Nuance commissioned an independent research company, Ignetica, to carry out research into the Challenge of Clinical Documentation in NHS England Secondary Care Trusts (Jan to April 2015). The results are now out and have great relevance and value for Health CIO/CCIOs and other decision makers within UK Healthcare making investments in EPRs and other digital healthcare projects Get the headlines from the research and hear how Alder Hey’s Paediatric Intensive Care Unit are overcoming some of the challenges highlighted in the research Presented by: Frederik Brabant, CMIO, Nuance, Peter Booth, MD, Ignetica & Elaine Scott and Peter White, Nurse Leads of e-health projects at Alder Hey Paediatric Intensive Care Unit Presented by: Frederik Brabant, CMIO, Nuance, Peter Booth, MD, Ignetica & Elaine Scott and Peter White, Nurse Leads of e-health projects at Alder Hey Paediatric Intensive Care Unit Chaired By: Jon Hoeskma, CEO, Digital Health

1. © 2014 Nuance Communications, Inc. All rights reserved. 1
Overcoming the
Challenge of Clinical
Documentation
Nuance commissioned research on: Understanding
the patient, process and economic implications

2. Ignetica Ltd (www.ignetica.com) Client Confidential
Project Site www.ignetica.clientsection.com
Health CIO Network: 19 June 2015
The impact of clinical documentation on clinicians, patients & trust economics.

3. ClinDocs – Summary Findings
Ignetica Ltd (www.ignetica.com)
Page 3
Client Confidential
Project Site www.ignetica.clientsection.com
Introduction
• In response Nuance commissioned IgneticaLtd to undertake a
light touch (clinician perceptions)study to provide this insight.
• The study is not intended to test the impact of a new
technology, nor to audit records to evaluate their
accuracy/completeness (there are of course other studies in
these areas).
• The focus of this study is to understand the situation and
implications when ClinDocs are not as complete or accurate as
clinicians would wish.
• In so doing, to also understand the context of clinicians
interactions with clinical documentation
It is widely recognised that quality of clinical
documentation can be considerable challenge, but
there is very little research which identifies the
extent of the impacts on clinicians,patients and
ultimately trust economics.
Ignetica Ltd has prepared this presentation based on the full research report for the sole use of Nuance Communications in accordance with the terms of engagement for this project. The document should not be
used for any other purpose without the express permission, in writing, of Ignetica. Any recommendations, opinions or findings stated in this report are based on circumstances and facts as they existed at the time
Ignetica performed the work. Any changes in such circumstances and facts upon which this report is based may adversely affect any recommendations, opinions or findings. © Ignetica Ltd, 2015

4. ClinDocs – Summary Findings
Ignetica Ltd (www.ignetica.com)
Page 4
Client Confidential
Project Site www.ignetica.clientsection.com
Study approach
Qualitative Research & Hypothesis
The study involved several phases designed to provide a hypotheticalmodel of the potentialimpacts,to test and
refine this with clinicians andthen though wider survey insight across four centres …
Initial Hypothesis
• Literature review and end-to-end Acute CinDocs mapping
• Identification of areas most sensitive to accuracy & completion
• Development of initial hypothesis for review
Engagement with 4 Trusts representing Acute Healthcare
• 2x Large University Trusts, 1x Large DGH + Community and 1x
Mental Health Trust (& allied network)
• Review with Trust CCIOs to test and refine the hypothesis
Development of hypothesis to be tested & enumerated
• Finalisation of the hypothesis logic and development of survey to
further test and fully enumerate.
Primary Research
• Web-based clinician survey deployed at the four trusts
• 197 responses received (c40% Drs, 20% Nurses, 27% therapists)
Data Analysis
• Full data analysis per centre and overall
Impacts Analysis and reporting
• Analysis of the impacts for clinicians and patients
• Analysis of the economic implications
• Final reporting
Quantitative Research & Analysis

5. ClinDocs – Summary Findings
Ignetica Ltd (www.ignetica.com)
Page 5
Client Confidential
Project Site www.ignetica.clientsection.com
Survey insight …
Based on the hypothesis,the survey was undertaken to understand on a wider basis how frequently info is not
available when required,including the reasons,responses,implications and operatingcontext …
Reasons
The reasons for information
issues
How clinicians cope with
these challenges
Responses Implications
For clinicians, patients and
overall economics
?
How frequently do
ClinDocs not inc
the info you need …
.. at the time and the detail
you require ?
• How likely are information delays to cause extended LOS/pathway?
• How satisfied are you that your notes are as complete as you would wish?
• Would your notes be more complete if you had more time available?
• What would be the benefit of more complete notes?
Clinician
Perceptions
• Methods used for ClinDocs access (e-health stage)
• Methods used for ClinDocs addition (e-health stage)
• Clinical Role (Dr/Nurse etc)
• Clinical Area (Medicine, Surgery etc)
• Age profile of respondees
Baseline &
Demographics
• Time spent reviewing clinical documentation
• Time spent adding to clinical documentation
• Percentage of adding time that is narrative based
• Analysis of working time by setting
• Time is spent searching for info
Core activity &
ClinDocs timing

6. ClinDocs – Summary Findings
Ignetica Ltd (www.ignetica.com)
Page 6
Client Confidential
Project Site www.ignetica.clientsection.com
Responses
What the study has told us …
The study has provided insight spanning accuracy and completion,context of how clinicians interact with ClinDocs
and the their views on the current situation …
Reasons
• 27% | Not sufficiently complete
• 14% | Not clear in meaning
• 13% | Not clear in legibility
• 14% | Known but hasn’t yet
been included in notes
• 16% | Diagnostics/ investigations
are still required to ascertain the
information
• 11% | It is not clear what
investigations/ diagnostics have
been requested
• 6% | Other
• 33% | Search for information
• 12% | Request investigation/
diagnostics, may duplicate.
• 12% | Work without because
too critical to wait
• 26% | Work without the
information because not
critical & would take too long
to resolve
• 12% | Wait and check again
later to see if it is then present.
• 6% | Other
Implications
Time consumed and delayed
• Time consumed searching for
info (52 mins pp/day 69.9 Dr)
• Time consumed rechecking
(63 mins pp/week overall)
• Delay to delivery of care (from
info request to being available
to act on)
Activities (leading to cost)
• Most common duplicated
activities/ diagnostics
Information Gaps
• Views on working without info
DR=36.4%
Nurse=28.4%
Therapists =9.5%
How frequently do ClinDocs
not include the info you need
at the time and the detail you
need?
All
Not
available
27.4%
Available
72.6%
• 41% directly linked to accuracy
completion with 11% influenced by
accuracy and completion
• Searching & working without
information because NOT critical
are most frequent responses
n=141

7. ClinDocs – Summary Findings
Ignetica Ltd (www.ignetica.com)
Page 7
Client Confidential
Project Site www.ignetica.clientsection.com
Clinician view on LOS/Pt journey
Respondees were asked for their views on the potential for info-delays to impact patients journey/LOS,with all
(other than therapists)regarding it as more likely than not …
n=85
Mean rating (1-5)
Per role or field
Distribution of ratings
• 80% of doctors felt it was possible,likely or very likely to extend patients
stay/journeys and “Likely” was the most popular response

8. ClinDocs – Summary Findings
Ignetica Ltd (www.ignetica.com)
Page 8
Client Confidential
Project Site www.ignetica.clientsection.com
The implications
The impacts have implications for Clinicians,Patients and overall economics as summarised below …
Clinicians
Staff Productivity
• Time consumed searching for info (52
mins pp/day overall and 69.9 for Drs)
• Time consumed rechecking for info (63
mins pp/week overall)
• Sessions not utilised effectively due to
information not being available (eg 3.5
OP clinic appointments per clinician
week due to info issues)
Staff Satisfaction
• Level of Frustration (68% indicate
frustration in responses)
Patient Experience
• Delayed and disrupted delivery of care
(extended timescales, duplicated OP
appointments and potential IP LOS)
• Duplicated diagnostics (eg bloods)
Patient Safety
• Working without full information (though
normally because not critical 26%)
Patients Economics
Time Value £7.6k pa (Drs £19.5k pa)
• Time consumed searching for info
• Time consumed rechecking for info
Cost Optimisation (£2.5-6.8k pp/pa)
• Duplicated investigations/diagnostics
• Opportunity cost of under- utilised
capacity due to information issues
Revenue Enhancement (£12.5k pp/pa)
• Potential opportunity to utilise OP capacity
through reduced info issues
• Potential opportunity to utilise IP capacity
through reduced info delays

9. ClinDocs – Summary Findings
Ignetica Ltd (www.ignetica.com)
Page 9
Client Confidential
Project Site www.ignetica.clientsection.com
Wider context – ClinDocs time
• Overall over 50% of time is spent on reviewing or adding to
clinical documentation.
• In a sense this isn’t a surprise due to its central role in the
clinical process,but it does highlight how even small info
improvements can have a big impact.
• From an Adding perspective a total of 10.8 hours is
consumed on average per clinician per week, with 68.6%
being narrative
• As shown this means 7.4 hours perweek is spent
generating narrative content and 3.4 hours on structured
data on average.
• This is a very significant measure since it is this activity
which is key to producing accurate and complete clinical
documents. And clinician's believe with more time their
note would be more complete ...
It has also provided further insight,for example on the time spent reviewing and adding to clinical documentation
and what proportionof the later was narrative content …
Hours per week n=119
Hours per week spentadding to ClinDocs

10. ClinDocs – Summary Findings
Ignetica Ltd (www.ignetica.com)
Page 10
Client Confidential
Project Site www.ignetica.clientsection.com
More complete notes with more time?
The overwhelming response from clinicianswas that with more time (or therefore technology which means the time
is more productive)their notes would be more complete …
n=85
Mean rating (1-5)
Per role or field
Distribution of ratings
• “Very likely” was the overall modal response,with 75% of respondees
indicating somewhat likely, likely or very likely.

11. ClinDocs – Summary Findings
Ignetica Ltd (www.ignetica.com)
Page 11
Client Confidential
Project Site www.ignetica.clientsection.com
Queries & Further Information
Queries arising from this document should be forwarded in the first instance to Peter Booth at
Ignetica via email: peter.booth@ignetica.comor direct dial +44 (0)1606 888578
www.ignetica.com
Tel: +44 (0)1606 301100
End of Document

12. © 2014 Nuance Communications, Inc. All rights reserved. 12
Download a copy of the Clinical
Documentation Research
http://engage.nuance.co.uk/study-
nhs-trust-clinical-documentation-
challenge

13. © 2014 Nuance Communications, Inc. All rights reserved.
Real Life
Elain Scott, Alder Hey Children’s Hospital PICU

14. An NHS Nurse Technology Fund Award
Case Study and Benefits Realisation at
Alder Hey Children’s Hospital
Elaine Scott
PICU Lead Nurse for Badger EPR
Peter White
Senior Staff Nurse PICU,
Clinical Nurse Educator

15. Synopsis:
A Case Study describing Alder Hey Paediatric Intensive Care Unit’s
(PICU) Nurse Technology funded project to roll out a speech-enabled
EHR including the rationale, challenges, implementation strategy and
the realised benefits for patients, the team and the hospital.

16. The grant for our project
•Response to the call for applications in December 2013
•Bid for software and noise-cancellingmicrophones
•Fit with current strategy for EPR
•Badger PICU
•Structured data
•Nursing model

17. Typing – wpm - 2015 Speech – wpm - 2015
Mean
16.53846
Mean
98.91667
Standard deviation
6.036215
Standard deviation
8.836158
Median
16
Median
98
Maximum
29
Maximum
124
Minimum
9
Minimum
73
IQR
11-20
IQR
93-104.25
Freeing up Time to Care
Study of note production speed n=20

18. Not just structured data.
Importance of “story”
•Determiningdiagnosis
•Communicationwith families
•Root cause analyses
•Rationales and interpretations

19. Interface issues:
Problem Our solution
• Meditech v.5 – old system – DOS style interface -
soon to be replaced by Meditech v6 and by Badger
• Notes recorded in a ‘Memo box’ and assessment in a
‘wrapped text box’.
• Unable to select words or use dropdown menus in
Meditech 5.0.
• No integrated spellchecker
• Work around achieved using dialog box.
• Verbal commands work properly
• Special transfer commands

20. •Difficultyof supporting training.
•Isolation of trainers
•Time to train
•Intrusive environment
•Clinical priorities
• Our attempts to solve these problems.
Training problems:
“It just flows….”

21. Uptake from the nursing staff:
• Very positive response from first users.
• Used exclusively for notes by several staff (except for
certain situations – child protection, etc.)
• Nurses creating own templates which may be shared
with everyone.
• Some resistance from ‘older’ nurses – upset at the
general shift towards everything on a computer.
• Difficulty for Indian nurses.

22. Problem solving:
•Not optimal specificationPCs
•Accepted speed over quality – full
spec PC 5 passes, only 3 on PICU
• Long loading times.
•Connectivity

23. Where are we now?
• Badger Nursing goes live this weekend
• Planning a re-invigorationof staff participation
• Reassessment of the benefits of speech-to-text
• Incorporationof user performancefeedback
• Flexibility to capitalize on our Badger implementation

24. White P. and Scott E. (2015)
'Applying speech-to-text systems in documentation'
Nursing Times, 111(15), pp. 15-17
The future?
•Standardization for high quality notes
•Nursing and Midwifery Council’s (2010) guidance
•Mobile solutions
•Discrete programming for particular situations
•Empowermentof PICU nurses by giving them the right tools
for the job.

25. © 2014 Nuance Communications, Inc. All rights reserved. 25
Read the full Alder Hey story here:
http://engage.nuance.co.uk/speech
recognition-icu-epr

26. © 2014 Nuance Communications, Inc. All rights reserved.
Want to overcome your
clinical documentation
challenges?

27. © 2014 Nuance Communications, Inc. All rights reserved. 27
Clinical Document Improvement
ComputerAssisted Coding
Quality Analytics
Tools to capture, understand,
share clinical documentation
Front–end speech recognition
solutions to free up resources
and improve productivity
Nuance Healthcare offering
Do More
with Less
Digitise
your
hospital
NHS Productivity
Challenge
$22B Budget Deficit
Paperless NHS 2018
Records digital, real-time &
interoperable 2020
Improve
Quality
Quality and Compliance
CQC, HSCIC, Monitor
etc

28. © 2014 Nuance Communications, Inc. All rights reserved. 28
Call us on + 44 (0) 7887 051154!
or stay touch via:
www.twitter.com/voice4health
www.nuance.co.uk/healthcare

29. © 2014 Nuance Communications, Inc. All rights reserved.
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