Over here

“Great product, but it sure needs a lot of support.”

While some trusts are struggling to implement Cerner Millennium through the National Programme for IT in the NHS, others are keen to get the system outside it.

So is Millennium over big, over corporate and over hard to deploy? Or is it a great system but one that needs time, money and a direct relationship with the supplier to implement effectively? E-Health Insider’s US correspondent, Neil Versel, talks to IT bosses about their experience.

With a dozen or so implementations of Cerner’s Millennium care records system underway in England, it’s clear that the plug-and-play delivery model originally envisioned by the NHS has run into difficulties.

But then, it’s fairly early in the process; and if the experience of health organisations in other countries is any guide, a successful Cerner project requires no small amount of patience, time and – yes – money.

“Great product, but it sure needs a lot of support,” says US-based health futurist and IT market analyst Mark Anderson. “That’s definitely not a product that’s going to be easy to implement.”

Groundbreaking in its day

When it was introduced in 1997, Cerner Millennium was one of the first systems to merge clinical, financial, administrative and outcomes management functions onto a single platform.

Subsequent versions incorporated additional functions across multiple specialties; from inpatients to outpatients, from imaging and laboratory to perioperative care and pharmacy, from home health to bio surveillance and analytics.

The present version, Cerner Millennium 2007, is the 15th major architecture to be launched by Cerner since its inception in 1979.

The US-based company has largely has done its own software development, whereas many of its competitors have built their enterprise systems via mergers and acquisitions. Cerner says it will have cumulatively spent $2 billion (£1.45 billion) on research and development by 2010.

Toronto and Dublin

Around the time Millennium debuted, Toronto East General Hospital embarked upon a complex Cerner implementation that even today remains a work in progress. But that was deliberate. “One of the stumbling blocks was always around funding,” says chief information officer Pegi Rappaport.

“I don’t know if we’re ever going to be complete because we’re always trying to improve,” adds Bobby Gheorghiu, project manager of benefits in IT services at the Canadian hospital.

Toronto East has been lucky in some ways because it had few legacy systems. “Because we started in 1997, it was all paper,” Rappaport says. It also tends to deal directly with Cerner, rather than through any third-party implementation partners, such as Perot Systems or IBM.

St James’s Hospital in Dublin, the largest in Ireland, started a Millennium installation a decade later, in 2006. Chief information officer Martin Buckley says the only difficulty he has encountered was connecting it to the hospital’s existing iSoft patient administration and laboratory systems.

His IT team had to build customised interfaces, working with specialists from both vendors. The key success factor, Buckley says, was having senior executives both from the hospital and from Cerner involved. “That project mode filtered down from the executive level,” he says.

Coincidentally or otherwise, NHS implementations have tended to be smoother when the trust has been working directly with Cerner rather than with a local service provider as part of the National Programme for IT in the NHS. When contacted for this analysis, Cerner would not comment on its UK contracts, but it did facilitate the interviews with the Canadian and Irish hospitals.

Rappaport says she feels that a best-of-breed approach takes a lot more IT support than the type of single-vendor installation Toronto East went for. “Not having to do an integration is huge for me,” she says.

Nevertheless, she says it has also been routine to integrate Cerner Millennium with mandatory provincial reporting systems, such as for emergency department wait times and public health. Rappaport says the necessary configuration changes “are not that difficult.”

Critical voices

Of course, Cerner is not without its critics. Dr Scot Silverstein, a medical informatics consultant on the faculty of the College of Information Science and Technology at Drexel University in Philadelphia, says Cerner produces “very corporatized, very formal information systems.”

“Cerner is very much in that mindset of clinical IT as business IT,” says Silverstein. “End user involvement has been kind of secondary.”

He contrasts the company’s approach with that of the US Department of Veterans Affairs, where end users have been part of the management of a widely praised technology roll-out at hundreds of veterans’ hospitals and clinics.

Cerner likes to boast in its marketing materials about having scores of physicians on its payroll, but Silverstein believes that misses the point. “There’s a difference between physicians on staff vs formally trained medical informatics professionals on a staff.” And there’s a third level, with formally trained medical informatics professionals in leadership positions.

Silverstein’s views are based on installing a Cerner Clinicals data repository as director of clinical informatics at two-hospital Christiana Care Health System in Wilmington, Delaware, in 1996-98. “We’re now 10 years later and the same patterns continue,” he claims.

Gradual deployments

Those who have been successful with Cerner urge patience, and generally recommend a gradual implementation rather than a “big bang.”

Although Toronto East has been working on its IT infrastructure for years, a C$10 million (£5.6 million) grant from the Ontario provincial government in 2005 allowed the hospital to accelerate its technology projects. When the acceleration started in 2006, 46% of paper processes had been automated, Gheorghiu says, and that number now is up to 75%. The goal is to reach 95% by next year.

Gheorghiu says usage of electronic medical records spiked in the first half of 2007 as users became more familiar with them. Since mid-2006, access to the system has increased by 66%, even though the number of users has remained fairly constant.

Similarly, St. James’s has gone incrementally, putting in Cerner PACS, radiology information system and scheduling components before attempting clinical documentation. Next up, the 1,000-bed teaching hospital will work on e-prescribing and medication administration, and Buckley says the greatest concern is user acceptance.

“The challenge will not be a technical one,” he says. “We certainly would see the order entry of Cerner fitting in real well with the architecture of Cerner.” Buckley says it has been a self-financing investment, with a full return expected after five years.

Medical College of Georgia

Another organisation to deploy incrementally is the Medical College of Georgia and the affiliated MCGHealth system in the US. Chief information officer Harold Scott says he has had no cost overruns in an internally financed plan.

“We spread it out over five years to get a return on investment,” Scott says. MCGHealth’s normal capital budget for IT was $4 million (£2.9 million) per year, a reasonable sum for a 478-bed main hospital and 154-bed children’s hospital.

That implementation has continued in stages since January 2004, with laboratory, pharmacy, RIS, imaging and ICU monitoring, plus CPOE in the paediatric hospital.

Next up is the electronic medication administration record for both hospitals. Scott says MCG did the less-complex modules first to help users acclimate. “Folks were familiar with the technology by the time we got to the more difficult stuff,” he explains.

Clinical documentation still is not complete and the five-year plan already has exceeded its original timeline. “Right now, I’d say we’re 85% there,” Scott says. It will take another two to three years to reach full implementation.

When the planning started in 2001, MCG had a scheduling, management and physician billing system from IDX, a nameplate later bought by GE Healthcare, and the accounting software was from McKesson. Cerner was the primary vendor for clinical IT.

“At the time we did this, there was not single vendor that did everything end-to-end,” Scott says. “Cerner is no more difficult that Eclipsys, Siemens, Epic, GE or McKesson,” he adds, rattling off the names of the biggest players in the US hospital market.

“If you’re on time and on budget, all the other things will go away. If you are late and over budget, you will lose credibility.” That is something NHS officials need no reminding of.