The extra time afforded by the recently announced delay in opening the new Royal Adelaide Hospital (new RAH) may prove a godsend for the roll-out of the planned closed loop medications management system, but may also see the new enterprise pathology system implemented at another hospital first.
A report by the South Australian Auditor-General Andrew Richardson tabled this week has highlighted the complexity of the state’s eHealth program, with the difficulties being faced by the troubled Enterprise Patient Administration System (EPAS) and the move from the current building rescheduled to November 2016 having flow-on effects on both the new Enterprise Pathology Laboratory Information System (EPLIS) and plans for a closed loop medications management system.
In the case of pharmacy, this may prove a blessing in disguise, potentially allowing time for an electronic prescribing interface between EPAS and the i.Pharmacy dispensing system to be ready by the time the hospital opens.
However, it might not be enough to overcome the challenges facing the EPLIS roll-out, with the possibility that it will still not be fully operational by the time the hospital opens and the likelihood that it will be rolled out to one of the other hospitals on the schedule first.
According the report, the plan for pharmacy services at the new RAH is based on the principles of closed loop medications management and will be progressively rolled out over 18 months following initial operation.
The existing i.Pharmacy system from CSC is being transitioned across to the new RAH, where it will be integrated with a Rowa automated pharmacy distribution system (APDS) from CareFusion and in-pharmacy robotics, and 81 automated dispensing cabinets (ADCs) linked to CareFusion’s Pyxis software.
It will also be linked to the Oracle Corporate System for pharmacy patient billing and procurement and supply chain management. The use of APDS was expected to result in a reduction in stock waste of between four and 10 per cent, with savings of up to $71 million over the 15-year life of the APDS asset.
The new RAH will have two pharmacies – one for inpatients on level 1 and one for outpatients on level 3 – and the overall solution will have a patient queuing and wait management system to handle pharmacy outpatient management.
However, one of the big challenges was always going to be ePrescribing, which is meant to be done through EPAS. The auditor-general has found that a decision on whether EPAS electronic prescribing functionality would be ready for initial operations at the new hospital was still pending as late as April this year.
“Certain constraints of EPAS current system functionality have presented challenges to pharmacy electronic prescribing,” the auditor-general writes. “These include barcode scanning functionality for consistent identification and administration of medication to patients, and the complexity and effort required to configure matching patient medication profiles across systems.
“SA Health originally advised that there would not be an electronic prescribing interface from EPAS to i.Pharmacy for initial operation of the new RAH. As such, prescription orders appearing in EPAS will require printing and a manual check if the medication is available in the ward ADC.
“At the time of this report, SA Health had not indicated whether the new RAH delay will allow this functionality to now be available at initial operation.”
The auditor-general also found that while EPAS is essential to the pharmacy plan, the EPAS program and the pharmacy program only commenced formal meetings in May 2015, although SA Health insists there has been ongoing dialogue. The auditor recommended that the project should continue frequent communications with other relevant programs, including EPAS.
He also recommended that SA Health reassess whether the new RAH delay provides sufficient time to provide electronic medications management functionality at the hospital’s initial operation.
The auditor criticised the ambitious time frames in the original project plan, but said the announcement of the delay should reduce the implementation risks. However, contingency plans will still be needed.
Pharmacy billing will also have to have a contingency plan as Sunrise Financial Manager, the EPAS financial module, does not currently have the functionality to process pharmacy patient billing. Billing is also causing problems for the EPLIS roll-out, although on a larger scale.
Pathology
The auditor-general has taken a detailed look at the status of the $30 million EPLIS project and noted a number of risks, both to the new RAH and to public and private pathology services.
With the new RAH, the auditor found that pathology program delays have occurred, staff will be unfamiliar with EPLIS and its associated workflows when the hospital opens, procurement of some laboratory instruments is yet to be finalised and there are major integration challenges to be faced. He also found deficiencies in system contingency plans.
Concerning the wider pathology program, he has warned that the budget and its contingency for EPLIS may be insufficient, there are ongoing resource challenges, and there are major challenges with pathology results reporting, which is contingent on EPAS.
SA Pathology’s current system, Ultra, is reaching the end of its life and is increasingly prone to failure, the auditor reports. The system used at the current RAH can’t receive inbound orders from OACIS or external medical practitioner software, and even the two versions of Ultra in use by SA Pathology are not compatible with each other.
Ultra will be replaced by a pathology system from Cerner’s Millennium suite following a decision made in November 2013. Deployment of EPLIS is planned for a number of sites within SA Pathology, including eight metropolitan hospitals, 11 regional laboratories and 65 collection centres, 38 in metropolitan areas and 27 regional.
The original plan was to implement EPLIS at the new RAH and Frome Road Laboratories by April 2016. This would then be followed by the Women’s and Children’s and The Queen Elizabeth in July 2016, Flinders Medical Centre, the Repat General and Noarlunga in August 2016, and Lyell McEwin and Modbury in October. Ultra will continue to be operated alongside EPLIS until May 2017.
However, the new RAH delay will upset these plans, and the auditor reports that the program had yet to determine the implications to the overall EPLIS rollout plan and the associated costs. There are now tentative moves to roll out EPLIS at another site before the new RAH. This may cause changes to the budget as well, although these appear to be minimal.
The auditor found that there have already been program delays with EPLIS, including a time when the program was put on hold. And while the delay in opening the new RAH will provide additional time for the program to complete all required activities, he warns that further program delays may still lead to compromises in the scope and quality of delivery.
“This has the potential to result in a sub-optimal solution on initial operation at the new RAH and/or delayed patient pathology services being offered,” he writes.
Like EPAS, he warns that the switch to EPLIS will cause problems for users as workflow practices will be different. In the case of SA Pathology, the software is not being adapted to workflows but the other way around.
There are also major integration challenges to be faced. For EPLIS to work as expected, it will have to interface with EPAS for test ordering and results viewing, the Enterprise Master Patient Index for patient identifiers, the PowerHealth Billing & Revenue Collection (PBRC) system for pathology billing functionality, the Oracle Corporate System and medical device integration. Much of this will be done through SA Health’s Health Integration Broker.
And despite the new RAH opening being delayed, thus providing the program with additional time, the auditor says there are still a number of integration challenges with other systems that need to be addressed prior to any testing at the new RAH.
One of the big problems the auditor-general has uncovered is that the essential integration with EPAS for ordering and reporting has still not been finalised.
“For electronic ordering functionality to be operational, development work is required within both EPAS and EPLIS to match the SA Pathology order and results catalogue,” he writes.
“Although the program originally scheduled EPAS integration testing to be completed in May 2015, at the time of our review Cerner was still developing the SA Pathology order and results catalogue in EPLIS. This catalogue is now expected to be finalised by mid-October 2015.
“On completion, the order and results catalogue will be provided to the EPAS Program for integration into the pathology order and results interface. Until completion, the EPAS Program’s associated development costs and timelines for completion remain outstanding.”
He reports that SA Health is currently working on a contingency option should electronic pathology ordering not be available at the new RAH, including performing manual workarounds using paper forms.
There was also a delay with the billing system – SA Pathology does private pathology work as well as public – and procurement of laboratory instruments and robotic tracks has yet to be finalised.
Budget bottom line
In terms of budget blow-outs, the auditor-general warns that the problems with the EPAS roll-out may affect the EPLIS bottom line.
“The new RAH laboratory was designed on the assumption that electronic pathology ordering would be received through EPAS,” he writes. “At the time of our review, SA Health was working on identifying the extent of work and cost of this solution. In addition, the source of funding to deliver this functionality is yet to be determined.
“Should this functionality not be delivered in time for initial operation at the new RAH, a suitable contingency is required.”
More money will need to be found to archive legacy data from Ultra, which could cost up to $3.6 million, and up to $5 million extra may need to be found for a secondary data centre solution for disaster recovery. The original plan only accounted for a single data centre solutions.
“Given the project time frames and the minimal contingency funds remaining for the remainder of the project, there is a high risk that SA Health will not have sufficient approved funding to support the implementation of the new EPLIS and its ongoing operations,” he warns.
And finally, there are problems with the legacy Electronic Data Interchange (EDI) solution, which is used to send pathology results and reports from Ultra to GP and specialist desktop software. It is also used to send reports Flinders Private Hospital and some other external requestors, and acts as a gateway service to send medical imaging reports to GPs from the existing RAH, the Women’s and Children’s Hospital, The Queen Elizabeth Hospital and the Lyell McEwin Hospital.
Private practitioners will need to continue to use EDI as EPLIS does not have the functionality to directly interface with private medical practice software through its external interface engine, the auditor reports.
A replacement solution is being sourced but in the meantime, EDI will be retained. “From an SA Pathology business perspective, we were advised a long-term interface solution is imperative to provide private clinicians not only with the ability to view pathology results, but to also order pathology results electronically. At the time of our review, we were advised that a solution has yet to be determined.”
In conclusion, the auditor-general found that the EPLIS program has experienced a number of interruptions and changes that can be attributed to delays in governance approvals, inadequate early program planning and portions of time when the program was put on hold.
And despite modifying the implementation approach and the announcement of the new RAH opening delay, there is still a risk that EPLIS will not initially be fully operational as per the program’s implementation schedule, he found.
“In terms of the new RAH, the program schedule is dependent on other SA Health programs and vendor requirements. There is also significant change facing new RAH pathology staff in transitioning to the new hospital environment.
“Given these challenges, significant focus will be required on the business change management strategy and tasks to ensure a fully functional implementation is finalised in a timely manner. These tasks include interface integration of key components, close monitoring of the status of pathology hardware procurements, proactive monitoring of resourcing as the program progresses and thorough contingency planning.
“There is minimal contingency funding available for the remainder of the program and recently a number of additional activities have been identified. These activities are required to produce the planned EPLIS functionality, support ongoing operations and ensure benefits are realised through a successful transition.
“We consider that the program may require additional funding to complete all program necessities, with expected benefits potentially delayed.”