The document presents an alternative "incremental" approach to implementing an electronic medical record system compared to the traditional "big bang" scanning approach. It discusses using a forms-based system to incrementally collect and transition information to electronic format over time with minimal disruption. This is demonstrated through the experience of Waikato DHB's mental health services implementing forms progressively for specific information like outcomes measures, then expanding to other clinical documents. Benefits include cheaper costs, immediate access to current electronic records, and redesigning processes to support the electronic system incrementally rather than retaining paper-based workflows.

1. Not with a Bang
An Incremental Electronic Record
Implementation
Paul Docherty

2. Agenda
1. Housekeeping:
Purpose, Definitions Context and Disclaimer
2. Why an Electronic Record?
3. Implementation Approaches - Scanning
4. Incremental Approach
5. Comparison of Approaches
6. Questions

3. 1. Housekeeping
Purpose:
To present an alternative to the big bang approach normally associated
with Electronic Record implementation
Disclaimer:
The opinions expressed are my own
This is not an academic presentation
Context:
Contrasting the difference between Waikato DHB MH Services,
Waikato DHB Medical Outpatients and Auckland DHB.
Electronic Record (Electronic Medical Record):
For the comprehensive documentation of the care received by one
patient delivered by one organisation

4. 2. Why an Electronic Record?
Good Reasons:
1.
2.
3.
Paper-based notes are not always available at the point of care
(particularly in after hours and crisis situations)
Notes are up to date (and complete)
To improve clinical access to information
There is a link between improving Clinical Decision-Makers’ access to
information and the quality of their decision making
Bad Reasons:
1.
2.
Savings on Paper and Administration Processes (filing)
Hopes of mining the information for research and clinical audit

5. Whitianga Mental Health Clinic
Whitianga Clinic – Waikato DHB
•
•
•
A Mental Health Clinical & Community
Services base – 2 permanent MH staff
+ 5 visiting
1 ½ hours from Thames Hospital
3 hours from Waikato Hospital
•
After hours crisis staff located at
Hamilton / can be dispatched from
Thames
•
With an Electronic Record Crisis staff
have immediate access to the records
for Whitianga patients

6. Auckland DHB – Grafton Road
Grafton Hospital / Greenlane Redevelopment (~2003)
•
•
Centralise ED and Theatre to Grafton Road
Centralise Outpatients to Greenlane
•
Without an Electronic Record 2,000+ Clinical Record (file) movements
per day (estimate)
•
Problem: What is the likelihood that Clinical Record would be on the
wrong campus (or lost in transit) – particularly since unwell people who
attend Outpatients in the first place

7. 3. Record Scanning
Scanning
•
Post event (ED, OP, IP) – all paper associated with the event is
scanned, QA’d, and published.
Back Scanning
•
•
Decision needs to be made to back scan existing notes
Scope of back scan is hopefully associated with a risk assessment
Objectives Met?
•
•
•
Record is available
Not necessarily immediately (delay to scan)
Back scan is often cumbersome

8. 3. Record Scanning Issues
Visible Issues
•
•
•
Expensive setup, Expensive to back scan
Can be delay in scanning after event (next day, days later)
Maintenance costs equivalent to manual filing
Invisibles
•
•
•
Disruption caused by big bang implementation
Information not easily available for research and clinical audit
Existing ‘poor’ processes retained due to paper based recording
Outcome
•
•
•
•
Service disruption at transition
Clinical resistance to use
Paper use can often increase [bad reason noted above]
Result is often ‘e-paper’

9. 3. Scanning
Without a location issue a business case for scanning can be
very difficult to write and justify.
A business case based on ‘saving’ in print cost should be
discarded.*
*personal view

10. 4. Incremental Approach
Forms (Waikato DHB – MH)
•
•
Leveraged National or Required Collections to incrementally introduce
an Electronic Record
New forms were introduced over time and supporting business
processes reworked.
Data Migration
•
•
May or may not be required depending upon existing information held
electronically
There may never be a clear demarcation between paper and electronic
Document Substitution Approach
•
•
•
Progressive implementation form by form
Focus on high clinical value, high compliance value first
Left-over paper may never be included (scanning may be used)

11. 4. Waikato DHB – Early Steps
Early Timeline:
•
•
•
•
•
Introduced Form Toolkit to collect HoNOS (outcome measures) –
required by MoH in 2005.
Progressively introduced forms for collection of clinical information
required by PRIMHD over time (2006 - 2007)
Progressively introduced forms to support clinical process improvement
and KPI reporting
No effort was made to include historical information
Paper based clinical record was maintained in early steps

12. 4. Waikato DHB – 2011 - 2013
Recent Timeline:
•
•
•
•
First ‘Dictate’ that non collection information must be recorded
electronically – Treatment Plans required 2011
Risk Assessment must be recorded electronically - 2012
First electronic only forms (no longer requiring printing) – 2012
Mental Health Electronic Record Strategic Objective approved – 2013
Usability:
•
•
•
At all stages clinicians were included in the process and decision
making
Forms introduction matched existing staff capability (mostly below the
pain threshold)
Training of staff occurs side by side with introduction of new forms

13. 4. Strategy
Early Objectives:
•
•
•
To provide a platform for the collection of Outcomes measures for
Mental Health
To provide a platform for future collection requirements - knowing that
additional collections were in the pipeline
That this collection platform should integrate with existing systems
Current Objectives:
•
•
•
To have a single electronic file containing 80% of all documentation
and 100% of all high value documentation – within 2 years [for MH]
Continue with document substitution strategy
These objectives are inline with overall service goals

14. 4. Forms Toolkit
Side effect of implementing a generic form toolkit for
National Collections was that it enabled the collection and
reporting of other types of clinical information.
Business case for purchase of the form toolkit was justified
solely on the basis of meeting the then current HoNOS
requirement.

15. 5. Comparison of Approaches
Scanning:
•
•
•
•
•
•
Big Bang with Service Disruption
Expensive setup / ongoing maintenance
Expensive back scanning
Notes are available
Notes are up to date (delay for scanning)
Existing paper-based business processes are maintained
Forms / Document Substitution:
•
•
•
•
•
Incremental Implementation with minimal Service Disruption
Cheaper implementation (than scanning)
Notes are available immediately
Business processes are progressively redesigned around with
electronic support
May take many years to transition from paper to electronic

16. 5. Comparison of Approaches
Scanning:
•
•
•
•
•
•
Big Bang with Service Disruption
Expensive setup / ongoing maintenance
Expensive back scanning
Notes are available
Notes are up to date (delay for scanning)
Existing paper-based business processes are maintained
Forms / Document Substitution:
•
•
•
•
•
Incremental Implementation with minimal Service Disruption
Cheaper implementation (than scanning)
Notes are available immediately
Business processes are progressively redesigned around with
electronic support
May take many years to transition from paper to electronic

17. Thank you … questions
Paul.Docherty@WaikatoDHB.Health.NZ
Phone: 07 838 8899 x 23131

18. 6. Discussion Points
Why is a form better?
•
•
•
•
•
Auto population of patient and user demographic information
Auto population of previous patient information from previous forms
Forms can contain required fields
Forms can check ranges to avoid silly data entry errors
Forms can contain Business Rules such as date checkers
Advanced Form Use Allows:
•
•
•
•
Living documents
Progressive documents
Multi author documents (with auditability)
Form applications (combinations of forms with reporting)

19. 6. Discussion Points
Flying below the radar:
•
•
•
Incremental introduction avoids change pain
Progressively users do not realise their use is increasing
When forms are easier to use than paper there is no stopping uptake
Culture of Innovation (How you know you’ve got one)
•
•
•
Users ask what’s coming next (Change enthusiasm)
Users make unprompted suggestions
Users make positive criticism – cross referencing other forms
Below the Pain Threshold
•
•
•
Incremental change
Well communicated change
Having leadership support (Staff feel supported)