From Down Under: The Story of the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck?

I'd opine that bad luck had little to do with it.

A paper by an Australian professor of informatics about travails with a new ED EHR, manufactured by a large American HIT vendor, appeared recently (it is currently unavailable.) I remind that the issues affect a most critical area, the ED's in over 200 hospitals in Australia's most populous state, New South Wales (NSW). The paper is here.

[10/24 note: not available at present at this link or from its author in Australia; I pulled it from the Drexel U. server in the U.S. at the author's request while his right to post it on his department's server in Australia is being discussed Down Under - ed.]

[Jan. 2010 followup: an attempted censorship situation was resolved. See this update. Current paper in ver. 6 is here - PDF.]

Highlights:

... One criticism of [new ED EHR] is that the clinical documentation is built on the American model which doesn't fit the Australian workflow. In the same vein another commentator said it was a "system designed by administrators for administrators with no understanding whatsoever of clinical workflow and need".

... At the operational level in EDs staff dislike the software for various reasons such as: too many keystrokes to load data, hence, too complicated search pathways to find data, plus they are unable to get extraction of reports.

Their dislike has reached very intense levels with many staff dismissive of its usefulness. In more than one hospital the system was credited with causing a 50% decrease in the number of patients seen by a doctor in the first 20 minutes of arrival at the ED. In at least one hospital the direct data entry of clinical notes as done with [old ED EHR] [an earlier system - ed.] has been abandoned and transferred to paper as the [new ED EHR] process was seen as too cumbersome and time costly.

... Other comments about [new ED EHR] were: "I prefer looking at a paper result than the counter-intuitive waste of my time trolling through the system.

... I keep forgetting how the damn thing is supposed to work and find it more a time waster than a help."

... Similarly, "every single user *hates* it with a passion ... ENTERING the data is a pure nightmare"

And another:

... "it is exclusively used by the nurses and entirely ignored by the doctors"

And another:

... "Clumsy, complicated (not complex), user hostile, and above all slow at any task I tried".

... “We stated the system was dangerous (multiple reasons) and that we would not use it in its current state. We also got agreement that the nurse practitioner not use it for clinical details."

... “We in X and Y had a major confrontation with the NSW ‘gurus’ and refused to use it in ED in its current state. A clinician produced a well researched document to support our claims of its cumbersome stupidity. “People present (at the meeting) were local vmos, nurse practitioner who works in ED and the local ceo etc, plus reps from [new ED EHR vendor] , NSW health etc. One clinician was present by videoconference. Nurses presented a long document detailing multiple concerns.

“The meeting was quite emotional and heated as they tried over and over again to pull the wool over our eyes. For example, they started out offering “more support”. One clinician replied that this was like giving us a defective car then sending out someone to show us how to drive it.

I asked was the support available at 3 A.M.? Blank faces.

They dissimulated info that “other doctors” in small country hospitals were trialing the system and had “no problems”. When asked which hospitals and which doctors again blank faces. They finally came up with a name who one of our partners rang that night and found him to be furious his name was used and that they were about to dump the system too...

The conclusion probably sounds familiar to HC Renewal readers:

... I wish to make a salient point about the nature of the delivered software with respect to the whole process of change management in the introduction of new IT infrastructure. In these situations there is always a great deal of noise and attention given to the processes of systems review, workflow redesign, and staff training.

In many ways this is paying attention to the smoke rather than the fire. The actual design and operation of the software is fundamental to the successful introduction of information technology. It is a necessary condition that the software works in a fashion that optimally fits the activities and workflow of the recipient organisation, and this fit is the single largest determinant of a successful system wide implementation. Like any foundation if it is not properly designed and constructed the edifice above it will collapse no matter what amount of attention and details you put into it. The delivered software is the foundation of any clinical information system. It would seem that in this case this understanding has not been grasped by authorities in NSW.

... Without optimal design and implementation there will be no cost efficiencies and productivity gains delivered by IT, but rather, it will contribute to the spiralling expense. We can only hope that Government will understand that a modest investment in R&D for clinical information systems is needed to create the desired improvements in productivity, cost reduction and patient safety.

I believe our own government here could learn from this.

Read the whole thing, including the series of ethical issues the author raises. I believe the lessons apply not just to the one vendor mentioned, but to most HIT vendors, especially the large ones.

Also note the observations from another Australian, Dr David G More MB, PhD, FACHI in an essay entitled "The Blight on the Landscape Health IT Awards" at this link.

-- SS