Cerner: some pros and cons

Below is a transcript of my interview with Andre Snoxall, e-record programme director at Newcastle Upon Tyne Hospitals NHS Foundation Trust, which has broken away from the National Programme for IT [NPfIT]. The Trust is to implement Cerner systems from the University of Pittsburgh Medical Center

Snoxall spent much of the last 10 years as CIO for a number of trusts in New Zealand. He’s Australian.

In the interview Snoxall talks about:

– Why in his view Cerner implementations in London and the south of England have gone wrong

– How Newcastle’s plans to avoid some of these difficulties.

– Cerner’s strengths and weaknesses

– The trust’s biggest challenge – communications

– Why Newcastle’s Cerner systems may be more advanced than those under the National Programme for IT [NPfIT]

– Newcastle’s plan to minimise the use of the Cerner for reporting to the government on  patient activity

– Newcastle’s plan to use its own Cerner system for seven years – by which time it hopes that local service providers under the NPfIT will have a replacement

Andre Snoxall:

“On the e-records programme our first priority is to standardise the way we manage patients across the entire trust, so that, if you have an outpatient appointment in any part of the trust, you’re entered into the same system. When you’re admitted to the hospital through A&E or an outpatient appointment, the process is standardised; when you’re in the hospital we know what bed you’re in what ward you’re in and who is looking after you. That’s the first focus.

“The legacy systems [up to 100 of them] are very good but developed in isolation of each other.”

How will you bring all that data together?

“It’s really about standardising processes. It’s very little to do with the computer system and more about how you are going to inspire and engage people, and get them working together to work towards common goal…

“[We’ll use] the use Cerner suite of products to centralize all that information.”

Everyone will see standardised screen displays throughout Newcastle’s three hospitals?

“That’s right. Any of the legacy systems will be integrated with Cerner.”

Your biggest challenge?

“It’s to get everyone to understand that they cannot do things the way they did them before. This is a very big trust, with 11,000 people. [The challenge is] getting everyone on the same wavelength, the same path, and knowing who they will need to talk to work through any issues and doubts.

“The big issue is communication more than anything else.”

How will you avoid problems in the south with Cerner implementations there?

“Knowing the problems that are there is half the battle. We have partnered with UPMC [University of Pittsburgh Medical Center] who I believe are the largest single Cerner customer in the world. Therefore we believe they have got – and this is part of the reason we partnered with them – a tremendous endless amount of clout with Cerner.

“They have the ability to influence the way that product is developed. We are hoping that through that relationship we will hopefully get a version of the product that’s more advanced than the ones that have currently been implemented.

“However we are not putting all our eggs in that basket. We recognised that organisations such as Barts and the Royal Free [Hampstead] have encountered  a number of issues largely because of deficiencies largely in the way the product handles the 18-week pathway.

“We will look at how we may avoid as much of those as possible, through workarounds and through whatever means are available. We have more time, another nine months to try and get that right.

“Hopefully we won’t end up with all the same sorts of problems. Now that’s not to say we expect everything will be perfect from day one.  We don’t think it will. But forewarned is forearmed.

A lot of problems are down to the fact that you need more people to be able to manage the patients than would be optimal [at go-live and afterwards].” [my emphasis]

Is it important to have a direct relationship with the supplier, no middlemen in terms of local service providers?

“It does help. Our contract is with UPMC and it is accountable for delivering on its commitments to us. That’s where there is a difference [when compared to] the local service provider. But in many ways UPMC is fulfilling that role of the local service provider.”

Though there is some local reconfiguration possible, under the NPfIT, trusts have to go to committees to make changes to Cerner, and then everything has to be agreed to a standard specification. Isn’t there a danger of your being the same remote position regarding changes you may want to make to Cerner?

“UPMC is committed to helping us manage our waiting lists to NHS standards. If something doesn’t work they would take it straight back to Cerner to get those changes made. Our problem with regard to patient administration is that Cerner is behind some of the other systems in the marketplace. No matter how willing Cerner are to sort the problem, there is a software development cycle that may simply not be able to deliver by the date we need it.”

Why choose Cerner then?

“Because of the richness of the product. [One priority] is managing the patient’s journey. [Another priority] is about improving patient care through providing excellent clinical systems. We are looking to provide a single record that will support our doctors and nurses in doing the best job they can do. Cerner is in my mind the premier product in the world to do that.

“It doesn’t advertise itself as being just a PAS [patient administration system]. You need to have that. But the focus is on the clinicals: the ability to support doctors and nurses in their jobs.”

What’s so strong about Cerner?

“The breadth and depth of the database in being able to pull together large amounts of disparate information. There is lots of information from different sources to support clinical activity.

“In intensive care units they collect vast amounts of information directly from machines that are monitoring patients and the key is to make that information available to the clinicians responsible for those patients from anywhere that they want to log in. When you walk into an ICU today that doesn’t have good e-records lying behind it, you’d probably find at the end of the beds a big table with lots of computer screens attached to lots of different machines. Or lots of paper where they have transcribed the information from the machines, which gives them one view of everything. But that view is only accessible if you are at the end of the bed – not if you are on call or at another part of the hospital.”

Cerner gives you all the ICU information in one place in graphical form?

“It’s pulled together in one particular viewing tool called Powerchart where you can look at different parts of the ICU treatment or monitoring. You could not put it all on one screen. You can go through different screens to get the complete picture. Not only that – you can go to standardised nursing observations.

” If you are having temperature and weight monitoring as an inpatient it [Cerner] can cater for that, and cater for what happens in operating theatres: storing information off anaesthetic machines to provide an overview of what’s happening throughout that episode as well.

“Healthcare is so broad as to what may happen to you within a hospital. You need a suite of products which includes a specialist module for theatres, or a specialist module for intensive care or a specialist module for inpatients.

“In theatres, different surgeons have different requirements: they have particular music they like; they have a particular scalpel type they want to use; they have a particular instrument tray. The system helps to ensure that when the surgeon arrives for an operation all the right tools are there for them.”

How does the system tell staff what scalpel the surgeon wants to use?

“For each person it looks after – surgeons and anaesthetists – it maintains a list of order sets. When people know who is coming in to a theatre to do a particular operation they will know the order set to make available. It will be the same suite of screens.

“If the patient has a bad reaction to an anaesthetic in the theatres, it’s very important that this is conveyed to anyone else in the hospital who is going to administer a general anaesthetic to that patient. You have that information at the moment but on different systems. It takes an extraordinary amount of effort to try and get a full picture of a patient’s history.”

And Cerner’s weaknesses?

“The big one is patient administration – the 18-week pathway. There is always another system that will do part of it better. If you were to go for best of breed you’d be picking off dozens of systems and then trying to integrate them all.

“The Cerner system is designed around a US-philosophy where you look at a table of numbers rather than a graphical representation of a trend. In the UK they like to look at a graph and see the trend. There are enhancements we are going to want as we go along to bring it up to how UK clinicians like to work. That’s part of working with the vendor.”

What have you learnt from the problems with Cerner implementations at Barts and Royal Free Hampstead?

“That’s to do with the patient administration systems. Everything I heard that is negative about Cerner – that’s seriously flawed about the system – is being able to support the 18-week pathway.”

What about being able to complete statutory reports on what treatments you’ve administered, at least to get paid?

“A lot of that comes down the same thing. We are taking all the relevant information we need to report to the government in a separate data warehouse. We are not going to be using the Cerner system to do reporting, except to take off some key information.

“The system is really designed to support clinical work. It’s about what is happening in the very short term. It is not necessarily about reporting activity.”

What about the booking of appointments and administration?

“My personal focus is on the clinical side but I can’t do one without the other. So I have to make sure it is capable of managing the trust’s workload which is, of course, really important.”

How difficult will it be winning over staff, doctors and nurses to ensure they make use of the new systems?
 
“They are not scared of the technology. There will always be some people who will need training, who have avoided computers all their lives. But in general this is a good place for IT literacy.”

Will your Cerner system be compatible with NPfIT systems?

“It has entirely able to connect to the spine. We are putting in a temporary solution for up to the next seven years to get our in-house processes in order. At that time we hope that CfH [Connecting for Health] will be able to take us to the next level. We will engage with the spine.”

Is it a £15m programme over two years?

“Yes. Because we have paid up front for the maintenance and support of all of the Cerner for the entire seven years.”

Is that a good idea? What if it all goes wrong?

“We don’t think it will all go wrong. It makes it very easy for us to choose the individual solutions we need to pull in for the trust. If we look at a new system for a particular area and Cerner already have a software product it makes it easier for us to build a business case to put that product in. Maintenance of the support and the purchase of the software is not the biggest cost. It is quite often the consultancy you need to make it all happen. [The money we have paid for] maintenance and support includes any Cerner software we need to buy.”

Links:

Cerner begins to see interoperability – Healthcare Informatics website

Newcastle’s break-away trust – NPfIT was “taking forever” – IT Projects blog

E-records without a central database? – IT Projects blog

 

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Dangerous stuff here! The Newcastle expert admits that he is not a PAS person. Yet CERNER demands of clinical staff that they do PAS activities e.g. preschedule, in real time in a busy clinic, the next appointment, so that the clerk can complete the booking - maybe OK in a quiet 20 mins per slot clinic, impossible in a 5 mins per slot 5 patients at a time Orthopaedic fracture clinic, when the 5 simultaneous clinic lists cannot be seen inoverview in PowerChart - they can al be seen in Appointment book, but appointment book does not open into the clinical record.

I have seen Veterans Software in action - it does all the CERNER stuff. I work with CERNER R0 every day, struggling with the PAS and Clinical screens, because I know I need to get it to work.

Homerton have done well out of direct dealing of hospital with CERNER, and Newcastle are doing the same - no middle man to create Chinese whispers.

Provided in Newcastle they have clinicians who understand the importance of PAS, the many different ways that various clinicians and nurses work, management that believes in clincians and robust dealing with CERNER, it could work.

They need to remember that USA hospitals are full of administrative staff, already used to inputting huge quantities of data, so that they can get payment from insurance companies. Newcastle may need to budget for up to 5% extra salary bills for administrative staff to feed the beast.

In my opinion it remains a moot point whether the costs of runing Payment by Results, are worth the investment. The administration involved in producing HRGs is immense and costly. Of course Trusts must knowhow much work they do, and the total costs of running the business, but this "USA style cost a cup of tea to the insurance agency" appraoch surely is not needed, when there is only one monopoly Insurer - namely the "National Insurance" that comes out of my salary every month.

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