Epic: Changing the Way Medicine is Practiced

Now that Epic, Yale’s electronic medical record (EMR) system, is in place across the entire Yale New Haven Health System, clinicians and patients are reaping the benefits of a single database poised to transform both clinical care and research.

On the clinical side, Epic’s seamless flow of data enables collaboration among physicians; facilitates communication between providers and patients; improves access to health information; and helps to standardize care. From the research standpoint, having a wealth of data in one place represents a potential that investigators are just beginning to explore. While the system is refined and updated continuously, clinicians are becoming increasingly comfortable using it. “There was a steep learning curve, but we wouldn’t want to go back to the way things were,” said Allen Hsiao, M.D., associate chief medical information officer for Yale New Haven Health System (YNHHS), and associate professor of pediatrics (emergency medicine) and of emergency medicine. “We’ve all gotten used to having a better understanding of our patients and their illnesses as a whole because of all the information we have available to us now. Having ambulatory, inpatient, emergency department, and operating room information all in one place has dramatically changed the way we practice medicine for the better.”

The Big Bang

Yale’s implementation of Epic—completed under budget and on time—is nationally recognized for its efficiency and is serving as a model for other institutions. Over the span of three years, Epic has been implemented at Yale-New Haven Hospital; Greenwich Hospital; Bridgeport Hospital; the Yale Medical Group (YMG); Northeast Medical Group; and Yale Health, the health plan for Yale employees and students. There are currently over 1,200 physicians using Epic in their offices and more than three million patients enrolled in the system. “We moved quickly, but always with an eye toward patient safety and the care we provide,” said Lisa Stump, VP, associate chief information officer for YNHHS, who served as project director for the Epic implementation.

Yale chose a “big bang” approach to implementing Epic, bringing the entire system—comprising clinical care, scheduling, and billing—live simultaneously at each site. “That makes it a much more robust experience for the end user, and the users get the benefit of seeing an integrated record,” said Lisa Edwards, director of clinical applications for YNHHS. Rather than getting bogged down in perfecting each element, Yale took a broad approach in soliciting input from all stakeholders and user groups, following a clear plan that included standards for building and testing as well as adhering to a strict timeframe. Physicians from across the health system collaborated to create standardized protocols, using their collective experience to create a single source of content. As a result of careful planning, the collaborative build phase, in which decisions were made on ways to customize Epic for Yale’s needs, was completed in just six weeks for the ambulatory application and 12 weeks for the inpatient and revenue cycle applications. Every time a site went live, the Epic team immediately addressed problems, allowing the team members to devise solutions and improve each successive go-live. For example, when the first YMG practice went live in October 2011, there were more than 250 trouble tickets for issues that needed fixing; when the last YMG practice went live in November 2013, there were only three.

Improved Communication, Information, and Efficiency

Comprised of 19 modules that have been fully integrated and customized for Yale, Epic is seamless from the user’s perspective. It provides a wealth of information that was previously either inaccessible or cumbersome to access. “Before, whatever the patient didn’t know firsthand was a black box to us, which is magnified if the patient is unconscious or has altered mental status,” said Hsiao. “Now we can draw on the expertise of all of our colleagues in Epic—their notes, conclusions, diagnoses—as well as the information in the patient’s record.” This integration helps physicians keep better track of patients from visit to visit. “You can open the chart in multiple locations and see what all the providers have contributed, so it’s really become the patient’s chart,” said Ada Fenick, M.D., assistant professor of pediatrics (general pediatrics). “You see a more holistic view of the patient.”

For Christian Pettker, M.D., associate professor of obstetrics, gynecology, and reproductive sciences, having access to information from different sites has been useful. He and his colleagues can now access electronic fetal heart rate monitoring from any location through a link in Epic. “It’s very helpful for us to get advice from each other or to review charts for quality assurance. That’s been very powerful for us,” he said.

Epic promotes collaboration among physicians by allowing them to connect easily with one another—an advantage in caring for patients and managing work flow. Its robust messaging system allows asynchronous communication and immediate access to information that avoids the hassles and delays of the past. Epic also allows providers to identify specialists quickly, even down to expertise in a particular area.

Epic was touted as a way to improve efficiency and it delivers on this promise, once the data have been entered and providers have learned how to use the system. Jonathan Grauer, M.D., associate professor of orthopaedics and rehabilitation and of pediatrics, is impressed by the time Epic saves in patient reporting and communication. “Yesterday, by the end of the day I had read the radiologist’s report for almost every one of the X-rays I had taken; I had dictated all my notes, signed off on them, and probably three-quarters of them were finalized and sent to everybody. That used to take weeks and now it’s hours.”

Ongoing Improvements

The Epic implementation at the end of January at Yale Health marks the completion of the installation; however, the project is ongoing. “We need to continue to invest time and energy making it work better and even more efficiently,” said Daniel Barchi, chief information officer of YNHHS. “The work will go on for years because this is a tool we would like to use for the next 15 or 20 years based on our investment."

Optimization is being handled through a multi-pronged approach. Enhancement requests can be submitted through the Epic portal for review by experienced clinical support staff members, who are available to help providers when problems arise. Advanced-level training is also available both in the classroom and in the clinic. Epic training experts and analysts are scheduling site visits to each of more than 100 YMG practices to observe the physicians’ work flows to determine whether there are efficiencies to be gained. Although this process will take time, providers won’t have to wait long to benefit from lessons learned along the way; this information will be integrated into the system and disseminated to providers so that everyone benefits.

“Epic can be improved and we will improve it, for instance to decrease the number of clicks for physicians, but it’s going to take some time,” said Hsiao. In the meantime, Yale is installing a new version of Epic—an onerous process due to the content and customized information contained in the system. Many improvements requested by Yale will be addressed. For example, since Epic wasn’t designed to document academic workflow, the last person who signed the note was identified as the author. In the new version, both the trainee’s and attending’s names will appear and it will be clear who is the authority. Other academic medical centers will benefit from these changes, and as more of them come online with the system, they will join Yale in guiding Epic on needed functionality.

“The EMR and its tools are dynamic,” said Stump. “What often sounds like a negative—you mean I have to keep working on this forever?—is really the positive of having a flexible set of tools that allows us to adapt to changing needs of patients and the way we deliver care.”

As Yale continues to improve Epic, it will be able to broaden its capabilities across the entire continuum of care. For example, Yale is a beta site for Retrieve Form for Data Capture (RFD) and is working with Epic and Forte, the company responsible for Yale’s clinical research management system, to support data transfer directly into case report forms. Yale will also implement Epic’s electronic ICU tool which allows intensivists to monitor ICU patients 24/7. A central location with information displays of clinical parameters will allow physicians to assess the patient’s condition and communicate with nurses.

Now that the system has been deployed throughout the Yale New Haven Health System, the focus can shift to quality improvement. “We now have the ability to leverage all the tools we have in place to help drive and support these programs,” said Edwards. “This is a really exciting time.”