Clinical documentation has ‘come a long way since pen and paper’

A smartphone will become “like a stethoscope” to clinicians in coming years, a chief information officer at a clinical documentation firm has argued.

Speaking to Digital Health News in the lead up to the NHS’ 70th birthday on 5 July, Simon Wallace – CCIO at Nuance Communications – reflected on how clinical documentation has evolved since the health institution was born.

“When the NHS came into being, it was all about pen and paper,” he said.

“The first landmark in terms of clinical documentation came in the early 1960s when the Dictaphone came along so doctors started dictating letters on to cassette tapes.

“Fast forward to the late 1990s when the data protection laws came into force and patients were given the right to their records, which meant organisations had to get much more smarter – which is when the need for going digital really came onto the agenda.

“Then when you reach the early 2000s and the evolution of electronic patient records (EPRs), there was a drive for accuracy.”

Looking back at clinical documentation, he said Jeremy Hunt’s commitment for the NHS to be paperless by 2020 was an “important step”. Despite the health and social care secretary’s pledge, Wallace argued there was more to be done in terms of adoption of technology.

“Clinical documentation has made huge progress over the years but there is still a lot more to be done with artificial intelligence and speech recognition,” Wallace said.

He also predicts that “virtual assistants” will become more prevalent, though he was quick to add such assistants will not “replace doctors”.

On the issue of traction and uptake of clinical documentation within the NHS, Wallace said there has to be “trust” from staff for the technology to work.

He added: “The lack of traction could be because there have been technologies that have come and gone and have not lived up to its reputation.”

In February 2018, South Tees Hospitals NHS Foundation Trust reported significant time savings following its implementation of Nuance.