ELECTRONIC HEALTH RECORDS: Red flags for Nova Scotia’s health mega-deal

Lack of consultation, poor management blamed for problem-plagued rollouts elsewhere

Governments worldwide are eyeing the Holy Grail of health records — a computerized network giving doctors and other health-care providers electronic access to a patient’s health information across a health-care system.

History shows, however, that if such complex rollouts are not expertly handled, these projects can turn into expensive messes.

How bad can it get? Try half-billion-dollar cost overruns, lab tests with the wrong names on them and incorrect dosages for drugs.

When projects go badly awry, investigations have blamed two common culprits: Faulty management, including underestimating complexity and costs, and lack of consultation with frontline health-care providers.

Physicians around the world — while acknowledging the benefits of this type of technology — have had many complaints about EHR technology.

Those include difficult-to-use and time-consuming software, glitches that can threaten patient safety and, worryingly, an increase in doctor burnout.

LESSONS FOR N.S.?

Do previous missteps in Canada and Australia, where projects similar to Nova Scotia’s ambitious One Person One Record EHR plan went off the rails, hold any lessons for this province’s government?

Premier Stephen McNeil’s Liberals are pushing ahead with their controversial multimillion-dollar OPOR plan, despite last fall’s criticism the tender process has been unfair.

As in other places that experienced problems, the goal here is to build a computerized clinical information network to give physicians everywhere electronic access, when needed, to patients’ medical records.

So what’s gone wrong in other jurisdictions implementing EHR systems?

Most examples below involve Cerner, the world’s biggest player — with US$5.142 billion in revenue in 2017 — in the growing global market for EHR software and services.

That’s not meant as a slight against the company. Cerner scores well in independent client satisfaction surveys. Other EHR firms have also had issues with software rollouts. But Cerner, along with Allscripts, are the two U.S.-based companies shortlisted for Nova Scotia’s OPOR project, a deal likely to be worth hundreds of millions of dollars.

TROUBLE IN QUEENSLAND

Recently, in Queensland, Australia, a centralized electronic medical record rollout using Cerner software has been under intense criticism.

“Senior doctors have warned patients will be seriously harmed if the rollout of Queensland Health’s $600 million (about C$566 million) integrated electronic medical record project (ieMR) continues,” a Jan. 29 report in The Brisbane Times stated.

Similar to OPOR in Nova Scotia, ieMR’s goal is to see patient records eventually be electronically shared with health-care providers across more than two dozen Queensland public hospitals.

Physicians in the Australian state have charged that flaws in the system have led to numerous problems, including blood tests labelled with incorrect patient data, double dosing of medications and difficulty locating critical patient information.

In December, Queensland’s auditor general said eHealth Queensland had badly underestimated costs, hadn’t done risk assessments or examined alternative options and failed to respond to concerns from staff — most supportive of moving to electronic health records — at many state hospitals.

The project’s estimated cost has doubled to more than C$1.15 billion.

Queensland health authorities maintain the project has helped patients.

MORE FROM DOWN UNDER

The Times’ reports also cited previous Cerner electronic medical record software deals that ran into problems in Australia. In one, a 2003 project in the state of Victoria, poor planning and lack of understanding by health authorities was found to have led to significant cost overruns. The eight-hospital rollout was shut down.

Allscripts — the other EHR finalist in Nova Scotia — also recently made news Down Under.

South Australia’s government is now planning to overhaul its Allscripts software-based integrated electronic medical record (EMR) and patient administration system (PAS), known as EPAS, according to a Jan. 30 story in itnews.

The reasons sound familiar. A government-ordered review blamed poor project management for a lack of clinician engagement, usability issues and cost overruns that could inflate the original 2011 budget of C$384 million to C$443 million through 2021.

BACK IN CANADA

Meanwhile, Cerner has also had its share of problems in Canada.

The company’s been mired in controversy in B.C. over a 2016 deal to provide EHR systems to hospitals on Vancouver Island. That project has been plagued by — you guessed it — mismanagement by the local health authority, ballooning costs and clinicians’ worries about patient safety.

After the system was first rolled out in March 2016 at Nanaimo Regional General Hospital, the situation got so tense that some medical staff reportedly refused to use the system.

A 2018 investigation by B.C.’s Health Department found the local health authority (Island Health) had mishandled the project — failing to plan, botching implementation and failing to listen to advice from clinicians that could have avoided some problems. The province’s safety and quality officer also found critical deficiencies in the system.

Island Health, saying an initial budget of $173.5 million to implement EHR systems in the island’s four hospitals won’t be enough, estimated close to $228 million will now be needed. A second report for the province done by Ernst & Young warned even that figure may be low.

PROBLEMS IN P.E.I.

Closer to home, P.E.I.’s auditor general — in a 2010 report — sharply criticized that provincial government’s bungled implementation of a $12 million 2005 EHR project to install Cerner systems in Island hospitals.

The AG’s report blamed mismanagement and inadequate planning by P.E.I.’s health department for the mess. The EHR rollout was later taken over by a new entity formed in 2010, Health PEI.

The hospital computer information system (CIS) component of the project alone cost $25.1 million when finished in 2011.

Observers on the Island say the project has still not provided a province-wide solution. Doctors can access the hospital-based system from their offices, but other health information systems — including for prescriptions, lab tests and physicians’ electronic medical records (EMR) — don’t interconnect with the Cerner software.

What’s the bottom line message from all these examples? Simply put, ineffective management and inadequate consultations with medical professionals can put expensive EHR rollouts in jeopardy.

RED FLAGS?

There are troubling signs there may be similar problems in Nova Scotia.

In December, Nova Scotia auditor general Michael Pickup blasted the provincial government for poor management and oversight of health sector information technology.

“The Department of Health and Wellness does not provide effective leadership and direction on information technology (IT) in the health sector,” Pickup wrote in his latest report.

The auditor general said four organizations responsible for IT in health care — the health department, Department of Internal Services, IWK Health Centre and Nova Scotia Health Authority — have not formalized roles and responsibilities and do not adequately manage IT risks.

In other words, the auditor general found too many loose ends that could result in misunderstandings or miscommunications.

LACK OF CONSULTATION

Meanwhile, earlier in December, Doctors Nova Scotia president Tim Holland complained his group’s members had not, to date, been sufficiently involved in selecting a system to be used in the OPOR project.

Holland hailed the potential benefits of a well-integrated electronic health record system. But — pointing to the debacle on Vancouver Island — he warned there’s a potential for disaster if EHR projects are mishandled.

Government officials rejected Holland’s criticism, insisting close to 50 doctors had helped in selecting a software system provider.

But it’s not a good sign — given what’s happened elsewhere — that Nova Scotia’s biggest doctors group is complaining about a lack of consultation regarding the province’s huge electronic health record project.

Last week, Nova Scotia information and privacy commissioner Catherine Tully told the province’s public accounts committee her office had not been consulted about OPOR. She said she had concerns about whether government had properly assessed the system’s privacy risks.

Faulty management. Lack of consultation with clinicians and others. The very same factors blamed when large-scale EHR projects ran into trouble elsewhere.

BIAS ALLEGED

All of that comes on top of an October investigation by this newspaper that revealed serious allegations of bias and questionable government conduct in the OPOR tender process.

That report included a 2016 email from a senior NSHA bureaucrat that told a potential OPOR vendor that government officials wouldn’t be meeting with EHR companies. That same year, however, there’s evidence that representatives of Cerner’s consortium and Allscripts met with senior government officials over dinners.

Cerner and Allscripts were shortlisted last June as finalists for the tender.

That decision prompted one critic to ask why government would eliminate other large, capable EHR companies — based only on written submissions, before clinicians could actually test-drive vendors’ software — thus limiting Nova Scotia’s choice to Cerner and Allscripts?

Given the amount of money involved and importance of getting it right, it’s a fair question.

PROCESS ROLLS ON

But the Liberal government’s response to date has been to insist the tender process has been fair. They’ve refused to comment on many specific allegations.

Some critics argue McNeil’s government should pause before plunging ahead on the OPOR project. But there’s no sign that’s being considered.

Asked last month about the status of the OPOR tender, government spokesman Brian Taylor said government was finalizing the next phase of the process.

“It is not uncommon for large tenders to take some time to complete,” he said in an email. “The province is progressing through this complex procurement with the necessary attention to all details.”

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