Canadian Cerner install under investigation again, but mishaps go deeper than the tech
British Columbia Health Minister Adrian Dix launched a second investigation into the Cerner electronic health record system of Island Health (Vancouver Island Health Authority) on Sept. 20 -- a result of a rollout that has caused severe turmoil between the health system and the providers who don’t want to use it.
The $174 million system was launched in March 2016 at the Nanaimo Regional General Hospital, Dufferin Place Residential Care Centre in Nanaimo and Oceanside Health Centre in Parksville.
Not long after the rollout, British Columbia Provincial Patient Safety and Quality Officer Doug Cochrane launched an investigation into the EHR to address the many complaints from providers.
What he found were critical functional deficiencies in the EHR: any user could inadvertently order unsafe medication doses, multiple orders of high-risk meds would remain active, the EHR extensively used small font sizes, drop-down menus had long lists that were tough to read, and the display was dense and difficult to read and navigate.
Further, end users were reporting issues with system responsiveness, log-in problems when changing computers, unexplained screen freezes, connectivity problems with the barcode readers and the PharmaNet integration wasn’t effective and added to the burden of medication reconciliation.
To its credit, IHealth said it addressed many of the issues. However, problems are still ongoing. In fact, use of the CPOE system was suspended in Feb. 2017.
Officials planned more EHR rollouts to the rest of IHealth facilities this year. But physicians and clinicians have repeatedly complained about the system’s dangerous dosage errors, system functionality and the amount of time spent on a laborious platform.
In fact, some providers have all-out refused to use the new EHR and have reverted to handwritten orders. A move, which first had IHealth officials asking other physicians to enter the handwritten orders into the system, according to Canada’s Times Columnist.
However, providers are now being penalized for not using a system they say is unsafe.
The EHR was “introduced as a wholesale change” in March 2016, said President of the Nanaimo Medical Staff Association David Forrest, MD. And he admits before the planned implementation, he knew nothing about EHRs.
“It’s archaic that we were still writing charts and orders in the era of iPhones,” said Forrest. “It didn’t make sense that we weren’t leveraging technology.”
However, while most physicians were ready for the change, Forrest claimed that the planned rollout was rushed -- the initial rollout was slated for August 2015 and was pushed back. And those in charge of the project felt pressured to get the EHR installed before the fiscal year in March.
But in private discussions, Forrest heard many express concerns prior to the rollout that it simply wasn’t ready. In fact, pharmacists, in particular, were vocal about the readiness of IHealth, as “computer order processes hadn’t been prepared properly.”
“But they forged ahead with it anyway,” said Forrest. And to make matters worse, “the launch itself was ill-timed.”
“It launched on a Saturday, during spring break, which means we were understaffed due to employees on holiday,” he said. “It was the worst possible time to launch -- and it was pointed out beforehand.”
As seen with successful installs -- for example, Penn Medicine, WellSpan and Vanderbilt -- training physicians before a new EHR is crucial. By allowing providers to get into the system and play with the tools, they can get a sense of what they can expect during routine care and how to mitigate potential errors.
However, as the rollout was rushed, Nanaimo providers were unable to do so.
“There was little opportunity for physicians and allied health professionals to receive good training with this,” said Forrest. “It was a mess.”
In fact, Forrest said that physicians “were asking for the ability to use the system, well in advance, but they really didn’t have [the system] ready.”
Providers were given basic training of the system, but it became clear to physicians that “the systems in place for training weren’t adequate and wouldn’t reflect on how the system was going to work.”
Forrest did his individual training with one of the physicians in charge of the CPOE system, and the message he received was: “We don’t know how this will work when we go live, we’ll have to learn on the go.”
Physicians were also told they could develop their own order sets as they went along and modify the screen to meet routine needs of patient care.
For example, as Forrest is an infectious disease doctor, ordering blood work is incredibly common. He wanted to create favorites in his workflow before the launch to make it easier to accomplish daily tasks.
“But the system was not available to do this until literally 24 hours before launch,” said Forrest.
Further, the ability to create modified workflows was apparently temporary, as the hospital decided to “homogenize orders,” and providers wouldn’t be able to create their own order sets.
Compensation also proved problematic, as Canada’s health system is made up of socialized health insurance plans that insure all citizens, and few Canadian providers are salaried. Physicians are paid on a fee-for-service basis, which made it difficult for IHealth to determine how to reimburse doctors for time spent on training.
“As we’re not salaried, we’re only paid for clinical services,” said Forrest. “[The health system] suggested training, where we would be paid by credits -- and not paid cash. It took a bit to pay physicians for their time.”
“We wanted a real opportunity to play with the system, but were given no financial incentive,” he added. “And doing so would take away from clinical income.”
There were problems in the order entry process as soon as it went live, said Forrest.
“Medication orders would go missing. And some orders would change the instant it was entered,” said Forrest.
For example, system limitations would force Forrest and other providers to continuously go back into the system to ensure modifications made to medication orders would remain. He explained that the EHR had a default that wouldn’t allow providers to change the dosing frequency.
Not only that, but his workflow screen would not match the pharmacy’s or the nurses’ for the same patient.
“I would enter the order correctly, and they wouldn’t see it on their screen. As a result, clinicians wouldn’t see necessary orders,” said Forrest. “While that particular problem was addressed, there are others that [IHealth] has been slow to address.”
Issues with medication orders are a huge safety concern, especially when it comes to blood thinners and insulin. Forrest explained these are medications that can cause major problems if under- or over-dosed. So much so that these are often micromanaged.
In fact, there was a patient with an insulin order set through an infusion as he had a severe elevation of blood sugar, said Forrest. While there was an order set available, it had to be tweaked to allow the order to continue for an extended period of time. However, it wasn’t a permanent fix, and it continued to be problematic.
Those in charge of the EHR project watched the provider put in the order to make sure it was done correctly. And sure enough, Forrest said the screens would change and the clinician’s screen did not match the provider’s for the same patient.
The IHealth team said it fixed the problem, but Forrest said that 10 months later the same thing happened with a patient who had high blood pressure.
“It shows [the IHealth team] just created a workaround for the problem, but didn’t actually solve it,” said Forrest. “It’s an indication that there are serious issues with how the system works.”
But it’s not just the computer program itself. Forrest said, “It’s human interaction when there’s a problem with the platform.”
“Most EHRs are cumbersome and complex in terms of entering simple orders,” said Forrest. “Before we could easily add notes to clearly state intent.”
But when providers attempt to add notes to the record, it can take 5 to 10 minutes and customized entries into the system can get buried in the workflow. Further, if someone downstream misses a step within the EHR process, clinicians can easily miss provider notes because there’s no clear way to view it.
“EHRs are complex, and it’s difficult to do things right,” said Forrest. “It’s not unique to Cerner… But systems too complex lead to human error. It’s almost a guarantee you’re going to have errors.”
“We need to have EHRs, but the fundamental error is that they’re based on billing software and not clinical needs,” he added. And for a nonprofit health system, an EHR platform that lacks consideration of clinician needs has caused many of these issues.