'We cannot remain silent': Queensland clinicians' fears on electronic medical record

Their fears have been detailed in letters written by hospital staff, and by peak health bodies writing on their behalf, to Queensland Health’s director-general Michael Walsh, to the Health Minister, and to eHealth Queensland’s former chief executive Richard Ashby.

Patient safety risk examples given by some clinicians in their correspondence included difficulties administering medications and medications going missing in the software.

Health Minister Steven Miles said Queensland Health consulted "in depth" with all hospital clinicians before, during and after the rollout of the integrated electronic medical record at hospitals.

"There have been no reports of patient harm linked to the implementation of the ieMR, indeed the [Queensland Auditor-General] has found the system is improving patient outcomes," Mr Miles said.

"However, all systems, including paper-based systems, have risks and Queensland Health works with clinicians to identify and address these risks."

In one incident, eight clinicians spent half an hour trying to decipher a medication dose prescribed through the integrated electronic medical record (ieMR) system to determine whether a patient had received the correct dosage.

Clinicians also highlighted the “inordinate amount of time to complete simple prescribing tasks” and ward rounds taking many hours longer each day because of the software.

Dr Ashby resigned late last month for “personal reasons” after Mr Walsh referred allegations of an undeclared personal relationship with a Queensland Health staffer to the Crime and Corruption Commission.

The CCC has been investigating eHealth Queensland, the department responsible for the ieMR, for months.

The ieMR is designed to connect all the state’s public hospitals, allowing all clinicians to access any patient’s medical record from any hospital.

Clinicians have expressed strong support for installing an electronic medical record at hospitals, believing it will improve patient care and lower the burden on the health system, but have raised concerns the ieMR is not being rolled out safely.

One letter from clinicians said while they were supportive of electronic health systems, they protested the rollout of “inferior” systems that risked patient health.

Mr Miles said issues or suggestions on the ieMR rollout were dealt with as they occurred.

"No hospital or health service would even attempt a transformative project of the scale and importance of digital hospital without the backing of the majority of clinicians and other stakeholders," he said.

A Brisbane Times investigation has revealed serious safety concerns with the ieMR, including an independent 2014 report that warned of potentially “catastrophic” consequences on a par with the 2011 payroll debacle if the software was rolled out.

Queensland Health requested that report be modified to remove the warnings. The independent consultant who wrote the report refused.

Mr Miles had earlier questioned why the LNP did not heed the report commissioned during the Campbell Newman LNP government and said Labor had made changes to address some of the report's concerns.

In one letter, a clinician wrote that the ieMR’s prescribing system “was prone to mistakes especially in a rapidly evolving situation of a critically sick patient”.

The ieMR software was purchased “off-the-shelf” from US medical technology giant Cerner in 2011 and is modified to suit each hospital as it is rolled out.

"The Director-General himself personally meets with clinicians twice ahead of any digital hospital rollout to understand they are happy with the training they have received, and asks them whether they believe the system can go live safely and effectively," Mr Miles said.

"If the clinicians don't believe this is the case, the rollout does not proceed."

Cerner has been contacted for comment by Brisbane Times and has not provided a response to questions.

In July 2018, the Australian and New Zealand Intensive Care Society wrote to Mr Miles on behalf of Queensland intensive care specialists, calling for “genuine dialogue” to resolve the concerns of their members.

ANZICS president Stephen Warrillow wrote in the letter that the association would “advocate for an independent and expert review should concerns persist”.

Dr Warrillow told Brisbane Times that while some concerns raised by clinicians had been recognised since he wrote the letter, and efforts were being made to fix them, others persisted.

Describing intensivist clinicians as technically minded people who work with some of the sickest patients in Queensland - a “highly structured, highly trained, elite team” - Dr Warrillow said they were eager to see high-quality software installed to help them care for their patients.

He said his Queensland colleagues did not feel all their concerns had been listened to, and it would be “sensible and correct” for an independent review to be undertaken if their concerns continued without change.

“It is good governance and simply sensible to ask for an appropriate body to make any appropriate inquiries,” he said.

“These are not people who complain lightly.

“If they are finding it difficult we would be wise to listen.”

One letter from a clinician, obtained by Brisbane Times, warned of patient risks through the ieMR’s intensive care module and said “we cannot remain silent and allow this risk to continue”.

“If potential for harm to a person is seen and this risk can be removed or reduced - we cannot remain silent and allow this risk to continue,” the clinician wrote on behalf of colleagues.

“If a patient is harmed and we have done nothing to address a potentially preventable harm, the tort of negligence is fulfilled and we are liable for the consequences of this."

The clinician’s letter said the feedback from Queensland Health had been that clinicians “[lacked] education and engagement with the system”, but that all the clinicians at the hospital using the software found it inappropriate for the intensive care unit.

The letter said clinicians would work hard to train completely in the ieMR software, but they could not be held to blame entirely for such issues.

“While these measures will demonstrate our commitment and engagement with the digital hospital, I fear that the risk of harm to patients is not generated solely by lack of education or engagement with staff, but also by the system itself,” the letter warned.

Mr Miles said the "most important" part of the ieMR's roll-out was ensuring patients were safe and staff were confident in using the system.

"Training is just one element of that support," he said.

"Hospital and Health Services' digital hospital project co-ordinators and patient safety officers are present in each ward or hospital department, as their relevant module goes live, and afterwards."

Another letter from clinicians in mid-2017 about Cerner's anaesthetics module, SA Anaesthesia, said they had been told "non-Cerner software will be unavailable as of 2020".

"Despite early grave reservations about the product there has been a relentless drive to roll out SAA, including the purchase of expensive software," the letter signed by multiple clinicians said.

"Any deficiencies that we identified as a group were forwarded to either Cerner or the SAA Governance Committee and universally dismissed as either trivial or an end-user problem."

The letter said clinicians were "enthusiastic" about digital programs in hospitals but believed the Cerner software "will profoundly affect patient safety and care".

Another letter about Cerner's anaesthetics software from clinicians said the SA Anaesthesia software was "unacceptable to frontline anaesthetic clinicians" because of multiple issues.

Clinicians at Mackay Hospital were named and shamed on weekly reports sent out by the Queensland Health team responsible for the ieMR’s rollout if they weren’t “compliant”, according to a 2018 AMAQ letter to Queensland Health director-general Michael Walsh.

Any clinician who made an error with the ieMR was named on a weekly report for not achieving 100 per cent compliance, which had a “detrimental effect” to hospital morale.

In September 2018, the AMAQ wrote to Mr Walsh and chief clinical information officer, Keith McNeil, detailing concerns raised by Mackay Hospital clinicians.

The detailed letter, obtained by Brisbane Times, noted “several major problems” across multiple areas of the ieMR installed at Mackay Hospital, including the software’s intensive care, anaesthetics and obstetrics modules.

Mr Miles said the safety risks of not transitioning to a digital system were "considerably higher" than staying on paper, "given the known risks of paper-based systems such as duplication, illegibility, lost records, timeliness and other safety issues".

Ward rounds doubling in length, medications going missing in the system and patients not receiving prescribed blood tests or receiving unnecessary blood tests were several examples cited in the letter of the ieMR’s impacts.

“We understand that many of these issues have been raised with the Digital Health Team without a satisfactory outcome to date,” the AMAQ’s letter said.

“We also note that the Digital Health Team sends out weekly reports listing staff who have not been 100 per cent compliant with various aspects of use of the system.

“While the intent may be to encourage compliance, it has a detrimental effect on culture within the hospital given the reason for non-compliance is often the unintuitive user interface, the poor fit to workflows of the software and inadequate or malfunctioning equipment.”

Queensland Health chief clinical officer Keith McNeil responded to the AMAQ’s letter on behalf of the director-general.

Dr McNeil wrote that the Princess Alexandra Hospital, the first hospital to “go live” with the ieMR, had also noted issues but over the 18 months since installation they were “no longer considered to be an issue” and that was as a result of training on the ieMR.

He wrote there was “no evidence to indicate” that the system was time-consuming or difficult to work with “when properly used”.

“Like other areas of clinical practice, appropriate and comprehensive training is important,” he wrote.

A motion submitted to the AMAQ council in March 2018, obtained by Brisbane Times, detailed nine key concerns clinicians had about the rollout of the ieMR software.

The motion, passed unanimously, proposed a new committee of experts and clinicians be formed to “collate, analyse, advise and disseminate information on benefits, disbenefits as well as clinician concerns” about the ieMR.

The AMAQ confirmed it had established the committee and would continue to work with Queensland Health to ensure clinicians’ concerns about patient safety were put to rest.

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