By Tony Collins
When a public-facing go-live goes wrong should communications be neutral in tone – or accentuate the positive?
On 8 December 2011 North Bristol NHS Trust went live with the Cerner Millennium electronic patient records system under the NPfIT programme.
At first Trust staff thought the difficulties were confined to a mix-up over outpatient appointments but it later transpired that there were 16 “clinical incidents” between 1 December 2011 and 17 January 2012 that were related to the Cerner Millennium implementation.
The Trust has published regular public information notices on the benefits, expected benefits, and problems arising from the Cerner implementation.
Reassuring in tone, the notices have made no mention of anything more potentially serious than administrative “issues”: non-existent appointments were set up and letters sent to patients in error. The notices said that though the “issues” caused disruption and frustration, patient safety had not been compromised. The Trust apologised to staff and patients.
No mention was made in the notices of staff having reported clinical incidents in which the new patient records system was a causal factor. The NHS usually categorises each clinical incident as a “near miss” or “actual harm”.
In Campaign4Change’s various conversations with the North Bristol Trust over the potential seriousness or otherwise of its IT problems, one thing has been clear: it is pleased with the level of public information it has given out over the problems:
- regularly-updated messages on its website,
- briefings to the media including interviews for regional BBC and ITV channels by Ruth Brunt, the Trust’s chief executive,
- board papers,
- on-time answers to requests under the Freedom of Information Act
- leaflets and posters placed in outpatient clinics and on car parking machines explaining that the Trust was implementing a new computer system and apologising for any delays patients may experience
The Trust also gave GPs a dedicated telephone number, fax number and email address for GPs or their patients to contact for further advice.
Profuse public information
We agree that the Trust has run a diligent public information campaign; and its communications staff have always responded quickly to our calls – and with the documents we requested. The staff were frank in answering our questions. They told us that no decision has been taken yet on whether the Trust will publish the results of an independent inquiry into the Cerner implementation.
But if the Trust doesn’t publish the lessons from its Cerner implementation, it may wish to be reminded of a warning by the Local Health Board of Merthyr Tidfil, at the top on its Clinical Incident Reporting Policy paper: - To err is human; to cover up is unforgivable; to fail to learn is inexcusable.
If the Trust does not publish how will others learn from its mistakes?
Accentuate the positive?
The quantity of public information released by North Bristol NHS Trust is not an issue – but how informative is it? Does the wider culture of the Trust still force staff to accentuate the positive?
The first of the Trust’s website statements on the problems of the Cerner implementation came about five weeks after the go-live. The opening sections of the statement made no mention of any problems. Indeed a series of bullet points listed the benefits of the system:
- Patient records will now be securely stored electronically on a single system, replacing paper records.
- Authorised clinicians can quickly find and share information on patients and their medical history and no longer rely on paper filing records.
- Clinicians will also be able to access records at the patient’s bedside and can input information and statistics immediately.
- Patients will no longer have to repeat their details to different clinicians as they will be accessible in one place.
- Tests and outpatient appointments can be set up immediately with the patient.
The Trust’s website statement went on to say that “many”wards as well as A&E at Frenchay Hospital [Bristol] are using the new system.
Only if you’ve read this far will you see a reference to problems.
“However, we have experienced some unexpected problems in the last few weeks with outpatient appointments…”
The current media statement is, again, more upbeat than neutral. The vague mention of problems is countered by the equally vague claim of “huge” improvements.
“At North Bristol NHS Trust we have been implementing a new electronic patient record system to replace an outdated, less efficient system. Our wards, two minor injuries units, the Emergency Department, theatres and maternity are using the new system.
“However, we have experienced some unexpected problems with some of our outpatient clinics resulting in non-existent appointments to be set up and letters sent to patients in error. Our priority is always patient safety and we are clear that this has not been compromised.
“These issues have caused disruption and frustration for our patients and our staff and we recognise that this has not delivered the level of service that we expect, and the public expect, from us. We apologise wholeheartedly for that.
“Our staff have shown real commitment, hard work and dedication to continue to deliver patient care. Our Information Management & Technology Team worked very hard to rectify these problems as quickly as possible and we have seen huge improvements.
“The system in all outpatient clinics has now been rebuilt and relaunched. These clinics are now in a position to effectively use the new electronic records system. We anticipate there will be a further transition period for staff in those clinics. We firmly believe that the new system, once fully implemented, will improve services for our patients and provide real value.”
Campaign4Change pointed out to North Bristol that board papers on the troubled Cerner implementations at Barts and The London were commendably detailed and informative.
Barts had referred breaches of government targets on waiting times, complaints from patients, delays in the reporting of statutory and other trust performance information, extra costs, losses of income because of reduced activity, and the effect of data errors. There has been little of any of this from North Bristol’s public information campaign.
Freedom of information
Indeed North Bristol has refused to answer questions that were asked under the FOI Act by D Haverstock of the South West Whistleblowers Health Action Group.
The Trust refused Haverstock’s requests for:
- a copy of your Cerner implementation plan, including pilot
- the criteria on which the go-live decision was taken
- a copy of the issues log for the implementation, with a full history of closed and open items.
- reports on Cerner Project Board/Steering Committee meetings.
The Trust did give Haverstock a vague answer to her question on whether the Trust will have to take over the running costs of Cerner from 2015 when the Department of Health’s NPfIT contract with BT ends.
The Trust said the running costs for Cerner will become the Trust’s responsibility from October 2015 – but it doesn’t know for certain what the costs will be.
“The exact costs are still being calculated, but will be around the same levels as our previous patient administration system, we estimate,” said the Trust.
North Bristol declined to answer Haverstock’s other questions because “at this time the Trust feels that to answer your questions regarding the Cerner Millennium implementation would compromise our position with BT and Cerner”.
Rightly, Haverstock challenges the Trust’s use of the word “feels”. Rejections of FOI requests should be based on facts not its feelings.
Says Haverstock in her request to the Trust for an internal review: “Subjective feelings are not a valid reason for rejecting an FOIA request. What is your objective, evidence base for rejecting this request? [Thank to Theyworkforyou.com for this information.]
Poorly-designed health IT can kill, according to a US Institute of Medicine report “Health IT and Patient Safety Building Safer Systems for Better Care” in November 2011.
The report says:
“Poorly designed health IT can create new hazards in the already complex delivery of care.
“Although the magnitude of the risk associated with health IT is not known, some examples illustrate the concerns.
“Dosing errors, failure to detect life-threatening illnesses, and delaying treatment due to poor human–computer interactions or loss of data have led to serious injury and death …”
There’s no evidence that the problems at North Bristol have caused any harm to patients. Indeed the Trust, in reporting the clinical incidents in response to a BBC’s reporter’s FOI request, says its “robust safeguarding processes, as well as additional checks and balances in all departments” have “ensured that clinical safety was not compromised and no patients were put at risk”.
It adds: “Our priority is always patient safety and there is no indication that this has been affected.”
But would we know if patient safety had been affected? In its public information campaign the Trust has been prolific. But the accent on the positive, rather than a neutral and factual account of the specific problems, has left us with little confidence that all the truth has yet come out.
In an IT-related crisis it is not a mass of information that the public and media regard as helpful but specific answers to specific questions. Has North Bristol managed its IT-related crisis well? Up to a point, Lord Copper.