Academic claims NSW Health censorship

A professor at the University of Sydney who wrote a scathing essay about NSW Health's implementation of a Cerner system within emergency departments has accused the government of pressuring his institution to take the essay down, which it did, if only temporarily.

A professor at the University of Sydney who wrote a scathing essay about NSW Health's implementation of a Cerner system within emergency departments has accused the government of pressuring his institution to take the essay down, which it did, if only temporarily.

One would have thought that Cerner was aware of the failure of the contract to specify the necessary reporting module and so it appears to be a form of gazumping.

Professor Jon Patrick

"Version 4 of this essay was temporarily withdrawn on Friday, 23rd October by the university following a complaint from NSW Health," Professor Jon Patrick said on the Health Information Technologies Research Laboratory website. He believed the university was correct to investigate the complaint and didn't consider it at the time as an act of censorship.

NSW Health had not responded to's requests for comment at the time of writing and Cerner declined to comment.

Patrick's belief in that investigation seemed shaken two weeks later though. "It is now two weeks since the original essay was withdrawn. In that time I have been able to establish confidently that NSW Health phoned my head of Department and asked him to remove the article without giving a specific complaint," Patrick said on the website.

The head of department refused; however, a person from another faculty "took up the cause" and was able to persuade someone in power to order the withdrawal of the essay, according to Patrick.

"To this time I have not received a specific complaint let alone a written complaint. The university's Office of General Counsel has studied the essay at my request through my Dean, and found that it is 'consistent with the university's Public Comment Policy'. I am awaiting further investigations by the university."

Yesterday the issue was resolved. "The university has affirmed my right to publish my critical essay, and the attempt to censor me has been mitigated," Patrick wrote. The essay was republished in a new longer version, with no removed content.

The department is partway through a three-year strategy to implement standard electronic medical records across all of the state's 220 hospitals using software from US e-health specialist Cerner. This is to be completed by June 2010. The emergency department system, FirstNet, is one of the core components to be rolled out to all hospitals. It has already been implemented in many of them.

But it has not been well received, Patrick's essay claimed, with some hospitals even rolling back implementations, fearing the system's impact on patient safety. "The need for a systemic study became clear during work that was being undertaken at a number of NSW hospitals when clinicians and administrators constantly expressed their dissatisfaction, even hostility, to FirstNet, to the point of often refusing to use it," Patrick's essay said in its opening paragraphs.

He pointed to a recent study carried out by Professor Johanna Westbrook, at the University of Sydney, where 13 physicians and seven nurses were interviewed. The study found that although the sharing of patient information between systems was positive, the FirstNet interface "considerably" increased the administrative workload of clinicians, the study claimed. Another study carried out in 2005 at the University of Pittsburgh Medical Centre said that after clinicians started entering instructions for patient care electronically using Cerner, there was a statistically significant increase in mortality from 2.8 per cent to 6.57 per cent.

Patrick believed the problem became clearer, however, when talking to knowledgeable professionals in different locations and operating environments. He pulled together the opinions of many clinicians who had experience in clinical information systems.

FirstNet had made a positive impact in that it allowed service and workflow tracking. It also allowed doctors to quickly receive discharge summaries from hospitals. Yet Patrick considered these benefits to be secondary gain, quoting one professional who said that being glad about such positives was like being happy about a house burning down because you could roast potatoes on the fridges.

Another clinician who had IT training said that FirstNet required 30 per cent more time to complete data entry of patient information than his current system, according to Patrick's report. One hospital created a graph which said that there had been a 50 per cent decrease in the number of patients seen by a doctor in the first 20 minutes of their arrival at the emergency department. In more than one hospital, staff had reverted to paper-based data entry because FirstNet was seen as too cumbersome in comparison to prior systems. The system was considered to be slow, partially due to the network and hardware it was running on.

While the systems weren't working, IT wasn't responding to staff concerns, according to Patrick's essay. The abridged comments of one rural NSW physician were quoted:

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 3am? Blank faces. They dissimulated info that 'other doctors' in small country hospitals were trialling 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.

In another incident IT management refused to create an issues register for problems, according to the essay.

Some have controversially claimed Cerner's technology was not up to scratch in general, according to Patrick. The academic pointed to statements by Richard Granger, the former director of UK's Connecting for Health national clinical IT program, responsible for the roll-out of all technology for the UK's National Health Service. He was quoted as saying that "some of the stuff that Cerner has put in recently is appalling".

Yet, when it came to making changes, Patrick claimed the company wasn't keen to respond to requests from users in its small Australian user group.

He was also less than enamoured with what he believed were contractual conditions between Cerner and the NSW Government. He said staff had been told that their difficulty with getting certain reports using the system was that software modules needed to generate some reports weren't included in the original contract with Cerner, which meant further costs would be incurred to get those modules.

Patrick claimed that the module's non-inclusion in the contract was deliberate by Cerner. "One would have thought that Cerner was aware of the failure of the contract to specify the necessary reporting module and so it appears to be a form of gazumping, that is, effectively raising the price of the sale after final offers have been accepted," he said. He was also concerned that NSW Health might have signed a contract that included a "held harmless clause" — where the vendor is free from recriminations on system faults or their consequences, and the contractee is stopped from expressing the deficiencies of the software in public.

The choice of Cerner had been almost automatic, he claimed, after Australian rival iSoft didn't cover the scope of the tender and since alternate rival Epic wasn't marketed in Australia. A second round of tenders was called but no alternative was found.

Patrick said in his essay that open source could be the answer to vendor lock-in, an opinion he has previously expressed in the media, and that in the long term, the government should be spending money on research and development of clinical systems for Australia. He believed that it wasn't possible to know all requirements in advance of making software because of the variety of users with autonomous behaviour which all have a limited view of how others operate.

He thought the system should be flexible in its interface so that hospitals could make it optimal for their needs. "The era of rigidly designed user interfaces that do not allow any variation for user preferences or a capacity to model the user's needs is long gone," he said. Cerner had not seemed to keep up with this trend, he said.

NSW Health was offered the opportunity to provide comments to an early version of the essay but declined the offer, according to Patrick. The positives and negatives of the Cerner system was also discussed in the Garling report.