Can internal medicine coverage crisis be averted in Nanaimo?

Nanaimo – Internists here who, for ethical (“Do no harm”) and safety reasons, refuse the computerized order entry system (CPOE) their 247-bed Nanaimo Regional General Hospital has been piloting for months, have called an emergency meeting of their medical staff association (MSA). It is scheduled for May 31.

Dr. Dave Forrest,

“I think we’re at a crisis point, not just in terms of what happens with IHealth (the EHR) but, frankly, I think the ability to provide cardiology and internal medicine services at NRGH is really in jeopardy,” said MSA president and intensivist, Dr. David Forrest in an interview.

“Internal medicine is a critical service that’s required throughout the hospital so not to have that is going to be catastrophic. But exactly what the staff will do I don’t know at this point.”

Just last February 75% of the attendees at another urgent MSA meeting voted to suspend use of the CPOE and return to paper orders because they shared the concerns now focused on nine internists. But things have become more conflicted since then and, with a senior internist, Dr Paul Mitenko, suspended recently for writing paper orders, many doctors are afraid of being disciplined if they take a stand. Previously it was only nurses who were in this position of not being able to speak out against IHealth for fear of getting disciplined.

The nine internists -— Dr Forrest included — have been locked in a conflict with their health authority, Island Health, for many months:

On one side, doctors who have completely lost faith, not just in the CPOE, but in Island Health’s ability and intention to fix it. (British Columbia’s quality assurance officer, Dr. Doug Cochrane, did an independent review of the EHR last year and released a list of 22 recommendations that included fixes to the CPOE and the closely interwoven pharmacy module — but the internists say glitches that put their patients at risk have not been fixed, and the process for reporting and dealing with errors is ineffective).

On the other side: a health authority that says the CPOE cannot be withdrawn from the hospital’s new electronic way of doing things without collapsing the whole modernized system and reversing all the documented safety and efficiency gains of IHealth. Nobody thinks that’s a desirable goal. Plus there’s the matter of the $174 million dollars invested.

Everything came to a head over call coverage. It’s in the acute areas of care that Nanaimo doctors have been most concerned about the CPOE, not just because these patients are so sick but also acute care involves entering more complicated CPOE order sets into the system — generating and/or encountering more glitches. Doctors in the ICU and ER have been writing paper orders for that reason (for now, they are under the radar). Meanwhile, the nine internists began writing paper orders whilst on call on April 27.

That didn’t last. The system Island Health put in place for processing the internists’ paper orders (using other staff members — and “shadow doctors” recruited from far afield at $1,850/shift — to enter the paper orders into the CPOE) was clearly identified as unsafe. No alternative was offered. Island Health simply announced that paper orders would no longer be processed. Overnight, the nine “paper-based” internists could not take call. They had to get other colleagues to cover them while they consulted their own lawyers and the Canadian Medical Protective Association.

“What the CMPA told us (about our situation) is that we are effectively suspended. Island Health has not made it possible for us to provide on call service,” Dr. Forrest said.

“It’s not that we are not willing. It is that we are not able,” he emphasized.

Since Island Health first refused to process paper orders, on May 11, colleagues have doubled up and covered the paper-based doctors’ call duties. That is clearly not sustainable. According to Dr. Forrest, two of the paper-based internists have just gone on medical leave. One was scheduled to go on call  May 26.

“If you look at the rota for the next two weeks, on six or seven of the days the on-call doctor is one of the paper-based internists,” Dr. Forrest said.

What’s going to happen? That’s a tense guessing game right now. The big unknowns are the shifts currently covered by paper based doctors, with no replacement on record, Friday and on through the weekend. Four shifts altogether. Outside recruits are not so keen to cover shifts in Nanaimo as they were a couple of weeks ago, said Dr. Forrest.

Written by Ann Graham Walker on May 26, 2017 for The Medical Post


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