The “best implementation of Cerner Millennium yet”?

By Tony Collins

Edward Donald, the chief executive of Reading-based Royal Berkshire NHS Foundation Trust, is reported in the trust’s latest published board papers as saying that a Cerner go-live has been relatively successful.

“The Chief Executive emphasised that, despite these challenges, the ‘go-live’ at the Trust had been more successful than in other Cerner Millennium sites.”

A similar, stronger message appeared was in a separate board paper which was released under FOI.  Royal Berkshire’s EPR [electronic patient record] Executive Governance Committee minutes said:

“… the Committee noted that the Trust’s launch had been considered to be the best implementation of Cerner Millennium yet and that despite staff misgivings, the project was progressing well. This positive message should also be disseminated…”

Royal Berkshire went live in June 2012 with an implementation of Cerner outside the NPfIT.  In mid-2009, the trust signed with University of Pittsburgh Medical Centre to deliver Millennium.

Not everything has gone well – which raises questions, if this was the best Cerner implementation yet,  of what others were like.

Donald said there had been an inevitable impact with:

– patients attending for clinics that did not exist

– patients receiving multiple requests to attend clinics

– patients not receiving follow-up appointments.

Personal letter to patients

Donald told the trust’s board that patients affected would receive a personal letter.  He also said that it was becoming clear that the level of administrative support required to underpin the new system was “high”.

The level of additional support for go-live, and then on an ongoing basis was being quantified. There were 24 additional staff in post. Donald said that he would be discussing this further with the managing director of Cerner “with a view to being reimbursed for this additional cost”.

Was the trust was aware of the additional costs before buying the system? To this question Donald advised the board that the business cases submitted to the board had assumed that administrative costs following implementation would be lower. Donald undertook to distribute a briefing note to the board on the additional short and long term administrative costs to support Cerner Millennium.

[The trust’s Board papers say that Berkshire’s Cerner Millennium system is costing about £30m, which would make it one of the most expensive EPR implementations in the NHS. The papers show that Berkshire’s EPR is funded through loans.]

Had the additional administrative costs had been included in the revised financial forecast for the trust? The Director of Finance advised the board that this was not the case. “However, the additional costs had been included as a potential risk to the achievement of the forecast position,” said the trust’s minutes.

The board noted that the impact of the implementation of the Cerner Millennium system on the ability to deliver performance standards had been considerable.

“In particular, it had been necessary to undertake high volumes of manual data validation to assure accurate reporting. Given this, Monitor had agreed to accept the final validated performance of the Trust at the end of each quarter as the basis for the Trust’s governance rating.”

Cancer waiting times

On some cancer waiting times the EPR system “has had a significant impact on the ability to manage the referral process”,  said the trust’s papers. In addition, there was a backlog of work to be cleared and the production of summary information in key clinical areas.

Patient complaints

The latest information from the trust on its Cerner system is from a freedom of information request submitted by the Health Service Journal which reported last week:

“The Royal Berkshire Foundation Trust’s nursing director has suggested that a high level of complaints about staff is in part down to the implementation of the Cerner Millennium electronic patient record system.”

EPR a “long journey”

In September the head of health informatics at Royal Berkshire was reported as informing a meeting of the trust’s Council of Governors that staff can now start to think of the benefits of the Cerner implementation. She added:

“It’s very important to remember that implementing [Cerner] Millennium is just the start of the process. It will take many years. We’ve got a very long journey until we’ve got the electronic record.”

In response to the getreading.co.uk article Cerner spokesman Simon Hill said:

“The Royal Berkshire NHS Foundation Trust and Cerner have embarked upon a trust-wide change management programme.  The cornerstone of these changes require the installation of Cerner Millennium, the new information system, which gives clinicians real-time access to high quality patient information.

“As with all significant change management programmes, there will be challenges; the Trust and Cerner are working hard to ensure that any disruption is kept to an absolute minimum.

“By improving clinicians’ access to real-time high quality information, the Trust will be able to continue to improve its services to local people throughout the region.”

Comment:

Royal Berkshire NHS Foundation Trust is one of the largest general hospital foundation trusts in Engand. It employs about 4,800 staff and provides acute medical and surgical services to Reading, Wokingham and West Berkshire.

It’s inevitable that in such a large trust the widespread implementation of an all-encompassing system such as Cerner will hit some patients. Some Cerner implementations go well and bring important benefits to hospitals and their patients. Some implementations go badly. One question the NHS doesn’t ask, but perhaps should, is: what level of problems is acceptable with a new electronic patient record system?

It appears from some EPR implementations in the NHS that there is no such thing as a low point. No level of disruption or damage to healthcare is deemed unacceptable.

Berkshire’s chief executive Edward Donald speaks the truth when he says that the trust’s implementation of Cerner was more successful than at other NHS sites. This is despite patients at his trust attending for clinics that did not exist, receiving multiple requests to attend clinics and not receiving follow-up appointments.

Do all such problems matter? To patients yes. To the NHS perhaps not. It would appear that the NHS is geared to care in only a perfunctory way about patient record IT implementations that worsen the care and treatment for patients. The promise of better patient care in the long-term seems to justify any problems in the meantime.

If problematic IT, data quality, or poor practice in data collection, affect the safety and health of patients – which became a potential issue at Imperial Healthcare NHS Trust – how much does anybody in the NHS really care?

The unfortunate truth is that inherent secrecy within the NHS means that the full impact on patients and details of an unsuccessful EPR implementation can remain hidden.

It is a mark of complacency of the Department of Health and the NHS that the board of the Royal Berkshire NHS Foundation Trust learned that it had met all its Care Quality Commission quality registration standards and would achieve an amber-green governance rating for the quarter. This was an improvement on the amber-red rating for the previous quarter.

In the same minutes the board noted that the trust had “failed to achieve the targets in respect of cancer 62 day waits for first treatment and cancer two week from referral to first seen for all urgent cancers”. Even so this would result in an amber-green governance risk rating.

One wonders whether NHS trusts can receive good ratings for their performance, whatever the actual performance.

The worrying thing for those who use the NHS is that, as far as new IT is concerned, it is like flying in a plane that has not been certified as safe – indeed a plane for which there has been no statutory requirement for safety tests. And if the plane crashes it’ll be easy for its operators and supplier to deny any responsibility. They can argue that their safety and risk ratings were at “green” or “amber-green”.

The lack of interest in the NHS over the adverse effect on patients of patient record implementations means that trusts can continue to go ahead with high-risk EPR go-lives without independent challenge.

Unless there is a political intervention, trusts in England will continue to repeat the cycle in a number of Cerner implementations:

– go-live

– chaos

– a trust admission that potential problems, costs and risks were underestimated

– a public apology to patients

– a trust promise that the problems have been fixed

– trust board papers that show the problems haven’t been fixed or new ones have arisen

– ongoing difficulties producing statutory and regulatory reports

– provision in trust accounts for unforeseen costs

– continuing questions about the impact of the new system on patients

– a drying-up of information from the trust on the full consequences of the EPR implementation, other than public announcements on its successful aspects.

As a commentator on E-Health Insider said: “When will this nonsense stop?”