A A

The Nova Scotia Health Authority’s incoming top man has a resume coloured by controversy.

Dr. Brendan Carr, who will become the NSHA’s new CEO and president on Dec. 16, filled the same roles at Vancouver Island Health during the 2016-17 failed rollout of a multimillion-dollar computerized health record system.

That’s relevant, given Nova Scotia is expected to soon embark on its own controversial electronic health record mega-project – called One Person, One Record (OPOR) — worth a half-billion dollars or more, depending on who you ask.

Two U.S.-based companies, Cerner and Allscripts, were qualified in June 2017 to be final bidders for the OPOR contract.

So, what happened in B.C.?

Carr, a Dalhousie grad, left his role as vice president medicine at Nova Scotia’s Capital Health in 2012 to become executive vice president and chief medical officer at Vancouver Island Health. In August 2013, he became that organization’s CEO and president.

Problems arise

Two-and-a-half years later, in March 2016, Island Health introduced an $173.5-million electronic health care records system called iHealth (Its familiar-sounding vision: One Person, One Record, One Plan for Health and Care) at Nanaimo Regional General Hospital and two nearby smaller facilities. It was to be the first step of iHealth’s eventual rollout across Vancouver Island.

Problems surfaced almost immediately. Doctors at the Nanaimo hospital warned some medication orders and physician instructions were being altered, or even arbitrarily cancelled, by the Cerner-supplied software. By May, frontline physicians in the emergency and intensive-care departments had gone back to pen and paper, calling the system — which they refused to use — “fundamentally flawed and unsafe.” Other departments threatened to follow suit.

Island Health’s management paused the broader rollout to address complaints but rejected the hospital medical staff association’s request to halt iHealth’s use.

Carr told reporters he agreed there were concerns, but insisted the issue was a lack of resources for staff, not the software.

But doctors’ complaints continued, including that the system had decreased productivity, such as forcing delays in surgeries.

By July, then Liberal health minister Terry Lake stepped in and asked Dr. Doug Cochrane, B.C.’s patient safety and quality officer, to do an immediate third-party review of iHealth.

Review backs doctors

Cochrane agreed with Nanaimo’s doctors, his November report finding the new system had indeed increased the risk of errors and decreased productivity. His 26 recommendations included correcting errors, simplifying the software interface and encouraging more collaboration with frontline health-care workers.

Cochrane suggested iHealth could continue to be used in Nanaimo but recommended the system’s further rollout be paused until problems were addressed.

Carr, responding to Cochrane’s report, “apologized for the gap that prevented the health authority from hearing the concerns of doctors,” according to The Victoria Times-Colonist on Nov. 17, 2016.

However, the situation did not improve at Nanaimo’s hospital.

In February, 2017, the medical staff association executive again asked that iHealth’s provider order entry system be taken offline while being repaired.

Carr, saying the association’s concerns were being taken seriously, agreed. But management changed its mind in late March, saying it wasn’t technically possible. Island Health instead pledged to work with staff and provide more supports.

Authority, doctors clash

In April, some Nanaimo physicians — saying the software could still “cause dangerous drug dosage errors” — defied the authority and again reverted to pen and paper, The Times-Colonist reported. In response, one doctor was suspended while another faced disciplinary action.

By June, 2017, Dr. Alan Ruddiman, the then president of Doctors of B.C., told CBC “the system in place at this hospital remains absolutely fraught with serious problems ... and this simply cannot continue.”

The disciplinary actions were “totally unconscionable on behalf of the health authority,” he said.

Carr defended the system, saying he “didn’t agree there is greater patient risk at all,” and that most physicians at Nanaimo’s hospital successfully used iHealth, which had flagged thousands of potential drug interactions.

Island Health continued to work on addressing recommendations from the Cochrane report, Carr added.

Carr resigns

Then, in mid-June, Carr suddenly announced he was leaving Island Health to become president and CEO of the William Osler Health System in Ontario, closer to home.

Observers in B.C. speculate an apparent change in government – the NDP was poised to take power in a coalition with the Greens after a May general election – and the iHealth mess may have been factors in Carr’s departure.

Late that summer, NDP Health Minister Adrian Dix ordered yet another independent review of the iHealth rollout.

Rollout halted

In December 2017, Ernst & Young reported the project had been mismanaged and was significantly over budget. They recommended iHealth’s rollout be halted until problems addressed by the report’s nine recommendations had been resolved.

iHealth had not been properly planned or implemented, Ernst & Young said. A majority of doctors and health-care staff at Nanaimo’s hospital doubted they could make the system work, even with help. And although Island Health estimated another $54.1 million, on top of the original $173.5-million budget, would complete the project, the report suggested that was optimistic.

In January 2018, Dix indicated a mediator would be named to lead the rest of iHealth’s rollout across Vancouver Island.

Throughout this time, all parties — including politicians, doctors (even those with complaints about iHealth) and health authority officials — backed the need for electronic health records.

Carr declines interview

The Chronicle Herald reached out to Carr — via staff with the William Osler Health System in Ontario — to ask him about what happened in B.C. and what lessons he took away that might be applicable in Nova Scotia.

Carr declined to be interviewed but a William Osler spokeswoman released a statement (see below) on his behalf. In it, Carr said he couldn’t comment on specific matters but offered an assessment of electronic health record systems.

EHRs can promote patient safety, improve co-ordination among clinicians and provide tools to make their work easier, he said in the statement. Patients can access their health information online.

“EHR implementation is also incredibly complex. Beyond the technical intricacies in implementing these systems, helping busy clinicians — who are working with complex patients — to efficiently and effectively incorporate the EHR into their routines and work flows is extremely important, and can often be challenging,” Carr’s statement said. “This requires a considerable and sustained effort, with a number of stakeholders and through a range of supports, as clinicians’ experiences can vary greatly.”

Confidence in process

Nova Scotians Health Minister Randy Delorey - File

Both Health Minister Randy Delorey and the NSHA’s chairman, asked if they were aware of events on Vancouver Island in 2016-17, expressed — through spokespersons — confidence in Carr’s appointment.

In a statement to the Herald, NSHA board chairman Frank van Schaayk said that while he couldn’t discuss specifics, “I can assure you that there was a thorough and thoughtful search and selection process … Dr. Carr is an accomplished leader with exceptional credentials, qualifications and experience. We have identified the right leader to take our organization into the future.”

We also reached out to various authorities in B.C., including current leadership at Island Health, the Nanaimo hospital’s medical staff association and the minister of health.

Only Island Health chose to comment. The B.C. health authority’s electronic health record system is now “implemented across all of Island Health’s acute, ambulatory, long-term care and mental health services,” said spokeswoman Valerie McKay.

The Nanaimo implementation provided key lessons, including “important advice related to physician engagement, site readiness, and training and education for those who have followed with similar activations,” the health authority said in a statement (read in full below).

Meanwhile, Nova Scotia Department of Health spokeswoman Heather Fairbairn said the OPOR procurement process here continues.

“We are taking a careful and prudent approach to make sure we have a system that meets the health care needs of Nova Scotians and protects their private health information,” Fairbairn said in an email. “As the procurement process is currently ongoing, it would be inappropriate to comment further at this time.”

Dr. Brendan Carr's statement

Dr. Brendan Carr - Contributed

“While I cannot comment on specific situations as I do not yet work for Nova Scotia Health Authority, nor for Island Health, I can provide general thoughts on electronic health record (EHR) systems based on my experiences.

EHRs are valuable in that they enable organizations to improve patient safety, promote better coordination amongst clinicians, and provide useful tools to make it easier for clinicians to do their work — as well as for patients to access their health information online. In addition, EHRs allow clinicians to collect and have timely access to meaningful information that is used in a collaborative way for diagnosing, and in care planning/treatment.

EHR implementation is also incredibly complex. Beyond the technical intricacies in implementing these systems, helping busy clinicians — who are working with complex patients — to efficiently and effectively incorporate the EHR into their routines and work flows is extremely important, and can often be challenging. This requires a considerable and sustained effort, with a number of stakeholders and through a range of supports, as clinicians’ experiences can vary greatly.”

Statement from NSHA board chair Frank van Schaayk

Frank van Schaayk, chair of the Nova Scotia Health Authority’s board of directors. - File

"While I’m not able to discuss the particulars of a confidential recruitment process, I can assure you that there was a thorough and thoughtful search and selection process. The executive search process was led by a 15-member committee that included a broad range of NSHA board and executive members, physicians and community leaders. The committee unanimously recommended Dr. Carr and the board of directors unanimously supported the recommendation. Dr. Carr is an accomplished leader with exceptional credentials, qualifications and experience. We have identified the right leader to take our organization into the future."

Vancouver Island Health statement

“Electronic Health Records (EHR) support health systems to improve patient safety and decision-making, enhance communication and collaboration among care providers, strengthen continuity of care across teams and sites, and involve patients more directly as a member of the care team. Island Health is pursuing a vision for a single, integrated EHR for all of the services it provides — from primary care, through community and acute care, to long term and end of life care.

EHRs are challenging to implement as they require a significant change in clinical practice and workflow. In our journey of EHR implementation over the past 20 years, Island Health has learned many lessons from those around the world that have proceeded us, and in turn, we have contributed to this knowledge base with our experience from our many First in Canada achievements, but also our more difficult and complex implementations. Our own reflections and reviews undertaken of our implementation of advanced EHR functionality at the Nanaimo Regional General Hospital (NRGH) have provided important advice related to physician engagement, site readiness, and training and education for those who have followed with similar activations since our go-live at NRGH three years ago.

Island Health continues to advance our EHR, with recent efforts focused on automating clinical documentation across Island Health’s community based nursing and allied health services, expanding the implementation of our integrated primary care Electronic Medical Record, and both optimizing and expanding the use of the advanced EHR at our hospital sites, including NRGH.”