Pioneering London hospital hit by crashes and delays

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Royal Free Hampstead NHS Trust, whose staff treat 500,000 patients a year from around the world, has run into "significant" problems including system crashes, delays booking patient appointments and data missing in records. 

The difficulties raise questions about whether the trust's board, under central pressure, went live too soon with Release 1 of the Cerner Millennium Care Records Service. The trust had already postponed go-live at least twice. It finally went live in June.

The Royal Free's board was told last week: "Some individual clinics have genuinely struggled to manage the implementation of Cerner. In the main these clinics tend to be those with the largest volume of patients."

Appointments are said to have been lost in the system - and some staff have told the local paper, the Camden New Journal, that there have been weeks of "chaos". One clinician said more time was being spent on booking appointments than in his clinic treatment patients.

The Royal Free is the first NHS trust in England to go live with the Cerner Millennium London Cluster Release 1 [LC1] of the Care Records System from BT Health, the local service provider for London. Cerner's LC1 links to the NHS data spine and supports the use of electronic swipe cards to access patient records. 

Other trusts in London and the south of England have gone live with the Release 0 of the Cerner Care Records Service. The Care Records Service - the roll out of which is running four years late - is a central part of plans to build a database of 50 million summary health records under the NHS's £12.7bn National Programme for IT [NPfIT].

The Royal Free, which is close to Hampstead Heath, has a leading cancer centre. It is also renowned for its specialist treatment centres. It has been preparing for the go-live of the Cerner system for more than a year.

Go-live "comparatively successful"

The trust says that its Cerner launch was "comparatively successful when compared with other acute trusts".  Barts and The London NHS Trust delayed cancer visits after its Cerner Release 0 go-live. The deployment of a NPfIT Care Records System at Milton Keynes Hospital NHS Foundation Trust "developed into an untenable situation which resulted in near melt down of the organisation," according to papers released to E-Health Insider under the Freedom of Information Act.

Royal Free's board was told last week that some of the problems were expected but not all. Executives have set up arrangements to prioritise problems in such areas as the scheduling of operating theatres, handling of inpatient waiting lists, outpatient clinics, maternity, gynaecology, paediatric services, pathology, radiology and nuclear medicine.

Risk of loss of essential clinical data ... potential issues of clinical safety?

Action is being taken to reduce risks of "loss of essential clinical and commissioning data set information" and "potential disruption to core business and clinical processes".

The board was also told that consultant staff have been given the opportunity to "discuss any concerns, particularly with respect to potential issues that could impact on patient safety". A paper to the board last week adds: "Their concerns have been listened to and where necessary action has been taken." 

The trust anticipates re-building parts of the Cerner system in the light of experience.

The problems:

Some key hospital work - such as ordering blood tests - takes longer than before

These problems have at times "resulted in frustration" and caused delays to clinics, the trust board was told. One concern has been the responsiveness of Powerchart, a part of the Cerner system which should allow clinicians to access records at any time from any location.  BT Health and Cerner has deployed upgrades to make the system respond faster.

The board paper says: "The Outpatient Appointment Centre has experienced a significant increase in the time taken to process individual patient appointment bookings."

"Extremely challenging"

A board paper written by Charles Bruce, Director of Clinical Service Improvement, Adrian Tookman, Medical Director, and Healther O'Brien, Director of Information Systems, said staff could see the advantages of the new system but "it is recognised that some administration processes take longer than the green screen technology of [the] McKesson patient administration system and the workflow in outpatients has proved extremely challenging". The paper adds:

Extra clinicians needed to reduce pressure after "significant issues"

"There have been significant issues around the admission processes for pre-assessment, waiting list management and the scheduling of theatre lists." The trust has responded in part by providing "additional clinicians to reduce pressure on busy clinics".

Many of the problems are because of a lack of understanding of the software and new working practices. But there have also been technical glitches.

Crashes

The board paper said: "The system itself has had some technical issues with unexpected crashes .. in some modules" although suppliers have "put in place several fixes" which have improved stability. Cerner and the supplier of the operating platform Citrix are "working hard to ensure that all problems are resolved".

New releases of software are due in September and October/November 2008 to help support the faster booking of follow-on appointments for patients.

Backlogs

"Administration staff have made a tremendous effort in clearing the backlog with over 12,000 records updated and changed in the past three weeks, which ensures that payment for June activity is received. Backlog for July 2008 is currently being assessed and will include a mix of outpatient records with missing discharge details, appointments that have no outcome and patients on an inpatient of day-case waiting list that need to be reviewed." The aim is to have the backlog cleared by a commissioning deadline of 21 August 2008. "Review workshops are being carried out across operational areas to identify issues which cause backlogs to be generated."

Snomed - like "learning a new language".

Cerner uses the Snomed terminology for clinical agreed - the standard approved by the Department of Health and NHS Connecting for Health. "It is proving to be like learning a new language in some clinical areas".

What's the trust doing about the problems?

Daily operational meetings are taking place with all general managers and it has set up a Cerner User Group. As a back-up, the trust has manual, paper-based processes and system workrounds.

The board paper said the shared knowledge and "consequential management will provide a solid foundation for the trust to move to a comprehensive  electronic patient record as further system software is released."

The risks of a go-live were first raised by Royal Free staff on 22 January 2007 when Cerner presented its Millennium software to more than 100 trust staff including IT and information staff, clinicians, senior nurses, general and operational managers, medical secretaries, ward clerks, the bed management team and others. 

After the event staff raised potential problems which were later discussed with the NPfIT local service provider for London, BT Health, and with NHS Connecting for Health.

Trust statements to Computer Weekly

A trust spokeswoman said in statements to Computer Weekly:

 "With change on this scale, it is inevitable that it will take time for staff to familiarise themselves fully with all the functions that they need to use but overall we are pleased with the progress being made..."

"Cerner, the Care Records System, is one integrated system.  It replaces our patient administration system (McKesson Totalcare), our A&E system (Symphony), our theatres system (PICIS), our results system, (McKesson Totalcare) and our maternity system (Protos). 

"Having one system is advantageous to the trust as maintaining all the above systems has proved challenging in the past with various interfaces and suppliers... 

"Certainly the complexity of the system has proved to be difficult for some clinicians running extremely busy clinics as processes do take longer than paper flow, but this is being addressed by the executive with the offer of additional clinical and administrative clinical staff to help reduce the workload while the clinicians adjust to the new systems. 

"The advantages for the future where results are available for all patients in all clinical areas and the gradual reduction in reliance on paper records will benefit the patients in the long term, but it is recognised that while staff are getting used to the system a small number of our patients may have to wait longer than expected in clinic...
 
"Following go-live, a backlog of some 1,800 new referrals (out of an annual total of 100,000 new GP referrals) was experienced within our out-patient appointment centre. The issue was identified on 7 July and additional staff were allocated to assist in backlog clearance. This exercise was completed on 16 July. It is therefore the case that appointments relating to the backlog were delayed for a short time."

**

Comment:

It's unclear whether some of the "significant" problems have taken the Royal Free completely by surprise, or whether it was decided, in the hope the risks were not too great, to ride some rough waves to pioneer technologies which have a high political profile. Clinicians may like the systems eventually, but at what cost to patients in the meantime?

Links:

Barts and The London NHS Trust delays urgent cancer visits after NPfIT go-live - June 2008

Royal Free hospital "chaos" - Camden New Journal - July 2008

Bugs in Royal Free systems - Camden New Journal - July 2008

Minister defensive over Cerner NPfIT sites - IT Projects blog - February 2008

Fujitsu's leaving the NPfIIT is a sign of strength - minister - July 2008

Whitehall officials pledge not to repeat troubles of Care Records Service go-live at Nuffield - but similar problems have already occurred at another hospital - IT Projects blog April 2007

Lessons from troubled go live of Care Records Service at Nuffield Orthopaedic Centre - letter from the National Audit Office - April 2007

Barts go-live ends up in The Sun - 2008
 

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