Contingency plans for EPAS and ESMI at new Royal Adelaide
A contingency plan is being developed alongside the current build of the Enterprise Patient Administration System (EPAS) for the new Royal Adelaide Hospital (nRAH) that would see some legacy clinical software retained and a hybrid paper/electronic medical record used should EPAS not be ready in time for the hospital's opening next year.
A report tabled in the South Australian Parliament last week by SA auditor-general Andrew Richardson shows that despite a stabilisation phase being implemented by SA Health to fix some of the issues plaguing the roll-out of EPAS, more delays have been experienced including in the deployment of version 14.3 of the software from December 2014 until May this year.
Version 14.3 was meant to fix many of the bugs – from billing problems to lack of clinical usability – that have caused a massive reduction in the initial scope of the roll-out of EPAS.
Mr Richardson reports that this version has now been delivered at live sites and he has been advised it has addressed a number of PAS and billing issues. Some remain outstanding however, including registration screens and functions, patient screens, outpatient waitlist and outpatient scheduling functions.
Mr Richardson said his office will be investigating the effects of v14.3 in the coming year.
While some of the bugs look likely to be fixed, the report reveals that there are still major problems with the roll-out particularly as it relates to the nRAH.
For example, the EPAS project office for nRAH was working towards a deadline of mid-April 2016 for implementation when in fact the system needs to be ready and testing completed prior to January 17 2016 in order to be ready for state operational commissioning (SOC). Project staff only found out about this in February.
In addition, Allscripts has been testing technical integration in its corporate development environment rather than a testing environment that mirrored the EPAS production system. This has since been rectified with the establishment of a new SA Health test environment.
While the auditor-general reported that the EPAS program office was working with Allscripts to implement an EPAS build at the nRAH that includes all of the functionality currently configured and operational at live sites, this is dependent on some other implementations being ready in time.
These include an interface with the Enterprise Pathology Laboratory Information System (EPLIS) being rolled out by Cerner and the Enterprise System for Medical Imaging (ESMI) being rolled out by Carestream, which itself is facing very tight deadlines for implementation at nRAH (see below).
Delays with the Oracle Corporate System (OCS) have also caused problems for planning the EPAS roll-out, and the auditor-general highlights risks that these delays are likely to have on the implementation of other systems such as ESMI and several mobile access devices from Allscripts that are due to be implemented at nRAH.
These include the Sunrise Mobile MD II application for orders and results and Sunrise Mobile Care (SMC) for reviewing and administering medications.
The audit reveals that a “hybrid record team” is investigating the option of implementing a hybrid medical record on initial operation of the nRAH.
“This approach is a combination of paper based as well as electronic records of information,” the report states. “A concern remains around the implementation of a hybrid record due to its associated impact on workflows.”
Should EPAS not be ready for implementation, the contingency approach will involve retaining a number of legacy systems such the patient administration system known as APMS and the OACIS clinical information system for renal and pathology functionality.
“As part of this process these legacy systems may require certain functional upgrades and/or workarounds to achieve required business process flows,” the report states. “[The auditor's office] understands that work is being conducted on the nRAH contingency plan in parallel with work on building the EPAS solution with functionality fit for the nRAH.”
SA Health may also need to factor in alternate paper storage options and daily transport arrangements should EPAS not be ready.
Savings benefits evaporate
SA Health has long put a lot of the blame for the delay in the roll-out of EPAS down to problems with its billing system. This led to a contractual dispute between the government and the vendor, which the auditor-general reveals has been settled for a sum of $13.25 million.
The report also reveals that Allscripts has had to engage a third party to provide a billing interface solution to Medicare.
It details the blow-out not just in the cost of the system but in savings benefits. In the original plan, EPAS was supposed to be rolled out to all hospitals in the state at a cost of $220 million over 10 years, made up of a capital cost of $151 million and operating cost of $69 million.
That turned out to be a massive underestimate, with the eventual plan approved in December 2011 costing $408 million over 10 years (capital cost $143 million; operating cost $220 million; risk based contingency $45 million).
As the auditor-general reports, the business case for EPAS was based on sufficient savings benefits being realised as costs were incurred to enable it to become self-funding. This would see an overall favourable position of $11 million over 10 years to 2020-21.
Program funding had to be increased to $422 million to cover inflation, but it was revealed recently that there had to be a huge write-down of the savings benefits by $75.8 million. This is primarily due to $42.8 million in delays, an overestimate of savings in terms of medical record staff to the tune of $33 million, and the fact that the operating room system ORMIS and iPharmacy will not now be replaced.
Potential risks to ESMI
The report also draws attention to potential risks for the new $19 million state-wide medical imaging system ESMI and its implementation at the nRAH.
This system has been built by Carestream to replace in part the existing Kestral radiology information system (RIS) as well as provide a commonly configured picture archive and communication system (PACS) to replace Careconnect and OACIS.
Part of the reason for introducing it was to roll it out to the Women's and Children's Hospital (WCH), which did not have a PACS and which was recommended by the state coroner after the death of a child whose diagnosis may have been delayed by a lack of imaging technology.
ESMI involves an enterprise RIS, an enterprise PACS and a voice recognition system used by radiologists to produce medical imaging reports without an intermediary typing stage.
ESMI implementation has now been completed at the Women's and Children's Hospital, The Queen Elizabeth Hospital and Lyell McEwin, but the auditor's report looks at some of the key risks and the system’s readiness for the nRAH.
The nRAH was excluded from the original ESMI business case as it was expected to be transferred across from the existing RAH with the migration of certain other existing systems to the nRAH.
However, due to the vast amount of concurrent ICT projects then being implemented, a “slowdown” of the ESMI program was approved by the Minister for Health in 2013. The expected project close date was revised to March 2016 from the original 2013-14 financial year, and the existing RAH will now receive it in August. Flinders Medical Centre will receive ESMI in October, the Repat in December and some smaller regional hospitals in February and March next year.
“Although the revised plan noted the exclusion of the nRAH, the program had completed a high level planning exercise in December 2014 for implementation of ESMI into the nRAH,” the report states.
While the ESMI program office maintains that it will be implemented into the existing RAH in August, contingency planning has also been necessary for the nRAH in case EPAS is not ready, the report says.
This includes continuing using Kestral, but that would also require that either EPAS was up and running at nRAH or APMS was used instead, as well as the implementation of ESMI at the existing RAH.
“At the time of writing this report, the nRAH program is still in the detailed planning stage of an imaging solution at the nRAH,” the auditor-general said.
“The outcomes of this stage include producing a program schedule, resource plan and a program implementation plan. The detailed implementation plan is expected to be completed and presented to the ESMI program and will include details of the build and system testing stages.”
Remaining EPAS risks
According to the auditor-general, there remain a number of risks facing the EPAS implementation at nRAH and the other hospitals to follow. These include:
- lack of staff familiarity with EPAS and associated workflows at the nRAH
- configuration functionality specific to the nRAH may not be completed in time
- demands on limited resourcing may affect implementation timeframes
- potential for further program scope creep may affect implementation timeframes and budget
- approved EPAS budget may require additional funding
- some EPAS functional issues remain unresolved
- some billing functional issues remain unresolved
- further patient administration system (PAS) functionality is required before the system can be deployed to a large complex site, such as the nRAH
- problems with periphery devices to access EPAS
- EPAS roll-out approach and timeframe for additional sites outside the nRAH remains unclear.
Global Health suit
The state government is also being sued by software vendor Global Health for breach of contract and infringement of copyright for continuing to use Global Health's Chiron software in some of its regional hospitals.
Chiron is an MS-DOS-based system first developed in the 1980s that was replaced by Global Health back in 2003.
However, rather than swap over to Global Health's new system, MasterCare ePAS, SA Health continued to use Chiron in the expectation that Allscripts' EPAS would be rolled out to all hospitals in the state.
This is now on hold but rather than upgrade to MasterCare, SA Health is continuing to use Chiron, despite Global Health decommissioning it in March.
Last month, Global Health's subsidiary Working Systems Software started legal proceedings seeking a permanent injunction restraining SA from using Chiron.
SA says it is relying upon the Crown compulsory licensing regime for Commonwealth and state governments under the Copyright Act 1968, which Working Systems contends does not apply to computer programs.
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