Fiona Stanley committee calls on minister to come clean on clinical ICT
A parliamentary committee that has been investigating problems with the operation of ICT services at Perth’s Fiona Stanley Hospital (FSH) has called on WA Minister for Health Kim Hames to report to parliament on the roll-out of digital medical records throughout the state, along with the implementation of a closed loop medications management system at FSH and the stability of its paging system.
The committee also recommended that the WA Department of Health add an acknowledgement of receipt function to its Notification and Clinical Summaries (NaCS) application for discharge summaries following the distressing death of one patient, and took a swipe at WA Health for its failure to provide relevant information to the committee on the performance of ICT at the hospital.
The Education and Health Standing Committee, chaired by former GP and Liberal MP Graham Jacobs, has a great deal of knowledge in this area, having conducted hearings into the commissioning of the hospital that resulted in the comprehensive More than Bricks and Mortar report in 2014. That report showed that the complexity of the ICT systems chosen for the hospital, particularly clinical IT, was the main reason it failed to open on schedule.
In July this year, an independent review of the hospital’s operational clinical and patient care carried out by the Australian Commission on Safety and Quality in Health Care (ACSQHC) and MMK Consulting found that ICT was still causing problems less than a year after it opened, with the patient entertainment system, cardiac telemetry system and the BOSSnet DMR system all singled out.
The parliamentary committee decided to do a follow-up inquiry into the operation of the hospital and the transitioning of patients following media reports about alleged failings at the hospital, including some horror stories about the breakdown of sterilisation services in operating theatres, claims of staff dissatisfaction from the Health Services Union, the Australian Nursing Federation and the Australian Medical Association, and the tragic death of a 41-year-old patient, Jared Olsen, from medication misadventure.
Dr Jacobs said it was important to undertake a further inquiry to determine whether the alleged failings were just teething problems or indicative of more systemic problems, and whether there were associated costs to taxpayers or risks to patient health and safety.
In addition to evidence from Mr Olsen’s father and the three unions, the committee heard evidence in August from FSH intensive care specialist Ian Jenkins, who lashed out at the ICT capability of the hospital. Dr Jenkins told the committee that the BOSSNet DMR frequently crashed, support for IT applications was inadequate and discharge summaries being issued to GPs were “appalling”.
The committee, which handed down its report yesterday, found that while action has been and continues to be taken over many areas of concern in the report, there were certain aspects of the transitioning of patients and services to Fiona Stanley from other hospitals that did cause risks to patient care, with particular concern over medical records.
“Aspects of the patient transition since the facility’s staged opening were not well managed, with delays in patient records being transferred between sites meaning a treating clinician had limited information on which to base his or her consultation,” the committee found.
“The transfer of patient records following the opening of Fiona Stanley Hospital was poorly managed by the Department of Health and put patients at risk.”
While these problems seem now to have been largely overcome and the required information is now appearing within the DMR, the committee recommended that the Minister for Health provide an update on the status of the transfer of medical records for patients attending FSH from other hospitals in WA.
Digital medical record
The DMR came in for a fearsome tongue-lashing from Dr Jenkins in his evidence as well as from hundreds of other doctors working at Fiona Stanley who the AMA surveyed for a written submission to the parliamentary committee.
There were complaints that the system frequently froze or crashed, that it could not interface with other clinical software such as the MetaVision ICU system, and many complaints about the length of time that it took to admit a patient into a ward or load patient notes in outpatient clinics.
The operational review carried out by the ACSQHC and MMK also expressed concerns about the lack of integration capabilities of BOSSnet. However, industry sources told Pulse+IT at the time that as the software was a digital or scanned medical record rather than a fully integrated electronic medical record, it was being blamed for lacking functionality it was not meant to have.
The Department of Health also backed the system, telling the committee that the DMR had in fact delivered significant benefits including the visibility of medical records across FSH simultaneously by multiple users and at other sites, that notes were legible, date and time were accurately recorded and access to the record is auditable.
“Other witnesses, however, told the committee that the medical records were not accessible at other hospitals,” the committee reported.
“This does seem to be another example of an issue where the expectations on either side are not in alignment. The committee understands that medical records are accessible at the other major hospitals in [South Metropolitan Health Service, including Fremantle Hospital and Royal Perth] but that smaller general hospitals do not yet have access.
“Similarly, no hospital in the North Metropolitan Health Service is able to electronically access a medical record created at FSH. Ideally, the medical record system would be rolled-out across the state, but the reality of limited budgets and IT capabilities means that the solution so far implemented is appropriate in the circumstances.”
Despite WA Health committing to rolling out a DMR throughout the state – and that it would be installed at the new Perth Children’s Hospital – the committee reported that it was actually not clear whether or not that would be the BOSSnet DMR.
It recommended that the Minister for Health report to parliament on the adoption of digital medical record systems, including BOSSnet, across the rest of the health system, including:
- the extent to which DMR has been adopted in other Western Australian hospitals
- the extent to which a DMR created at Fiona Stanley Hospital is updatable, useable, or otherwise accessible by or for other public hospitals in Western Australia, and
- the timeline and estimated cost for rolling out a DMR system at other tertiary and general hospital sites in Western Australia.
“Although the DMR system would clearly benefit from further integration, it is clear that the system as it currently exists is a vast improvement compared to existing paper-based systems,” the committee reported.
“It is the committee’s understanding that improvements to BOSSnet’s level of integration have taken place since the system first went live, and that a number of documents now publish directly into the medical record including discharge summaries.
“Furthermore, the DMR is not a static build; it will experience progressive upgrades that should address many of the early concerns so far expressed. A simultaneous upgrade was intended to address an issue that reportedly accounts for at least 70 per cent of the incidents reported for BOSSnet — namely problems arising from print requests for radiology.”
As to the system’s reliability, the committee said it was not in a position to provide definitive commentary on the matter, but it was important to put on the public record that WA Health believes that issues with the network and infrastructure built and maintained by Serco and BT had affected the performance of the system and were quite often the reason for problems assigned to BOSSnet.
For example, of 40 failures apportioned to BOSSnet since the start of the year, 10 related to the radiology print function, four to servers, 11 to lack of storage space, one where the issue related to remote access, one caused by Windows patching and one in which a user tried to print an exceptionally large report.
The committee concluded that the DMR in place at Fiona Stanley Hospital represents “a significant improvement on existing paper‐based records systems”.
“Ongoing upgrades will help to address some usability issues, including the level of integration with other clinical information technology systems,” it said. “As user familiarity improves the committee expects increased acceptance of the system by clinical users.”
NaCS and discharge summaries
The committee also made a strong recommendation that changes be made to WA Health’s Notification and Clinical Summaries (NaCS) application so that receipt of electronic discharge summaries by GPs can be recorded.
The recommendation follows evidence by Jared Olsen’s father Philip. Jared Olsen died after being prescribed drugs for inflammatory bowel disease that he was unable to metabolise. He was treated and discharged from FSH, but a discharge summary emphasising that he receive additional blood tests to check for toxicity from the medication never reached his GP.
“Unfortunately, FSH’s database had the wrong address for Jared’s doctor, meaning that the discharge summary never arrived anywhere and Jared’s doctor was never able to follow up with him the importance of having that second round of blood tests,” the committee reported.
“The department told the committee that there is no capacity in the electronic discharge summary system to receive a ‘delivery receipt’ once a discharge summary has been sent. This means that the clinician generating the summary has no means of confirming whether it has reached its destination.
“The promise of technology in the health care system must be that it can help to improve outcomes for patients. Merely replacing the traditional mail-based delivery of discharge summaries with its electronic equivalent does not improve patient outcomes, especially when the additional functionality available in electronic systems, such as delivery receipts, is not incorporated.”
The committee found that relying upon giving a hard copy of the discharge summary to the patient was insufficient as a failsafe, and recommended that WA Health find a way to add a delivery receipt notification to NaCS to ensure the patient’s GP has received it.
Waiting times for discharge medications have also caused problems for patients at FSH, which the committee said should be resolved when the promised closed loop medication management system (CLMMS) is rolled out.
However, exactly when this will happen is still unclear, and the committee has recommended that Dr Hames report to parliament regarding the status of the roll-out and the current wait times for dispensing of discharge meds.
As the committee reports, it has some history with the medications system, finding from its inquiry into the commissioning of the hospital that delays in making a decision on CLMMS contributed to the overall delay in opening the hospital.
“Ultimately, FSH did not open with CLMMS in place; however, the system is expected to go live through the remainder of 2015 and into 2016. It was not implemented at the time of hospital opening because it was felt that implementing the process changes necessary whilst simultaneously opening the hospital would have introduced unnecessary clinical risks.”
The committee found that the lack of a CLMMS was not the sole reason that discharge meds were being delayed, finding that uncertainty involving prescriptions from patients transferring from other hospitals was also to blame.
Paging and communications
Paging and communications at the hospital have also raised concerns. While there have been reports that there is a mobile phone black spot in the hospital, there also appears to be a problem with the internal hospital WiFi network.
The AMA told the committee that clinicians were resorting to walkie-talkies because neither the paging system nor the duress system worked properly, and the HSU said there were problems with wireless connectivity in the mobile communications system used by its members.
These sorts of complaints led to WA Health conducting a review of the hospital’s WiFi network last year, which found that the network had trouble supporting the number of devices that were used at the campus at any particular time.
The committee reports that WA Health commissioned an independent consultant to help fix the problem and ensure that the system is robust enough, but it has also recommended that Dr Hames report to parliament on the reliability of the paging system for a three-month period. It wants details on the uptime of the system, the dates, times and lengths of any outages, the extent of those outages and the abatement and/or failure points incurred by Serco as a result of any outages.
While Serco was criticised in the report for some of its failings – for example, the committee concluded that it should never have been given responsibility for sterilisation services, there are major concerns over its cleaning contract and its use of porters rather than orderlies has resulted in 170 nursing assistants having to be hired at a cost of $1.82 million – the committee was unable to discover whether its management of non-clinical ICT had an adverse effect on clinical activities.
WA Health measures Serco’s key performance indicators (KPIs) closely and does not think network problems have badly affected clinical activities, but as the committee reports, the same can’t be said for clinical software provided by its own IT branch, Health Information Network (HIN).
WA Health reported to the committee that FSH had been affected a number of times by its internally managed ICT systems, which it says may have then adversely affected clinical services.
However, the committee reports that WA Health was not forthcoming with more information.
“Unfortunately, the department did not provide additional information about the problems or their potential impact upon clinical care in its response,” the committee reports.
“Given the nature of the committee’s question, it would have been of greater assistance if the answer had outlined the nature of the ICT problems that were [affecting] FSH and whether they were [affecting] the delivery of clinical services.
“It is entirely possible that the problems encountered were minor, and that their impact on clinical service delivery was insignificant, but the answer in no way assures the committee that this is the case.”
The committee put on the record that it was concerned that WA Health “did not always provide materially relevant information in the answers to some of the questions put to it regarding the performance of the information and communications technology systems at the hospital”.
Managing the transition? The report of the inquiry into the transition and operation of services at Fiona Stanley Hospital is available from the WA parliamentary website.