Sunday Insight has an article from a junior doctor, Rosemary Wyber, complaining about the tedious and archaic systems currently running in the Nation’s hospitals. There is, of course, nothing new to this. The MacDoctor used to work in the public hospital system until about 5 years ago and the situation was the same then as it is now. The information systems in public hospitals can’t be described as archaic – they are paleolithic. The problem stems from the fact that medical information on a patient, particularly during the inpatient phase is almost entirely paper-based.
Nearly every GP in Auckland has a computerised patient management system consisting of an electronic patient medical record database, an investigation ordering system, a prescribing module and a recall and results management system. It would be difficult to cope with the modern GP’s work load without it. Public hospitals, apparently, sweep their inefficient systems into a bin marked “too hard” which is then dumped, in toto, onto the head of the hapless house surgeon (and the nursing staff).Yet, if GPs, – with a thousand privately-owned practices – can co-ordinate and computerise their records, why can’t the hospitals?
It is not as if there is any doubt about the worth of a proper patient management system. Hospitals in the US, who have designed their own or adapted a packaged product, report massive reductions in transcription and prescribing errors and appreciable reductions in unnecessary testing and reduced delays in patient investigations. Boston’s Brigham Woman’s hospital, which developed an in-house solution, reported an ROI of a mere 18 months – and their savings calculation included only unneeded tests and reductions in bed days – it did not include savings for avoiding medical errors nor reduction of sick days for less stressed staff.
If this is such a no-brainer, why this luke-warm response from the DHB?
“[Dr] Robinson [Chief Medical Officer Capital and Coast DHB] says the DHB has made considerable efforts to listen to the concerns of resident medical officers (RMOs), including holding patient safety forums and meetings with hospital management. A staff and patient safety survey is scheduled for August which will measure how well managers and doctors engage with each other.
““Clinical administrative tasks, such as attending to charts and completing discharges, do not end when an RMO finishes their training. Senior medical staff and GPs perform many administrative duties,” Robinson says.
““The board believes it goes to considerable lengths to ensure RMOs are made to feel welcome and that their opinions are valued during their time here.””
If you haven’t fallen asleep trying to read such anodyne waffle, the MacDoctor will attempt to explain the reasons why there has been no change:
- DHBs will not commit to a patient management system (PMS) because:
- Capital expenditure is tightly regulated by government and too precious to squander on “kite flying”
- No one is brave enough to stake their job on implementing one
- Getting buy-in from doctor and nurses would be less fun than herding rabid cats
- Senior doctors will not commit to a PMS because it is out of their zone of familiarity. This is the zone doctors construct around themselves to prevent them from making mistakes. It is unsurprising that many consultants in private practice are still using paper notes – particularly the ones who work mostly in hospitals. With the advent of online PM systems, even specialists with multiple offices around Auckland can run an electronic PMR. Yet paper is still in vogue.
- Government officials hide when they hear the words “Patient Management System”. They are often heard to mutter the word “INCIS”, or the word “NOVOPAY”, while they are hiding under their desks . Governments and large IT projects do not do well together. IT Projects are a career killer. They are always mired in controversy, run way over time and way over budget. Here is why:
- Government does not understand the meaning of “mission creep” – it keeps wanting to add things that would be nice for bureaucrats but not for the people using the system
- The lesson of the Novopay debacle is that no-one seems to understand that you must first simplify the old system rather than try and duplicate it’s inefficiencies
- The further up the government hierarchy you go, the less people want to know about the project – just “in case”. This ensures that there is no-one available to spot the project going off the rails when there is still time to fix the problem easily
- Governments always insist on using the cheapest bidder. In IT this is usually a very bad thing.
So, as a service to medicine, The MacDoctor will suggest how he would do it, if he were Tony Ryall:
- For project director, find a doctor with good IT knowledge and, preferably, business management skills. There are not many of these people. You may have to import one. A nurse or allied health worker will not do. Doctors have a reasonable insight into most aspects of medicine including nursing and allied health. The reverse is not true, not even for nurses. Also, you will need this doctor to talk to consultants. Many consultants will either not speak to a nurse at all, or be obstructive. Trust the MacDoctor on this one.
- Fix a decent budget (MacDoctor’s guess $50-100 million) and a realistic time frame (MacDoctor’s guess 3 years to construct and 3 to 5 to roll out). Be aware that there will likely be considerable ancillary capital costs when DHBs scramble to upgrade their ancient and wheezing servers.
- Allow your project director to choose the best IT company, rather than the cheapest. Please.
- Make sure that you are constantly updated by your director, preferably face-to-face meeting. Nipping problems in the bud is what makes the difference between a great project and a complete disaster.
MacDoctor’s guess is that this project will pay for itself within two years of roll-out. Efficient hospitals, happy house surgeons and nurses, safer patient care and cost saving as well. What’s not to like?