Local approach to EMRs essential for OS vendors

Australian hospitals looking to implement a full EMR from one of the commonly used international vendors should ensure that the product is Australianised or it won't work successfully in the local environment, UnitingCare's Richard Royle says.

Mr Royle, the driving force behind the construction of Australia's first fully integrated digital hospital, St Stephen's at Hervey Bay, said that while the Cerner system used at the hospital now acts as the one source of truth for all clinical data, it was obvious early on in the implementation that clinical groups would not accept the system unless it was tailored to local needs.

UnitingCare Queensland received a $47 million grant from the federal government in 2010 to construct the 96-bed hospital as a showcase for a digitally integrated facility, with close to half of that money allocated to IT.

Mr Royle told the Connect FutureHealth summit in Melbourne last week that the main reason he was successful in getting the funding was that he put his hand up for it.

“It was 2010 and Julia Gillard was the prime minister and Nicola Roxon was the health minister, and they sought submissions from the industry to encourage health and hospital services for regional, rural and remote communities,” he said. “We submitted for developing a new fully digital hospital in Hervey Bay as the first in the country.

“Interestingly, the reason that Nicola Roxon agreed to fund us for that grant is because at the time, she said the federal government was waiting on one of the state governments to put forward [plans to build] a fully integrated digital hospital and none of them had. So I put my head above the parapet and they said 'you're the bunny, let's see how it goes'.”

The hospital opened its doors to patients on October 13 2014, and since then 290-odd people have trekked north to view its operations, including people from both the public and private hospital systems, health funds and various governments.

On December 5, the hospital received its certification as a HIMSS Level 6 facility, predominantly due to its fully closed loop electronic medications management (EMM) system from Cerner.

UnitingCare Queensland has a long history with the Cerner Corporation, having implemented a Cerner EMR at Brisbane's Wesley Hospital back in 1999. Mr Royle again chose Cerner for St Stephen's, but this time with a difference.

“It is a fully integrated system and there is a significance to that,” Mr Royle said. “There is one source of truth for all data in this hospital and that all goes through the Cerner system. This is fairly unusual, even for Cerner.

“Everything filters down to the Cerner box. We have integrated every piece of equipment in the hospital into the Cerner system. There is no going between different systems in the hospital; it is all one software piece.”

Cerner has had its fair share of bad press in Australia, particularly during the early years of its roll-out in NSW Health emergency departments. While the full roll-out of the EMR is now ongoing in many NSW public hospitals, it was necessary for NSW Health to implement a remediation plan to iron out the difficulties before it could continue.

The plan to introduce the system to some Victorian hospitals under the HealthSmart program was also fraught with difficulty and has been abandoned in some instances. Cerner is also used in many Queensland public hospitals, where it is known as the integrated electronic medical record (ieMR).

When UnitingCare set out on implementing Cerner at St Stephen's, it took the step of hiring a hospital administrator who had been involved in a previous implementation in a similar sized private hospital in the US as the program manager, Mr Royle said.

However, that did not mean it was all smooth sailing, he said. “What we were doing here was essentially going through what is an American software system and Australianising it.

“The biggest problem that I witnessed when I looked at some of the implementations around this country, is that this is not what has occurred. They have tried to implement an American system into the Australian health system and it doesn't work.

“To be fair, Cerner recognised that within about four weeks of starting this. For example, we started with our groups of physicians, surgeons and anaesthetists and they gave us immediate feedback on what some of the problems were with the software pieces that Cerner had for those three components.

“We fed that back to Cerner to rebuild the software as another draft, and the immediate response we got back from Cerner in the US was 'no, this is the way it's done and we're not going to change it'. To which we said that if you are not going to do that, then this system won't work in this country.

“In fairness to Cerner, they recognised that ... and they did change the software and adapt it to what the requirements were in the Australian system. There are some Australian requirements and there are some significant nuances to that. That allowed us to get some success and some buy in.”

Mr Royle said his team took the 80:20 rule when it came to tailoring the system for the hospital's needs. “If you start to develop an electronic medical record, you can't tailor it too much because that then gets too expensive down the track in terms of maintaining it and you can't roll it out across the rest of the organisation.

“I can say that the system that we have in place in Hervey Bay, at least 80 per cent of that we can roll out across the rest of the organisation.”

Hunting and gathering

In addition to a full clinical suite, including SurgiNet and CareNet for nursing notes, the hospital has also spent time integrating communications and medical devices with the system. St Stephen's uses the Vocera hands-free communication system that is integrated into the EMR, along with nurse call and the real-time location system (RTLS).

“[RTLS] stops the nurses having to do what they call hunting and gathering,” Mr Royle said. “Every bit of equipment is tracked. If a nurse wants to find a wheelchair or an IV pole, they simply go to the nearest screen, they touch it and they will find where those things are.”

Everything is barcoded, including the patient, which Mr Royle said leads to some significant efficiencies. Medical devices all send data directly to the Cerner system, with Mr Royle estimating there are 20 devices, from anaesthetic devices to blood pressure monitors, that have been fully integrated.

“The nurse call system all goes through the Cerner system and it was our enterprise architects that built the interface into that,” he said. “Even the building management system goes through the one program.”

There is also no handwriting allowed. All clinicians have been provided with the Dragon dictation system that has been specifically customised for each individual. Mr Royle said nurses used the dictation system or typed their notes, whereas doctors predominantly talk into the microphone.

There is also a single sign-on system using smartcards that allows clinicians to tap on or tap off to any computer in the hospital and return to the same screen if they are interrupted. The hospital has also digitised the care pathway for 80 per cent of its DRGs in the system.

Mr Royle's pride and joy, however, is the closed loop medications management system. Understood to be the first in the country, it was this system that allowed the hospital to achieve HIMSS Level 6 and it is in this area that he hopes to realise the most benefits.

“A doctor orders the drug on their laptop or their PC, they can do that at work or they can do it at home, and the drug order is then sent directly to the pharmacist who produces them in single dose blister packs that are barcoded.

“The blister pack is then taken by the pharmacist and put into dispensing cabinets. The nurse is paged when the medication is due by the electronic system, they take the medication trolley around to the patient, they barcode scan the patient's ID, they barcode scan the computer and out comes the drug.

“It means the right drug to the right patient at the right time in the right dose. That has been clearly demonstrated in international research to have significant reductions of between 50 and 75 per cent in medication errors. That is one of the key pieces of benefits realisation we are doing.”

Mr Royle estimates that if the cost of digital health is excluded but the total cost of construction and fit out is included, then the total project cost comes to $595,000 a bed. That compares very favourably with the cost per bed for a public hospital, which these days is between $2 and $3 million, he said.

“We built it bloody cheaply but then we added the overlay of the IT,” he said. “It was a $47m grant of which $21m of it went to the IT. That's a big load of money and the reason it was a big load of money for only 100 beds was because there was a lot of one-off work here to Australianise the Cerner product, which is going to help the rest of the country who have selected this particular software.”

Clinical transformation

Mr Royle insisted that the project had to be looked at as a change management process, not an IT implementation project, and this is advice he would give to other hospital managers when looking at digitising their facilities.

“For goodness sake, don't get IT people to drive it or it'll be a disaster. The sheer number of examples around the world where there have been disasters is when that is what has happened. This is change management and it needs to be led from the top. I was personally involved in this all the way and you need your senior people to be involved in it.

“You have to develop a close relationship with your vendor. This is not a standard relationship – these are complex pieces to implement and you will come up with hurdles big-time and you have to have a close relationship with them. In my instance I developed a good working relationship with [Cerner's MD] and his number two and three in [the US].

“I had quarterly videoconferences with the number two and number three which was particularly useful because we found that the bureaucracy in Cerner would stop us from doing things and we were able to overcome those problems.”

UnitingCare set up eight redesign teams as part of what it calls its clinical transformation project, including three separate teams for doctors: a medical team, a surgical team and an anaesthetics team.

“We started with only two [teams for doctors] but it didn't take five minutes to work out that the surgeons and the anaesthetists couldn't get on together so we had to split them,” he said.

“These were very important, these teams, and it is these that made this project successful. We have about 1200 specialists across our group and we asked every one of them who would like to be involved in this project. We had quite a large number of people interested and we chose about 30 of them, and they include some very senior clinicians.

“The person who drove the medical doctor team is our director of intensive care from the Wesley Hospital. The fact that he was involved and became a superuser and ended up training a lot of our doctors up there further encouraged the doctors to realise that this would be very beneficial.”

Mr Royle said St Stephen's is the first hospital to have a chief medical information officer whose sole role is to be the link between hospital management and medical staff concerning the information system.

That doesn't mean it has been plain sailing, however. Nurses and their representative bodies have been concerned by the ability of the system to track exactly who did what and when, but Mr Royle said this capability was enormously beneficial in improving patient care.

And some staff have not been able to handle the change at all, he said. UnitingCare closed its hospital in Maryborough when St Stephen's opened and many staff came down the highway, but some have since returned.

“There are going to be some staff who are fundamentally challenged,” he said. “There are some who just can't work with the IT. Not many but some. They didn't have a choice here because I wasn't going to run a manual system along with an IT system. I was just running one. You can train them and we trained very hard, but there were a handful who said 'no, I can't cope with this' and they have gone to work in another place.”

Benefits realisation

UnitingCare is working with research group from an academic institution to study the benefits of going digital. These include the ability to better communicate with local GPs through sending discharge summaries and discharge medications lists straight to the GP's software, the benefits of computerised physician order entry and other elements such as reductions in medication errors through the EMM system.

He said he hoped to have some preliminary data from the benefits realisation study in the next four months and full data in a year. In the meantime, the hospital is aiming to achieve HIMSS Level 7 by the middle of next year, which Mr Royle is confident of achieving.

In the future, Mr Royle would like to harness the IT system he has chosen to do some very interesting work on population health. UnitingCare is in the unique position of playing a role in several sectors of healthcare provision in Queensland's Wide Bay area, which includes Hervey Bay.

In addition to the hospital, UnitingCare runs the BlueCare aged care service and UnitingCare Community, which provides community services such as Lifeline, child and family care, counselling and disability support.

With deep ties to general practitioners and private medical specialists, UnitingCare believes it is in a position to pilot population health research amongst the region's 110,000 people.

“In the Wide Bay area of Queensland our three organisations comprise a very large slab of acute health care, aged care and community care and there is the opportunity to do some work on population health.

“There is some very interesting predictive analytics work being done around the world in population health, which is essentially bringing data together from the likes of [hospitals], bringing the data together from the GP practices and aged care providers, overlaid with the demographics of the individual, overlaid with the predictive analytics models that the IT providers like Cerner and Epic and others are working on.

“You can start to predict what the health issues are going to be over the next five to 10 years. That has become a very interesting area of work ... and we have a chance to pilot that in the Wide Bay area. Our organisation covers a fair whack of that.”

Posted in Australian eHealth


0 # Amanda 2015-04-29 16:13
Hi there

Great article and must've been an amazing team of professionals who made this all happen so successfully!

Some observations:

1. You have made some major errors in your description of the "fully closed loop medication administration system" and how it works. The workflow you've described is incorrect.

2. The person who came over from the U.S., who had run similar implementations over there, was not employed as the hospital administrator. She was the Programme Director.

3. It's called St Stephen's Hospital, not St Stephen's Private

4. You need to let your readers know what EMM means.

Kind regards
0 # Kate McDonald 2015-04-29 16:20
Thanks for your comments Amanda.

You'll see that the description of the closed loop medication management system is in quotation marks, meaning it's a direct quote from Richard Royle, not my description. He was just summarising for the audience how it worked in general terms and wasn't meant to be a full description of the workflow, so that's not something I can change.

I can see where it is a bit unclear about the role of the US person. I meant that she was a hospital administrator in the US, not that she was hired for that role here.

I take your point about EMM and St Stephen’s Private and have fixed those two errors.


0 # bruce 2015-04-29 23:34
a lot of money for a small hospital to go digital. would be interesting to extrapolate out what it would mean for larger implementations . Are comments about the "australianisat ion" a concession about the need to customise such a solution?
0 # Amanda 2015-04-30 09:03
The automatic dispensing cabinet (ADC) is pre-stocked with all meds on a periodic basis, not on a per-order/per-p atient basis.


1. Doctor places a medication order in the patient’s electronic record
2. This order is also visible to the nurse, who has access to the same patient record
3. The nurse is presented with a medication administration notification within the patient record letting him/her know it’s time to administer that dosage (not paged)
4. Nurse walks over to the automatic dispensing cabinet (ADC) to get the blister pack, which he/she puts in the medications cart and takes to patient.
5. In the meantime, the pharmacist is alerted to review the medication order and verify it.
6. Nurse scans patient wrist barcode to confirm correct patient.
7. Nurse scans medication blister pack to confirm correct medication and register it within the patient record.
8. Nurse administers medication and records completion of administration in the electronic record.

In response to Bruce, a significant amount of cost is typically spent on foundational elements, and therefore you cannot multiple out from that to reach a cost for a larger hospital.
0 # katharina 2015-05-04 09:47
An interesting article.

We are on the EMR adoption journey with an AUSTRALIAN vendor and a current functionality set that can see us reach Level 6. The main challenge is change management and clinician engagement within the hospitals.

My question is around the cost model/business case for the automated pharmacy dispensing cabinet and UOM bar coding for medications. Given that most public hospitals in Australia do not have automated dispensing machines and UOM bar coding, what is the strategy to assist sites to acheive Level 6?

Does the HIMSS EMRAM need some adjustment to fit the Australian landscape or should all health services who can demonstrate EMR capability to reach HIMSS Level 6 be funded to support the implementation of UOM bar coding for medicaitons?
0 # mark 2015-05-05 10:43
As an interested clinicians working in this area of informatics, I was read this articles and was dismayed that most of the challenges have been recurring in the Australian healthcare system for the last 15 years.
I agree that large multinational IT companies have difficulty adapting software to the Australian system and it still amazes me that the government spends so much money per implementation site on software rather than investing in the development of an appropriate solution like many European (not UK) sites.
In reality Australia healthcare is extremely unlikely to be able to fund a level 6 at every hospital thus in 10 years time we will continue to grumble about being so far behind.
0 # Mark 2015-05-06 10:02
As a person who has helped implement the first Cerner system in NSW, mainly PathNet, I am interested in the details of what you call "Australianisat ion"of the system. There may be things we can implement at other sites.
I am also interested to know what you do with your Pathology and if you have these results feeding into your EMR.

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