully analysing the template to identify what was missing. The group had to consider the way the template would be used in the community, questioning whether it would be intuitive enough for staff to use, whether it captured the required data and whether it was more efficient than writing notes. It also had to ensure that the template adhered to the trust policies and guidelines, and that it worked well on both EMIS Mobile and Web. This process was completed in July 2019, and the templates were released to all district nursing staff in September 2019.
Benefits of the paperlite model/mobile working
With the introduction of mobile devices, several benefits were noted. Since staff could check their diaries from anywhere, they were able to plan their day much earlier rather than waiting until they arrived at the base. This improved efficiency and increased the number of patients being seen. It also allowed staff to become more flexible, for example, those who went home during their lunch hour could still be kept up to date on any changes to their schedule. Furthermore, contingency planning for situations such as snow days or flooding was greatly simplified with mobile devices. Staff members can receive live updates on which patients need to be visited and can be reallocated to a closer team within the trust if needed.
Although the paperlite system has not yet been fully implemented, the benefits are obvious. As stated previously, the data provided through EMIS is not 100% accurate. Once paper notes are eliminated, data will be captured more accurately. It is hoped that this will lead to more funding being made available, as accurate data about local population needs will be better captured.
From the financial aspect, the implementation of a paperlite/mobile working system requires funding up front, but the savings once the system is in place are considerable. Faxing, printing and the overall use of paper will reduce dramatically. Mileage costs will also reduce, since staff members will not have to come into the base every morning.
Issues faced
Implementing a mobile working/paperlite culture is not without its challenges. One of the main issues faced was staff engagement. Although the use of technology within the community is by no means a new phenomenon, many staff members were hesitant about it and did not feel confident. This lack of confidence meant the devices were not used as regularly as desired. Additionally, since this was a pilot trial, staff members were not explicitly required to use their devices regularly, although they were encouraged to do so. This meant that many staff member's confidence in using the devices dwindled over the course of the pilot, further causing them to avoid using the devices regularly.
Another challenge was connectivity. The area in which the pilot was conducted has a patchy mobile signal at best, which is not uncommon in many of the more rural areas. Thus, there were times when staff could not update work lists or access past evaluations to analyse any changes in the patient's condition. Furthermore, the bases that tested the devices were not set up with an accessible Wi-Fi connection for many months, so staff often could not get a reliable connection while at base.
Finally, the trust decided to use Android devices, as opposed to Windows or IOS, and although this is a cheaper option and just as reliable, staff are more familiar with IOS systems and struggled initially to get used to another operating system. Although this was a somewhat easy challenge to overcome, it was important to reflect on before the full implementation of mobile devices.
Recommendations for other adopters
On the basis of this pilot, several suggestions are available to others who wish to implement a paperlite system within community care. Firstly, a long trial period is beneficial. The initial pilot introduced the concept of mobile working, and the next 8 months were spent ironing out any issues with the system, creating customised EMIS templates and, most importantly, spreading the word among staff. Secondly, it is ideal to involve as many clinical staff members in the pilot as possible. This helps ensure that the system works in the context of the daily job, and staff members will be less hesitant knowing that one of their colleagues has had a say in the establishment process.
It is important to involve IT services at the outset. A project like this is a considerable undertaking, and IT staff members need to understand that it will be very different from their usual work of supporting trust-site staff. It should be ensured that they understand the implications of having to look after community staff; visiting the IT building is not feasible for community staff, so other options must be explored. For example, a monthly drop-in clinic could be set up for any IT issues within the community, and IT staff should moving around regularly to provide good, consistent support.
Finally, time should be set aside for less technically able staff to become comfortable with a new way of working. There will be members of staff who will struggle with the introduction of more technology, and will therefore make mistakes and feel disempowered. If left unaddressed, this disempowerment and confusion spread quickly, and cause more engaged staff to lose motivation. Extra training should be made available for those less confident, and the use of peer-teaching should be considered. Often, it is difficult for IT staff to explain how technology works within the context of community care, and tech-savvy colleagues are perfectly placed for this. Not only will this help to engage those who may be less enthusiastic about the increased use of technology, but also the staff teaching them will feel more involved in the project, improving retention.
Conclusion
From September 2018, Stockport NHS Foundation Trust is implementing the use of mobile devices and then a paperlite culture, across all district nursing teams.
Since the pilot ended, many aspects that were previously a challenge have now been addressed. When inputting data on EMIS Mobile, any unfinished items are saved to the device and uploaded when a suitable connection is avail. Although this may sound cumbersome, it is far more efficient than the paper alternative. Furthermore, all bases now have Wi-Fi installed, reducing the problem of data remaining not uploaded.
It is understandable that more issues are likely to arise when this initiative rolls out trust-wide, and feedback will be sought from all stakeholders. However, no new initiative is without its downfalls, and the paper system is far from perfect. The NHS seems almost obsessed with the use of paper, viewing it as a safety blanket. Significant changes have been undertaken within the health service, which were not initially well-received by staff but were eventually accepted as they understood how these changes improved practice. The paperlite system is likely to follow this trend.
KEY POINTS
- Various clinical areas of the NHS are adopting healthcare technology to improve efficiency and patient outcomes, and district nursing is catching up with this concept
- Paperlite represents a culture of reduced dependence on paper for record keeping, appointment planning, knowledge sharing, etc
- The Stockport NHS Foundation Trust is in the process of adopting paperlite culture through mobile working
- The key themes that emerged from a pilot of paperlite in the trust were peer teaching and the need for better communication and integration between IT services and clinical staff.
CPD REFLECTIVE QUESTIONS
- How do you feel about the use of health technology within community?
- What is in place at your place of work in terms of mobile working or paperlite, and how could it be improved?
- What is one aspect of your working day that could be improved by the use of a paperlite/mobile working system?