Essay 1:8 – The Classification and Indexing of paper records for Digital Clinical Systems: Lessons and Solutions

Principia Medicinae Digitalis Sotoniensis
Essays on the Evolution of the UHS Clinical Data Estate 1980 -2024

Chapter Author David Rew QVRM MChir FRCS. Consultant Surgeon

13th October 2024

Publication Plan 

The essays which comprise this series will be made available in the first instance on my professional website, https://www.wessexsurgical.co.uk as downloadable PDF documents
for review, comment and as a basis for further contributions. They will be amended, updated and supplementary as necessary and as any new material becomes available. All those colleagues with knowledge and experience of the UHS digital programme are welcome to contribute, by communication with me through david.rew@wessexsurgical.co.uk.
Once the project is as complete as is achievable, final copies of each of the essays will be submitted to the University of Southampton ePrint server for formal publication.

Copyright
The copyright of this collection is invested in Mr David Anthony Rew as the originator of the project, editor, principal author and compiler of the collection of essays. The content of each essay is made available on a Creative Commons Version 2 CC BY basis, under which Licensees may only copy, distribute, display, perform and make derivative works and remixes based on it on the basis of Full Attribution, including formal Citation where appropriate in books and academic publications. Full acknowledgement is given to all contributors to the written work at appropriate points in the text.

Essay 1:8: Document Classification and Clinical Information Capture

Chapter contents
Introduction:

The state of clinical documentation at University Hospital Southampton in 2013
The Move to Acquire a Commercial Enterprise Document Management System in 2013
Implementation of the EDMS Acquisition and Integration Programme
The Systematic Audit of Paper Holdings at UHS in 2013-2014
The Scanning Plan for Historic Documents
The Scourge of the PDF
The Paper Document Discovery Programme in 2015
The Wider Rationalisation of Paper-Based Processes
The Indexing of Electronic Documents in the UHS eDMS – Jan 2015 onwards
Matching the paper document holdings to the design features of OnBase
The High Level Subject Taxonomy (“Top Tabs”) proposal in the OnBase v16 interface
Treatment Function Tabs
The Mapping of National Treatment Function Codes to UHS Practice
The OnBase Tab model of information display
The Rationalisation of Document Types in the UHS eDocs System
An Overarching Description of Four Document Types
Categorising "Place Request" Hierarchies and Terminologies in Equest
Photographs, video and multimedia imagery as "Tests" rather than Documents
The Document Scanning Plan
Specific Considerations for the Digitisation project:

Essay Summary

Introduction:

The transition from paper to digital healthcare systems has been epochal in its unique global
challenges, and massively experimental. In this essay, I have sought to explore the challenges in moving from paper-based to digital medical record systems, with particular reference to the rationalisation of document structures, indexes and classifications in preparation for the adoption of a commercial Enterprise Document Management System (EDMS) in a large tertiary NHS Hospital.

This essay reviews the complexities and the lessons learned during an ambitious transition programme to digitise a very complex 50+ year old paper archive, while simultaneously
adopting a commercial EDMS at University Hospital Southampton(UHS) from 2014 onwards.

I have drawn in particular upon the rigorous and insightful work of Toby Cave of the UHS IT
Team, who was charged with technical leadership of the project, and upon the various scoping discussions which we enjoyed during the project. Toby expended prodigious energy, patience and courtesy through the UHS Clinical Records Digitisation Programme.

To view the full 35 page essay, download PDF.