Moving to a paperless walk-in centre

At the heart of this city, the WiCs treat over 200 patients a day. They assess and treat a wide variety of cases, with minor ailments ranging from wounds and sprained limbs to coughs and colds. These WiCs are some of the busiest in the country, and provide an invaluable addition to GP surgeries in the city and aim to take the pressure off A&E departments. In addition, the centres also deal with diagnostics such as screening, for example, for deep vein thrombosis.

The WiCs treat over 200 patients a day.

The WiCs have proven popular with patients in the city. One patient recently commented that, “It’s the convenience of coming to the walk-in centre if you cannot get an appointment at your doctor’s surgery. It is even open during unsociable hours allowing us to bring the children or ourselves whenever we want to.”

Following a primary care trust restructure in the city in 2006, all four centres were brought under the same PCT. This included the UK’s first specialist paediatric WiC. Previously, the centres had been working in isolation — two using an electronic system and two on a paper-based system. To get the best out of the facility, Liverpool PCT identified the need for an integrated, community-wide system that would enable all four centres to store and share patient and staff information and to operate as one virtual care centre. This would benefit patient care and provide an effective means for the PCT to allocate resources, based on realtime information. Benefits that had been realised from the two centres running on the electronic system needed to be extended to all four centres.

Before paperless

Before the change to an integrated system, working from isolated paper-based systems created a host of difficulties for Liverpool’s WiC staff and the PCTs. In terms of patient histories and records of care at the centres, it took time for staff to locate the details they were looking for, and they had no access to other centres’ records (where a patient might have previously been treated). Patients were thus forced to wait longer than necessary, which contributed to the queues.

There was also no facility for a centralised staff rota that would enable nurses to work at more than one site. This meant that the PCT could not utilise staff at the busiest locations and make the best of the resources available.

The triage function enables staff to prioritise care for patients more quickly.

To tackle these issues, Liverpool PCT engaged Clinical Solutions to provide a single integrated patient-management and clinical-consultation system that would facilitate the transfer of medical records onto a central database that could be viewed and accessed by all four sites. The consistent and comprehensive patient data would enable staff to work at any of the city’s WiCs and adapt quickly to the patient records system. In addition, it would also provide clinical decision support for triage nurses. The key driver for this was the ability to access patients’ healthcare records and their histories of care in the city.

Aims and objectives

This project set out to meet a number of key aims and objectives:

• it aimed to provide a single integrated database of patient records throughout the new PCT;
• it should improve productivity and create cost-effective working practices, by enabling staff to work at any of the city’s WiCs;
• it had to be built with the potential to be integrated with the national data spine at a later date;
• it should be scalable, to be able to expand to meet future growth;
• it would provide clinical decision support;
• it would assist Liverpool PCT with building business cases for securing immediate and future funding to allow service redesign and meet changing healthcare needs, by being able to map trends and forecast costs; and
• it would provide consistency within clinical governance frameworks.

Choice of supplier

Following a competitive tendering process, Liverpool PCT selected Clinical Solutions (CS) to provide a system that would meet its objectives. Caroline Rand, Head of Information Management and Technology, said it was chosen because “Clinical Solutions has a history of working with two of our centres so had seen first hand the kind of challenges that WiC staff face.

We knew that CS had the commitment and ability to develop a system that would meet our changing needs going forward. In tactical terms, no other system on the market could give the range of functions we required. The key element was access to clinical decision-support software. Also important was the commitment made by Clinical Solutions to work with the PCT to ensure that the solution can connect to the national spine. This will future-proof our investment.

“The system is robust and scalable, with technical support being offered on a 365-day/24-hours-a-day basis. In addition it provides an audit trail to facilitate clinical governance. The reporting facilities and option to warehouse key data were also key to meeting the PCT’s needs.”

Risks and challenges

For Liverpool PCT, the biggest risk of this project was cost: it needed strategic justification for a long-term investment. There was the potential for risk associated with training and manpower, as a limited number of staff worked at all the centres and could not afford to be out of action while they trained to use the new system.

There were also potential issues with security. It was imperative that the system met data-management guidelines, and patient data confidentiality was of utmost importance.

Aware of the risks and challenges to implementation, Clinical Solutions appointed a dedicated project manager upon agreement of the contract and engaged with Liverpool PCT’s data analysts, the IT department and training specialists on the implementation.

Before introducing any system changes, CS carried out software framework upgrades and set-up community working protocols. The existing sites, at City and Old Swan, were upgraded from a Visual Basic (VB) to a .Net version of the system and staff were trained in the new functionality. On the other two sites the system was installed in partnership with the PCT’s technology team, in order to allow its IM&T department to give ongoing support to the healthcare community.

A full implementation took place at the fourth site on 13 March 2007. At each stage of the process, CS ran an implementation review to identify and resolve any problems as they occurred.

Overcoming obstacles

Training was easily adapted at the Sir Alfred Jones site to accommodate the busy staff who were operational and had little capacity for additional study. This problem was tackled by identifying a few key individuals who became specialist inhouse trainers. They were given the skills and tools to train and advise their staff on an ongoing basis, at a time suitable to them, and this also kept external training costs to a minimum.

In terms of data security, the transfer of all patient data to the off-site data centres realised immediate benefits. It is protected and backed up regularly to ensure it is always accessible by any of the four WiCs. Paper records are no longer liable to loss or unauthorised viewing, as the system can be configured to give different levels of access depending on the rights granted to the individual user. And access to the system is protected by means of a dual password log-on process. As every action is logged by the system, audit trails of when records are accessed or created, and by whom, are easily traceable.

Seeing the benefits

Following implementation of the integrated system in Liverpool, the PCT immediately had the ability to allocate resources more effectively. A nurse from one site explained how she was able to offer help to one of the busier sites when she was not tied up at her usual centre. A holistic view of the resources now enables PCT managers to identify when there is capacity at the walk-in-centres for more patients, thus relieving the pressure on local A&E departments.

Elizabeth Norris, a senior nurse practitioner at Liverpool Old Swan Walk-in Centre, told me about the changes she has seen since the integrated system has been working across all four sites. “We can see that we’re beginning to save both time and money as we no longer need to pay for storage for paper records and all the information is in one place. This makes life easier for the admin staff as the system generates the letters to send to GPs. The triage function enables staff to prioritise care for patients more quickly, and the clinical decision support is a great help for the more junior nurses.

“The impact on patients will take a little longer to realise but as they visit more than one of the walk-in centres, they will not need to reregister and will be treated by a nurse who has access to a history of their previous visits and treatment.”

Caroline Rand added: “We recognised the benefits to both staff and patients of switching to an electronic system at the first two sites. The expansion of the technology across all four walk-in centres has enabled staff rotation by improving the availability and speed of access to information.

“The reporting functionality helps the PCT in building a solid business case to secure future funding and facilitate commissioning. The central point of management and visibility for all data, which is essential to effective and consistent planning, has improved data security and quality.