Welcome to the paperless ward driven by data

Major advances in medical technology have an immediate impact, a punch factor that drastically improves the way we can treat the sick and the injured.

Wilhem Conrad Roentgen's discovery of the X-ray at the end of the 19th century and the more recent invention of the CT scanner not only meant doctors no longer had to cut people open to look inside but also initiated development that led to further breakthroughs.

The onset of electronic patient records (EPRs) hasn't registered that sort of dramatic change in the medical profession - but the consequences could be just as important.

More than just a digital version of the old-style paper records in brown envelopes at the foot of the bed, an EPR is part of an intelligent system that aims to streamline the workflow of the hospital and cut down on wasting time and resources.

From the time a patient enters the hospital to their discharge and beyond, their EPR tracks every event and every procedure, the medicine and equipment used, the treatment involved, who is administering the procedure and when all this is happening.

For the physician, it can be customised to the individual user, suggest treatment and carry an encyclopaedia of medicines and a directory of hospital best practice.

For administrative staff, it can keep track of stock and order more when necessary, keep a tally of the costs involved and of how long a particular piece of equipment lasts before it needs to be replaced.

Different types of hardware are being experimented with. Originally, Personal Digital Assistants (PDAs) were popular, as they are small and robust, but given the amount of information displayed on screen and the pressurised environment medical staff work under, they are perhaps too small and fiddly.

Laptop-sized flatscreen tablets, although more unforgiving if dropped, have a big enough screen to display information legibly and are light and portable. These can be positioned around the hospital at waist-high stands and carried around from there.

At interface level, the software works on a file-and-folders system, like a standard PC operating system. Each tablet is connected to the internet, medical databases and the main hospital network. To speed up access and input, staff can use lightpens or voice recognition. The system is designed to be as user-friendly as possible, as, unlike in other professions, medical staff don't always have time to wait for the IT staff to show up if there is a breakdown in communication between human and machine.

The implications of EPRs are huge, but hospitals are complex operations, with different departments with different requirements and the process of joining all the dots is a long and arduous one.

Now, after years of development and research, Irish hospitals are beginning the changeover at a time when the need to modernise administration has rarely been more acute.

Martin Mooney, divisional manager of Siemens Medical, has been involved with the Adelaide & Meath incorporating the National Children's Hospital (AMNCH) in Tallaght and the Galway Clinic in Doughiska, Galway.

"One of the thrusts behind this is the need to cut down on administration costs and focus resources on the patient," he says. "Say, for example, a patient needs an X-ray, and he goes down to get it at lunch. The guy comes round delivering the lunch but the patient isn't there, so the lunch goes to waste.

"It's only a small example but, if you apply to it the whole hospital, you can see how you can streamline the workflow with a proper system.

"With a proper IT solution, if the X-ray machine breaks, a flag goes up to all the wards, saying 'don't send anyone down until one o'clock as the machine will be broken until then'.

"Then a flag is raised in the kitchen, which says 'don't bring lunch to that patient, he'll be in the X-ray at that time'.

"There is a desire to manage the whole operation, streamline the process, anticipate what might or might not happen. Funding for IT has traditionally been much smaller than what is required because the money is being swallowed up in administration.

"For a decent EPR system, you're talking €5 million. St James's and St Vincent's [ hospitals] would be spending €3 to €5 million, so it's not an enormous sum like €100 million. It's manageable."

One of the obvious advantages of the system is that it can help alleviate the chronic bed shortages in Irish healthcare at present.

"The issue of beds is a tricky subject at the moment," says Mooney. "It's not going to be as simple as 'that bed will free at five o'clock, so we can put Mr Johnston in by seven', but the system can be adapted to suit the procedure and maximise bed usage."

To those used to working in a paperless office environment, this might seem to be coming five or 10 years behind everything else, especially if the majority of your knowledge of hospitals has been gleaned from ER.

EPR systems have been developing over the past 10 to 15 years. The idea was first stimulated in the US, where an ageing population were getting sicker for longer and there was an increasing shortage of doctors and nurses. The litigation culture in the US also called for a more precise recording system.

But the medical profession is very entrenched by nature and it has taken a long time to make the change from the old system to the digital hospital.

"Hospitals are lumbered with legacy systems from the past, stacks of old notes, rooms full of old X-rays," Mooney says. "It is rare that you get a greenfield site to work on. In Ireland, there are private hospitals being built that are starting from scratch, in particular the Galway clinic."

The last major greenfield site in the Republic was the AMNCH in 1998.

Radiography has been at the forefront of the drive to go digital and, at the time, the AMNCH was the only filmless X-ray department in Britain and the Republic.

Helen Sweeney is superintendent III radiographer in Tallaght. She moved there seven years ago when the hospital first opened.

"We went filmless back in 1998," she says. "The amount of space we have now compared to before is just unbelievable, it's brilliant. Also, before, the biggest problem for any radiology department was X-rays getting mislaid or being put back in the wrong place. That never happens now.

"We came out here with a 'big bang' situation, where it would have been more costly to go with our old systems.

"The concept was so new that, when we went to tender in 1996, we didn't know exactly how to phrase the ad in industry journals."

With the benefit of a fresh start and new systems, the need for the AMNCH to install one integrated system is not as pressing as for the other large public hospitals, but the change will come.

"Of course, with technology, you always have to be looking over your shoulder," says Sweeney. "We aren't using EPRs here yet, but we will eventually. I believe Vincent's are tendering and James's may even be installing, but it takes time for these systems to interface across the hospital.

"When we moved out here, each department chose the 'best-of-breed' system that would suit its own individual needs, and these came from different vendors.

"The integrated systems being offered at the time were coming from Germany and the US, whereas the vendors we were dealing with had designed their product specifically for an Irish market, so there weren't a lot of modifications required. Now vendors are looking at the Irish market specifically."