SA Health on a PR offensive as rural GPs warn of dangers with EPAS
Rural GPs in South Australia have again raised the alarm over problems with the Electronic Patient Administration System (EPAS) being rolled out to SA hospitals, leaking a letter to the media that lists a host of problems with the under-fire system, from unintuitive screens to excessive time for progress notes to real dangers from medication drop-down menus.
The Adelaide Advertiser reported today that the Flinders and Far North Doctors Association (FFNDA) had written to SA Health CEO David Swan outlining 37 different problems they had experienced with EPAS, following two years of using the system at Port Augusta Hospital.
The letter comes as SA Health goes on a PR offensive about EPAS, which is due to be implemented at the Queen Elizabeth Hospital in June and at the new Royal Adelaide Hospital in November.
SA Health has released a series of videos featuring interviews with doctors, nurses and patients who have had experience with EPAS, which is being configured by US firm Allscripts in a $422 million roll-out.
One video features Port Augusta and Royal Adelaide ENT surgeon JC Hodge as saying EPAS has revolutionised his handling of patients at Port Augusta. “[As] a result, it’s more streamlined, I see more patients, it’s more efficient. I’ve been happy, the patients are happy.”
Dr Hodge's colleagues at the FFNDA are not so happy, however. The leak of the letter to the Advertiser comes almost two years after a leak by the same association to Adelaide online news site InDaily, in which doctors warned that EPAS was causing ”rage attacks”, leading visiting medical officers to insist on a return to a paper-based system while the problems were being sorted out.
Country SA hospitals are heavily reliant on local GPs providing on-call and rostered services, particularly to staff emergency departments and for obstetrics. The FFNDA warned two years ago that doctors were refusing to work shifts if they had to use EPAS.
It seems that despite remediation efforts by SA Health and Allscripts, local doctors still do not believe the system is safe and are asking for it to either be completely reconfigured or a different system chosen.
They point out that they all use a GP clinical system every day and are not Luddites, describing a high level of frustration.
“When the members of FFNDA initially raised our concerns with the safety and efficiency of this program, we were accused of 'resisting change' and 'not wanting an electronic system',” they write. “We would like to remind you again that the overwhelming majority of us work primarily as general practitioners working in private practices that use electronic medical records 100% of the time.
“We have for years embraced electronic medical records and their expected efficiencies. EPAS has been extremely disappointing in not delivering these efficiencies as would be expected of a contemporary program.
“Therefore, we ask again – please take EPAS away and completely remodel it into a more user friendly, efficient and safe interface. Or, if that is not possible please replace EPAS with something much better.”
PAS and EMR
EPAS has been designed not as a simple PAS but as a full electronic medical record with interfaces to many of the other enterprise-level, state-wide clinical systems being rolled out, including the new pathology system known as EPLIS, provided by Cerner, and a medical imaging system known ESMI, from Carestream. The problems with EPAS and the delay in the build of the new RAH are being blamed for causing knock-on effects on EPLIS and ESMI.
EPAS was originally devised to be rolled out to 80 metro and rural hospitals and state-run clinics, but the scope has been severely curtailed in the six years since the tender was announced. At the time it was set to cost $300 million for the whole state system, but this has now climbed to $422 million and less than a dozen hospitals – albeit the tertiary ones – are likely to receive it in the next few years.
The smaller hospitals are expected to continue with a mixture of paper records and the ageing OACIS clinical information system, which is supported by Canadian firm Telus Health. Many rural hospitals still use the MS DOS-based Chiron PAS, about which SA Health is currently embroiled in legal action with marketer Global Health.
EPAS itself is based on a number of modules from Allscripts' Sunrise suite, including Sunrise Registration, Enterprise Schedule and Financial Manager, which together make up the PAS and billing, and Sunrise Clinical EHR suite for the EMR and integration.
Allscripts is one of the top half-dozen EMR vendors in the US – its rivals include Cerner, Epic, Meditech and GE – and it has very good rankings with market research firms such as Black Book and KLAS as well as annual revenues of over $1 billion.
In Australia, though, things don't seem to be going so well. The FFNDA says in its letter to SA Health's Mr Swan that it is “imperative” to highlight ongoing issues with EPAS as the program is set to be rolled out at other sites.
“We are now expert users of this program and yet it continues to take longer to access and document information than using a paper-based system,” they write. “It is a non-intuitive interface that requires users to actively look for information on various screens, rather than being able to see at a glance what is required, in particular observations and administered medications.”
Long list of problems
The letter details a long list of issues ranging from hardware and network problems, such as not enough workstations in the ED or during busy times on the wards, and long log-in times when using a personal SA Health HAD log-on. This log-on is also causing troubles for GPs when trying to access other applications such as the Intelerad radiology system and results from IMVS (SA Pathology).
In terms of prescribing, there are complaints about poorly set out screens for ordering medications and extra clicks to enter drugs. While the doctors acknowledge that legibility has improved and there are fewer prescribing errors, they point to other known errors with most EMRs that use drop-down menus.
These long menus have been shown to introduce new errors not seen with paper systems such as selecting the wrong drug inadvertently. The doctors also complain about the time it takes to write up multiple drug orders and the cumbersome procedure to prescribe warfarin.
There are problems with medication administration as well, they say. It is hard to see what drugs have been given and there is a lag in the time between nurses signing off that they have administered a drug and that showing up in the system.
They have issues with the SNOMED and ICD10 descriptors for diagnoses, and rather than describe drug intolerances as sensitivities, everything is being recorded as an allergy, which means multiple warnings pop up when entering medication orders.
Endless drop-downs are also causing problems when ordering imaging and pathology, and the doctors have had to devise a safety net to ensure that results that are received in EPAS after the patient is discharged are also sent to their private systems to ensure critical results aren't missed.
They complain of a lack of auto-save functionality but also that there are too many document templates, and like many doctors, they admit to using free text for progress notes because this is faster than the structured sentences often provided with EMRs.
Ominously though, they say there is no way of telling who wrote the note after it has been modified and that it is easy to copy and paste someone else's notes into a new one.
They acknowledge that doctors all use the system in different ways but there seems to be no quick and easy way to find what information doctors need from the system, they say.
The system is also not working to improve patient flow, despite being sold as ideal for that, they write. But one of the main criticisms is that documentation takes too much time to be completed, which is affecting patient care.
“It is much more common to see nursing and other clinical staff sitting at workstations than providing hands-on care at the bedside,” they write. “Patients frequently comment on this to staff. Recently a patient was down-transferred to another site with complaints of inadequate attention to [activities of daily life] by staff and inadequate bladder/bowel care, attributable to problems with recording/viewing information in EPAS and the time taken to care.
“Recently, a post-partum patient had delayed detection of [post-partum haemorrhage] as staff were preoccupied with data entry.”
They complain that despite taking longer to do notes and orders they are still paid the same fee, and that several experienced doctors will not now provide services to Port Augusta Hospital largely due to concerns with EPAS.
“Other local doctors will not consider doing any inpatient or on-call work because of what they have heard about the problems with EPAS,” they say. “We have currently half the number of doctors participating in the on-call roster than we did two years ago.”Do you know any more? Please feel free to contact us confidentially and anonymously here.
Posted in Australian eHealth