By Tony Collins
At the foot of the Blue Ridge Mountains, Georgia, in America’s deep south, about 70 miles from Atlanta, is Athens .
It was named at the turn of the 19th century to associate its university with Aristotle and Plato’s academy in Greece. It is home to the Athens Regional Medical Centre, one of the USA’s top hospitals.
There on 4 May 2014 the Centre went live with what it described as the most meaningful and largest scale information technology system in its 95-year history – a Cerner EHR implementation.
Now the Centre’s CEO James Thaw and CIO Gretchen Tegethoff have resigned. The Centre’s implementation of the electronic health record system seems to have been no more or less successful than at UK hospitals.
The main difference is that more than a dozen doctors complained in a letter to Thaw and Tegethoff. A doctor leaked their letter to the local paper.
The letter said the timescales to install the Cerner EHR system were too “aggressive” and there was a “lack of readiness” among the intended users. They called the system cumbersome.
The letter referred to “medication errors … orders being lost or overlooked … (emergency department) and patients leaving after long waits”. An inpatient wasn’t seen by a physician for five days.
“The Cerner implementation has driven some physicians to drop their active staff privileges at ARMC [Athens Regional Medical Centre],” said the letter. “This has placed an additional burden on the hospitalists, who are already overwhelmed. Other physicians are directing their patients to St. Mary’s (an entirely separate local hospital) for outpatient studies, (emergency room) care, admissions and surgical procedures. … Efforts to rebuild the relationships with patients and physicians (needs) to begin immediately.”
The boldness of the letter has won praise in parts of the wider American health IT community.
It was signed by the centre’s most senior medical representatives: Carolann Eisenhart, president of the medical staff; Joseph T. Johnson, vice president of the medical staff; David M. Sailers, surgery department chair; and, Robert D. Sinyard, medicine department chair.
A doctor who provided the letter to the Athens Banner-Herald refused a request to openly discuss the issues with the computer system and asked to remain anonymous at the urging of his colleagues.
One report said that at a meeting of medical staff 200 doctors were “solid in their vote of no confidence in the present hospital administration.”
Last week Thaw wrote in an email to staff: “From the moment our physician leadership expressed concern about the Cerner I.T. conversion process on May 15, we took swift action and significant progress has been made toward resolving the issues raised … Providing outstanding patient care is first and foremost in our minds at Athens Regional, and we have dedicated staff throughout the hospital to make sure the system is functioning as smoothly as possible through this transition.”
The problems at the Athens centre raise questions about whether problematic Cerner installations in the NHS should have consequences for CEOs. Health IT specialists say that, done well, EHR implementations can improve the chances of a successful recovery. Done badly an EHR implementation can harm patients and contribute to death.
The most recent installations of Cerner in the NHS, at Imperial College Healthcare NHS Trust and Croydon Health Services NHS Trust, follow the pattern of other Cerner EHR go-lives in the NHS where there have been hints of problems but the trusts are refusing to publish a picture of how patients are being affected.
What has gone wrong at Athens Regional?
IT staff, replying to the Banner-Herald’s article, have given informed views on what has gone wrong. It appears that the Athens Regional laid off about a third of the IT staff in February 2014, about three months before go-live.
Past project disasters have shown that organisations often need more, not fewer, IT staff, advisers and helpers, at the time of a major go-live.
A further problem is that there appears to have been little understanding or support among doctors for the changes they would need to make in their business practices to accommodate the new system. Had the organisation done enough to persuade doctors and nurses of the benefits to them of changing their ways of working?
If clinicians do not support the need for change, they may focus unduly on what is wrong with the new system. An organisation that is inherently secretive and resentful of constructive criticism will further alienate doctors and nurses.
Doctors who fully support an EHR implementation may find ways around problems, without complaining.
One comment on the Banner-Herald website says:
“While I have moved on from Athens Regional, I still have many friends and colleagues that are trying to work through this mess. Here is some information that has been reported to me…
“Medications, labs and diagnostic exams are not getting done in a timely manner or even missed all together. Some of this could be training issues and some system.
“Already over worked clinical staff are having to work many extra hours to get all the information in the system. This obviously takes away from patient care.
“Senior leadership tried to implement the system in half the amount of time that is usually required to do such things, with half the staff needed to do it. Why?
“Despite an environment of fear and intimidation the clinical staff involved with the project warned senior administration that the system was not ready to implement and posed a safety risk.
“I have ex-colleagues that know staff and directors that are involved with the project. They have made a valiant effort to make things right. Apparently an 80 to even a 100 hour work week has been the norm of late.
“Some questions that I have: where does the community hospital board stand with all this? Were they asking the questions that need to be asked? Why would the software company agree to do such a tight timeline? Shouldn’t they have to answer some questions as well?”
“Hopefully, this newspaper will continue to investigate what has happened here and not cave to an institution that spends a lot of money on frequent giant full page ads.
“Please remember there are still good people (staff, managers and administrators) that work at ARMC and I am sure they care about the community they serve and will make sure they provide great patient care.”
“The last three weeks have been very challenging for our physicians, nurses, and staff,” said Athens Regional Foundation Vice President Tammy Gilland. “Parts of the system are working well while others are not. The medical staff leadership has been active in relaying their concerns to the administration and the administration has taken these concerns very seriously. Maintaining the highest quality of patient care has always been the guiding principle of Athens Regional Health System.”
NHS trusts go quiet about the effect on patients of EHR implementations despite calls by Robert Francis QC and health secretary Jeremy Hunt for openness when things go wrong.
Imperial College Healthcare NHS Trust, which comprises St Mary’s Paddington, Hammersmith Hospital, Charing Cross Hospital, Queen Charlotte’s and Chelsea Hospital, and Western Eye hospital in Marylebone Road, went live with Cerner– but its managers and CEO are refusing to say what effect the system is having on patients.
An FOI request by eHealth Insider elicited the fact that Imperial College Healthcare had 55 different consultants working on the Cerner Millennium project and 45 Trust staff. The internal budget for electronic patient record deployment was £14m.
Croydon Health Services NHS Trust, which comprises Croydon University Hospital (formerly Mayday) and the Purley War Memorial Hospital, went live with Cerner last year, also under BT’s direction.
The trust has been a little more forthcoming than Imperial about the administrative disruption, unforeseen extra costs and effects on patients, but Croydon’s officials, like Imperial College Healthcare’s spokespeople, refuse to give any specific answers to Campaign4Change’s questions on the Cerner implementation.
It was probably unfair of doctors at Athens Regional to judge the Cerner system so soon after go-live but their fierce reaction is a reminder that doctors exist to help patients, not spend time getting to grips with common-good IT systems.
Would an NHS CEO resign after a rebellion by UK doctors over a problematic EHR implementation? It’s highly unlikely – especially if trusts can stop news leaking out of the effects on patients. In the NHS that’s easy to do.