A right Royal mess

Eight months on from its go-live with Cerner Millennium, Royal Berkshire NHS Foundation Trust is still struggling to reach a “full business as usual model.”

The trust continues to experience problems with appointment booking and reporting and expects to spend a further £6.2m this year on implementing the system; against a budget of £2.5m.

Not what was hoped five years ago

The situation is a far cry from what the trust hoped to achieve when it quit the National Programme for IT in the NHS in 2008.

In mid-2009, it signed with the University of Pittsburgh Medical Centre, which had done a deal to implement Millennium across Newcastle, to implement the US system in Reading.

The plan was to get theelectronic patient recordsystem live between July and September 2011. But the trust did not go-live until June last year, more than 1,000 days after project start-up.

By this time, UMPC was nowhere in sight, and there were reports that the project had been dogged by problems with poor project management and an over-reliance on contractors.

Now the system is live, problems continue. A report presented to Royal Berkshire’s Council of Governors last month says an issue causing particular problems has been the complexity of the appointments system.

This resulted in a variety of errors while users got used to the system, meaning that appointments had to be changed, often multiple times.

As a result, patients were sent multiple letters, which was confusing. So the system was configured to only send a letter to a patient if it was specifically told to. This meant some patients received no letter.

Letters are now being produced automatically. The trust has also introduced telephone calls to check that patients know about appointments, as well as text reminders.

These workarounds will continue for a number of months; but have contributed to more staff being needed and so additional costs.

“Many of the issues are as a result of the software functionality within Millennium. Work is underway with Cerner to try and find ways of improved configuration or system changes for letter production,” the briefing to governors says.

Warning signs

Reports released to EHI under the Freedom of Information Act show that significant issues were flagged up to the trust as early as June 2010.

Two reviews of the deployment completed pre-2012 reveal a lack of direction on data quality, a disengaged IT department, and problems with clinical engagement.

‘A review of Information Management and its readiness for Cerner Millennium’, was authored by Elizabeth White and SandeepVirk in June 2010.

It reveals that IT staff felt they had little control over the data being reported, and that more generally “they have had little or no involvement in the Cerner Millennium project.”

The report also details a striking lack of direction over data standards and quality.“Standards need to be clear at the outset of constructing a new system or else there will be confusion in analysis of problems encountered,” it says.

“No evidence was offered as to the provision of standards or quality advice for implementation, and these issues need to be addressed rapidly.”

A key issue, which the report found was not being addressed, was the need for one, sound, patient master index on which all activity would depend.

“The creation of a single instance of all patients is a pre-requisite for Cerner Millennium,” the authors say.

“This task is normally one of the most labour and time intensive tasks of deploying a PAS system such as Cerner Millennium.

“[Royal Berkshire] has already prepared a file for data migration which implies this task is complete – however this is not evident in the architecture, conversations and operational working practices throughout the trust.”

Another key issue was the construction of the key standards and resource structures held in Millennium data collection worksheets – consultants, GPs clinics waiting lists – which ultimately determine the quality of data reporting.

“[Royal Berkshire] does not have a data authority in the trust to enforce and advise policy,” the report reveals.“Individual departments are setting up systems and databases with a disregard to conformity.

“There are currently hundreds of systems that have been written in the trust each with their own governance and standards setting. There are likely to be vast differences in the quality and the inter-operability of this information.

“There are also likely to be difficulties in finding common points for joining this data together, generating significant quality, transparency and efficacy issues when the data is aggregated together.”

This lack of standards was likely to become more apparent when the Cerner Millennium system went live, the authors say.

Managing expectations

The trust had“vast expectations” of the EPR programme. It hoped that it would address many of the issues it faced, including: a lack of integrated data across the organisation; accurate data; timely information; the ability to solve departmental problems; and enhanced clinical functionality.

However, the report identifies these as being, “largely above and beyond the remit of the project.”

“These expectations need to be managed or the programme will always be deemed to be a failure amongst key staff in the organisation,” it adds.

This was particularly the case for Millennium reporting, which had proved difficult for “all UK sites implementing the system,” the authors note.

When the report was written, the thinking within the trust was that reporting would be done via Power Insight, the Informatica warehouse designed to pull data from the Cerner system.

However, there was no evidence that this was in widespread use elsewhere;although Wirral University Teaching Hospital NHS Foundation Trust, another ‘out of programme’ Cerner site, had gone live with it in June 2010.

“The national programme currently universally uses the IM200 dataset, which is a subset from ‘Power Insight’ of key data needed by trusts,” the report notes.

“This has taken BT [the NPfIT local service provider for London and those parts of the South that received Millennium] more than four years to customise for the UK health space. Therefore, the testing and output of ‘Power Insight’ must be rigorous before the trust commits to using this as its reporting basis.”

Were clinicians involved?

If reporting was always likely to be a problem, other reports suggested that clinical issues might rear their heads as well.

A review that went to the board in February last year, this time written by Kevin Fong of University College Hospital, London, interviewed seven clinical sub-groups leaders. None felt that they had had sufficient opportunity to see the build to ensure that the final product would suit their purposes.

“If one accepts that the process of defining requirements and developing the build is one of iteration, then there appear to have been, thus far, an insufficient number of iterative cycles and insufficient user exposure to the product for the system to satisfy the users’ end requirements,” the report says.

“There is in general a lack of people conversant in both the clinical and information technology aspects of the EPR project. This is represents a principal difficulty in this project.

“A process of mutual education is also necessary if clinicians are to be able to ask the right questions and IT contractors are to be able to return the right answer.”

Where to from here?

The whole debacle is starting to gain traction locally. The Reading Chronicle recently reported on the extra costs associated with the project and complaints about the slow booking process.

It quoted patients describing the “huffing and puffing” of staff as they were forced to write key information on slips of paper.

Meanwhile, Royal Berkshire continues to pay for significant data correction each month as well as extra staff to run the system.

When it comes to trying to stabilise its EPR, Royal Berkshire says its three priorities to resolve are: upgrades to Bedview, Vital Signs and the A&E system; action to reduce the backlog of follow-up appointments, and action to make sure the trust is capturing all of its activity and therefore income.

EHealth Insider asked the trust to comment on its Cerner Millennium project and, specifically, to comment on the reports supplied under FoI requests.

It received a statement from the trust, which reads: “We commissioned the reviews which are now two years old in order identify areas where more attention was required from the trust.

“Where issues were identified we put actions in place to ensure that we would have the best possible outcome for this implementation. It was extremely helpful to have this perspective on the project.

“We will continue to review and learn throughout the implementation and embedding of our electronic patient record.”