Health Minister Adrian Dix has released a report on the review of Island Health’s IHealth system.
The Ernst & Young report, Review of Island Health’s IHealth Electronic Health Record System, makes nine recommendations (below) and outlines findings (further below) in the areas of system planning, implementation, governance, leadership and budget.
The report found that the implementation of IHealth has been one of the most significant changes of practice for many hospital staff members and physicians.
It is clear that there was deep mismanagement of the project: it was not properly planned or implemented, with some issues thought to be preventable if the health authority had leveraged advice from other Canadian experiences. This coupled with the pre-existing and long-standing contentious relationship at Nanaimo Regional General Hospital (NRGH) created an extremely challenging situation.
As a result, the project is significantly delayed and facing serious financial pressures. Island Health will not be able to complete the full project scope within its initial $173.5-million budget. Island Health estimates an additional $54.1 million is required to complete the project. However, Ernst & Young suggest that more will likely be needed.
A mediator will be put in place to support stakeholders moving forward together. At a minimum, the mediator will:
- Meet with all stakeholders to ensure agreement that the report accurately describes the situation that has developed at NRGH;
- Help stakeholders produce an accord on how everyone will work together to identify and resolve issues, make decisions, communicate with each other and report progress;
- Assist stakeholders in developing a work plan to implement the actions required to address the recommendations as they are applicable to IHealth at NRGH; and
- Monitor adherence to the terms of the accord and progress against the work plan, until no longer required by the Minister of Health.
While the issues at NRGH are addressed, Island Health has been directed to apply the learnings from this report, and from the work at NRGH, to plan future acute-care electronic health-record implementations and map out a measured and realistic plan that is funded appropriately.
Health-care systems across Canada and globally are adopting electronic health systems to deliver health and medication information where and when it is needed. They make a patient’s health information easily transferable, giving each care provider access to a complete medical record, including any diagnoses, tests and examinations recorded by other providers, helping ensure accurate diagnosis and appropriate care. Electronic health-record systems can also give patients access to their own health information and support their active participation in their care.
- The Ernst & Young report is available online.
Nine IHealth review recommendations
From their observations, Ernst & Young has made the following recommendations:
- Move forward with IHealth, clearly articulate this decision, and communicate the expectation that all stakeholders will put their effort toward constructively working through issues toward a better system.
- Fully investigate all safety concerns related to IHealth and address the perception that the system is less safe than the previous paper processes.
- Stabilize IHealth at NRGH before moving forward with other sites.
- Ensure that the right leaders are in place in all levels at Island Health to move forward with IHealth and work toward building a culture of respect and trust.
- Review the governance structures for the IHealth program as well as Island Health more broadly to confirm that they are able to function effectively and contain appropriate linkages with key stakeholders.
- Ensure that all future activations are contingent on a detailed readiness assessment and that sufficient training, support and change-management resources are in place.
- Develop a realistic financial and resource forecast that recognizes the change management, training and support requirements for moving forward.
- Review and confirm a funding model necessary to cover all operational impacts of and requirements for a successful delivery of the re-baselined plan.
- Pause IHealth 2.0 plans and develop a detailed, comprehensive and realistic plan to move forward.
IHealth review findings
Electronic health record systems are becoming a standard part of 21st-century medicine. They connect a patient’s care team with comprehensive information about a patient and support standardization, provide decision support, and offer important patient safety features, including reduced medication error and adverse drug effects, and eliminating transcription and translation errors.
In 2012, Island Health decided to expand its electronic health record system to achieve these benefits. Following implementation at NRGH, a number of concerns were raised and some continue to persist. The Ernst & Young report examined these concerns and made the following observations:
- Culture and Governance: The report suggests that the culture and governance at NRGH and Island Health has played a part in the IHealth challenges; there is a general climate of distrust in the hospital; stakeholders are deeply polarized, entrenched and dissatisfied with the current state of IHealth, with just under 50% of staff and physicians surveyed agreeing that it would be possible to work collaboratively to make IHealth a success.
- Readiness: The report observed that IHealth was activated in Nanaimo despite NRGH not being fully prepared. Local NRGH stakeholders were not sufficiently engaged, consulted or trained to use the system, and the local site at NRGH was in a poor state of readiness when the system was activated.
- Benefits Realization: Peer experts suggest that the site-level benefits envisioned by Island Health are achievable, and that IHealth is capable of delivering them, though it is concerning that the situation has not stabilized in the past 18 months.
- IHealth Functionality: The report notes that functionality issues raised by the Medical Staff Association (MSA), while concerning, are not inconsistent with issues experienced at other sites that have implemented similar programs. The report notes that a strong majority of physicians and a majority of nurses report being less productive now than under the previous paper-based system.
- Risks to Patient Safety: The report also notes that of the 28 Patient Safety Learning System (PSLS) level 4 and 5 patient-safety events submitted at NRGH since March 2016, only three have been reported as being related to the computer system. However, the report criticizes Island Health’s lack of an effective and efficient process for investigating safety concerns and reporting the resolution back to end users.
- Project Finances: Island Health has not fully funded IHealth. Ernst & Young state that Island Health will not be able to complete the full project scope within its initial $100.3-million capital budget envelope. Island Health will not be able to complete the full project scope within its initial $173.5-million budget. Island Health estimates it will require an additional $54.1 million to complete the project. However, Ernst & Young suggest that more will likely be needed.
- What’s Working Well: The report notes that the IHealth system is functional (if cumbersome) and the project team is made up of dedicated, professional and skilled staff. It also notes that the IHealth team has been steadily making improvements to the system.
- Progress on Cochrane Recommendations: The report notes that IHealth has made progress on the Cochrane recommendations, and that has resulted in meaningful improvements to the functionality and usability of the system.
It also notes that some stakeholders may not be fully satisfied with the completion of some recommendations, and that some stakeholders have not engaged in the process, which could serve to be a continuing challenge.