EPAS instability, lateness and cost blow-out to affect new RAH
The implementation delays, cost-blow outs and inadequate clinical usability being experienced with the roll-out of South Australia's Electronic Patient Administration System (EPAS) is likely to have an effect on the design of the new Royal Adelaide Hospital (nRAH), which will now need to plan for paper record storage, the SA Auditor-General has warned.
In a critical report handed down last week, Auditor-General Simon O'Neill has revealed that the design and build phase of EPAS is 16 months behind the original completion date and is unlikely to be fully operational until well into 2017. The new RAH is due to open in 2016, with its physical design, proposed workflows and equipment selection influenced by the intended roll-out of EPAS.
Mr O'Neill also revealed that the Health Reform Cabinet Committee at one stage considered cancelling the whole project and removing EPAS from its activated sites, as well as stopping the implementation and only using EPAS at its current sites, including Port Augusta Hospital, Noarlunga Hospital and the Repatriation General.
The committee also considered continuing the implementation or taking SA Health's preferred option of delaying the implementation until functional deficiencies could be resolved. It appears that the latter option has been selected, with the EPAS roll-out paused for the time being and a “stabilisation” phase entered into.
Along with the known problems with the system's billing module – which has led to the SA government issuing a claim against the developer, US giant Allscripts – problems with clinical functionality are also emerging.
Pulse+IT understands that many clinicians at active sites are refusing to use the new system either because they consider it potentially dangerous or it does not suit their workflows. However, no clinicians have so far been willing to speak publicly about their concerns.
The InDaily news service reported in May that clinicians at Port Augusta Hospital had become so frustrated with the system that there had been emotional breakdowns and “rage attacks”.
The Auditor-General's report says the recommended stabilisation phase aims to resolve key functional issues including:
- Product and system remediation of known issues, especially for the patient administration and billing modules
- Develop a fit for purpose solution, including to meet some additional functionality
- Standardise workflows and organisational change
- Update the training approach
- Business as usual to support the current sites that have implemented EPAS
- Planning for post-December 2014. Should the EPAS product and system be appropriately stabilised the priority site for the next activation will be the nRAH which opens in 2016.
“In addition to these six streams SA Health is planning contingency options for the nRAH in the event that EPAS is not ready to deliver its requirements,” the report states.
The implementation will also not fulfil its original scope, which included the replacement of iPharmacy and operating theatre management. EPAS was originally planned to replace over 70 legacy patient administration and clinician information systems, including the OACIS system used at many sites that was originally designed to become a statewide electronic health record.
It was planned as an integral part of SA Health's IT upgrade, which includes the development of an Enterprise Master Patient Index and new statewide medical imaging and pathology systems. SA Health is currently preparing for the roll-out of Cerner's pathology module.
However, in addition to the delays and clinical functionality problems, EPAS has also run over budget. The estimated total cost over 10 years was $408 million – $143m in capital costs, $220m in operating costs and a risk-based contingency of $45m.
The business case put to Cabinet stated that when efficiencies were included and the costs of maintaining legacy solutions was calculated into the cost-benefit ratio, EPAS would realise a benefit of $11 million over 10 years.
However, program funding was increased to $422 million in 2011-12. The current budget shows an underspend, but there has also been a “significant deterioration” in its budget position, the Auditor-General reports.
“In February 2014 the responsible Minister advised Cabinet that the program was several months behind the original schedule, with increased costs and a reduction of expected benefits, creating a net financial cost of over $50 million,” he said.
While SA Health has reported some benefits from the implementation, including continuity of patient information across active sites, drug dosing alerts that have potentially avoided medications misadventures and the provision of real time clinical information to assist in monitoring the progress and movement of patients, there have been some major issues.
These include the discovery of 4833 defects, not just in the billing or records modules but in clinical and patient flow systems as well. As of October this year, 338 of those defects are still unresolved.
And some clinicians simply do not like the system. As reported in one assessment from Noarlunga, “It is now clear that the PAS functionality is not sufficient to meet SA Health’s requirements and staff are experiencing considerable frustration in trying to use the new functionality”.
In addition to all of these fears, the Auditor-General has issued a warning about the potential effect on the new RAH.
“The EPAS solution has a critical inter-relationship with the current design of the nRAH, which has influenced its physical design, proposed workflows and equipment selection,” he reports.
“SA Health recognises that, from an operational perspective, if EPAS was not rolled out to the nRAH the current impact on the proposed model of care of not having an integrated electronic system is unknown. Any alternative solution is expected to require modified processes and manual workarounds.
“As the nRAH is physically designed to have minimal storage and use of paper records due to the proposed functionality of EPAS, a solution for central paper record storage at clinics and wards and daily transport of paper records will be required.”
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