Category Archives: BT Health

Uupublished plan to throw another £13bn at the NHS’s IT problems?

By Tony Collins

The Health Service Journal yesterday revealed details of NHS IT investment plans that have been costed at about £12.9bn over the next five years.

The HSJ’s award-winning technology correspondent Ben Heather  says the sums currently involved – which could reduce as proposals are “reined in” – are on a par with the notorious National Programme for IT in the NHS.

He says that officials working on the plan have produced an estimate of between £10.9bn and £12.9bn for the cost of supporting proposals across 15 long-term plan “workstreams” ranging from creating personalised care to improving cancer survival.

The figures form part of the work of the digital and technology workstream for the long term plan, which is being developed by NHS England and NHS Improvement.

“The sum would be on par with the National Programme for IT, the most expensive push to improve IT systems in NHS history and an infamously costly and troubled project. It is likely to reduce substantially, however, as ambitions for the plan are negotiated and reined in over coming weeks.”

The plan is due to be published in late November or early December. The health secretary is known to be a keen advocate of new IT-related investments.

It is likely that a sizeable portion of the new £20bn planned for the NHS – which will be financed partly by tax increases that are due to be announced in the budget later this month – will go on NHS technology.

But the Health Service Journal suggests the investments will be controlled centrally, which may be a bad sign given that one of the major flaws in the failed £13bn NPfIT was that money was controlled centrally rather than by local groups of doctors and nurses.

Comment

On the face of it the current investment proposals bear no resemblance to the NHS IT programme NPfIT which was “dismantled” in 2011.

The NPfIT comprised a handful of specific major projects that were to be implemented nationally under the umbrella of “ruthless standardisation”.

The current proposals look very different. The investments fall into vague categories such as digitalising secondary care, improvements to IT infrastructure, data gathering and analytics.

The proposals have all the appearance of a different way the NHS has found to waste vast sums of public money.

It has never been acknowledged by the Treasury, NHS England or the Department of Health that the NPfIT wasted billions on spending that was invisible to the public, such as numerous consultants, years of globe-trotting by officials, first-class hotels across the world, sponsored conferences and unreported funds for marketing items that included DVDs and board games designed especially to promote the IT programme.

For officials, there’s nothing more exciting than going to work on a £13bn technology programme where money flows more freely than water. It’s no wonder officialdom is lobbying for the money.

No doubt it will be easy for officials to obtain the new billions. At any time in the recent history of the NHS it would have been easy on paper to justify £13bn for new NHS technology. Much of the £13bn could be justified simply enough by submitting plans to HM Treasury to modernise what already exists.

It was easy to justify the NPfIT. Tony Blair approved it at a Downing Street meeting that lasted 40 minutes. Computer Weekly obtained minutes of the Downing Street meeting after various FOI appeals.

But the NHS needs £13bn to be spent wisely on technology. The last thing the NHS needs is for Whitehall officials to be involved. History shows that Whitehall has the reverse Midas touch when it comes to major NHS IT investments. It is local groups of doctors and nurses who know how to spend the money wisely.

If either NHS England or the Department of Health and Social Care is involved in the new proposals for NHS IT investments – and they both are – it’s almost certain the new plans will end up as costly failures.

How would the public feel if they realised that a sizeable portion of their increased taxes for the NHS is almost certainly destined for the dustbin marked “mismanaged Whitehall IT schemes”.

Revealed: Officials’ £13bn funding ask to modernise NHS IT

Another NPfIT scandal in the making?

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Has Fujitsu won £700m NHS legal dispute?

By Tony Collins

The Telegraph reports unconfirmed rumours that Fujitsu has thrown a party at the Savoy to celebrate the successful end of its long-running dispute with the NHS over a failed £896m NPfIT contract.

Government officials are being coy about the settlement which implies that Fujitsu has indeed won its legal dispute with the Department of Health, at a potential cost to taxpayers of hundreds of millions of pounds.

Fujitsu sued the DH for £700m after it was ejected from its NPfIT contract to deliver the Cerner Millennium system to NHS trusts in the south of England.

At one point a former ambassador to Japan was said to have been involved in trying to broker an out-of-court settlement with Fujitsu at UK and global level.

But the final cost of the settlement is much higher than any figure agreed, for the Department of Health paid tens, possibly hundreds of millions of pounds, more than market prices for BT to take over from Fujitsu support for NHS trusts in the south of England. The DH paid BT £546m to take over from Fujitsu which triggered a minor Parliamentary inquiry.

A case that couldn’t go to court?

The FT reported in 2011 that Fujitsu and the Department of Health had been unable to resolve their dispute in arbitration and a court case was “almost inevitable”.

But the FT article did not take account of the fact that major government departments do not take large IT suppliers to an open courtroom. Though there have been many legal disputes between IT suppliers and Whitehall they have only once reached an open courtroom [HP versus National Air Traffic Services] – and the case collapsed hours before a senior civil servant was due to take the witness stand.

Nightmare for taxpayers

Now the Telegraph says:

“Unconfirmed reports circulating in the industry suggest that a long-running dispute over the Japan-based Fujitsu’s claim against the NHS for the cancellation of an £896 million contract has finally been settled – in favour of Fujitsu.”

It adds:

“Both Fujitsu and the Cabinet Office, which took over negotiations on the contract from the Department of Health, are refusing to comment. The case went to arbitration after the two sides failed to reach agreement on Fujitsu’s claim for £700 million compensation. Such a pay-out would be the biggest in the 60-year history of the NHS – and a nightmare for taxpayers.”

The government’s legal costs alone were £31.45m by the end of 2012 in the Fujitsu case.

Francis Maude, Cabinet Office minister, is likely to be aware that his officials will face Parliamentary criticisms for keeping quiet about the settlement. The Cabinet Office is supposed to be the home of open government.

Earlier this week the National Audit Office reported that Capgemini and Fujitsu are due to collect a combined profit of about £1.2bn from the “Aspire” outsourcing contract with HM Revenue and Customs.

Richard Bacon, a Conservative member of the Public Accounts Committee is quoted in the Telegraph as saying the settlement with Fujitsu has implications across the public sector. “It should be plain to anyone that we are witnessing systemic failure in the government’s ability to contract.”

What went wrong?

The Department of Health and Fujitsu signed a deal in January 2004 in good faith, but before either side had a clear idea of how difficult it would be to install arguably over-specified systems in hospitals where staff had little time to meet the demands of new technology.

Both sides later tried to renegotiate the contract but talks failed.

In 2008 Fujitsu Services withdrew from the talks because the terms set down by the health service were unaffordable, a director disclosed to MPs.

Fujitsu’s withdrawal prompted the Department of Health to terminate the company’s contract under the NHS’s National Programme for IT (NPfIT).

Fujitsu’s direct losses on the contract at that time – which was in part for the supply and installation of the Cerner “Millennium” system – were understood to be about £340m.

At a hearing of the Public Accounts Committee into the NPfIT,  Peter Hutchinson, Fujitsu’s then group director for UK public services, said that his company had been willing to continue with its original NPfIT contract – even when talks over the contract “re-set” had failed.

“We withdrew from the re-set negotiations. We were still perfectly willing and able to deliver to the original contract,” he said.

Asked by committee MP Richard Bacon why Fujitsu had withdrawn Hutchinson said, “We had tried for a very long period of time to re-set the contract to match what everybody agreed was what the NHS really needed in terms of the contractual format.

“In the end the terms the NHS were willing to agree to we could not have afforded. Whilst we have been very committed to this programme and have put a lot of our time, energy and money behind it we have other stakeholders we have to worry about including our shareholders, our pension funds, our pensioners and the staff who work in the company. There was a limit beyond which we could not go.”

The termination of Fujitsu’s contract left the NHS with a “gaping hole,” said the then chairman of the Public Accounts Committee Edward Leigh.

Thank you to campaigner Dave Orr for drawing my attention to the Telegraph article.

Comment 

In an era on open government it is probably not right for officials and ministers at the Cabinet Office and the Department of Heath to be allowed to secretly plunge their hands into public coffers to pay Fujitsu for a massive failure that officialdom is too embarrassed to talk about.

Why did the DH in 2008 end Fujitsu’s contract rather than renegotiate its own unrealistic gold-plated contract specifications? Should those who ended the contract be held accountable today for the settlement?

The answer is nobody is accountable in part because the terms of the dispute aren’t known. Nobody knows each side’s arguments. Nobody even knows for certain who has won and who has lost. Possibly the government has paid out hundreds of millions of pounds to Fujitsu on the quiet, for no benefit to taxpayers.

Is this in the spirit of government of the people, by the people, for the people?

Medication errors 6 months after “admin” system goes live

By Tony Collins

When Croydon Health Services NHS Trust went live with Cerner Millennium in October 2013 a spokesman told eHealth Insider:

“The new system will give everyone working at the trust better access to information and an accurate picture of what all of our services are doing. This will allow staff to make quicker, more informed decisions about the care patients need. It will improve the quality, safety and efficiency of care.”

The go-live has indeed brought some benefits. The trust says these include more efficient management of medicines, more detailed patient information being conveyed between shifts and departments, and better management of beds.

But earlier this week Campaign4Change reported on some of the problems associated with the go-live including 50,000 patients on the trust’s waiting list and a “serious incident” declared over diagnostic waits including extended waits for patients with suspected cancer.

Said the trust’s Audit Committee in March 2014 – 6 months after the go-live of the Cerner Millennium Care Records Service [CRS] :

“CRS Millennium Lessons Learned

“KB [COO and Deputy Chief Executive] outlined the context in which the implementation of CRS had taken place from the time the Business case had been approved in 2010 to the commencement of deployment in January 2011 and its subsequent implementation to date.

“She noted the 7 official “go live” dates which were reflected in the lessons learned report many of which fell during a period of organisational change.

“She noted that the deployment in CHS [Croydon Health Services NHS Trust] had been the most comprehensive deployment to take place nationally.

“It was noted that Programme Team had considered the lessons learned from other [NPfIT] Care Records Service deployments as part of the implementation programme at CHS and that there was no evidence of harm to patients despite the challenges around delivery of service.

” However significant operational challenges were experienced and a deep dive into the implementation of CRS was carried out and the findings submitted to the Finance & Performance Committee and the Trust Development Authority.

“In relation to ‘no harm to patients’ SC [Chairman] asked what empirical evidence there was to support the findings of the Deep Dive.

“KB explained from October 2013 to date there were 50,000 patients on the waiting list, but a patient validation exercise had taken place which had confirmed that no patients had come to any harm.

“The potential backlog would be cleared by the end of March but in the meantime those patients on waiting lists would be subject to a further clinical review to ensure that there was no harm.”

In fact the trust is still working through the backlogs; and long waiting times are not the only matters arising from the Cerner Millennium implementation. A medication safety report for the month of March 2004 highlights these lessons:

“The patient was prescribed Furosemide for acute pulmonary oedema on 12/03/2014. The drug was not administered and the reason not documented. On review of the incident, it was identified that there was a mis-communication between both nurses and the fact that they have started using a new computer system had caused confusion which led to the error. Once error identified the dose was given and ward sister has ensured that staff will go for further training if unsure on how to use the CRS Millennium system…

“Third incident was a failure to administer fluids (Normal Saline) in an acute kidney injury patient with an admission creatinine of greater than 700. Again there was confusion with the electronic prescribing system and the nurse thought that patient did not have a drug chart as the electronic prescribing system had gone live whereas in fact there was a paper drug chart for the fluid. The position of the venflon on the patient arm also contributed to the delay. Once error identified the fluids were given but were not running to time and patient improved. Ward sister has ensured that staff will go for further training if unsure on how to use the CRS Millennium system and staff were also briefed about poor documentation of the incident…

“Fourth incident occurred involved a patient prescribed ACS protocol for NSTEMI, Positive trop T. The aspirin 300mg, clopidogrel 300mg and fondaparinux 2.5mg were not administered and not signed for. Omission of medicines was discussed with doctor looking after the patient and the patient did not come to any harm. Omission occurred as agency staff did not know how to use CRS Millennium. On review of incident all staff were briefed on importance of patients being administered medicines on time and in particular a discussion took place between agency staff and for agency staff to have adequate CRS Millennium training. There are champion users nurses on wards who are able to train Agency staff.

NPfIT

Cerner Millennium is provided to the trust under a national contract hosted by the Department of Health and managed via a Local Service Provider (LSP) contract with BT. The contract covers trusts in London and the south of England.

The DH contract expires on 31st October 2015 after which point the DH will no longer fund any of the services currently hosted by them. This includes both the software and licencing costs for Cerner Millennium as well as the BT data storage facilities and other costs.

The DH requires all trusts with Cerner under the NPfIT to commit to an exit strategy before 31st October 2015.

Comment

Is Cerner Millennium merely an administrative system as officials at Croydon Health Services NHS Trust claim it is?  The implication is, with an administrative system, that it cannot be involved in any harm to patients. Officials at Connecting for Health when they ran the NPfIT used to describe Cerner Millennium as an administrative system.

It is the deployment of this “admin” system at Croydon that is implicated in medication errors, a waiting list of 50,000 people, and long waits for diagnostic tests for people with suspected cancer.

If Whitehall and NHS officials cannot see the system as other than administrative, this is a mistake that may help to explain why a poor service for patients, which sometimes has serious potential clinical implications,  is so commonplace, even months after go-live.

50,000 on waiting list and cancer test delays after NPfIT go-live

50,000 on waiting list and cancer test delays after NPfIT go-live

By Tony Collins

Croydon hospitals have built up a waiting list of 50,000 patients since a Cerner electronic patient record system go-live last October, according the trust’s latest board papers.

And, since the go-live, more than 2,200 patients have waited at least 6 weeks for diagnostic tests, of which 160 have been identified as “urgent suspected cancer and urgent patients”.  This backlog may take until the end of August to clear, say the board papers of the Croydon Health Services NHS Trust which includes Croydon’s Mayday Hospital, now the University Hospital.

The trust has declared a “serious incident” as a result of the diagnostics backlog. An SI can be reported when there is possibility of unexpected or avoidable death or severe harm to one or more patients.

“No harm”

The trust concedes that its waiting times pose a “potential clinical risk” but the board papers say several times that there is no evidence any patient has come to harm.  This assurance has been questioned by some trust board members. The trust continues to investigate.

Croydon is the latest in a long line of trusts to have had serious disruption after a Cerner go-live under the NPfIT, with BT as the installation partner.

The trust has kept the implications for patients confidential. This may contravene the NHS’s “duty of candour” – to report publicly on things that go wrong. The duty has come about in the wake of the suffering of hundreds of people in the care of Mid Staffordshire NHS Trust.

Croydon Health Services NHS Trust has decided not to publish its “Cerner Deep Dive” or Cerner “Lessons Learnt” reports, and discussions on the reports have been in Part 2 confidential sections of board meetings.

The trust defended its “Part 2” approach in its statement (below).

Meanwhile the Health and Social Care Information Centre, which runs the NPfIT local service provider contracts, including BT’s agreement to supply Cerner to hospitals in London,  has commissioned Cerner to capture the benefits nationally of Cerner installations.

Q&A

My questions and points to the trust, and its responses are below.

From me to the trust:

Croydon had good reasons to go live with Cerner, and DH funding was a further incentive but the trust does not appear to have been in a position to go live – at any stage – with a Big Bang Cerner implementation. The 7 aborted official go-live dates might have been a sign of why.  It would have been a brave decision to cancel the implementation, especially as:

–  the trust had spent 2 years preparing for it

– DH, BT and Cerner had put a lot of work into it

– there was DH pressure to go live especially after all the missed go-live dates.

The latest board papers say 6 or more times in different places that there has been no harm to patients as a result of the delays and waits.  Some members have raised questions on this and there is the matter of whether the trust is commissioning its own assessments (marking its own work).

On this:

– 50,000 on waiting list

– Cerner deep dive not published

– Lessons Learnt not published (concealment of failures, against the spirit of duty of candour called for by Robert Francis QC and Jeremy Hunt?)

– Diagnostics – an SI reported. The trust has considered the contributing issues which related to Cerner implementation but has not published details of the discussion. Again a concealment of failures?

– An accumulation of over 2,200 patients that were waiting over 6 weeks for diagnostics. Out of that number 160 patients were identified as urgent suspected cancer (USC) and urgent patients.  Can the trust – and patients – be sure there has been no harm?

– “… external assurance through an external clinician will provide the assurance that no patients have suffered harm as a result of the length of the waiting times”. Bringing in an external clinician to provide an assurance no patients have been harmed seems to pre-judge the outcome.  The trust appears to be marking its own work, especially as the backlog of patients awaiting diagnostics may not be cleared until the end of August.

– Managing public and GP perceptions? “Members agreed that GP interactions should be held off until the investigations had produced definite findings. However the Communications Department are on standby to publish information to GPs if required, and the Trust is ready to react to other enquiries. The Trust will in any event publish the incident report after the investigation has been completed.”

– “… the implementation of Cerner in October 2013 had an impact on activity levels and the delivery of RTT standards”. Again no report on this published.

– “An independent assessor would re-check all patients to assure that no harm has resulted. The Committee noted the progress report and requested that this is referred to a Part 2 meeting of the Trust Board …” Concealment of failures again?

– In the past the DH has been prepared to treat patients as guinea pigs in Cerner Big Bang implementations. The philosophy appears to be that the implementations will inevitably be disruptive but it’s for the good of patients in the longer term. That this approach may be unfair on patients in the short term, however, seems not to trouble the NHS hierarchy.

It’s clear clinicians and IT staff are doing their best and working hard for the benefit of patients but the implementation was beyond their control. Meanwhile complaints are increasing, Croydon Health Services was one of the lowest rated trusts for overall patient experience and a sizeable minority of local residents don’t choose the local hospitals for care or treatment. That said some patients rate their care very highly on NHS Choices (although some don’t). The University hospital is rated 2.5 stars out of 5.

One of the most surprising statements in the board papers is this: “… despite the weaknesses in the programme, the overall success of the deployment had been recognised at a national level”. A success? Can the trust in essence say what it likes? Nobody knows for sure what the facts are, given that the trust decides on what to publish and not to publish.

The trust’s response to the above points and questions:

“Due to a temporary failure of our administrative systems, the Trust found in February 2014 that a number of patients who needed to be seen by the imaging service were in breach of the six week waiting standard.

“We have taken immediate action to correct this and are undertaking a thorough review to confirm that no patients were harmed as a result.  The Trust is now working hard to treat patients currently on our waiting lists.  This is referenced in our publicly available Board papers.

“CRS Millennium has delivered a number of improvements that support improving patient experience at the Trust, including more efficient management of medicines, more detailed patient information being conveyed between shifts and departments and better management of beds within the organisation.”

Lessons?

Below are some of the lessons from Croydon’s Cerner go-live. Although the trust hasn’t published its “Lessons Learnt” report, some of lessons are mentioned in its latest board papers:

  • Insufficient engagement from operational and clinical colleagues
  • Time pressures were felt when a full dress rehearsal stretched the capabilities of the information team.
  • Insufficient time and resources were allocated to completion of the outline business and full business cases, as well as to due diligence on the options and costs.  [Business cases for Cerner are still unpublished.]
  • Trust directors agreed that a business case for a project of the size and complexity of the CRS Millennium should have taken longer than 6 weeks to prepare.
  • A failure of senior managers to take stock of the project at its key stages.
  • Too strong a focus on technical aspects
  • Clinicians not always fully appreciating the impact of the changes the system would deliver
  • The hiring of an external change manager to lead the deployment who proved to be “less than wholly successful because of the resulting deficiency in previous experience or knowledge of the culture of the organisation”.
  • The individual left the organisation part way through deployment which led to further challenges.
  • The right people with the right skills mix were not in place at the outset to achieve the transformational change necessary to successfully deploy a new system such as CRS

Comment 

NHS trusts have good reason to modernise their IT using the widely-installed  Cerner electronic patient record system, especially  if it’s a go-live under the remnants of the NPfIT, in which case hospitals receive DH funding and gain from having BT as their installation partner.

But why does a disruption that borders on chaos so often follow NPfIT Cerner implementations? Perhaps it’s partly because the benefits of Cerner, and the extra work required by nurses and doctors and clerical staff to harvest the benefits, is underestimated.

It is in any case difficult to convey to busy NHS staff that the new technology will, in the short-term, require an increase in their workload. Staff and clinicians will need to capture more data than they did on the old system, and with precision. The new technology will change how they work, so doctors may resent it initially, especially as there may be shortcomings in the way it has been implemented which will take time to identify and solve.

The problem with NPfIT go-lives is that they take place in an accountability void. Nobody is held responsible when things go badly wrong, and it’s easy for trusts to play down what has gone wrong. They have no fear of authoritative contradiction because they keep their implementation assessments confidential.

What a difference it would make if trusts had an unequivocal duty of candour over electronic health record – EHR – deployments. They would not be able to go live until they were ready.

The disruption that has followed NPfIT Cerner go-lives has been serious. Appointments and tests for suspected cancer have been lost in the administrative confusion that follows go-live. There have been backlogs of appointments for tens of thousands of patients. Operating theatres have gone under-used because of mis-scheduled appointments.

Now and again a patient may die unnecessarily but the problems have been regarded by the NHS centrally as collateral damage, the price society pays for the technological modernisation of the NHS.

Richard Granger, when head of the NPfIT, said he was ashamed of some Cerner installations. He described some of them as “appalling” but since he made his comments in 2007, some of the Cerner installations have been more disruptive than those he was referring to.

Provided each time there is no incontrovertible evidence of harm to patients as a result of a go-live, officials give the go ahead for more NPfIT Cerner installations.

Guinea pigs?

Disruption after go-live is too often treated as an administrative problem. Croydon’s statement refers to a “temporary problem with our administrative systems”. But new patient record systems can harm patients, as the inquest on 3-year-old Samuel Starr heard.

It’s time officials stopped regarding patients as guinea pigs in IT go-lives. It compounds the lack of accountability when trusts such as Croydon keep the reports from the go-live secret.

Trusts need better technological support but not at the cost of treating any harm to patients as collateral damage.

A tragic outcome for Cerner implementation at Bath?

Openness and honesty is a rarity after health IT problems

Mishandled electronic health record transition

A botched Cerner EHR implementation?

Trinity Medical Center reaches Cerner settlement

CEO and CIO resign after troubled EHR go-live

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.

“Medication errors”

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.

Swift action

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.”

UK implications?

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.”

Keeping quiet

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.

Comment

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.

Athens Regional CEO resigns

A tragic outcome for Cerner Millennium implementation?

Athens Regional is addressing computer problems encountered by doctors

Athens Regional is addressing computer problems after patients put at risk

CEO forced out?

 

Coroner criticises hospital’s new IT after boy’s death

By Tony Collins

Avon coroner Maria Voisin said yesterday that a new booking system at the Royal United Bath was responsible for three year-old Samuel Starr not being seen and given timely treatment.

It’s rare for a coroner to criticise a hospital’s new IT in direct terms. It is also rare for evidence to emerge of a link between the introduction of new hospital IT and harm to a patient.

Since patient administration systems began to be installed as part of the National Programme for IT in 2005, the disruption arising from go-lives has led to thousands of patient appointments being delayed at a number of trusts. Usually  trusts contend that no patients have suffered serious harm as a result.

Yesterday at the coroners court near Bristol, the coroner Voisin said: “Due to the failure of the hospital outpatients booking system, there was a five-month delay in Samuel being seen and receiving treatment. Samuel’s heart was disadvantaged and he died following urgent surgery.”

Catherine Holley, Samuel’s mother, said her first warning of Cerner implementation problems came in June 2012, about three months before her son’s death, when the RUH cardiologist’s post clinic letter said:

“I apologised to the parents that I should have seen him in January of this year, but I am afraid a few patients have fallen foul of the Millennium changeover and I suspect this is the case here”.

The RUH installed the Cerner Millennium system at the end of July 2011. After the go-live the trust’s board reports, and a post-implementation review of the system by Pwc in February 2012, raised no serious concerns.

One of Pwc’s main criticisms of the system was the lack of clinical engagement – a common problem with NPfIT deployments.

Some excerpts from Pwc’s report:

“Given the issues and delays there is a still a good deal of uncertainty about whether the planned benefits can be realised. It is therefore important that there is a concerted effort to focus on driving out these benefits, early in 2012.”

“The go live itself did have some issues, but most of those interviewed felt that, relative to other Cerner Millennium implementations, it had gone well. Since the go-live the Trust has been working hard to address the issues, and to help users use the system more effectively…”

“There are a number of issues which arose during the audit which, although not directly covered within the audit objectives, are important in ensuring that the trust realises all the potential benefits from the Cerner Millennium implementation. These are as follows:

“There is a need for greater clinical engagement to ensure that clinicians are using the system in the most effective way – the Trust operates a Clinical Engagement Group which meets on a monthly basis.

“However feedback from a number of interviewees is that this meeting isn’t as productive as it might be and that the Trust needs to think of other ways to improve clinical engagement.”

Pwc said that the trust needed a clinical lead for Cerner Millennium who would focus on key clinical priorities and “sell” the benefits of Millennium to other clinicians. The trust also needed a CIO who would be responsible for IM&T, the Business Intelligence Unit, the Care Records Service team, Records Management, and managing the end of a [local service provider] contract with BT in 2015.

Pwc said the risks included:

  • The end of the contract with BT in 2015
  • Recent issues with BT delivery, with several significant outages of service
  • The issues with clinical engagement.

None of the trust reports – or Pwc’s review –  mentioned any adverse impact of the new system’s implementation on patients.

In 2011, several months after the go-live, the RUH’s “Insight” magazine quoted the Chief Executive James Scott as suggesting the go-live had been a success.

“Thanks to everyone for their hard work and patience during the switchover period,” Scott is quoted as saying. “It has been a major project for the RUH (and our partners BT and Cerner are describing it as the smoothest deployment yet), but we now have the foundation in place to meet the future needs of the Trust and the NHS.”

Care plan?

Catherine Holley expected Samuel to go onto a care plan after he had successful heart surgery at the age of nine months, in 2010. But it proved difficult to arrange an appointment for a scan on the new Cerner Millennium system installed at Royal United Hospital, Bath.

When the scan was eventually carried out Samuel’s heart had deteriorated and he died in September 2012 after an operation that was more complicated than expected.

This week’s three-day inquest at Flax Bourton Coroners Court heard that although Samuel’s medical records had been created on Millennium, no appointments were transferred across.

Speaking after the inquest, Samuel’s parents said they believe the system at Bath failed their son and that mistakes were made.

“It was devastating to hear evidence that an improperly implemented computer appointments system and a series of human errors resulted in the death of our son,”said Paul Starr’s Samuel’s father.

“We accept that mistakes happen but we believe that leaving a child unmonitored for as long as Samuel was, with so many opportunities to attend to him, goes beyond a simple error.

“Our three year old son had a complex cardiac condition and had been scheduled for regular cardiac reviews. In fact he was not properly assessed or nearly 21 months because of further delays.”

A Freedom of Information request revealed that there were 63 missed paediatric cardiac appointments as a result of problems arising from the Cerner implementation – some of which took nearly two years to discover.

Comment

It’s unlikely to have been the Cerner system itself at fault but an  implementation that involved several organisations including the Southern Programme for IT, a branch of the dismantled National Programme for IT.  As such nobody is likely to held responsible for what the coroner called a “failure” of the IT system.

Then again blaming an individual would be pointless.  Learning lessons – the right ones, and not just technical ones – is the objective. It may make a world of difference if those in charge of major go-lives in hospitals acknowledged that delayed appointments, or difficulties arranging them, and a disrupted administration, can harm patients – or worse.

IT in the NHS is seen as an integral part of hospital care when the technology, clinicians, nurses, administrators and other users are working in alignment. But when the IT is not working well, it is seen as something techie which has little or nothing to do with patient care and treatment.

Samuel Starr’s inquest draws attention to the fact that the difference between a good and bad IT implementation in a large hospital can be the difference between life and death.

But hospital deployments of patient administration systems have been going wrong with remarkable regularity for many years.  Isn’t it time to learn the right lessons?   

A tragic outcome for Cerner Millennium implementation at Bath?

By Tony Collins

Three year-old Samuel Starr died in the arms of his parents as his they read him his favourite stories at the local hospital. 

At an inquest this week his parents, and specialists, raised questions about whether long delays in arranging appointments on a new Cerner Millennium system at Bath’s Royal United Hospital, which replaced an old “TDS” patient administration system, was a factor in his death.

Ben Peregrine, the speciality manager for paediatrics at the RUH in Bath,  told the inquest:

“Samuel’s appointment request must have fallen through the cracks between the old and new system.”

After successful heart surgery at 9 months, Samuel should have had regular scans to see if his condition had worsened. But he didn’t have any scans for 20 months, in part because of difficulties in organising the appropriate appointments on Bath’s new Millennium systems.

Though there is no certainty, Samuel may be alive today if he’d had the scans.

In a review of Samuel’s death, which took place in November 2012, the details of which have only just been made public, Bristol Children’s Hospital concluded that appointment delays might have played a part.

It said: “Death was felt to be possibly modifiable if [there had been] earlier surgery before cardiac function deteriorated.”

Samuel had his first surgical procedure, open heart surgery at Bristol Royal Hospital for Children, on 3 March 2010. He was discharged six days later, and referred to the Paediatric Cardiac Clinic at the Royal United Hospital in Bath for check-ups.

This week’s inquest heard that the first check-up took place in Bristol in October 2010, when an echocardiogram, also known as an ‘echo’, was carried out. Samuel’s parents, Paul Starr and Catherine Holley, expected a follow-up appointment in January 2012 but by March they’d not received one.

Their community nurse rang the hospital five times in as many months for a follow-up appointment but could not arrange one. When another echo was eventually taken in June 2012 – 20 months after the first – it was found that Samuel needed urgent surgery which proved more complicated than expected. He died on 6 September 2012.

Paul Starr told the BBC that during the long delays in obtaining an appointment for a further scan Samuel’s heart function went from good to bad. He said: “It is not like he had bad care in that time. He had no care at all.”

Ben Peregrine, the speciality manager for paediatrics at the hospital, told the inquest:

“The new system is now up and running as best as it can be, but as long as there is still humans entering the information there will always be room for error.”

The BBC reported that the delay in Samuel’s treatment “came after a new computerised appointment booking system was introduced at the RUH in 2011. It was only after an appointment had been set that doctors discovered the three-year-old, from Frome in Somerset, needed open heart surgery.”

BBC West’s Inside Out obtained a hospital document “Issues for discussion including any action or learning to be taken as a result of the child’s death. Issues that require broader multi-agency discussion” that has as its first bullet point:

“Failure of the RUH Millennium computer software to organise appointments at the designated time leading to a delay of three months before Samuel was seen by (redacted) in Bath.

“Parents have since told me that Samuel had not had an ECHO for 20 months prior to June 2012. At his previous cardiac appointment (April 2011) [redacted] failed to carry out an ECHO because he was not expecting to see Samuel despite Samuel’s parents being sent an appointment for this day.”

It appears that events at Bath after the Cerner go-live have, in the main, followed a pattern at a dozen or so other trusts that have installed the Millennium system.

The pattern was outlined in a Campaign4change post in December 2012:

– 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.

Catherine Holley, Samuel’s mother, believes the Millennium implementation at the Royal United Hospital at Bath might have followed the above cycle.

Bath went live with Cerner Millennium at the end of July 2011. An upbeat trust statement at the time to E-Health Insider said:

“We can confirm that the new Cerner Millennium IT system successfully went live on Friday 29 July – as planned – at Royal United Hospital Bath NHS Trust.

“BT and Cerner worked closely with the trust and the Southern Programme for IT on the implementation over the past year – a complex and major change management programme.”

As part of its investigation into Samuel’s death, the BBC asked the RUH how many appointments were overdue to delayed because of the new computer system. Said the BBC’s Inside Out West programme:

“They told us there were 63 overdue appointments some with delays of up to 2 years before they were discovered.”

Separately an FOI request to the trust on the Millennium installation brought the response that there have been 65 cardiac outpatients’ appointments “that have been identified as being were missed due to problems with the delayed and that occurred around implementation of Cerner Millennium… All of these appointments have been followed up and actioned as required.”

The RUH is not discussing Samuel Starr’s death. A spokesperson said the inquest is expected to give Samuel’s family and everyone involved in his care a clearer indication of the circumstances surrounding his death. “We have offered our sincere condolences to the family of Samuel Starr following his sad death.”

Contradictory

RUH Board reports on Millennium’s deployment have had a general “good news” tone. But some of the reports have mentioned potentially serious problems. This was in an RUH board report in 2011 on Millennium:

“… there were significant issues with clinic templates and data that had not been migrated. This affected encounters with long term follow up appointments. As a result this meant that there was unplanned downtime across Outpatients and backlogs developed in addition to those produced as a result of planned downtime”.

Comment:

What’s striking about the reports to the Bath board of directors on the Cerner Millennium implementation is their similarity, in tone and substance, to the “good news” reports of deployments of Millennium at other trusts.

The go lives are nearly always depicted as successes for clinicians that have had minor irritations for administrators.

Now we know from the RUH Bath’s implementation of Millennium that when appointments are delayed as a result of inadequate preparations for, and structural settlement of, a new patient administration system, it can be a matter of life and death.

Indeed the BBC, in its investigation into Samuel Starr’s short life, raises the question of whether delayed appointments have been a factor in other deaths.

But do trusts genuinely care about the bigger picture, or do they regard each case of harm or death as an individual, unique event, to be reviewed after the problems come to light?

At the RUH Bath, IT appears to be treated as a separate department, too little interweaved with care and treatment. Managers talked enthusiastically of smartcard use, the work of the service desk, the need for more printers, resolving BT outages, the benefits of the service security model, champion users and floorwalkers, completing the Readiness Workbook, and keeping the Deployment Hazard Document up to date – while the parents of Samuel Starr could not get an appointment on the new system for their son to have a vital heart scan.

In 2011 a senior executive at Bath told his trust staff: “Our partners BT and Cerner are describing it [the go-live of Cerner Millennium] as the smoothest deployment yet” and “we now have the foundation in place to meet the future needs of the Trust and the NHS”.

Will things improve?

The comment in my post of December 2012, which was about Royal Berkshire’s implementation of Cerner Millennium, seems apt so some it may be worth repeating (below).

“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…

“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 electronic patient record system go-lives without independent challenge.”

This very thing seems to have happened at the RUH Bath – with possibly tragic consequences.

Thank you to openness campaigner Dave Orr for drawing my attention to the BBC’s investigation into Samuel Starr’s death.

RUH booking system might have contributed to boy’s death – BBC

Boy died after scan delay – BBC

Best Cerner Millennium implementation yet?

BT earns £1.3bn extra from “dismantled” NHS IT scheme

By Tony Collins

The Department of Health paid BT £1.3bn more from the “dismantled” NHS IT contracts than the company first expected.

In 2004 BT expected £2.1bn from its contracts under the NHS IT scheme, the National Programme for IT. In fact BT’s payments totalled  £3.4bn to March 2013, according to information contained in a DH letter to the Public Accounts Committee.  The DH’s letter has gone unpublicised until now.

The size of the payments to BT, in the light of financial pressures elsewhere in the NHS, indicate that Connecting for Health, and its successor the Health and Social Care Information Centre,  regard BT’s data spine, the N3 broadband network,  and Cerner and Rio patient administration systems as indispensable.

The Public Accounts Committee has described the NHS IT scheme, the NPfIT,  as a “failed” programme.

Though important parts of BT’s work on the scheme have been successful, a national care records service in which an individual’s electronic patient record can be accessed across  the NHS, hasn’t materialised.

A cut-down version, the Summary Care Record, exists but the NHS and MPs regarded the creation of a detailed national electronic patient record as the main reason for the National Programme for IT.

Despite the extra money  is delivering far fewer Cerner Millennium systems to London’s acute trusts than originally intended, and none of the GP systems.

Payments to BT

After BT won three NPfIT contracts in 2003, the company said in its annual report of 2004 that the deals would be worth a total of £2.1 billion. The NHS deals were among “some of the largest BT has ever won”, said BT’s  2004 annual report. 

Now the DH’s letter to the Public Accounts Committee shows the amounts paid under NPfIT contracts to March 2013: 

  • N3 broadband network  – £937.7 m [BT]. Original contract value £533m.
  • Spine (including Secondary Uses Service)   £1.083.8m [BT]. Original contract value £620m.
  • Core contracts for local clinical systems in London (London Programme for IT, formerly part of the NPfIT ) –  £865.9m [BT]. Original contract value £996m. BT is delivering to far fewer trusts than it originally envisaged.
  •  Core contracts for the south of England – £586.3m. [BT]. No payments were due to BT for the south of England in the original contracts. BT replaced Fujitsu as the local service provider in the south. The DH spent a total of 737.3m on NPfIT contracts in the south of England to March 2013 but of this £151m had been paid to Fujitsu. The Fujitsu NPfIT local service provider contract is the subject of a protracted legal dispute between the company and the DH.

MP Richard Bacon, a member of the Public Accounts Committee, has criticised the size of some of the payments to BT.

Further payments are due to BT under the NPfIT contracts and it may also receive new payments for work under the Care.data project.

Comment

BT’s stunning financial success from the NHS IT scheme shows the value, from a supplier’s perspective, of getting a foot in the door. For some time it has been a monopoly supplier to the NHS. Its grip on the NHS, the HSCIC and the Department of Health, could be diminished if the HSCIC split up its work and awarded a set of new contracts. That is unlikely to happen. Indeed the signs are that some Whitehall officials would like to tie in the NHS to BT for the foreseeable future.

NHS database: is it a top IT priority?

By Tony Collins

It’s called the NHS database but the new “giant” medical records system is to be run by the Health and Social Care Information Centre, largely for the benefit of researchers.

Though it may help patients in the longer term, say by helping to identify what treatments work and don’t, it is arguably not the NHS’s most immediate IT priority.

I said on BBC R4’s Today programme this morning that a top NHS IT priority is providing secure links to health records so that patients with acute and chronic illnesses can be treated in one part of the NHS one week and another part of the health service the following week – perhaps in a different county – and have their updated records accessible wherever they go.

At present patients with multiple problems can end up being treated in different NHS or non-NHS centres without each organisation knowing what the other is doing.  This is dangerous for patients and gives the impression the NHS is technologically backwards.

Links can be made to existing medical records – there are millions of electronic records already in the NHS – without creating a big central database. The records can reside where they are at the moment, inside and outside the NHS, and be linked to securely by clinicians and nurses, subject to the patient’s specific consent.

Indeed patients should be able to look at their record online and correct any mistakes.

Research database

My comment on BBC R4 Today that a research database is a good idea has brought a mixed response – understandably, because are risks. We need some facts from the Health and Social Care Information Centre on who is going to run the database, and how information will be made genuinely anonymous.

The HSCIC concedes in its information material that some patient information on the database will be potentially identifiable, but it implies this is acceptable if the organisations using the data can be trusted.

Why must information be potentially identifiable? And to what extent can the HSCIC be trusted to run the database? It is, after all, managing contracts under the National Programme for IT, a scheme which Jeremy Hunt called a “huge disaster”.

How much extra will be paid to BT which runs the SUS database under the “dismantled” NPfIT? It is likely that BT’s Spine and SUS-related work will link into the new “NHS database”. Have any new contracts gone to open competitive tender?

Hospital group wins $106m settlement in Cerner dispute

By Tony Collins

 A US health organisation Trinity Medical Centre has won a $106m settlement in  a legal dispute with Cerner, which is one the main suppliers of patient record systems to NHS trusts in London and the south.

Under the NPfIT BT has installed Cerner at trusts that include the Royal Free, London, Barnet and Chase Farm Hospitals NHS Trust, Weston Area Health NHS Trust, Barts Health NHS Trust, North Bristol NHS Trust and more recently at Croydon Health Services NHS Trust.

The Wall St Journal says a clinical patient accounting program Trinity bought from Cerner in 2008 was defective and didn’t deliver the promised benefits, which Cerner disputed. Trinity sought about $240m in damages; Cerner estimated $4m.

The companies agreed to submit the dispute to arbitration which began in October 2013.

Cerner said it “strongly disagrees” with the award and believes the claim was based on unique circumstances. It called the award the only material judgment against Cerner in its 34-year history.

US lawyer Michael Dagley says his firm won a $106m settlement for North Dakota-based Trinity Medical Centre in an arbitration case against Cerner.

The firm says that Trinity alleged in 2012 that patient accounting software and other services purchased from Cerner were defective, producing thousands of billing errors.

“We think it’s tremendously significant because it represents the first major victory that we’re aware of by a health care provider against a software vendor,” Dagley said in a statement.

“Providers are under pressure to automate and vendors are under pressure to offer integrated products. Providers want one vendor for all their IT needs, so the vendors have this incentive to deliver software to the market as quickly as possible, and that can lead to products being introduced that are immature and defective, which in health care, can cause tremendous damage.”

Last year Cerner said it believed the chance of a material loss related to the matter was remote and it had 147 hospitals and 735 clinics using the patient accounting program.

Despite the settlement Cerner’s share price has held up well.

Trinity Medical Centre is a non-profit organisation with about 2,700 employees.