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Sunday, 23 November 2014
ED FirstNet Technology Problem List

Analysis of Problems Defined by ED Directors

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Introduction 

This analysis aims to identify the major classes of strategies and concerns staff have in coping with the undesirable properties of the FirstNet software installed in Emergency Departments in NSW. The experiences of 7 Directors of EDs have been synthesised to gain a more general understanding of the scale and nature of the problems they are facing when using FirstNet. The interviews with the ED Directors are presented in Appendix 2 of Part 2 of the report A Study of an Enterprise Health Information System which contains the full record of discussions held with each Director. 

This analysis aggregates the Directors' comments around 4 topics thought to be a greatest value  in assessing the quality and future of this technology for Emergency Departments. These are: 

Topic1: Workarounds & Abandonment (see Table 1)

Topic 2: Functions Lost from the pre-FirstNet System or Desirable Functions (see Table 2)

Topic 3: Processes with added Risk to the Integrity of the EMR (see Table 3)

Topic 4: A Resolution Future of Problem List (see Table 4)

The analysis undertaken under each of the 4 topics listed above describes respectively that : 

* the staff will go to enormous lengths to overcome the limitations of the technology. 

* the staff draw on their knowledge of the technology they have used in the past and their knowledge of what is available outside of their workplace to provide them with a sense of what they need to conduct their work at an optimum efficiency.

* the staff are concerned about fulfilling their medico-legal obligations and that  they fear the FirstNet technology will impair their responsibilities in this sphere.

* the  range of problems that the Directors have identified as preventing the care of their patients at a satisfactory level of efficiency, the location of their possible source-points within the technology, and estimates of the time to resolution. 

Data Sources 

Some of the problems presented below have been rewritten from the original report along with amalgamations of similar descriptions. Problems with vague descriptions have been omitted, as it is less likely that the source of such problems can be readily identified. The likelihood of resolving the problem depends upon which function of the software is the cause the problem.

The explanations and dates presented in the Tables are postulated on an interpretation of the likely cause for the fault drawn from the report. We have been informed by attendees at the user group meetings, known as the AAG, which is responsible for managing complaints and corrections, that problems are almost always listed for remediation after two years so that is the date used in this table. Programming problems that have to be referred to the vendor are considered by our informants to be irresolvable as the small Australian user base has little influence over the vendor’s work programs compared to the demands of the large North American user base. 

Please inform us when these problems in these lists are corrected or if new problems arise, or the problem herein can be stated more accurately. 

1. Workarounds and Abandonments

These Table entries are strategies used by staff to pursue their work despite the interferences created by the technology (aee Table 1). This Table lists 25 types of work tasks in which workarounds are in place or delivered functionality has been abandoned. These strategies permeate virtually all aspects of the patient journey including pre-arrivals, clerking, triaging, ordering tests, recording vital signs, and many aspects of clinical documentation. The only process of the patient journey that does not record a workaround/abandonment is the discharge summary. The actions of the staff demonstrate a large scale evasion in using the system to the point where nursing staff show extreme levels of avoidance. In effect from the beginning of the patient journey in the ED all the way through to the end the staff have to wrestle with the information system to give the best care to the patient. Whereas an intuitively designed fit-for-purpose system should make the patient’s journey easier, and more efficient for the staff. The current situation supports the comments of a number of Directors who only use the system for admission and discharge.

An interesting example of ‘abandonment’ which has been reported recently involves the removal of letter prefixes to MRNs which signify the originating  hospital for the MRN. The removal of this prefix has  produced non-unique MRNs across an Area Health Service (entry 26). At first glance this appears to be an injudicious administrative decision without thinking through the consequences. However this may be an example of the software tail wagging the Health Care dog. The analysis of the software in parts 4-6 of the study discusses the use of numeric data types (floating point numbers) for primary keys and indices. There is a real possibility that the alphabetic component of the MRNs had to be removed to fit into the constraints of the underlying software code implementation. 

The non-unique MRN problem appeared coincidentally with the problem of names not being printed fully on labels which compounded the loss of unique MRNs (entry 27). Unfortunately the hidden consequences of the two problems meant that the work practices had to be changed to abandon the use of the technology that caused the compromise in labelling and MRN uniqueness so as to protect the registration of the pathology laboratory.

2. Functions Lost from the Pre-FirstNet System or Desirable Functions 

These are the functions that staff: 

1. were used to having in the previous technology used prior to the introduction of Firstnet and represents the extent to which they believe they have been moved backwards; or,

2. believe are the advancements that had been promised to them with the introduction of FirstNet which have not been delivered; or,

3. are aware of as common practice in surrounding technologies that should be available in a modern clinical information system. 

A major type of function loss is the ability to perform a variety of search actions, such as: free-text search, search by diagnosis, filtering patients on any selective field, recalling historical reviews of recent patients, and ad hoc reporting.  Other lost functions are a lack of alphabetical list sequencing, appropriate presentation of test results, alerts for some types of situations, and dynamic change in display from showing Presenting Problems to showing Diagnosis when it becomes available. 

Desirable functions have a wide range but the dominant selections are: recognising staff roles for varying displays, identifying research candidate patients, nursing alerts, rationalisation of tracking list icons, presentation of KPIs, access to clinical pathways, publishing a daily issues list, improved reporting functions, appropriate delivery of test results, reliable report computations, rationalising and correcting the contents of the SNOMED coding system.

The intensity of feeling about the loss of functionality is palpable amongst the Directors as they have had withdrawn from their service important tools needed to fulfil their professional responsibilities. This action challenges their sense of duty to their patients and staff and their role at the vanguard of public health. At the same time their knowledge of what is possible with technology leaves them entirely frustrated in knowing that:

* the system could be so much better; 

* what was promised to them was supposed to be much better; and 

* what was delivered is much worse than what they could have dreamt. 

It is their own knowledge of the value of technology to improve the quality of their work that leaves them so completely exasperated at being delivered a technology that falls so short of a reasonable standard in their eyes.

3. Processes with Added Risk to the Integrity of the EMR

This table presents new issues for staff which have been introduced into their work processes by this technology that they posit compromises the electronic medical record (EMR) in terms of satisfying their medico-legal obligations. Staff have recorded a range of circumstances where they think the integrity of the EMR is at risk, namely: 

* problems with preparing labelling and attaching it to correct patient records, 

* login issues that lead to computers being left logged on so anyone can work under someone else's identity, and 

* concomitantly where the writer of a document is not separately identifiable from the reader of a document, and 

* letters can be changed by the non-author and there is no record of the change or the second author. 

These situations have lead to doctors now keeping print reports so as to keep a record of changes to documents. 

A different source of error in dealing with the EMR occurs with the shifting display on the tracking list that can mislead staff as to which patient record they are actually working on causing them to enter content onto the wrong patient record. 

Other risk areas are an event management system that can be used to delete events that should properly be recorded about the patient journey and where staff have to acknowledge that they have checked reports when they haven’t really done so.

A focal point in the full report on this information system has been an emphasis on the need for organisations to make an extensive risk assessment of its use in their organisation. By their comments in this table the directors have made their own risk evaluation by directing attention to the risks that the EMR is most likely not correctly preserved as required by the law. They report the serious situation of being able to make changes to the clinical documents without them being recorded. This can occur on a daily occurrence. Such changes are not readily detected by staff and on occasions brought conflict between members of staff when they dealt with different versions of the same document not knowing that document content preservation was designed in such a brittle manner. 

The sense of responsibility for staff that service the ED in radiology and pathology combined with their negative experience with FirstNet is such, that they feel compelled not to trust the system to preserve the record of their work safely and correctly so they maintain a separate paper record with all its own drawbacks and risks. In one case the radiology staff did not trust the transmission of data from the laboratory information system to the FirstNet system. Such a loss in confidence in the underlying technology will ultimately permeate all aspects of its use and as described in a recent editorial, The Validity of Personal Experiences in Evaluating HIT undercuts the usefulness of the systems leading to its decay into moribundity.

4. General Problem List - What is the Potential for Resolution? 

This table is a list of malfunctions with the technology that hinder staff working as efficiently as they believe is possible. The malfunctions represent the frustrating aspects of the technology that waste time and increase the risk of more detrimental outcomes for patients.

Table 4 gives the rectification rating for many of the features already seen and adds in more problems collected from new hospitals in the last few weeks. The postulated types of change show 30+ problems need Software changes and nearly 30 require some form of adaptation of the configuration. Being mindful of the warning of the software validation experts that there is no clear line between software functionality and configuration functionality the separation here is also not completely unambiguous.

Among the list of problems the Directors describe nonsense practices such as advice from trainers to "Never use the save button", because of its uncertain behaviour, and  duplicate menu headings for different menus. Serious difficulties exist around ill-considered login/logout policies. Problems are exacerbated by system inadequacies where it fails to save current work and content disappears from the screen, leading to disruption of work practices and repeating already completed work. 

The Directors assert that preparing documentation is too complex and is unintuitive . It is bedevilled with superfluous and inappropriate content in: templates , problem lists, SNOMED CT codes, document lists, and order sets.

Descriptions of inappropriate and overly complicated workflow include: 

* doctors and nurse notes not kept in chronological sequence, 

* too many clicks to complete  a task (where there is navigation for the sake of navigation),

* searching documents to find specific content, 

* loss of contiguity of observations, 

* adding allergies,

* anyone able to assign a patient to another doctor/nurse,

* inadequate support for determining KPIs with associated KPI degradation, 

* violation of NSWHealth Guidelines, 

* redundant functionality causing delays, 

* duplicated steps in a workflow,

* non-operating functionality, 

* misdirected pathology and radiology reports,

* excessive and near unworkable procedures for conducting multiple order sets and follow up sets, 

* automatic deletion of orders, and inexplicably lost information,

* mixed workflows combining paper records and electronic.

There is one case that is the mirror image of the comments made by the software validation experts where users are informed that reported problems don't exist because the service provider has secretly fixed them. In this case a doctor requested that the preservation time for orders be extended from 3 weeks to three months. After 6 months of pursuing the issue he was told that the change had been made but in fact on testing the system he found that it had not been made. 

In a normal patient journey data is collected in one process and then needed in other processes at a later time. However in this case poor re-use of data occurs: times and values aren't loaded to where they are needed  e.g. time for Dr Seen is considered to be hopelessly corrupted and is ignored by Directors as indicative of anything useful; recommended tests for pre-arrivals are not presented on the triage screen;and,  diagnosis is not used to replace presenting problems on the tracking list when it becomes available.

Coupled with the difficulties presented in Topics 1-3 of this paper, this list of problems substantially enriches the story about the disadvantages of FirstNet in EDs showing the problems are pervasive and penetrate all aspects of clinical work. 

Conclusions 

 

Reviewing this compendium of difficulties and obstacles created for staff makes it entirely unsurprising that the patient throughput of most EDs dropped by 50% on the day FirstNet was introduced and now some years later throughputs are only just beginning to recover as staff have been able to instigate work practices to minimise the worst aspects of the system. 

The workarounds and abandonments give an expression of the frustration of staff and their strategy for retaining equilibrium in their work practices despite FirstNet's presence. In a number of cases we have seen the practice guidelines of NSWHealth surrendered by the imperatives of the technology with the imposition of the HSS. It is astounding that practices defined from years of clinical experience can be discarded so whimsically. Fortunately, in the case of one pathology laboratory, patient safety was put ahead  of the technological imperative lest it jeopardise the registration of the laboratory. The described function-losses with FirstNet compared to the pre-FirstNet systems, and the functionality needs expressed by the staff indicate that they are acutely aware of the value of good technology and have a strong desire to be equipped with something that works properly without creating unacceptable risks to patients and a draconian reduction in their efficiency. The risks posed by the system to maintaining the integrity of the medical record is something that staff are acutely concerned about as they feel it fails to fulfil their legal obligations.

Emergency Departments are too important to have to endure these stressful and unproductive conditions. It is time that the knowledge and experience of the Directors and their staff were listened to and taken seriously for the sake of improving our hospitals's use of technology.   After all we have to ask: What business would commit to an interloping "integrated" system whose services are being necessarily dismembered piecemeal as a matter of survival by the users? This is a system whose pieces are not used by the staff, but rather are shadow mirrored by them, not for redundancy but primacy. Who would want a system that is progressively de-activated by the staff to overcome the hazards and operational inefficiencies it has introduced? 

 

 

1. Workarounds and Abandonments 

No.  Problem Description  Workaround strategy and/or consequences Reported Date 
Allergies: The mechanism for recording allergies is far too lengthy and involved so that it discourages staff from doing the data entry. The allergies are written on a piece of paper which is physically pinned to the patient.  04-03-2011 
Vital Signs: Initially Vital Signs were input into the system but the response time for retrieving them was very slow. So much so that staff on a daily basis would execute one retrieval on one terminal wait some time and then go to another terminal repeat the same request, wait and then go to a third terminal. Instead vital signs are written on paper and kept at the bedside so that they are always readily available.  04-03-2011
Pre-arrivals: Information that is collected about a pre-arrival patient is not inserted automatically into the triage record but kept stored elsewhere in the system. Staff do not know that a pt has had pre-arrival information collected about them and so don't look for it. Staff do not search out the record as there are only 1:10 pre-arrivals and so it wastes too much time. The consequences can be that care is delayed as advice for immediate action e.g. recommendation to do certain tests, is not discovered by he attending staff.  16-03-2011
Recording Notes: The risk of some form of interruption whilst writing notes is very high. They can come from accidentally hitting a wrong key on the keyboard and the screen disappearing, to being interrupted by a staff member or a call to attend to an emergency.  Whilst writing notes continually copy them into the screen buffer using the ctrl-C mechanism of the keyboard. If called away from the terminal store the notes into a Word file.  16-03-2011 
Organising Notes:  The clinical notes of the same patient written by the nurses and the doctors are not saved together, thus when a nurse attends a patient who was previously attended by a doctor she has to search for the doctors notes separately and vice versa. The same single note is used for 24 hours, so that all the information is entered in the one place instead of creating a new note for each staff attendance. Therefore, only one note per day is created for the patient and the note is clear enough for staff to follow.    4-03-2011 
Clerking: Triage staff need to wait for the patient to be clerked. Clerking is a longer task than triaging so as patients bank up they are not receiving prompt triage and therefore increasing their risk of an adverse event. Nursing staff and often ambulance staff get frustrated as the triage process is delayed while clerical staff add patients onto the system. The patient cannot be triaged until they are on the system, even though this process violates NSWHealth guidelines. In an emergency, the patient is treated regardless, staff don't wait for the clerking to be finished. Clerical staff follow the patient into the resuscitation bay to obtain details.  04-03-2011 
Irrelevant Content: There are a great number of non-relevant content screens, that have to be clicked through to progress the work. People get through as quickly as possible, resulting in poor quality data, e.g. "Dr Seen" time is not reliable    
Non-workng functions: Some functions in the FirstNet do not work. The Print function is a good example. Following the advised procedure completing a sequence of screen requests for printing documents sometimes leads to uncompleted print jobs and the staff are at a loss as to resolving the problem.  There is a hot button on the screen that is known to be reliable for completing the print function, BUT it does NOT print any identifying information of the patient. Hence the staff use the button as a work around to a failed print request and may remember or not to write the patients details on the top of the printed paper.   04-03-2011 
9 Clinical Notes: The clinical staff currently do not use the clinical notes functions in the system as it is considered cumbersome and would need to be part of a hospital wide initiative.  Some staff have their own templates or prefer to prepare a word document.   04-03-2011 
10  Necessary presenting problems are not available in the supplied list.  The presenting problems are written into the notes and so distort their reporting.  04-03-2011 
11 

Orders:

1. The electronic order generates a label for each test. If all the tests are not entered at exactly the same time, each test will require a separate specimen tube with it’s own label. This is despite the fact that it is usual for groups of tests to be done on the same specimen. 

2. After Blood tests are ordered, any add ons is a problem as they cannot be sent electronically. 

1. The collection times are changed in the computer so that all collections occur at the same time, which is confusing and not intuitive.

2. These problems occur frequently. However, usually we can sort things out with Pathology by talking with them. The main consequences are delays in patient treatment.  

04-03-2011 
12  Reviewing Tests: Tests should be reviewed but:  It is accepted by ED supervisors that the vast number of basic pathology tests eg FBCs that are available for review before the patient is discharged from ED do not need to be followed up at a later date as it is assumed they are viewed and acted upon by the treating doctor during the patients stay in ED.  It is not possible to clear these results from the message centre in bulk.  They can only be removed by clicking on each in turn.   As the supervision doctors do not have time to follow up all these results they remove them from the system one at a time but without analyzing them by clicking an “OK” button that implies the result has been followed up. 4-03-2011 
13  Ordering: It takes the clinical staff a long time to make orders because they have to fill in the same information for different orders for the same patient. For radiology orders there are three mandatory fields for essentially the same information.  Staff generally copy and paste the information or make a token keystroke in the mandatory field.   04-03-2011 
14  Radiology reporting: The fact that a report is changed from its initial form is not identified and the original is lost entirely. So, if an abnormal report is missed the pt gets the wrong treatment.  The resulting behaviour is that radiology reports are printed out when they are generated. This leaves the problem of mixed paper and electronic record.   04-03-2011 
15  Radiology reporting: A form must be printed as patients go missing on RISPACS. This practice has stopped but the odd patient still goes missing, it has something to do with the AUID and has slowly been resolved,  Radiology have 2 screens up to monitor orders in FirstNet matching orders coming across Rispacs.   04-03-2011 
16  Alerts: There is one icon that encompasses two different alerts so it is difficult for users to see at a glance what the patient has an alert for, especially when there are 80 patients in the ED and 20 have alerts. In FirstNet, users have to open each patient’s chart and then remember or transcribe the alert onto the tracking screen (current practice), which makes it inefficient.  Currently, users do not use alert functionality in FirstNet because it does not work very well.   04-03-2011 
17  Printing: Printing certain fields can take a large number of mouse clicks which may be beyond the scope of the average user to remember.  Many staff rely on cutting and pasting into a Word document from which they print the desired text. 04-03-2011 
18  Unsigned Notes: Under the proposed system for faxing discharge summaries, once the clinical staff prepare and sign a summary they cannot change the destination within the system in order to divert the fax to another provider who is not the patient’s GP or elect not to send the fax for confidentiality reasons.  The planned workaround is to not sign the referral in the event that a decision is made not to fax. Without signing, the documents will not be stored, and it is necessary to print a hard copy for inclusion in the patient’s paper medical record.. 04-03-2011 
19   Effect of Slow response times: The e-gate to the IPM is not fast enough.  The clerk issues a new MRN for the patient. This causes down stream delays when the old MRN eventually arrives, and goes onto the tracking list. This creates situations where the blood results for a patient are not connected to the on-line record in FirstNet because they have been ordered using the new MRN.   4-03-2011 
20  Non-current Displays: FirstNet only displays the Presenting Problem on the Tracking list where it should insert the diagnosis when it becomes available.  Staff are required to type the diagnosis onto the tracking page for later ease of reference. This means staff need to transcribe the diagnosis from a mandatory field in the system onto the tracking page. This costs time and potentially introduces errors, especially given that selecting the correct pt record from the tracking list is so problematic.  04-03-2011 
21  SNOMED CT coding: it is not only hard to find things, frequently there are diagnoses not present.  Chose an alternative that is a best fit.   04-03-2011 
22  Training Limitations: The training volume is too great due to the complexity of the system so the absolute demand is too large especially when trainee staff rotate every 12 weeks.  Junior staff usually attempt to restrict their learning to the functions in the system directly concerned with their jobs. At times junior staff are distracted by, or waste considerable time attempting to familiarize themselves with functions that are only of relevance to senior staff or unhelpful in the ED setting.  04-03-2011 
23  Presenting Problems: Clinicians are not allowed to add more presenting problems to the pre-defined list that would help cover any missing classes.  This leads to triage typing the presenting problem and associated manchester discriminators into the comments, which reduces work efficiency and distorts the reporting of presenting problems.   04-03-2011 
24  Unsigned Documents: The documents are sent to doctors automatically after signing. Without signing, the documents will not be stored electronically in an identifiable location.  A report of the unsigned records used to be provided so as to enable chasing up doctors, but that is now abandoned. Hundreds of records were lost in the first year using of FirstNet.  04-03-2011 
25  System Complexity: The system is too complex to record a patient's day to day information. Nurses should enter all the data into the system.  Nurses keep the data entry as brief a possible so the notes are worthless.   04-03-2011 
26  NSW Health Policy requires patient to be registered with an Area Health Service unique patient identifier. The AHS used to achieve this by having a letter prefix for each hospital in front of an MRN. The letter codes were removed when Cerner Power Chart was introduced, and at the same time the "pools" of MRN's were amalgamated and became visible from a single ward based computer terminal. This resulted in multiple patients with the same MRN being visible on a screen at the same time. In one case 8 patients with the same MRN. Pathology, ED and Trauma all require a unique identifier. Non-unique IDs puts a Laboratory in violation of the mandatory requirements for registration. Loss of laboratory registration for a country hospital would mean blood samples would have to be sent to another distant hospital, with a delay in response time that would put lives at risk.

Pathologist ordered a cessation of the use of PowerCharts for orderingblood products and a reversion to paper orders.
In conclusion the software was rolled out without any opportunity for clinical staff to check that it conformed to standards and requirements.
16-03-2011 
27  Blood tests requested to be performed by the transfusion service should have on all documents the patient's full name, date of Birth and/or unique MRN. The print outs give only a fixed number of character positions, so long names are cut short. In the case of a newborn named as "Johnson, baby of Margaret Sonia" the last part of the name may be entirely lost: the request could then be truncated to "Johnson, baby of Mar".  There may be several patients with a common surname such as Johnson, and first name Marg, or Margie, or Marjorie, or Margaret. For newborns, there is no historical DOB to confirm identity, and without a unique MRN either, there is a real risk of mis-identification.  Printing of labels needed to be discontinued.   

 

2. Functions Lost from the Pre-FirstNet System or Desirable Functions

 NO.  Processing Function Lost/Desirable Functions  Date Reported 
It should recognize the roles of staff and serve them information and forms according to their roles. It has no intelligence to know about staff roles and personal customisation.  Desirable Functions  4-03-2011 

Does not allow triage nurse to flag patients for research activities.

Desirable Functions 

4-03-2011 

 The system should have a biometric login. Desirable Functions  4-03-2011 
Nursing task alerts do not work because there is: 
  1. no flashing, 
  2. no alerts, 
  3. when there is a change of status it has to be done manually, 
  4. Nurses do not want to use it because there is only one alert type and you can’t determine where the 'alert' is and what it means. 

Desirable Functions  4-03-2011 
Triaging a patient by a staff member - Staff pick a patient off the un-triaged list – this is an issue if two different staff pick up the same patient.  Staff need to be able to delete or send an ‘in error’ message to the ‘in error’ triage form that another staff member has completed.   Desirable Functions  4-03-2011 
 6 Ambiguous Use of Symbols in the Tracking List: Icons are used to represent specific tasks but are not removed/overwritten/transformed when their status changes so clinical staff have to look at all the symbols to get an idea of the current status of the patient and to interpret if a task is finished or not, or what state it might be in. e.g. in the case of the two actions which have one icon 'ask for bed' |'bed arranged', the first event symbol should be overridden/eliminated for efficiency and also to save screen 'real estate' as the screen is taken up by symbols that constitute superseded knowledge.  Desirable Functions  4-03-2011 

Lack of efficient List Sequencing. The choices are ordered by alphabetic order only by the first character, however, there are lots of forms starting with the same letter such as ECG and ED, the second letter of the word is not used in the sequencing. This wastes time for staff. 

Lost functionality  4-03-2011 
They have lost the capacity to print the contents based on their needs, such as GP contact number.  Lost functionality  4-03-2011 

It is not possible to generate ad hoc reports such as:

1. top ten diagnoses for a particular period;

2. disease incidence;

3. caseload of individual staff members;  

Lost functionality  4-03-2011 
10  Pre-FirstNet, reports could be extracted on every field rapidly and easily, and matched to the clinical process. While with FirstNet, they have no permission to access any data fields but only to rely on embedded standard reports.  Lost functionality  4-03-2011 
11 The daily patient list used to find a patient which included using key words search for diagnosis (from a vague description) could be generated easily pre-FirstNet. Lost functionality  4-03-2011 
12  Extracting a month’s worth of data via FirstNet’s Discern Explorer took as long as 40 minutes. In the pre-FirstNet system data was extracted in only 5 minutes  Lost functionality 4-03-2011 
13  KPIs relevant to running the ED should be present.  Desirable Functions  4-03-2011 
14  Certain clinical pathways are necessary to do the job easier and train staff.  Desirable Functions 4-03-2011 
15  There is no daily issues list.  Desirable Functions  4-03-2011 
16  The reporting functionality is poor from an ED managers point of view. The SNOMED diagnoses does not help as there is no simplified classification of common problems that gives an overview of our workload and changes in time.  Desirable Functions  4-03-2011 
17  CSF Testing - has 3 categories of tests: Microscopy and Biochemistry with results that come back during the patient visit. A third test is Cultures that are returned after a later period of time. This requires three separate orders in the current system but should be fixed to be one order, which they traditionally are. The results are reported separately which inhibits the efficiency at which staff can recognise their association and the importance for diagnosing cerebral diseases.   Lost functionality  4-03-2011 
18  For checking of test results they are sent to a personal inbox of the orderer. This is not satisfactory, as often someone else has to check the results. There is no mechanism to screen/filter the results making it necessary for each result to be individually read. This has lead to the workaround strategy of not checking results. While with the pre-Firstnet system they could filter the results, so that they could view the results more easily.  Lost functionality  4-03-2011 
19  Lab Results are sequenced in the reverse vertical sequence to customary reporting by world conventions. This results in not being able to look for patterns that have been learnt over a long time and so has serious efficiency issue. Now staff have to read the list of results starting at the bottom and moving up the list. NSWHealth have refused/ignored the request to change the ordering sequence.  Lost functionality  4-03-2011 
20  One can't get reports of patients who have left the ED more than 72 hours ago. Reviewing cases is an important part of learning and training of staff.  Lost functionality  4-03-2011 
21  Pre-FirstNet physicians could find a patient by searching the free text information, while FirstNet does not provide this function.  Lost functionality  4-03-2011 
22  Pre-FirstNet, physicians could access a patient record by viewing the date of their episode and the final diagnosis of the patient, but it is not easy with FirstNet and instead of the final diagnosis, the presenting problem is posted against the patient’s summary report.  Lost functionality  4-03-2011 
23  Alerts:  Lost the alerts functions for behavioural risky patients (violent, mental). Lost the alerts for clinical risky patient (e.g. rare diseases, frequent visitors, known treatment requirements, etc)  Lost functionality  4-03-2011 
24  In the interface the Diagnosis entry is supposed to replace the Presenting Problem entry if there is one, but this does not work in the system. Presenting problem is only relevant until the patient has seen a doctor then we require the diagnosis to be displayed on the tracking page. Pre-FirstNet system did this weil.  Lost functionality  4-03-2011 
25 

Analytics Service: 

1. FirstNet can show the ED is “full” whereas the staff understand the transient characteristic of “being full” but can’t see any real figures as there is no: 1) formal reporting, 2) nor predicted modelling.

2. The EMR consists of FirstNet, SurgiNet, PowerChart, Enterprise Scheduling, and Discharge Referrals. The rich source of information that the eMR collects is not used to feedback to the managers neither the real-time capability nor the capacity of this department in relation to another. For example, a high load of geriatric patient presentations in ED during winter season will become a ‘push’ factor from ED to an inpatient ward when it should be a ‘pull’ factor from the inpatient ward to ED. If EMR is able to provide information that gives the current capacity/capability of the ward, the ward in turn is able to predict when patients will be discharged, how many beds will be available and thus streamline the admission process. 

Desirable Function  4-03-2011 
26  A department map, which highlights the availability of the beds and the patient in it, allows for a quick visual assessment of the capacity of the department. The bed map was available pre-FirstNet.  Desirable Function  4-03-2011 
27 

SNOMED CT Search: The search function is not intelligent enough, clinicians need to enter a similar word and see a list of alternatives, because sometimes they do not know the exact diagnosis name as stored in the system. For example, CTPA is named with a different name in FirstNet called CT chest PE studies, this is hard for clinical staff to work with as CTPA is the terminology that staff would be used to.  

Desirable Function   4-03-2011 
28  FirstNet does not match the work process. It lacks an alert function and patient plan (a brief patient summary).  Desirable Function  4-03-2011 
29  Spell checking doesn't allow for own words to be added. Spellchecking does not include a medical vocabulary!   Desirable Function  4-03-2011 
30  All post discharge results from tests generated from the ED are sent to the ED Director, which is a large number. There is no facility to separate the results into different classes, such as Admitted, Classes of Discharge, Not created in ED, so as to make it faster for the Director to process.  Desirable Function  4-03-2011 
31  Can't unsort on any column. Shows LOS but not arrival time.  Desirable Function 

4-03-2011 

 

3. Processes with Added Risk to Integrity of EMR

No  Description  Date Reported  Date Resolved 
Sometimes when staff print a label, maybe 5 staff make orders simultaneously. When the labels are printed out, it is hard to match the label with the patient. Moreover, they are in a busy environment therefore, they just pick up a label and attach it to the sample. The system is designed firstly, and then the training focuses on how to make a barcode work properly.  4-03-2011   
When the clinical staff finish writing a document in the system, only one copy of the document is printed. If they want another copy of the document, they click the print button on the screen, so only the content in the document is printed out without the patient identification and other information.  4-03-2011   
The clinical staff are not guaranteed to collect the correct printer output, because 8 computers use only one printer, hence at busy times there is a serious likelihood that the wrong printout is collected by a staff member.  4-03-2011   
A referral letter needed to be re-sent to a different provider after the weekend. Staff went to the Discharge letter, ticked the box "Correct", and it was then noted that they could make changes to the original letter and save them to the system without needing to make any identification of self as editing the letter. The letter was saved under the name of the original authoring doctor and no record was made that it was the work of a different author or the extent to which it was changed. This means that the EMR does not constitute a valid legal record.  4-03-2011   

Senior Staff access the computer at least 50-60 times per shift. Due to time constraints it is impractical to log on and off each time. As a result logged in PCs are often left unattended, compromising security and creating a range of problems when users inadvertently access another’s PC. It is also possible to log into multiple terminals and to have them all open under your log-in at the same time.

4-03-2011   
Staff can click the indicator arrow in the first column, but the row is not highlighted. If a patient is removed or added to the Tracking List e.g. discharged or triaged then the list is added to (on a triage) or shortened (on a discharge). However the “select” arrow stays in the same physical position on the screen hence the patient it was pointing to will have changed, as the order of patients in the list will have changed. So if a doctor selects a patient, then pauses or leaves the screen for a short time the pt the pointer is indicating may change. If they are not aware that the system can change the pt it is pointing at without their intervention then they will not check the record and so subsequently open a different pt record to the one they intended. So commonly notes go into the wrong patients record. However those wrong notes may in turn trigger serious adverse interventions for that patient. There is at least one known occurrence of this happening.   4-03-2011   
If the service provider changes the report, the report will change in the system. Therefore, you can only get the updated report, meanwhile losing the original one entirely. Amendments and additions to the orders report are not preserved in the system. Hence staff were in dispute with other departments about the contents of their reports which would change. Now, staff print the reports so that they have the original record for settling disputes. NSWHeath has been requested to provide a log of changes to the report so the staff know what has been done to it.   4-03-2011   
8

The log of the system does not separate the writer of a document for a patient case from someone who views a record in the system. So it is difficult to identify who actually saw the patient.

4-03-2011   
FirstNet has an event management mechanism which enables users to add requests, confirm, and even delete events, so the veracity of the EMR cannot be secured.  4-03-2011   
10 

When the clinical staff are tracking a lot of patients it is very easy to choose the incorrect patient from the list.  Along with a screen that is fiddly it is easy to write in the wrong patient note. 

04-03-2011   
11  Reviewing Tests: Tests should be reviewed but:  it is accepted by ED supervisors that the vast number of basic pathology tests eg FBCs that need to be reviewed have been done befire he patient was discharged.  However it is not possible to clear these results from the message centre in bulk.  They can only be removed by clicking on each in turn. As the supervision doctors do not have time to follow up all these results they remove them from the system one at a time but without analyzing them by clicking an “OK” button that implies the result has been followed up. The system records that the doctor has followed up the result when they have not. 04-03-2011   

  

4. Problem List Description - What is the Potential for Resolution?

No. 

Problem Description 

Possible Explanation

Publication Date

Possible Correction Date 

Problems arise when the documents are saved but not signed. Documents may become difficult to find even for the experts. The FirstNet trainers state “Never use the save button”.  Cerner was asked to remove the save button. However, the answer was that it could not be done. 

Software Requirement

 
4-03-2011   Never

1. If the record is unsigned and the doctor walks away to an emergency leaving the data on the screen. The unsigned data can be cancelled by the next person who wants to use the computer.

2. When a doctor is preparing a note and something requires their attention elsewhere. The doctor leaves the device for a while. When he comes back, someone else takes over the computer, the previous note will not be saved as a draft. 

Software Requirement 

 
4-03-2011  Never 
The templates are not symptom generated and try to cover every topic and every specialty. Each template is like an index to a comprehensive textbook on socio-economics combined with medicine. You scroll through a list of demographic information, social information, signs and symptoms. As with other templates, you circle or backslash to confirm or deny. However, when this information is converted to prose, it is a series of disconnected phrases that do not provide a grammatically correct easy to read document. 
Software Requirement

 

 4-03-2011  Never
The FirstNet templates are a list of words. There are no diagrams although it is possible to find diagrams in another part of FirstNet. The templates do not flow according to usual work practice. They do not act as an aid to memory. They are not user friendly. If a junior doctor tries to use the template, it can take hours to document the record of a single patient. 
Design not matched to user requirements. Built into software
 4-03-2011  Never
Documentation Screen. To add a note click on the note icon and a window opens into which the note can be written. The note is then shown on the screen. Subsequently if you click on the text of the note it then disappears entirely. To add to the note you have to do a right click on the notes icon and then select Open to open the note. The delete process can only be reversed by moving to the top menu bar and selecting Edit and then Undo and without this knowledge new users are lead to the belief that their work has just disappeared and is irrecoverable. 
Software Requirements
4-03-2011   Never

1. Triage box allows about 2.5 lines of text or ~50 words. Choosing from the triage problem list of 51 items is not compulsory nor even close to being comprehensive so staff workaround by writing their own entries. The entries are free text and thus not part of a searchable “reason for presentation” database field. 

2. Most staff write in a text description of the problem as the problem list is defective with poor wording, "bleed haematuria" or unfamiliar descriptions "orbital disorder" and lacks common usage of terminology. 

 Configuration Requirements

4-03-2011 

 4-03-2013
The database search for diagnosis or problem requires an exact match and does not assist with finding synonyms or approximate matches not found because of spelling mistakes. 

Built into the software
 4-03-2011  Never
A referral letter needed to be re-sent to a different provider after the weekend. Staff went to the Discharge letter, ticked the box "Correct", and it was then noted that they could make changes to the original letter and save them to the system without needing to make any identification of self as editing the letter. The letter was saved under the name of the original authoring doctor and no record is made that it was the work of a different author or the extent to which it was changed. This means that the EMR does not constitute a valid legal record. 
Built into the software
 
4-03-2011   Never
All notes on a patient cannot be seen in one page. In 'Clinical notes', when nurses fill out 'continuation notes', they should read old notes from 'clinical notes' and then see 'pathway' but they have to move to other pages to find this material so it is inefficient. 

Built into software

 

 
 4-03-2011 Never 
10  Clinical staff have to sign in to confirm arranging a test for patients, at which time the user name cannot be changed. If one doctor signed on to one workstation and then went away to take care of patient, and during that time, another doctor has come to the workstation and signed the previous doctor off all his work will be lost. 

Built into software

 

 
 4-03-2011  Never
11  There is no button to add new clinical notes. When reviewing 'continuation notes', there is no button to add a new one. It needs to be done in another place, so it is inefficient. 

Built into the software

 
 4-03-2011  Never
12  Functionalities for clinical staff are of limited use. For example: From the list of medical pre-designed documents generated for the patient's electronic record, the index is not clear. Staff have to scroll through an index which has every document in the AHS from across many disciplines. For example, ED staff can choose Botox clinic documents. Staff are required to scroll through hundreds of documents one by one to identify what document they want to use. 

 Built into the software

4-03-2011 Never 
13  Once they have identified the document they want to use such as 'ED discharge summary', there are too many clicks to complete the form, and the process is unnecessarily complicated 

Built into the software

4-03-2011 Never 
14  Before seeing a patient, a staff member goes to the ‘To be seen’ tab, allocates themselves to the patient. The KPI package pops up and staff insert the ‘seen by time’. Ideally it would be good if there was an arrival time default inserted into this time as a prompt for staff. 

Configuration requirement

 
4-03-2011  4-03-2013
15  The Dr sees the patient and then returns to the computer and documents the interview. If they document in FirstNet when they record the patient’s chart they have multiple clicks to open the chart before they can start documenting. 

Built into the software

4-03-2011 Never
16  The Dr can enter a diagnosis via the documentation / diagnosis (chart) or depart process. A diagnosis is nine clicks to enter.  

Built into the software

4-03-2011 Never 
17  A diagnosis is not flagged or seen on the tracking list so other staff need to search through the entire documentation to find it. This is time consuming as it is not possible to identify externally which note from a set of documents contains the diagnosis. 

Configuration requirement

4-03-2011 4-03-2013
18  Dr “seen-time” needs to be on the tracking list (or LOS) since Dr “seen-time” is used  to manage dept case load, and ensure triage categories get a balanced throughput. 

Configuration requirement

4-03-2011 4-03-2013
19  FirstNet does not work well on differentiating practitioners and MOs, because both of them are  assigned patients in the same place. 

Configuration requirement

4-03-2011 4-03-2013
20  Unable to see previous observations - Lose ‘feel’ for patient as everything in silos.  Configuration requirement  4-03-2011 4-03-2013
21 

1. Poor graphical representation - graphing not finite enough to be of use. 

2. FirstNet has 'vital signs' functionality but the trends are not finite enough here the important thing for staff in ED is to see the trend. Successive results cannot be displayed together making it far more difficult to get a trend or sequence of processes. 

Built into software 4-03-2011 Never 
22 
Staff will not search for trends because the system is too slow, making staff reluctant to open charts.
Engineering, Configuration and/or installation problem 4-03-2011  Uncertain
23  No prompts for unusual observations, e.g. diabetic BSL or any form of useful alerts.  Built into the software 4-03-2011 Never 
24  Unnecessarily Difficult to add allergies: Staff think there are too many steps to record allergies and a complex and non-intuitive process. Adding an allergy is a 7 step process. Once the screen is opened it is difficult to work out 'how' to add the allergy. There is no rational flow to the data entry, nor are there prompts to guide the user. Staff are required to be trained or they would take a long time to work out the process.   Built into the software  4-03-2011  Never 
25  The Presentation record is shown in a tiny box with horizontal and vertical scroll bars so reading each record requires continual manipulation of the scroll bars. It should open as a large window that can be readily read without requiring other manipulations. The box to type in the record opens to a size that always needs to be enlarged to avoid the need to use scroll bars.  If it opened just 20% bigger it would be OK!  Configuration Requirement  4-03-2011  04-03-2013 
26  Certain basic information is needed in the top of the screen: MRN, DOB, Address, without needing to move to a separate screen to find the details.  Configuration Requirement  4-03-2011  04-03-2013 
27  Triage can't prioritise patients. The Triage scoring system is not sufficient to prioritise patients and in the past nurses have set priorities so that lower triage patients get some throughput in busy times. NSWHealth introduced a priority column in the Tracking list, but it didn't automatically alter the priorities when a new patient was inserted in the list, that is if a new patient was given priority 1 then all other patients in the list needed to have their priorities manually changed.  Even if this is done the patients order on the tracking screen does not change.   Software Requirement  4-03-2011  Never 
28  Loss of graphing of Vital Signs (compared to EDIS). This is a loss of a fast recognition process. There is complex but rudimentary graphing available but the axes have dynamic scaling so the pattern recognition advantage is loss - you have to check the scales to understand the graph instead of instinctive recognition.  Software Requirement  4-03-2011  Never 
29  Multiple admissions on the one day are not separated into DIFFERENT episodes so staff do treat them as differently and don't use the earlier record to be representative of the most recent record.  Software Requirement  4-03-2011  Never
30 

Keyboard Usage:

1. You cannot use any normal function or short-cut as learnt in the Windows operating system. 

2. The user cannot use control + c and control + v functions with FirstNet. 

3. Use of keyboard short cuts and mouse buttons is not consistent, that is, they can be used in some places and not in others. 

4. When filling out the Discharge Summary pressing ENTER to move to a newline quits the form altogether. To add a newline you must press CTRL ENTER.

5. One of the most frustrating aspects is the deleting of text if you hit the wrong button - this seems to affect the comments section on the tracking screen and free text boxes with documentation e.g. the discharge summary.             

Software Requirement  4-03-2011  Never 
31  The system allows any user to assign a patient to any other user, accidentally or deliberately, without their knowledge. As a result unseen patients can be taken off the waiting list and not be seen by a doctor until the error has been discovered.  Software Processing  4-03-2011  Never 
32  Co-ordination within the system isn’t apparent. For example, a person is discharged and he may have to be re-triaged. But the staff cannot identify that the person has come previously during the same day.  Software requirement  4-03-2011  Never 
33  System does not ensure that staff enter mandatory patient information.  Configuration Requirement  04-03-2011  04-03-2013 
34 

Staff Login Processes:  

1. Using the system causes daily grief where it logs out users too quickly.  If the system logs out automatically, the documents will not be saved, therefore, some important information is lost and has to be re-entered.

2. This especially happens frequently to nursing staff who are interrupted more often.

3. Not all the clinical staff remember to log off the system before they leave the terminal. There is a function on the top of the screen to change users, however, sometimes the clinical staff are be too busy to log in with their own identification. Therefore, all the patient information is identified with the previous person logged in.                                                            

4. Staff may accidentally place a long list of orders on a PC logged in to another user. The system does not allow such orders to be signed off, and orders must be cancelled and reentered under the correct log in. 

Built-in Software 
4-03-2011  Never 
35  Handover:  the handover button is not clear, i.e. it is not easy/intuitive to find. The description of interface is not clear and accurate such as assigned patients, reassign to provider, etc.- (see First Net manual)  Presentation Layer -Configuration requirement  4-03-2011  4-03-2013 
36 

Tracking List:  

1. Ambiguous Use of Symbols in the Tracking List: Icons are used to represent specific tasks but are not removed/overwritten/transformed when their status changes so clinical staff have to look at all the symbols to get an idea of the current status of the patient and to interpret if a task is finished or not, or what state it might be in. e.g. in the case of the two actions which have one icon 'ask for bed' |'bed arranged', the first event symbol should be overridden/eliminated for efficiency and also to save screen 'real estate' as the screen is taken up by symbols that constitute superseded knowledge. 

2. There are too many icons on the tracking list for users to realistically remember the functions behind them. 

3. Icons are gradually being increased as more hospitals come on line and request icons for their own particular functions, and it has made the icon set unusable for many staff.

4. "To Be Seen" Tracking List: On selecting a patient record it is instantly removed from the screen so you can't get to their record without going to another screen. It should not move the entry until some action is taken on the clinical record.

5. After sorting on a column in the Tracking list this can't be switched to sort on another column. 

6. Lack of Aids and Explanations: There are a lot of symbols in FirstNet but there are no tips on the meaning of the symbols shown in the system making learning more difficult for the new staff member. There are lots of icons(bed: Needs a bed. Key:needs full clerical registration . 'Patient Care','Disposition'), but no descriptions of the icons shown in the system, and they are not self explanatory.

Staff have to keep at their side a paper describing the symbols. For example: there are three indicators to represent different allergies and sometimes the functionality will be displayed when users right-click but there is no indicator showing that function exists. Hence staff at times fail to input appropriate data.

Software Requirement                Configuration requirement 

 Configuration requirement

Software Requirement 

 

Software Requirement 

 

Configuration Requirement 

4-03-2011 

 

Various 

37 

Triage:

In FirstNet, there are ~250 categorized presenting problems in the clinical screen. Staff need to match these to one of the 51 Manchester  scores, which determines the triage category.  The Manchester forms are not built into the system therefore, the triage nurse has to select the presenting problem, then manually search the paper copy of the Manchester forms to identify the discriminators (symptoms) and then assign the matching category.  

Configuration Requirement  4-03-2011  4-03-2013 
38  You do not have descriptions of simple diagnoses. When they search for the diagnosis, they may not get the result just because they use different language usage.  Configuration Requirement  4-03-2011  4-03-2013 
39  Nursing staff go to the un-triaged tab, locate a patient and click on the nurse protocol icon, on the form there is no mandatory arrival time for staff to calculate triage benchmarks, so it is too hard to calculate and adjust treatment times. This effects the quality and triage KPIs.   Configuration Requirement  4-03-2011  4-03-2013  
40  Triaging a patient by a staff member - Staff pick a patient off the un-triaged list – this is an issue if two different staff pick up the same patient. Configuration requirement  4-03-2011  4-03-2013  
41 

Clerking:

1. Creating Patient is Time Consuming - There is no way for a patient to be triaged on the system before being clerked first, which is inconvenient as it is time consuming and patients in life-threatening conditions need to be  triaged initially. The clerk has to go through 4 screens (an extensive process) to register a patient. The first screen is a patient search, the second is full registration, the third is return to the tracking screen, and the fourth move is to the triage screen. 

2. If the patient has no MRN in the PAS or the patient does not register in the PAS, it will prompt an error message when operating ‘add encounter’, and then the clerk has to deal with this issue by going to IPM. 

Software requirement  4-03-2011  Never 
42  In the Change NOK Details panel-the only choice is yes but if you click yes details disappear.  Configuration requirement  4-03-2011  4-03-2013  
43 
There are 16 steps for Drs to fast track discharge patients from the system, because there are hundreds of choices from PowerForms mandatory field 'doc type'. 
Software requirement  4-03-2011  Never 
44 

When a patient is moved  to different section of the department, clinicians need to change screens between different areas to track the patient. 

Software requirement  4-03-2011  Never 
45  Redundant functionality, e.g. having to specify twice in different drop down menus that you are doing a discharge summary.  Software requirement  4-03-2011  Never 
46  Alerts on the reason for Delay do not work - no flashing, no alerts, staff have to change the status manually.  Software requirement   4-03-2011   Never 
47  Some reports do not accurately reflect the real data to the extent that some are algorithmically incorrect. Reports are not accurate, that means the reporting mechanism is not accurate. Even if physicians enter correct data into every field, they could not obtain a correct report.  Query Configuration  4-03-2011  4-03-2013 
48  Instructions/recommendations were given that when running FirstNet reports, a maximum period of one month per report per run is allowed as anything more than a month will slow the entire system down.  Software or Operations Requirement  4-03-2011   Never 
49  KPI Degradation: The introduction of FirstNet destroyed the KPIs.  The times for “Dr Seen”  where blown out because it took so much more time to do all the documentation, including the time to get to the right place in FirstNet to enter the data – then the system defaulted to time of data entry not the time the staff actually took with the patient. Trainee staff on an 8-10 week rotation would leave the automatically entered time and not change it to the actual time. There are various screen fields where if the time is set back it doesn’t stay on the corrected time but changes back to default time. In one place it can be changed and it will stick but in other places it won’t.   Software or Operations Requirement  4-03-2011   Never 
50 

Pathology Ordering:

1. Electronic ordering requires many steps, multiple clicks. If you order a number of pathology tests, each order is timed for the moment you complete the order. ( e.g. There may be a minute or two between each entry.)

2. Each part of a pathology order has to be ordered individually and this requires repeat typing of all the patient information into each part even for orders for the same patient ordered at the same timeFor radiology orders there are three mandatory fields for essentially the same information.

3. Doctors are asked to sign and date specimen tubes. If the time written does not agree exactly with the time on the electronic order, the test is not done.

4. If a patient is admitted to the ward or discharged from the Emergency Department, Pathology orders recorded in FirstNet are no longer actioned and are cancelled. 

5. All tests are the responsibility of the orderer. Nurses can order some tests in advance of a doctor seeing a patient but cannot delegate the order to the doctor who subsequently takes the case.  The responsibility of following up the test is transferred by the system to a generic doctor, the name of whom the system insists the nurse must enter at the time the test is ordered. It does this by sending that result to the generic doctors inbox ( and not the treating doctors) for follow-up.

6. Some reports came from another hospital and so where not the patients of this staff member.

7. Order sets could be different for different hospitals but all are shown in the same screens making it more time consuming to use. Local development was invited but a user can’t block anyone else’s order sets so they see everyone else’s, which clutters the user's work. They can’t even have their own order sets as a default hence they have to hunt thru everyone else’s order sets to find their own.

8. Sometimes, the results have been sent to the wrong inbox or get lost. In one case a pt had a test, the director checked for it to come. The Lab could see their result in their system but the director couldn’t see it in the FirstNet so to the observer the result never appeared in the record.  

Software and Operations Requirement  4-03-2011   Never 
51  The key clinical information in the first mandatory field of the pathology and radiology forms is not automatically populated through to subsequent requests.  Configuration Requirement  4-03-2011   4-03-2013 
52 

Radiology Ordering:

1. Staff have been receiving the wrong X-rays. Orders from one hospital are known to have been sent to another hospital.

2. Completing the electronic ordering for x-rays is a problem. There are many steps that seem ridiculous, such as doctors are asked to confirm that male patients are not pregnant.

3. Each area x-rayed requires a separate electronic entry. Like Pathology orders for each entry requires duplicate typing of information.

4. As with Pathology, x-ray orders cannot be actioned if the patient is discharged or admitted to the ward.

Configuration Requirement                                                                                                Software Requirement 4-03-2011   4-03-2013 
53 

Patient Record Retrieval:

1. The Flow Chart retains data from 1000 events. If information is required on a patient prior to this, retrieval of data is difficult.

2. There have been a number of medico-legal cases where efforts to find the patient record have failed.

3. The many different screens are a problem because they offer multiple places and ways to record data. This makes data retrieval difficult. This causes problems with ongoing patient management.

4. When a user clicks on a patient note from the patient's document list to open it for viewing the system frequently and inexplicably opens another document in the patient's list of documents.

5. Accessing very basic information can be complex and non-intuitive. For example locating the GPs phone number requires opening the patient folder, clicking on “patient information”, clicking on “PPR summary”, left clicking to highlight the GPs name, right clicking to display “more info”, then left clicking on “more info” to get the number.

6. Inefficient Access to Progress Notes. FirstNet can only show the clinical notes of the latest episode readily. Staff have to change search criteria to find other episodes or past history. A lot of staff don't know how to change the search criteria because it is unintuitive. This can put patients at risk as clinicians have inadequate past history.

7. Tracking patients after discharge has proven difficult and time consuming. Some clerk  processing has to be carried out after the discharge has been completed and the flow needed to fulfill this work is too complicated.                                               

Software Requirement  4-03-2011   Never 
54  Alerts in the system are not relevant to ED.  Configuration Requirement  4-03-2011   4-03-2013 
55  Duplicate Menu Headings. Two menus have the same name 'Patient' but different content.  Configuration Requirement  4-03-2011   4-03-2013 
56 

Printing: Printing notes produces a hodge-podge order to the notes. There is no sequencing of the notes when they are printed. They need to be in chronological order. 

Software  Requirement  4-03-2011   Never 
57 

SNOMED CT:

1. Lists have many categories of information loaded together, diagnosis, signs, symptoms.

2. There are many nonsensical categories, e.g. "vomiting and wasting disease of piglets".

3. There is no reliable way of dealing with <diagnosis uncertain> or <diagnosis unknown>.   

Configuration Requirement  4-03-2011   4-03-2013 
58 

Training: Different trainers tell the staff different ways to use the system, which leads to inconsistent practice across the ED. This in turn increases the difficulty of using the system as different staff have stored information in different ways. 

Configuration Requirement  4-03-2011   4-03-2013 
59  Already recorded information of waiting patients is lost inexplicably.  Software  Bug  4-03-2011  Never 
60  The fracture clinic needs to plan its work in advance and orders x-rays 4 weeks in advance for returning patients. FirstNet is set up so that whenever an order is past three weeks it is removed from the system. So patient arrives to have an x-ray 4 weeks after their last visit and the order is non-existent. A new order has to be written  and the patient fitted in to the schedule effecting the radiology Departments and the consulting doctors timetable. The consultant complained and after 6 months they were told the problem had been fixed and appointments would be kept for 3 months. However in using the system in its current version the change has actually not been made.  Configuration Requirement   16-03-2011 Various 

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