Integration of information technology

Electronic medications management requires configuration

activities on both the requesting system, EPAS (for electronic
prescription ordering), and the receiving system, i.Pharmacy (for
receipt of electronic transmission through the Health
Information Broker).
A review of Project Manager Reports identified that in April
2015, a decision was still pending on the delivery of EPAS
electronic prescribing functionality for initial operations at the
new RAH.
Certain constraints of EPAS current system functionality have
presented challenges to pharmacy electronic prescribing. These
include barcode scanning functionality for consistent
identification and administration of medication to patients, and
the complexity and effort required to configure matching patient
medication profiles across systems.
SA Health originally advised that there would not be an
electronic prescribing interface from EPAS to i.Pharmacy for
initial operation of the new RAH. As such, prescription orders
appearing in EPAS will require printing and a manual check if
the medication is available in the ward ADC. At the time of this
Report, SA Health had not indicated whether the new RAH
delay will allow this functionality to now be available at initial
operation.
In addition, the project has noted a risk that electronic receipt of
transmission orders may only be available through an additional
i.Pharmacy licence module (electronic prescribing module).
CareFusion has also indicated that profiling in ADCs is not
possible unless an electronic prescribing module is operational.
73

Where the medication is not available from the ward ADC, and
should the CareFusion electronic prescribing module be active,
orders will have to be manually entered into i.Pharmacy, as is
the current process at the existing RAH. These orders require
the medication to be sourced from the in-pharmacy robotics.
At the time of this Report, the electronic prescribing module had
been procured and further analysis was required by the EPAS
Program and the project to develop and integrate the module
with EPAS.
Although SAHealth advised that the project and the EPAS
Program have increased communications to address these
requirements, the two parties only commenced formal meetings
in May 2015.
Risk exposure

There may be added costs of manual workarounds and

inefficiency in the delivery of patient medication.
Pending project decisions in relation to electronic medications
management have the potential to impact the project work plan
and may cause inconsistencies with the pharmacy workflows
being developed.
Recommendations

SA Health should reassess whether the new RAH delay provides

sufficient time to provide electronic medications management
functionality at the hospital’s initial operation. Should this
functionality not be available, any impacts on workflows and
resource allocations should be assessed in the development of
appropriate contingency plans.
The project should continue frequent communication with other
relevant SA Health programs, including the EPAS Program,
with timely consideration of forward planning.
Agency response

SA Health responded that the project maintains frequent

dialogue with EPAS and other SA Health areas with regards to
electronic medications management functionality.
Discussions have commenced regarding the scope of EPAS as a
result of the revised opening date of the new RAH. A formal
decision is yet to be made on the specific matter of electronic
medications management functionality.
The recommendation has been noted by the project with the
clarifications above. The target completion date is April
2016.
12.7.4.2 Electronic patient billing
The new RAH ICT Pharmacy Project Manager’s Report, dated
April 2015, indicated that financial management functions at the
new RAH will be performed through Oracle Corporate System
and the EPAS financial module (Sunrise Financial Manager).
However, the EPAS financial module does not currently have
the functionality to process pharmacy patient billing.
74

At the time of this Report, the project was working with SA

Heath Corporate Finance to identify an appropriate pharmacy
patient billing system for the new RAH. SA Health advised that
a patient billing discussion paper was due to be presented to the
Board.
We consider that this matter relating to the new RAH pharmacy
solution can be at least partially attributed to the delay in timely
activation of the project and SA Health programs operating in a
siloed manner. We also consider there to be insufficient forward
planning and cross-team communication mechanisms.
Risk exposure

Pending project decisions in relation to the billing solution have

the potential to impact the project work plan and may cause
inconsistencies with the pharmacy workflows being developed.
The absence of a fully functional, appropriately tested and
operational pharmacy patient billing system for the new RAH
has the potential to result in loss of patient billing revenue
through inaccurate or incomplete patient billing processes. We
note, however, that this risk is reduced with the additional time
now available to develop a solution.
Recommendations

SA Health should identify any patient billing functionality that

may not be available at initial operation at the new RAH. Any
impacts on workflows and resource allocations should be
assessed in the development of appropriate contingency plans.
The project should continue frequent communication with other
relevant SA Health programs and relevant business units, with
timely consideration of forward planning.
Agency response

SA Health responded that a pharmacy patient billing solution

using the Oracle Corporate System to support current workflows
was proposed and endorsed at the Project Board meeting on 7
September 2015.
The proposed solution is yet to be approved through the SA
Health eHealth governance process and a default position of
implementing the current manual process (as used at all non-
RAH i.Pharmacy sites) will be activated.
The recommendation has been noted by the project with the
clarifications above.
The target completion date is April 2016.
12.7.4.3 Interface solution between the
i.Pharmacy and in-pharmacy robotics

In April 2015 the existing state-wide SA Health standard

pharmacy management system (i.Pharmacy) software was
upgraded from version 5.7 to 6.7.3. This upgrade included
system enhancements required to comply with vendor
requirements and maintain the support agreement.
75

SA Health also intends to implement further software upgrades

to versions 8 and 9 to facilitate communication with multiple in-
pharmacy robots and ensure medication dispensing and stock
control activities at the new RAH. The i.Pharmacy vendor
(CSC), however, has indicated that version 8 will not be
released until 2016.
As a result of the initial new RAH deadline, an interim solution
was deemed necessary to provide the functionality intended by
upgrading to versions 8 and 9. In response, the project and CSC
were working to develop a specifically adapted bespoke solution
to interface i.Pharmacy and APDS (CareFusion Rowa). The
development of this solution requires a contract variation to the
existing i.Pharmacy master agreement with CSC, placing
additional pressure on new RAH implementation time frames.
Installation of this functionality specific to the new RAH
requires an additional state-wide version update (from 6.7.3)
scheduled for February 2016.
Risk exposure

The recent delay in the new RAH opening will provide

additional time for the project. However, any unexpected
delivery and configuration problems with the adapted bespoke
solution has the potential to impact the pharmacy
implementation.
Recommendations

SA Health should reassess its position with regard to the

implementation of the interim bespoke solution. If still required,
priority should be placed on developing this solution and
facilitating, as relevant, the timely finalisation of the contract
variation to the i.Pharmacy master agreement with CSC.
SA Health should identify the medication dispensing and stock
control functionality that may not be available at initial
operation at the new RAH. Any impacts on workflows and
resource allocations should be assessed in developing
appropriate contingency plans.
Agency response
SA Health responded that the revised opening date for the new
RAH has not impacted the delivery date or continued focus on
implementation of the bespoke solution, but has increased
available contingency.
SA Health has already received and is in the process of
installing and validating the bespoke adapter module from CSC
in an SA Health test environment.
The recommendation has been noted by the project and frequent
contact with CSC continues. No additional remediation actions
have been deemed necessary.
The target completion date is April 2016.

The nRAH was visioned with advanced technologies in patient care and
integration of innovative digital platform to reduce time consuming
administrative tasks. The nRAH is the first Australian hospital PPP contract to
specifically require the Project Company to deliver and operate an ICT
integration system in conjunction with the State’s ICT system. (Redwood,
2017) . Hansen Yuncken and Leighton Contractors (HYLC) designing and
constructing and the provisions of facilities management and non-clinical
support services by South Australian Health Partnership (SAHP).

Although a Florey Management model was used as a strategy to execute the

tasks within ICT team where several groups had a specific role within the
project and each group comprised of main and sub contractors. However this
management style was not strictly followed throughout the project cycle. A
strict monitoring mechanism could have been placed to see subcontractors
complying with the arranged management style.

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

With the introduction of EPAS, the paper-based records system would be replaced.
which replaces paper medical records to significantly reduce medication
errors and improve patient safety
The new Royal Adelaide Hospital was designed as a ‘paper-light’ facility but
due to significant problems with the Labor Government’s electronic patient
records system, the hospital remains reliant on paper records,” the
spokesman said.
it is costing the state $192,000 a month to store paper patient records off-site
and deliver thousands to the hospital each day.

With the it integration issue the technical completion was delayed and incorporating
of EPAS has not been achieved.

He cites delays in governance approvals, poor communication between the

software vendor and SA Health, and a lack of an integrated approach between
SA Health's IT unit and SA Pathology as problems.
EPAS program originally Funtctionality and"
The integration between EPLIS and another troubled health IT system,
EPAS (Enterprise Patient Administration System) is also yet to happen,
which has the Auditor-General worried.

SA Health's contingency is the continued use of paper forms should

electronic pathology ordering not be available at the new RAH.

some gaps in understanding the complex system

functionality and data requirements in the build and
configure stage 

The EPLIS business case2 indicates that the primary
objective of the system is to deliver a
SA Pathology is the state‐wide pathology service provider for the public
and private health sector.
‘SA Health Enterprise Pathology Laboratory
Information System (EPLIS) Final Business Case’, Version 1.0, dated 12
May 2015.

statewide laboratory information system to replace the

collection of ageing and disparate systems currently in
use. Many of these systems are at risk of failure. In
addition, due to system limitations the existing systems
cannot be further expanded to support the needs of the
new onsite pathology laboratory at the new RAH.
By replacing these systems with one integrated laboratory
information system, SA Health has the opportunity to
standardise and improve workflow processes across SA
Pathology. If successfully implemented it will also enable
the electronic ordering of pathology through
SA Health’s
Enterprise Patient Administration System (EPAS) and
allow the adoption of future technology advances in
pathology analyser automation. The end result will be
that SA Pathology is better equipped to meet increases in
service demands without increasing its cost drivers.
underestimating the effort required to complete
program activities 

we were advised that the build and configure stage was
sometimes conducted with an insufficient understanding
of the data and how all functional components worked
together. This resulted in some re‐configuration and re‐
testing that has impacted the program schedule.
program responsibilities and methods of engagement
had initially not been formally established between SA
Health IT and SA Pathology for an integrated approach to
the delivery and ongoing support of EPLIS 

lack of project ownership clarity had originally
restricted project communication and assignment of
accountability, responsibilities and decision-making 

initial poor communication and understanding of
the SA Health processes and environment existed between
18
Cerner (software vendor) and eHealth Systems 

software licencing procurement challenges
resulting in a six week program delay to the
implementation of the EPLIS development environment 

Building Design Problem
Eleven stories high and spread across ten hectares, NRAH
hosts 800 beds and 6,000 staff and the hospital sees an
estimated 85,000 inpatients and 400,000 outpatients every
year. Its innovative design uses cutting-edge technology to set
new standards in conservation and environmental
management. Through careful co-ordination and planning,
KONE successfully installed an extensive list of solutions that
helped the hospital meet its ambitious goal of achieving smoot
h people flow. This included no less than 41 elevators,
including helipad lifts and a network of Autonomous Guided
Vehicles (AGVs). The AGVs reliably cover up to 700km a
day delivering up to 500 kilograms of supplies, food and
equipment to different people across multiple stories.

Emails and letters between medical workers and

health bureaucrats show the former Labor
government in South Australia was repeatedly
warned for years before the new $2.4 billion Royal
Adelaide Hospital opened of a flawed design that
would cause ambulance bottlenecks and in-efficient
patient flow.
This is despite SA Health ­insisting there was “no
documentation” about measures to address
potential problems before they arose.
The statement from SA Health came in response to
revelations in The Australian last week that the
state’s flagship hospital will be re­designed just
eight months after it opened on September 4.
READ NEXT


 
 MARGIN CALL
 Intrigue on the

 menu?
 WILL GLASGOW, CHRISTINE LACY
The Marshall Liberal government is assessing the
impact to taxpayers of a new Auditor-­General’s
report that the final cost of the new RAH — once
ranked third on the world’s most ­expensive
buildings list — had ballooned from $2.3bn to
$2.44bn because of project delays and extra costs
for “transition, mod-ifications and contamination
remediation”.
Correspondence between bureau-crats and health
workers, -obtained by The Australian, show that
since at least 2015, the ambulance union had
warned that a ­“direct admission” strategy was
“fanciful”.
Planners imagined most -patients would go directly
to -single-room hospital zones as an alternative to
being admitted via the emergency department.
Top health bureaucrat Jenny Richter, who oversaw
the opening of the hospital, said last year the
emergency department waiting rooms were “small”
by design ­because “some patients won’t even go
through it (ED) ... (and) we expect the flow through
ED to be faster so waiting times will be smaller”.
“The RAH is all single rooms so patients can go
straight to a room without waiting,” she said.
“Because of the design we can implement a more
seamless experience for the patient going from
admission through to discharge.”
The reality has been -chronic overcrowding,
inefficient ­patient flow and constant “bed-block”
and ambulance gridlock.
Nurses forced to triage -patients in the back of
queued -ambulances in the -carpark will vote on
industrial action if the problems are not -resolved
within the next 10 days.
SA Health is consulting staff and -unions before
establishing a “discharge lounge”, despite ignoring
the proposal for years during the design phase of
the hospital.
In a letter to health bureaucrat Todd McEwan in
2015, the -Ambulance Employees Association
raised several concerns about a “design that relies
on -reduced flow through the ED”, noting it was
“fanciful” to assume the “treatment areas are not
going to be full and busy”.
Correspondence to several other top bureaucrats,
including Jayne Dunn and Laura Grelli, showed
union requests to discuss a discharge lounge were
ignored or repeatedly delayed.
In emails sent throughout 2016, union state
secretary Phil Palmer pleaded for health
-bureaucrats to address in planning meetings a
“Discharge Ward at the new RAH”.
“This is a significant issue in the efficient and timely
movement of patients out of hospital — a critical
part of the patient flow process,” Mr Palmer wrote
on June 6, 2016.
“The AEA therefore requests that the issue be
added to the agenda so a report can be given, and
discussion had, about our concern.”
By last August, Mr Palmer could express only
frustration as the concerns were -ignored.
“This is impossible to do if meeting after meeting is
deferred. This is an issue of significant concern and
is pivotal to efficiency in patient flow,” he wrote to
top health bureaucrats, without -receiving a
response.
An SA Health spokeswoman did not directly
address questions from The Australian, but in an
emailed statement said: “We are working closely
with staff and will be consulting with the SA
Ambulance Service and representative bodies to
ensure the proposed discharge lounge will meet the
needs of patients who are to be discharged home
or transferred to other facilities.”

Under a public private partnership (PPP) arrangement, SA

Health Partnership Pty Ltd (Project Co, now known as Celsus)
planned, designed, constructed and financed the facility to
completion, with the exception of State funded works. The SA
Government was responsible for State funded works including
core clinical equipment and certain precinct and utilities
infrastructure works.
Project delays and additional costs for transition,
modifications and contamination remediation resulted in
the project budget increasing by $346.8 million from
$2.094 billion at financial close in June 2011 to $2.441
billion at 30 September 2017. 
Additionally, financing
delay costs of $35.19 paid to Project Co in August 2016
were not included in the project budget and were not
recorded as a cost of the new RAH project. In my view
they should be recorded against the project. 

The State disputes all of these allegations and issued a notice
of dispute in September 2017 and commenced arbitration
proceedings in October 2017 to obtain relief from the
claims. 
In August 2017 the builder initiated legal
proceedings in the Federal Court of Australia against
Project Co, the State and the Independent Certifier for
alleged breaches of contract and other matters relating to
the construction of the new RAH.