UHWI’s digital pains
Hospital records system still not fully operational years past deadline despite $500m+ spend
After more than half a billion dollars in expenses and four years past its deadline, there’s no end in sight for a project to transform the University Hospital of the West Indies (UHWI) into a paperless institution, a Sunday Gleaner investigation has found.
And almost six years after signing the contract on behalf of the region’s premier medical facility, the Mona Campus of The University of the West Indies (UWI) is also unable to say whether procurement was properly done.
No one is also able to speak on the due diligence done before the project started.
In the meantime, health workers and hospitalised patients at the teaching institution continue to depend on paper dockets in key areas, fearful of worst outcomes.
The development comes as Health and Wellness Minister Dr Christopher Tufton announced last month that a committee was formed to oversee the Government’s $1.2 billion investment in a digitised integrated health information system for the country.
The UHWI was supposed to be the local model for the web-based Hospital Information Management System (HIMS) developed by Indian company Suvarna Technosoft.
On September 8, 2015, the UWI, Mona, through its then principal, Professor Archibald McDonald, signed a contract with St Lucia-incorporated Health Administration Systems (HAS) for the HIMS purchase and subsequent implementation at the UHWI.
Under the contract, the implementation would be done by the Douglas Halsall-led Advanced Integrated Systems (AIS), which has a stake in Suvarna.
All major project costs are covered by the struggling UWI Mona.
These include the one-time payment of US$1.25 million (J$143 million) for the HIMS licence and an annual maintenance fee of US$600,000, the two costs declared by The UWI – about J$540 million so far.
A copy of the signed contract shows that the standard licensing fee at US$4m with US$3 million expected to come from AIS for contribution to UWI hospital building fund (US$2 million) and US$1 million as contribution to implementation costs.
REDUCED MAINTENANCE FEE
The document suggests that the original maintenance fee was US$880,000, but was reduced following a discount for the hospital being the first HIMS Caribbean site.
There’s also an optional cost of US$15,000 for hosting the application.
What was supposed to take nine months to a year is now four years overdue with serious concerns stalking the leadership corridors at both the UHWI and The UWI.
A recent experience involving a staff and a patient has heightened frustrations over the system expected to herald in the needed digitisation of the hospital records and workflows.
“My mother has a chronic condition and has been going to the hospital for years. To my disbelief, at a visit a few months ago, the clinician could not bring up the details from the last visit. Older visits were coming up. He said this happened from time to time. I had to help with providing details. Otherwise, outdated information could have influenced the prescription,” explained the relative of a patient.
Visits to the hospital since January showed a heavy reliance on paper dockets in areas such as the accident and emergency and wards.
One doctor confirmed that she and other colleagues print out the records to “protect” themselves.
Some of those concerns find legitimacy in a scathing 2018 project status report done by Dr Patrick Anglin, the then project manager, who revealed that at the outset, “the application was not fit for purpose” and “massive customisations” had to be done.
Two instances were cited where local experts had to be called in to design electronic medical records for the doctor and nurses’ desk because Suvarna’s was “totally unfit for purpose”.
Anglin complained that the software was sold as a “fairly mature product which would only require ‘turn-key’ implementation over a 6-9 month period”.
In some instances, it was clear that some of the components were “not even available” although AIS/Suvarna said they were, noted the 29-page report obtained by The Sunday Gleaner.
Up to the April 4, 2018 date of the report, Anglin said there was “serious doubt” about the readiness of HIMS components for the UHWI’s emergency room, in-patient facilities (wards), radiology and lab information management systems.
Anglin also said an assertion from the HIMS suppliers and project team that the application met international standards was “patently untrue”.
NO INFORMATION AFTER MULTIPLE REQUESTS
“No information on these international standards and best practices used to create the application were forthcoming, even after multiple and sustained requests,” he said.
Privacy concerns, the relegation of the clinical staff to performing administrative duties and lack of application manuals were among the other problems.
The status report cited two explanations given for the absence of manuals – that in India “they do not use written documentation”, and the second, after some insistence, that the documentation was in Hindi and had to be translated to English.
“This is a serious ‘red flag’ and is more worrying since this application has not been implemented outside India,” the report said, warning that the hospital’s training unit could not take control of the system which created a dependency on AIS.
On privacy, the assessment said the HIMS did not impose restrictions required by some hospital areas and would require “massive customisations”. Password complexities for login were reportedly similar for most functions.
“At times, it feels like the application is still being developed and that the HIMS team is part of the development effort,” Anglin concluded.
But despite running beyond its deadline, being over budget and fraught with software and organisational issues, Anglin said the project could be rescued with “urgent” attention to accountability, the provision of manuals and for AIS/Suvarna to be “honest enough to provide credible timelines and state upfront when components are not present”.
Anglin’s report did not only speak to problems with the HIMS software, but also with staff, whose commitment he questioned, citing poor attendance at project meetings and the “indifference” with which UHWI employees treat HIMS team.
James Moss-Solomon, who chaired the UHWI board (March 2016 - March 2019), amplified some of Anglin’s findings, although declaring that he felt the HIMS was a “good system”.
Up to his departure, he said he was not satisfied with the project because of the delays, many modifications and resistance from staff “because it keeps a record of everything”.
“It’s how much due diligence was done,” he said, noting that the project added significant strain on the UHWI’s expenses to improve infrastructure such as the power supply system that has been around since the 1950s.
“It was far enough advanced that it had to be made to work,” said Moss-Solomon, adding that the costs overruns were “significant” and so bad that sometimes the hospital was late in making payments because of cash-flow problems.
In some ways, the former chairman said, the HIMS project was “bleeding” the hospital.
“There was more than one time I had to overstep my bounds and ask UWI if they were not going to make the funds available to the contractors whose bills were overdue.”
But Mona, he said, also reported having cash-flow problems in meeting its contractual obligations.
Up to March, The UWI was running a $1-billion deficit, amplifying the findings of a 2020 governance report which said the financial viability of the institution was threatened.
The money problems have been particularly acute at the Mona Campus, which is carrying 60 per cent of The UWI’s debt, bringing into question some of the commercial arrangements the campus has entered into over the last decade.
“Mona is in need of a revolution,” UWI Vice Chancellor Professor Sir Hilary Beckles said in March.
The UHWI redirected all questions about the HIMS to The UWI, Mona.
Among the questions asked of Mona was to confirm that the contract was properly authorised and procured.
The responses were preceded by a statement, which opened with a declaration that the project was not initiated under the current administration headed by Professor Dale Webber.
NO ANSWERS AT THIS TIME
Regarding procurement, approvals and source of funds, Mona said it could not provide any answers at this time because of a review that started under the Webber administration in 2019.
The review covers the Mona Health Services, the subsidiary of the university through which the contract was executed.
Webber took office August 1, 2018, replacing McDonald, who retired after five years in the top post. Before that, he served as Dean of the Faculty of the Medical Sciences.
McDonald is now the deputy chairman of the UHWI board and the lead chairman of the Cornwall Regional Hospital’s Independent Oversight Committee.
Although not giving a deadline, Mona said its Finance and General Purposes Committee is leading the evaluation, which involves consultations with key personnel, review of contracts entered into by its subsidiary companies, their financial performance, as well as governance arrangements.
Mona confirmed that the HIMS implementation was incomplete, with work outstanding on all wards except those being used for COVID-19 and some clinics for outpatients.
The application has been rolled out in areas such as registration, billings and collection, emergency medicine and some clinics.
It also confirmed that the initial deadline was April 2017, which it said “appeared feasible” because of the anticipation that UHWI would have just “adopt many of the practices and workflows that the HIMS represented”.
That supported Anglin’s view that an easy implementation was touted.
“However, it became evident that among other things, the complexities and uniqueness of the environment at the UHWI would require far more customisation than was anticipated. It is the extent of customisation effort that has caused scope shift, and timeline revisions that have inevitably led to delays,” the university explained, again raising questions about the procurement process.
UWI, Mona could also not say when the project will finally come to an end. “The project is currently under review and as part of that process we are reviewing the projected timelines.”
McDonald is dismissing concerns that proper due diligence, to ensure the success of the implementation and at the least cost, may not have been done.
“This kind of nonsense is really troubling. What do you mean if due diligence was done?” he said. “It had nothing to do with me. This thing was properly investigated, the suitability.”
Asked further why the significant customisations and the years in delay, McDonald said: “I can’t answer that. That has to be addressed to the people doing the implementation.”
Halsall, whose company, AIS, is driving the implementation, has declined to answer questions.
“We regret that we will not be in a position to respond because of non-disclosure agreement with our client,” said Shekar Reddy, the director of health applications.
The Sunday Gleaner has not received any response to emails sent to Suvarna.
Suvarna was incorporated in India in 2003 and offers a range of software solutions in healthcare. Its HIMS is said to be implemented in over 100 hospitals in India.