Wirral signs direct contact with Cerner

1

Challenge to Others

26 Feb 09 12:20

At last a trust taking a direct route towards success. Cerner's success story in the USA is obvious to any informed transatlantic traveller. The difference? Direct contracts between user 'hospitals' and Cerner as the provider are regularly in evidence. It may cost more, but you get what you pay for. The outcomes from CfH procurements have hardly been inspiring. NHS trusts may have spent less money, but they have received little for it. This sets a challenge to the Boards of NHS Cerner users in the South and London, to perform some effective corporate governance and risk reaching the sensible conclusion that the Wirral has. Direct contracting pays dividends.

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2

nearly right....

26 Feb 09 16:32

but sadly it is not true to say that Trusts have saved money. Once the additional costs of staff time, costs of maintaining a project team and (of course) lost revenue, it has cost them more. Much more.

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3

Out of the frying pan...

27 Feb 09 10:11

I am a simple elderly e-health outsider - and patient - and all this, like most things to do with NHS systems, makes no sense to me at all.

I had understood that the reason why the Cerner Millennium software didn't work here was just that it was US oriented and thereby not fit for UK purpose. I thought that Fujitsu walked away because of all the tweaks it had to do to make it OK for use in the UK.

So, why is it a good thing to get it direct from Cerner, American warts and all. Isn't this jumping straight out of the frying pan into the fire? Or, if the tweaks have to be done by Cerner instead of Fujitsu, isn't that just reinventing the wheel?

Please could some clever e-health insider explain in words of one syllable.

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4

The Crux of the Issue

27 Feb 09 13:56

E-Health Outsider has identified the very crux of this issue. Which version of the "truth" is right? Is Wirral is a Trust with a clear IT approach to moving forwards that knows better than to believe the publicity that he summarises or have they got it all wrong? If we could get a clear view of that it would help the rest of us to determine the best way forward in this post-Fujitsu world.

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5

Sorry!

27 Feb 09 14:06

As some one who worked with all the companies mentioned in the article i can tell the first comment poster; it makes no difference mate. If some one continues to make unreasonable calls and underestimates and rubbishes others intelligence you cant do anything.

Can you help explain the success of Rio and BT ?; its the attitude of suppliers and partners and the will to work together to succeed. You may read between the lines.

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6

Out of the frying pan...came a cordon bleu delight

27 Feb 09 15:26

The Cerner range of healthcare solutions, including Millennium, are certainly international, as in this global world are all world class healthcare solutions. The Cerner range is extensive and customised selections are made by individual healthcare institutions to suit their specific requirements.

The selection of Cerner products contracted by the LSPs in England is a small subset of that available and was chosen to fit the CfH one size fits all scenario. Is it an approach or philosophy that overseas countries have adopted? IMHO customising the Cerner subset to try to fit an English Trust’s actual needs has always been a challenge. I understand that many trusts in England installing Millennium were not even allowed to use the most basic customising tool, the Cerner Command Language.

Many of the trusts in England that have installed versions of Millennium can, IMHO, be criticised for going ahead without deploying proper governance processes. My understanding is that some trusts, whose Boards are known to have insisted upon Gateway reviews being conducted, did not proceed to implementation.

With few exceptions, trusts that have allowed their LSP to install a version of Millennium have not had comprehensive contract with either the LSP or Cerner. CfH have never published a copy of any contract that they might have signed directly with Cerner. In addition, few English trusts appear to have visited the USA to examine like healthcare institutions and hence to determine what selection of Cerner solutions fits them best.

The Wirral will have the opportunity to construct a solution that serves their patients and staff well. They will be able to put Wirral healthcare first rather than be constrained by CfH centralisation driven demands. Good luck to them.

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7

Different frying pans

27 Feb 09 20:24

Something of an answer to post 3. The Wirral had a very comprehensive American Clinical system before, with lots of central money to implement it as a HISS site, and with Frank Burns as CEO, but this is long in the tooth. Changing to another good clinical system makes sense.

The problems London and the South have been experiencing are because what was implemented initially under CfH was to cover Patient Administration, not clincial care, for those hospitals who were least advanced in use of IT. The US Insurance based admin processes, and lower pressure workflows have coped badly with the UK based models of commissioning and admin flows.

We are told that Cerner out of the box is a highly configurable system. The underlying database may need contortions to achieve the various reporting requirements, but with local control, this might be achieved.

As to Rio in London, those I have talked to on the ground are not as optimistic as poster 5. Active Clinical use again seems to be a problem here, with performance and flexibility constrained by the delivery model.

But IMHO those in control of the contracts for the South seem determined to learn no lessons.

(Post edited by EHI)

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8

To many Cooks

02 Mar 09 23:26

To many cooks...

The poster in 8 is reasonably close to the truth. However Wirral was never a offical HISS site and never received lots of money centrally, some, but by and large Wirral paid its own way. This is probaby a success factor, if you spend your own money your desire to achieve success is overwhelming.

Wirral has a rich clinical system, its base was American, its PAS was built inhouse using the TDS toolset and a large clinical data warehouse (locally built) was grafted on in mid 90's.

Another lesson Wirral learned along the way was dealing direct with suppliers, and also that purchasing and supporting from abroad is not a negative factor, pathology is from Australia and supported by "follow the sun" service from GE, the EHR (joint primary/secondary care record) was a joint development with a New Zealand company, (iHealth) that was subsequently bought by iSoft, the original radiology reporting system was a small company in the mid West of USA, our baby tracking and A&E staff attack software originated in from Mossad spook technology in Israel.

Yet another lesson was Wirral TDS Eclipsys software, was the original software purchased for the Wessex disaster back in the 80's and eventually deployed at Wirral, Winchester and Bath with varying degrees of success. This adds to the same old mantra - all suppliers have good sites, average sites and bad sites, but it is the same old software.

Wirral managed to keep their team together for a long time, and challenged them to use the toolkit that TDS was to develop the application in use today. Wirral also had leadership from Frank Burns as CEO and from a lot of its clinical community.

So what does that tell me?

1. Using you own money promotes ownership, and the will to get the job done 2. Local buy in is key 3. Software from non UK vendors is not an issue 4. Design by committee will at best produce an average result 5. Team loyalty and local skill base is paramount 6. Ability to change and customise in a short time is critical 7. Working direct with suppliers and developing "partnerships" is essential 8. Remembering we are building something for the NHS - i.e. trying to improve patient care, not bean counting, which so far has distorted the agenda in trying to deliver clinical systems 9. The rest of our efforts should now be focused on local delivery systems and bridging the new clinical networks that current PAS thinking does not and cannot address. 10. Doing it locally is not necessarily more expensive that national procurements 11. Buying software you can see in use in other hospitals (even US hospitals - the practice of medicine is world wide, the buying of medicine is colloquail) is key.

Ironically Frank Burns in Information for Health found in his research that most of the NHS wanted a central role and solution set and not local ownership, hence the Wanless Money and the Granger procurement and the faith in software that never existed. So what does the NHS want, told how or do it themselves?, either way needs resource.

Where does that take us? - well there are not enough qualified staff to do it either in LSP's or the NHS, so we have to create small localised groups focused on local delivery and clinical networks to find solutions and implement. A one size never fitted all of the NHS for anything from bed sheets to MRI machines so why should a computer be different? We need to swap experience and intellectual property freely.

These opinions are personal observations only and do not represent those of my employers.

Pete Marsh Director MECHealthIT & Technical Director Wirral Health Informatics Service

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9

Cooks Small and Big is Beuatiful?

03 Mar 09 22:07

Re: too many cooks

While Pete Marsh compains of too many cooks, he then goes on to argue too few qualified staff, but does not even tacitly note that many of us 'cooks' are also the qualified staff, and we relish a good polemic.

So I take issue [from my armchair I hear you say, but unjustly] with the idea that our whole informatics challenge can be solved by swinging periodically between a) a monumentalist belief in really big or b) new-age belief in cuddly local systems.

So what about scale? It was Schumacer who said 'Small is Beautiful' but that was only the tag line, the clever bit is 'to think of the most appropriate scale for an activity'. So to bring our thinking up to 1973 we could usefully ask 'what is the right scale for each fragment' and not the stale old 'what is the right scale'.

CfH have certainly established some fragments of new 'really big' stuff which innovators should be challenging themselves to use wisely, spine messaging aparatus, PDS, Healthspace.

I am led to believe (and do) that Wirral has the blend of skills, leadership, local resourcing and wisdom to do what has been alloted and that is the part which makes for progress as integrators & innovators. This is the role we expected of our LSPs to fill too, but sadly not bourne out despite staff compliments in the many hundreds.

So is it Valhalla to deal direct with suppliers? I would qualify this belief. Should we say instead don't deal with anyone who is not in command of their remit, so if suppliers show up a team who have an inadequate mix of experience and domain knowledge, should you not show them the door PDQ? After all shiny new offices full of suited and booted shiny new staff are for the sales brochrue, not the graft. The LSPs always needed a brave well informed muscular customer to challenge them, the same will be true for smaller scale procurement surely, need for an informed engaged customer. This more than merely the scale is a discriminator of success.

And what of the incitement to buy from overseas? Fine, but due diligence requires you ensure you don't let your opinion leaders see the gold plated 4,000,000 lines of code, localised over 15 years system, stage managed visit, no adminstrators, just a smattering of clinicaians, and then set off to buy only 40% of it and hope you are buying comodity software, not something that Wirral have fallen for, but not unknown - if my friends are to be believed.

Wirral seems to have a healthy respect for the clincal rather than PAS drivers too, 'not bean counting'. And as for challenging the 'PAS thinking' well hooray for that!

So thats my contribution for the year, not a single metaphor added, and thanks EHI the list in Pete Marshes post does deserve close scrutiny, who's next?

Bob

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10

Clinical and admin processes

andy.hadley@ferndown.nhs.uk

04 Mar 09 22:14

Bit suprised that Pete suggests Frank Burns wanted centralised procurement, don't remember that bit, and Sir John Patterson was after standards based XML exchange rather than the behemoths that were favoured by the subsequent ruthless standardisation.

But also, whilst I fully agree that the clinical process is very similar worldwide, and therefore clincial systems should therefore transport well, administrative, reimbursement and reporting frameworks vary widely.

So if you focus on the clinical, best you can find on the planet is fine. But for feeding the DoH monster, UK contracting rules and reporting frameworks, the underlying structure and concepts may be a poor fit.

And as the next bright idea falls out from the centre, even UK developed systems struggle. The pathways to support 18/13 Weeks/no delays are very different to the FCEs that came before.

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11

New Kitchen?

08 Mar 09 00:39

In response to last 2 posts Lack of staff knowledge comes from my travels as a consultant and various secondments to the NHS. The South Cluster was almost permanently asking for help/volunteers in its work before the FJ break up. Also the pools of staff who have worked on large scale clinical systems at EPR level 6 are few in number within the NHS. To many cooks does slow the cooking down and produce a bland cookpot, this was evidenced by some decision making by some of the clusters at compromise, where a decision could not be made it led to abandonment of the original objective as, too hard, or waiting for a standard, despite some urgent clinical imperatives we deal with today (Control of Infection – MRSA, C-Diifficle, ESB etc).

The reference to Big is beautiful and cuddly local systems. Well the NHS has not bought one, maybe it should of, at the same time of the procurement of the national programme, Kaiser Permanante in USA where going through a similar exercise I understand. EPIC and Cerner were amongst the short list, it was rumoured on the street that Kaiser had inserted in their contract that the successful supplier could not bid for the NHS contract, presumably to avoid a resource conflict. Well as we now know EPIC won it, and went on to build a single system that covered most of California and sized at 9 million souls, delivered on time and on budget. EPIC technology when I looked at it 2002 in Washington AMIA conference was impressive at that time in scale/functionality/ and enterprise wide form home to GP to Hospital. Also the company profile, it was owned by its employees, often a telling factor. In my experience IT companies publicly floated, lead to a lack of responsiveness, obscure changes on direction, loss of key staff, and focusing on the needs of shareholders produces a less attractive product. The NHS bought Lorenzo (at the time vapourware and PowerPoint, and even now has different code streams supporting the current alpha sites), said to scale to the size “the NHS needs” as one senior DoH presence remarked and Cerner. Cerner could not scale in a single database to cover 1 LSP never mind the whole of the NHS. The southern cluster architecture was based on 10 domains and not linked together other than by spine processes to come.

The question I believe is, does the NHS need a large system to cover everywhere, the answer is more likely to be no. Most of medicine in the NHS (even with choice agenda) is practised locally. Do we need to spend a fortune on getting 100% coverage? – When some trusts don’t have rudimentary EPR systems. I would argue we do need systems that cover the entire clinical pathway end to end. As Information for Health commented, the NHS is good but it is bad between systems of working. Too often the patient is “dropped” between different care islands. With today’s agenda of multidisciplinary working across organisations it can only get worse. So a Cerner solution size is likely to be appropriate. What is needed is to embed the Cerner secondary care record into the health care delivery mechanism for population health care from home to primary, secondary, tertiary and non NHS providers care as a seamless record.

The Infrastructure developments mentioned, well many were already projects in place or underway, it has helped many projects, N3 (although not enough bandwidth you cry) is welcome, but examples of delays in pre fetching PACS images start to concern me about the architecture. PDS , does not really give many benefits a real time lookup service was always planned for the tracing service. A true enterprise MPI is needed with the links to legacy and non legacy applications, with data quality protected b y maintaining system records within the MPI. In reality patients often have different addresses, go to different addresses temporarily (nursing home etc0. 15% of patients in Wirral do not tell their GP’s an accurate address since they have moved home ... contd

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12

New Kitchen part 2

petemarsh@mechealthit.co.uk

08 Mar 09 00:41

and do not want to change GP. So the PDS needs to track all addresses on all systems. A “Lazarus” button is needed locally to “undead” a patient on PDS quickly in event of a wrong patient being declared dead and resulting in shutting down, care processes, diagnostics, drug treatment, therapy, patient appointments . This can’t happen centrally and slowly, hospitals are 24/7 processes. I can’t comment on healthspace, my belief is the patient should be able to look at their own record from the legacy system and some GP’s already provide this service. Being able to collect patient data is important and again should become part of the patient electronic record, with the appropriate controls.

Suppliers direct? – I remember in the past a well known a comment about a major management consultancy training it’s newly employed graduates the night before they trained the local IT implementation crew. Now how to use a implementation tool and the effect of decisions based on those configuration changes are two worlds apart and that is what you pay for – experienced analysts who can advise on impact of decision making at the build level and not just how to collect data for configuration. How could we expect a bunch of LSPs some who had little track record in IT delivery at the coalface to build 21st Century NHS IT systems if they did not have the staff with that experience? What is required is the application vendors to prime the contracts and leave the LSPs to do what they do best, run data centres.

Due diligence, Wirral procured Cerner 3 times in effect and started out on this journey just after the millennium. I would argue that clinicians are the staff who needs to go on visits, along with people who can look under the bonnet and ask the awkward questions. Also the visits need to include real world clinical sites along with the “visionary” demonstrations from the suppliers direct. Implementation is very hard and buy in from the clinicians amongst others is key.

Central procurement, well it was not what Frank Burns wanted more what he discovered in his journey of 18 months writing the strategy, no doubt he will correct me next week down the pub if I read his thinking wrongly.

Feeding the DoH monster, I recognise this and we have had plaudits centrally for our work on 18 weeks on a 30 year old locally built PAS. The reality was, yes we changed the PAS front end a little, but the back end data warehouse is really the tool to feed information monsters. We identified this “apparent” weakness in Cerner, which is always being addressed and hopefully the upgrades going in will alleviate some of the past issues. The belief in Wirral is to integrate Cerner into the Wirral data warehouse and feed the DoH monster as is currently.

The future vision I see(desire) is one, devoid of PAS, but contains enterprise booking/resource systems, enterprise MPI, enterprise care pathways and order communications with a shared MAR (medication record), all these across (locally based clinical networks) and sitting across new/legacy organisational applications feeding a local clinical data repository, the responsibility and scale for which is at that PCT level (500,00 population/£500m revenue?) . With this in place Darzi is a walk in the park.

Again there are personal observations and do not reflect those of my employers.

Pete Marsh

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13

Where does the Local Health Community fit in?

09 Mar 09 09:30

The brave and understandable decision of Pete Marsh's Trust to go it alone with Cerner does beg the question of whether this is fully supported by the LHC and whether the local PCT plans to deploy Lorenzo have been affected by this development?

There seems to be a trend developing in the NW with an increasing number of PCTs going with Lorenzo and the Acute Trusts following their own paths as directed by business drivers such as 18 week RTT compliance with which the LSPs struggle to keep pace.

Another example of DH directives being at odds with NPfIT functionality timelines.

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14

local plan

petemarsh@mechealthit.co.uk

12 Mar 09 21:13

The local LHC are very supportive and have been for last 6 years. Wirral acute was given the green light from SHA/CfH after extensive work on gap analysis from what was current on offer and the existing system(s). Wirral already has a shared MPI, Order comms across primary and secondary care, a shared electronic record and a shared EPR - electronic data repository. They already tick the Darzi five, the plan is to slot in Cerner into the middle of that and not upset what is in place. This has been with full approval at all levels. The proposal to link GP data into the Cerner record merely parallels what happens now in the legacy systems, but without the overhead of logging into two systems. The future of non acute is probably speculative given recent announcements, I suspect staying within a standards based solution that can integrate will keep us afloat.

Again personal observations only Pete Marsh