Give Cerner a chance says ex-Royal Free employee

Responding to a feature-length article in The Guardian on the NHS IT scheme, Alex Homersham, who worked at the Royal Free in Hampstead when the Cerner Millennium system went live last June, says it’s unfair to criticise a system that’s still in its infancy.

Homersham says in a letter to the Guardian:

“Cerner is by no means perfect; however, I think it’s unfair to criticise a system still very much in its infancy, as it can only improve by being actively used in a healthcare setting.”

The Royal Free in June 2008 became the first trust in London to go live with Release “LC1” of the Millennium Care Records Service. 

Homersham said in her letter that she was a member of administrative staff working in the outpatients department at the Royal Free hospital when the NPfIT Cerner Millennium system went live.

She added that the report by the Guardian’s Andy Beckett was certainly correct in highlighting the number of system crashes that held up any kind of smooth transition from the old patient database.

“However, the administrative and clinical benefits were immeasurable. The system the hospital migrated from (PAS) was designed in the 80s, was insecure, and, because it was not web-based, all data updates had to be done manually.

“Clinical staff were not given access, making it more difficult for them to do simple things such as look at the size of their clinics, or check when they were next seeing a certain patient.

“Patients moving from A&E to a ward, for example, were held up while paperwork was transferred by medical records staff, whereas with Cerner, referrals could be read immediately by other departments. Regarding the issue of security, Cerner is only accessible via a smartcard, which is password-protected, and can be deactivated.

“I have now started working for another trust that has yet to start using the new IT system. The amount of extra faxes, phone calls and paperwork is time-consuming and unnecessary.

“The Conservative scheme to cancel and privatise the IT project has little to do with improving patient care, and is simply a way from them to gain votes and make money.

“Cerner is by no means perfect; however, I think it’s unfair to criticise a system still very much in its infancy, as it can only improve by being actively used in a healthcare setting.”

**

Background to the NPfIT Care Records Service problems at the Royal Free.

The Royal Free says it has received a double excellent rating from the Care Quality Commission, one of just seven London hospital trusts, the only London teaching hospital and the only hospital in North London to do so.

This is an impressive result given the problems it has faced. What happened after the go live at the Royal Free is described by the hospital’s Audit Committee in papers to its board meeting last month.

“During the first half of 2008/09, the Trust experienced an exceptional set of circumstances following the implementation of the Cerner LC1 IT system.

“A series of technical issues delayed full and successful implementation of the new system and resulted in errors in recording of clinical activity and disrupted financial reporting particularly with respect to invoicing and recovery for work done.

“This implementation has also had a financial impact on the Trust during 2008/09 and is a key contributor for the significant reduction in retained surplus against the Trust’s original budget for the year.

“While much work has been undertaken by the Trust to rectify the situation, and, indeed, the robust system of internal control has been restored, the head of internal audit has issued a limited assurance opinion for the year as a result of the circumstances faced in the first half of the year …

In agreement with the regulator, Monitor, the Board postponed the application partly
due the problems with Cerner and the impact on the Trust’s financial reporting during 08/09 …”

The Royal Free had also reported on clinical risks. Its board was told in November 2008 there was a “risk of breach of IRMER [Ionising Radiation (Medical Exposure) Regulations] due to Cerner/ris issues. Duplicate MRN [medical record numbers] cause problems and confusion over request and results leading to repeat requests and possible double exposure of patient.”

The implications of the Cerner go-live went beyond what might have been expected from a patient administration system. There were doubts over whether all the cases of suspected child abuse were being reported. A report to the Royal Free’s Board in January 2009 said:

“There is a weekly meeting that reviews the more worrying cases which is attended by colleagues from A&E and social care. In 2008 we discussed 578 cases compared to 731 in 2007.

“It is not clear why we discussed fewer children. It could be that fewer children with concerns were presented or that staff had become more experienced about measuring risk and so were less likely to put forward cases for discussion that did not meet the threshold.

“This reduction may also be in part due to the introduction of Cerner. Since Cerner was introduced, the Community Children’s nursing team who are responsible for providing the liaison service are aware that they have not always received notification of all the paediatric attendances and it took some time before we could resolve the problem.

“There are ongoing problems that have arisen due to the Cerner system and we are trying to resolve them with British Telecom. These problems relate mainly to demographic and clinical data not transferring through from the system onto the Emergency Department card.

“Until we can be confident that the community children’s nursing team are getting a card for each child that attends we have put in place a manual checking system which is carried out by an administrator.”

 

It further transpired that the Care Records Service implementation costs had exceeded the EU’s OJEU advertisement threshold. The Royal Free’s Board was told:

“Formal tendering procedures had not been applied due to the very exceptional circumstances; need for specialist expertise required and timescale which genuinely precluded competitive tendering, in line with the trust’s SFIs [standing financial instructions].

“It had never been anticipated that costs relating to the two companies providing urgent process redesign and implementation support (Cymbio and Ideal Training) would exceed the OJEU threshold.

“It was the trust’s intention to formalise arrangements for these services in January 2009, though it was considered unlikely that any other companies would have the necessary expertise / experience.”

 

On 13 February 2009, the Royal Free’s Chief Executive wrote to staff:

“The introduction of the [CRS] system has caused a £10m problem for the trust. The wider NHS has not left us unsupported and we are in discussion over how the Royal Free achievements can be recognised. I am assuming that there will be no need to change our current investment plans, but this will need to be kept under review.

“We continue to work with BT and Cerner to decide what clinical IT developments the trust would wish to pursue. We are particularly interested in assessing whether and how a better integration between other clinical systems and the main CRS can be achieved to improve the way in which our treatments are organised.”

**

Comment

Alex Homersham makes a good point that even an imperfect new system may be better than unnecessary phone calls, faxes and paperwork. It’s also worth saying the obvious: that the benefits of improved administration can be more than offset by clinical risks. Experimenting on humans, or at least with the care and treatment of patients, may be regarded by some as a necessary risk for the future benefit of all. But it’s wrong. Astronauts choose to risk their lives pushing back the frontiers of science. Patients just want to get well – they don’t want to take part in any IT-based experiment even if it’s for the eventual good of all.

The trick is to get minimise risk – if necessary by the extraordinarily careful (though slow) approach of Morecambe Bay.  

It’s true that things have improved at the Royal Free – but the problems aren’t over.

Links:

Why do health records have to be transferred anywhere?  Digital Identity Forum  

Doctors nearly in tears over Royal Free system – IT Projects blog  

NPfIT gateway reviews – Life with Leukaemia

NPfIT gateway reviews – James Barlow blog  

Technology should not be religion or a panacea – Tech and the law

When there are NHS IT problems don’t mention Cerner – IT Projects blog  

NPfIT – doomed from the outset? – free online health tips

Dr Foster Unit as an exemplar – Alertboot   

 

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Thanks for quoting me on your blog - just want to point out I'm actually female(!).

Anyway, I certainly wouldn't be so crass as to say improving administration is more important than improving clinical treatment - I was trying to point out that Cerner has been beneficial in both ways (for example):

Patients moving from A&E to a ward or emergency clinic were held up while paperwork was transferred by medical records staff, whereas with Cerner, discharge summaries and referrals could be read immediately by other departments.

A lot of people seem to be taking the "if it ain't broke, don't fix it" viewpoint, but the IT systems in use at the vast majority of hospitals are clinically useless and Cerner is the first step in linking up clinical care with administration.

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Alex

My apologies for getting your gender wrong. I'll correct the article. The first rule of journalism is 'don't make assumptions'.

Your letter was excellent which was why I made use of it in the post.

I take the point about the clinical and administrative benefits of Cerner. I spoke about risk because Royal Free took a very bold decision to introduce the Cerner system hospital-wide without a full appreciation of what could happen if things went wrong.

There's a view in officialdom that risks are dealt with by listing them on an assurance register.

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No problem, thanks for correcting (this happens to me a lot; in fact, when I worked at the Royal Free, my e-mail address was set up as alexander.homersham, and no-one in IT could work out how to change it...)

"Royal Free took a very bold decision to introduce the Cerner system hospital-wide without a full appreciation of what could happen if things went wrong."

You're absolutely right, and there's definitely an awful lot I don't know about clinical risk in such a situation (I'm 24, not clinically trained, and have only been working for the NHS for two years). I guess making such huge changes to the way the system works would always be a contentious issue when dealing with people's health. I hope that when CRS comes to the Trust I work in now, lessons will have been learnt from the things that went wrong at the Royal Free.

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