Clinicians, health unions call for RIVeR fix in Far North Queensland

Concerns about patient safety raised by clinicians using Far North Queensland’s new Regional Information via Electronic Records (RIVeR) system are so serious that one union is advising members to use alternatives and another is calling for a complete pause in its use until the concerns are addressed.

RIVeR, which is part of the $35 million Regional eHealth Project (ReHP) first funded in 2012, is a shared electronic health record based on Telstra Health’s Communicare primary and community care software and has been rolled out to 28 rural and remote sites in the Cairns and Hinterland Hospital and Health Service (CHHHS) and Torres and Cape HHS (TCHHS) catchments.

While the promise when the project began in earnest in 2015 – and a tender for the software awarded in 2017 – was to “deliver a primary and community care focused eHealth solution... supported by changes in processes and practices enabled by new and improved eHealth infrastructure and systems that enhance the quality of, and access to, patient and clinical information in primary, community and hospital-based healthcare facilities across Far North Queensland (FNQ)”, it has come in for serious criticism as it has rolled out.

Unions representing doctors, nurses and allied health professionals using the system are calling for action over a litany of issues, including problems with prescriptions, test results, patient recalls, and a clunky and slow interface.

TCHHS CEO Beverley Hamerton has rejected claims that patient safety has been compromised, and said she was confident the system was fit for purpose.

“We are working with clinicians and Telstra Health on refinements that can be made to the program and additional clinician training provided to improve the user experience and ensure the system fully supports clinical workflows,” Ms Hamerton said.

However, Queensland Nurses and Midwives' Union Cairns acting organiser David Beckham told Pulse+IT the union had written to TCHHS to outline concerns with RIVeR and to call for the implementation to be paused while those concerns are addressed. “QNMU concerns include failure to consult,” Mr Beckham said.

Together Queensland senior vice-president and Cairns Hospital anaesthetist Sandy Donald said patching the system up was like "putting lipstick on a pig", and his union was advising doctors that if they think RIVeR is creating serious safety issues, they should choose an alternative.

Dr Donald said doctors he had spoken to in both FNQ and in Western Australia were scathing about the system, which was due to go live in June 2020 but was delayed until late last year and this year during the COVID-19 pandemic.

“I've got members of the union in Cooktown who are doctors,” Dr Donald said. “They were struggling, they were at breaking point at the end of last year because they're so understaffed, and then they got hit with this software that halves the number of patients they can see.

“The doctors in Cooktown were pretty close to breaking point previously. At least two of the senior doctors were going to quit if they were asked to keep using Communicare.

“So the union advised them if they believe that Communicare is creating serious safety issues, or makes it so inefficient that they can't provide services, then they should choose the best available alternative.”

A report in the Atherton Tableland newspaper The Express last month said a visiting GP would no longer run a clinic in the small town of Dimbulah, near Mareeba, due to her problems using the system.

The original ReHP plan was to roll out ISA Healthcare Solutions’ MMEx after it won the tender in 2017, but that project turned out to be a failure for reasons still not explained, although a Pulse+IT source who requested anonymity said MMEx had struggled with the requirements of the project.

Queensland Health and MMEx agreed in 2019 to discontinue the implementation, and project leadership instead turned to Telstra Health, which had rolled out Communicare for similar purposes for the Western Australia Country Health Service (WACHS) in 2019. It is also used by North West HHS, and Communicare is used throughout Australia by the majority of Aboriginal Medical Services (AMS).

According to Queensland Health, the project aimed to deliver a primary and community care-focused eHealth solution, primarily to public health clinics providing healthcare to Indigenous people in some of the remotest communities in the country.

“The solution will support patient focused, integrated care and comprehensive healthcare services delivered as close to the patient's home as possible,” Queensland Health says.

While the aim was laudable, Pulse+IT’s sources say the project has not turned out well, leading not only to clinicians shunning the system but health IT experts deserting the project. Former TCHHS CIO David Bullock revealed in a LinkedIn post this week that he resigned as senior responsible officer for the project in 2019.

Dr Donald said feedback from his members had been overwhelming. Among numerous problems – which he said numbered over 100, not counting problems with physical infrastructure – feedback had been that the system was fundamentally poor.

“It's a dreadful interface,” Dr Donald said. “There certainly have been problems that should have been fixed before they [rolled it out] with the infrastructure. There are places up the Cape where it was dropping out five or six times an hour, so there certainly have been problems with very slow or unreliable network access, which can be fixed.

“But there are problems with the software that are just dreadful. Everyone I talked to, I can't work out why the hell they would roll this software out.”

Dr Donald said despite problems being raised that might have been fixed during a trial phase, the health services ploughed ahead with a full roll-out. Pulse+IT sources have indicated that money for the project was running out, and rather than return the funds and call a halt to the project, a decision was made to keep going. Dr Donald agreed.

“Overwhelmingly, the issue here is that it seems like the Torres and Cape are fixated on finishing the roll-out,” he said. “I'm not sure they're capable of understanding the problem... but the software is dreadful.”

Members have told the union that one of the critical problems with RIVeR is that it is very slow, he said. “It's got a clunky interface where they have to use lots of drop-down menus with very small fonts.

“So the first thing they have to do, working in a remote community with Aboriginal people who aren't terribly comfortable in that setting, is turn their back on them. Culturally, that is a dreadful thing to do. It interferes with the communication with the patient.

“And the way the system was set up, they were losing a lot of test results, all going into a single common folder. There were serious problems with prescriptions, including prescriptions just stopping without notice to anyone. That's very dangerous.”

Another problem is that the system can’t import records from other clinical information systems used in the region, including MedicalDirector and the Ferret tool. During the delay in rolling RIVeR out, a contemporary version of Best Practice was also rolled out to some sites in the Torres Strait, which had been using a very old version of BP, as an interim measure.

Those sites are still using BP and have not converted to RIVeR, Pulse+IT understands. While some in the Cairns region formerly used MedicalDirector and Cooktown sites have returned to that, it is not an optimal solution either as many nurses can’t access it.

And transfer of medical histories is a big problem, Dr Donald said. “Communicare doesn't import 15 years of data from MedicalDirector,” he said. “In some places there have been attempts to type a summary, but that always introduces errors.

“What is crazy is that in the Torres and Cape, in the northern area, they are using Best Practice. They have installed it, they have modified it and we're told it works well for everyone.”

Dr Donald said most people agreed that using a single program with a single record for each patient was ideal, but that was not the reality of what has been rolled out.

“There is one community on the Cape where they are using three different electronic medical records, and they also have a paper record, for the same patient,” he said.

“No one is absolutely committed to Best Practice but it will do what they need. They can use it in all of the remote clinics, it will import the MedicalDirector records, so they've got all of the old records, and it does prescribing.”

Dr Donald said the major problems with RIVeR were a clunky interface, lack of speed, thousands of pathology results for different patients going into one single folder, problems with prescribing, and lack of interoperability with other practice management systems.

“The other one is patient recalls,” he said. “When they need to get patients back, because that needs to be managed, apparently with Communicare that's another major problem.”

Dr Donald said he was seriously concerned that clinicians will leave the public health system because of the added pressures of using RIVeR.

“These people, they are dedicated,” he said. “People who've been working 10 or 15 years providing healthcare to some of the most vulnerable and remote communities in Australia, who will not be able to continue if they are forced to use this software. It takes away their time and it will drive people out.”

While there has been mention that the version of Communicare being used was first built 13 years ago, a spokesperson for Telstra Health said the first RIVeR sites went live in August 2020 with version 20.1 of Communicare.

“At the time this was the latest version of Communicare,” the spokesperson said. “Version 20.2 of Communicare was subsequently rolled out from November 2020 through to March 2021 across the remaining CHHHS and TCHHS sites.

“At the time this was the latest version of Communicare and contains all the latest medications workflows. In April 2021 version 21.1 of Communicare was made available for all Communicare customers. RIVeR provides a single patient record enabling the sharing of real time key patient information to all health professionals promoting continuity of care.”

TCHHS’s Bev Hamerton strongly defended the project, saying in a statement to Pulse+IT that the project was aimed at supporting better health outcomes for regional and remote communities in Far North Queensland.

“The RIVeR system was rolled out during 2020 and early this year to 28 sites across the Torres and Cape and Cairns and Hinterland hospital and health services, in partnership with Telstra Health,” Ms Hamerton said.

“The system utilises Telstra Health’s Communicare system which integrates with existing Queensland Health patient digital records.

“The system is designed to improve the sharing of patient information in rural and remote communities and help improve patient care, especially for those with chronic and complex health conditions.”

She said clinicians were consulted and were heavily involved throughout the development of the software, and that internal project surveys have shown “a majority of these clinicians largely see RIVeR as being better than paper records, and the system is consistently available at each site where it has been installed”.

“We are confident the RIVeR system is fit for purpose as a multidisciplinary primary health care record system, used by First Nations health workers, medical staff, nursing staff; and allied health workers such as physiologists, and occupational therapists.”

Ms Hamerton said it was typical during the introduction of new IT systems that there was a bedding down process.

“We value the continued input and feedback of our staff during this process,” she said. “Patient safety has not been compromised by the implementation of this new system, but it is being carefully monitored during this process.

“We are working with clinicians and Telstra Health on refinements that can be made to the program and additional clinician training provided to improve the user experience and ensure the system fully supports clinical workflows.

“As part of this process, both the Torres and Cape and Cairns and Hinterland hospital and health services have established a rapid response team of senior clinicians to work with all parties, including Telstra and eHealth Queensland, to identify opportunities to refine and improve on system functionality and usability, as well as developing new work practices and any additional training and education required.”

Ms Hamerton said RIVeR was delivering improved information sharing and care coordination for patients and staff already and this will continue to improve over time.

“The new system also is proving to be a “First Nations friendly’’ tool, opening real potential to make a difference to the health and wellbeing of Aboriginal and Torres Strait Islander people in Far North Queensland,” she said.

“We are also continuing to look at digital solutions for small hospitals in consultation with the Department of Health.”

Dr Donald said one of his criticisms was that feedback was not actually being listened to. “Originally they were looking at MMEx but they stopped and I don't think anyone was unhappy with that,” he said.

“It seems like they then were given about a year to implement Communicare, and they have almost completely ignored the feedback. A lot of the problems were picked up ages ago, but almost none of those problems, even the really glaringly obvious ones, have been fixed.

“I know there are people who either are or were part of the project. I know least a couple who quit, saying they can't support this.”

He said he had spoken to a small number of people who didn't mind using RIVeR “provided you don't use it for prescribing”.

“So as a simple text repository, it sounds like it probably can work,” he said. “But not everyone thinks it's better than paper.

“Having something that can be shared across multiple sites, so that we can track where the patient is, is obviously better than having paper in one place. But even with that, not everyone is convinced that it’s better than paper.”