ICT visio - - ^- -ategy

FirstNet as a building block in the broader eMR program

NSW Health is engaged in an eMR program that consists of a number of project streams, including FirstNet eMR, eMR Phase 2, and Medications Management. FirstNet eMR (the subject of this review) is completing the implementation of an eMR for EDs using components of the Cerner Millennium suite including Cerner FirstNet, Cerner PowerNote, PowerChart, and integration with PAS' s and laboratory systems. A subsequent project stream, eMR Phase 2, will build out additional clinical functionality including further enhancements and change requests to Cerner FirstNet, device integration, and further deployment of PowerChart. Another stream is planning to deploy the Medications Management module.

A high-level planning roadmap for these and other initiatives is maintained by NSW Health for the purposes of planning business cases and budget submissions over a five year period.

Other than this roadmap and the associated business case for funding purposes, we are not aware of any documented vision or strategy that articulates the overall objectives of the eMR program, relative priorities or dependencies, or a roadmap to provide more granular planning of the overall program. As a consequence, the program cannot refer to a 'big picture' view that would guide investment decision-making, and questions remain about whether the program is pursuing a State-wide eMR, multiple eMRs, hospital automation, or a combination of these end- states and objectives.

4.7.2 Business cdz governance

As part of the broader eMR program, FirstNet must support the State's established governance approach to enable the effective monitoring and utilisation of the resource base. This will require FirstNet to support statutory reporting, and reporting on clinical service delivery and hospital operations.

Effective governance requires FirstNet to support adherence to security, user identification, authorisation and audit policies and protocols.

Reporting does not enable clinical governance improvements to be measured

With a few exceptions, reporting has been flagged as a common area of frustration. Managers reported significant difficulty and frustration in accessing information to assist with managing their ED and other functions, as well as enabling a view of clinical trends. Some clinicians also reported a distrust of the data quality provided in reports, as noted previously.

Inadequate user identification and authorisation practices

At some sites users reported shared user sessions to avoid delays associated with logging out and then logging back in as a new user. Also, the requirement for clinicians to enter a user identifying PIN number to authorise a transaction has been disabled at some sites. This means that it is not possible to reliably determine the identity of the clinician processing transactions. This issue is exacerbated where clinicians share computers or user sessions.

Observations

4.7.3 Systen- `

System governance processes for managing change requests can be described as follows:

• Upon identifying a change request the end user logs this with the local user group, sometimes referred to as the local Application Advisory Group (AAG) for review.

• The local user group reviews each change request to determine whether to put it forward to the FirstNet State AAG. If the submission proceeds, the change request is logged by the State AAG for review and endorsement

• The FirstNet AAG Triage Group review changes and endorse, delegate to the AAG, or decline each one. All decisions made at Triage are then attached to the following AAG Agenda available for members to review, raise and revisit the decision if necessary

• If endorsed (as either mandatory or optional) each change request will be placed into scope for the next version of SBB conceptual design. LHDs are able to implement a change request prior to it appearing in the next SBB version. Actual configuration into the LHD is currently the responsibility of the Local Support team.

• The SBB Team tracks these changes and works with the LHDs to update the Change Control Tracker

• If a code change is required (i.e. the change request is an enhancement) this is raised with Cerner, which liaises with HSS to ensure the change is made.

The system governance process is in place, however, there was evidence this was not effective There is a clearly defined and established system governance process in place (as summarised above), however, a number of clinicians reported frustrations with the effectiveness of this process. Commonly, clinicians reported a perceived slowness and delays in change request implementation. One clinician reported a change request on the FirstNet discharge summary taking 18 months to be implemented.

There was evidence that one of the factors contributing to delays of this sort was that the change request process is not adequately robust. In some cases, requirements are not always sufficiently well articulated at the outset leading to rework and delays. Another potential factor is that some change requests are approved by the State AAG but not immediately implemented at the LHD level.

Other themes commonly reported include a lack of visibility of progress or status, and the need for many seemingly simple requests to require product enhancements.

The imbalance of clinicians and administrators on local AAGs influences change request decisions and priorities

Given these and other frustrations with the change request process, some clinicians reported that they had chosen not to participate in the local user groups. Also, some clinicians noted that local user groups were not held at convenient times for clinicians. These factors have contributed to the waning of clinical representation on local user groups. This in turn has influenced change request priorities and decisions.

Recommendations

5 Recommendations

NSW Health has implemented FirstNet as part of the overall eMR program to 59 hospitals across New South Wales. While there have been a number of reported issues associated with the deployment, use and operation of the system, many clinicians have reported that it now adds considerable value to the delivery of care and the operation of their Emergency Departments.

In the month of March 2011, 86 million transactions were processed; 2.84 million orders were placed and 17,188 users accessed the system on a daily basis.

Many of the issues that have been reported and observed relate to system operations, governance, implementation, leadership and training, and not specifically to the capability of the FirstNet system.

While the review confirmed that there are a number of issues with the use, implementation, support and configuration of FirstNet, we believe these can be remediated.

In deciding the future of the FirstNet solution, it is important to recognise that it comprises an important foundational component of a broader eMR architecture, where a patient's medical record may be stored and accessed from within a number of care settings across a continuum of care. Replacing FirstNet would require a new solution to be integrated with the broader Cerner based eMR solution set. While this integration is possible, it would add an additional level of complexity into what is already a very complex environment.

A range of issues and frustrations were identified across the FirstNet sites examined, which are notably impacting user satisfaction and the effective use of the system.

These issues highlight the urgent need for a formal program of site specific remediation activities. These needs might include remedial training, configuration and in some cases, upgrades to the currently implemented system. A well defined plan and program of work needs to be urgently put in place to bring all sites to a base level of acceptable infrastructure, functionality, useability and user training.

From this context, we strongly recommend that the following activities be performed:

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A detailed independent review should be undertaken of each site to identify what issues exist and what remediation activities are required to elevate the system and its use to a defined minimum standard. This minimum standard should be based on the capabilities delivered in the latest version of the SBB.

This review should be executed as a matter of urgency.

We further recommend that this remediation program be delivered by resources other than those already responsible for the current implementations or the planned eMR phase 2 to avoid resource conflicts with these activities.

Recommendations

plan

A formal project should be established and funded to implement the recommendations set out in the remediation plan.

There is currently considerable variance across each of the implementations of FirstNet in the LHDs.

While NSW Health has adopted the concept of a State Base Build (SBB) - many of the implementations are deployed on different operating system versions; different Cerner versions; different SBB versions;

different local configurations; and in some cases, local additions that are outside of the scope of the eMR program. This is driving inefficiency and complexity in the use, operation, support and management of these systems.

To address this issue, we propose the following recommendations: