Promised as a flagbearer for the brave new world of eHealth when it opens in April 2016, the $1.85 billion new Royal Adelaide Hospital (nRAH) will instead have to cope with a “hybrid” environment including paper records and workflow due to delays in a decade long program to implement a state-wide electronic health record.

Promoted as Australia's most advanced hospital, the nRAH is also facing supply chain issues due to SA Health’s a failure to complete a long running rollout of Oracle, initially commenced in 2010.

A report from the South Australian Auditor General handed to the Parliament this week says a 10 year, S214 million program commenced in 2007 to deliver a state-wide Enterprise Patient Administration System (EPAS) had “ambitious timeframes and an under estimation and lack of detailed understanding of the effort required. In particular, the underestimation of effort required to implement EPAS at a major hospital site.

“Although Audit has noted a number of improvements to the EPAS Program, challenges still
remain, including ensuring system readiness for the nRAH by 17 January 2016 for SOC
testing and commercial acceptance on 17 April 2016.”

All ICT for the nRAH systems must have testing completed prior to 17 January 2016, ready for State Operational Commissioning (SOC) involving testing of all new hospital operations ready for commercial acceptance.

In 2007, the state’s Department of Health (now Department for Health and Ageing) awarded a contract to Allscripts Healthcare Solutions Inc. (Allscripts) for the EPAS solution.

Initially scheduled for completion in mid-2014, this deadline has not been met and SA Health is due to report to Parliament in coming weeks on when this can be expected. Intended to be deployed state-wide by 2014, it has reportedly been successfully installed at just three hospitals.

While it was initially scheduled to be rolled out to the existing RAH in mid-2014, a decision has been made to not go ahead with this, although this has not yet been approved by Cabinet.

SA Heath has instead decided to deploy the new EPAS system directly in the new RAH, although this has raised concerns from the Auditor General.

“There remain considerable risks around the lack of readiness, capacity and capability to manage the level of required business change. This is compounded when the system is being implemented at South Australia's new major hospital site, the nRAH,” it notes in its report.

“Despite remediation of certain functional issues during the stabilisation phase, ongoing delays in the EPAS Program still present a heightened risk that the required minimum EPAS functionality will not be fully ready for rollout to the nRAH.”

“Timeframes remain a key risk for the EPAS Program to meet milestone commitments in the contract agreement with Project Co, such as technical completion and commercial acceptance deadlines for opening of the nRAH.

“The February 2015 eHSC minutes indicated that the EPAS Program only learnt of the 17 January 2016 requirement in the third week of February 2015. The EPAS Program was previously working to a deadline of mid-April 2016.

“In addition, the nRAH has a requirement for a reduced hardcopy paper workflow and storage. The nRAH was not in the original scope of the EPAS business case and as such the nRAH's reduced hardcopy paper requirements were not clearly articulated in the original EPAS business case.

“Recent feedback provided to Audit has indicated that a Hybrid Record Team is investigating the option of implementing a hybrid medical record on initial operation at the nRAH. This approach is a combination of paper based as well as electronic records of information. A concern remains around the implementation of a hybrid record due to its associated impact on workflows.

“A successful implementation of the EPAS solution into the nRAH is also reliant on a number of dependencies to facilitate efficiencies by reducing the requirement for paper work and manual handling, notably:

• implementation of and interface with EPLIS for information flow of patient pathology
• transition of ESMI and interface for online electronic ordering of imaging services
• implementation and interface with iPharmacy for information flow of medication
  management including drug ordering
• transition of Oracle and interface for recording patient billing for financial
  management purposes.

“The contingency approach adopted, should EPAS not be ready for implementation at the nRAH, involves a number of alternate legacy systems. In particular. Acute Patient Management System (APMS) for PAS and Open Architecture Clinical Information Systems (OACIS) for renal and pathology functionality.

“As part of this process these legacy systems may require certain functional upgrades and/or workarounds to achieve required business process flows. Audit understands that work is being conducted on the nRAH contingency plan in parallel with work on building the EPAS solution with functionality fit for the nRAH.

“There is also the risk that SA Health will need to factor in alternate paper storage options and daily transport arrangements.

“Given the tight implementation deadlines for the nRAH there is a risk that insufficient time will be available for adequate EPAS testing.

“The tight deadlines also heighten the risk that the alternative legacy systems may not be suitably upgraded to provide all required functionality.”

Additional concerns were raised over the aim for EPAS and nRAH clinical workflows to provide patient services at the bedside. These services include meals ordering and the provision of health related patient information, such as rehabilitation advice.

“One mechanism to provide this service across SA Health sites was via bedside computers. At the time of writing this Report, these devices were experiencing usability issues and have limited development support.” the report notes.

Supply Chain blues

 “Since July 2010. SA Health has been implementing components of its new financial management system, Oracle Corporate System (OCS) to replace SA Health and health unit legacy general ledger and financial systems.

“The system aims to provide a whole-of-health integrated financial management system, which includes procurement and supply chain management functionality.

“Throughout the implementation of OCS. Audit has noted project delays, increased costs and reduced benefits due to implementation problems.

“Without appropriate contingency plans in place the nRAH may not have all required medical and office supplies delivered in a timely manner for the first six to nine months following commercial acceptance.

“OCS Phase 1 (financials) was implemented in July 2010 at all locations identified in the OCS Program plan. This primarily involved some accounts payable and accounts receivable functions, general ledger maintenance and reporting, budgeting and forecasting.

“Phase 2 (procurement, supply chain and some financials) consisted of inventory management, product information management. iProcurement, purchasing, order management, warehouse management, accounts payable and cash management …. deployment was originally expected in the second quarter of the 2014-15 financial year. This deadline was not achieved, with delays primarily attributed to difficulties recruiting suitably qualified implementation staff.

“As a consequence, a revised implementation plan was formulated by SA Health, with the remaining sites to have OPS deployed in six groups. The revised estimated completion date was July 2015. Based on experience of the time required to implement the first two groups of health sites, the estimated completion was then further revised, with a program scheduled close date of August 2015.

“Despite the progress of the OPS Program there are a number of challenges that may impact expected benefits to the distribution network. Of particular concern is that until the Cabinet approved investment initiative to modify the existing SA Health Distribution Network is completed, the distribution centre will not have the capacity to support the proposed SA Health supply chain and distribution model. In the interim, an alternative distribution solution is required, with the associated impact on the nRAH …

The full report is available online HERE