Yale’s Epic challenge

In early October, Gary E. Friedlaender, M.D., a specialist in musculoskeletal oncology who chairs the Department of Orthopaedics and Rehabilitation, was in Australia for meetings. Yet even 9,000 miles away from his office in New Haven, Friedlaender could stay in touch with his Yale Medical Group (YMG) practice and access information about his patients, including charts, notes, and X-rays.

“I was able to take out my laptop, receive information, generate orders, and talk to other providers about patient care,” said Friedlaender, the Wayne O. Southwick Professor of Orthopaedics and Rehabilitation and professor of pathology. “Everything I needed was at my fingertips, and I can now connect wherever I happen to be.”

The reason is Epic, a suite of electronic medical record (EMR) applications that is being implemented throughout the Yale New Haven Health System (YNHHS): at Greenwich, Bridgeport, and Yale-New Haven hospitals, as well as at YMG and the Northeast Medical Group (NEMG) community practices.

“Epic will transform the way we teach and practice medicine, both at Yale and around the country and the world,” said Dean Robert J. Alpern, M.D., Ensign Professor of Medicine. “The Epic EMR will help us achieve a higher quality of care than ever before.”

The implementation process began in July 2010 when senior YNHHs, YMG, and School of Medicine administrators met with officials from Epic Systems, a Wisconsin-based software company, to sign a $250 million contract that would transform health care delivery throughout the medical center. The EMR has been in use since October 2011, when Yale Internal Medicine Associates (YIMA) became the first YMG practice to start using the Epic ambulatory application. As of December, 388 providers in 76 practices were up and running on Epic with the numbers increasing each week. Yale-New Haven Hospital (YNHH) is scheduled to go live in early February and the entire rollout will be completed by September 2013.

Orthopaedics went live in March 2012, so Friedlaender can log onto Epic, even from “down under,” and have all the information he needs in one place. “We were drowning in paper,” he admits, “and all too often, we couldn’t find what we needed in a timely way. The Epic EMR corrects all that. It’s indispensable to improving the health care of the future.”

Enough people, from doctors to front-desk professionals, have incorporated the EMR into their workflows to corroborate these assessments. One key observer and present Epic user is David J. Leffell, M.D., deputy dean for clinical affairs, and the David P. Smith Professor of Dermatology and professor of surgery. When the contract was signed, Leffell was YMG’s CEO and played an instrumental role in the selection of Epic. His practice went live with the software in July—but as he and countless others have discovered, the process is easier said than done.

“The implementation was painful,” Leffell admitted. “There’s a steep learning curve. It’s not as customizable as we’d like, and it’s clear that our aspiration for a totally paperless world is not achievable. But even now—this early in the project—the pluses outweigh the minuses.”

Those advantages are considerable. There’s immediate secure electronic access to a patient’s medical history, including vital signs, medications, allergies, lab test results, and X-rays. Then there’s the ease and speed of the EMR system’s interactions with providers and patients alike, along with such “smart” features as warnings about drug interactions and information about treatment protocols. Pharmacies, thanks to an e-prescribing provision, no longer puzzle over a physician’s handwriting, and staffers don’t have to hunt down errant charts. Through MyChart, an application that YNHHs included as part of its Epic implementation, patients can log into their own account to view their records and test results, interact with their providers, schedule appointments, and even pay bills. (More than 7,000 patients had signed up for MyChart by December.) And the wealth of data in the system will provide a mother lode of digital information to find more cost-effective ways to improve care.

As if these reasons aren’t compelling enough, there’s also a financial incentive. Within the American Reinvestment and Recovery Act, the $789 billion federal stimulus legislation of 2009, was a provision called the Health Information Technology for Economic and Clinical Health (HITECH) Act. HITECH makes available up to $20 billion to doctors and hospitals that institute EMRs and demonstrate what federal officials term “meaningful use” of the new technology. These benchmarks include using the EMR for a certain percentage of medication orders, entering demographic information, recording vital signs, noting smoking status, and maintaining an active medication allergy list, among other things. By meeting these requirements, physicians can become eligible to receive up to $44,000 in Medicare money over five years. But to garner the full $44,000 payment, each physician has to be using a certified EMR like Epic and hitting meaningful use targets by no later than this year.

An increasing number of YNHHs providers have done just that, and there is another powerful reason not to wait. Providers who choose to sit on the EMR sidelines or don’t achieve meaningful use by the end of 2015—and don’t qualify for a waiver—will be hit with a noncompliance penalty that amounts to 1 percent of Medicare payments in 2016, to rise to 5 percent in 2020. (There are Medicare penalties for hospitals, but no Medicaid penalties for either providers or hospitals.)

With the federal government encouraging and supporting the use of electronic medical records, it was time for all parts of YNHHs to act. YNHH, which was using separate EMR systems in the inpatient and outpatient clinic areas, was looking for a single integrated system. YMG, which still lived largely in the paper-records universe, wanted to go electronic.

After lengthy reviews and consideration of several candidate systems, a due-diligence committee chose the EMR software developed by Epic Systems, whose product is rated tops in evaluations by independent consultants. The integrated suite of software for both inpatient and ambulatory services is used by around 270 health care organizations worldwide, including Kaiser Permanente, the Cleveland Clinic, and Weill Cornell Physicians. Many academic medical centers, from the University of Wisconsin Hospital and Clinics to Dartmouth-Hitchcock, are also part of the Epic community. When a plethora of implementations currently under way are complete, about 250,000 physicians—one in every four in this country—will be working in an Epic system.

Yale’s “Manhattan Project”

Epic was chosen, and thus began what Leffell called “our equivalent of the Manhattan Project—an incredibly complicated process that exceeds anything we’ve ever attempted by orders of magnitude.”

The entire Epic model system, as the company calls it, consists of 19 separate but fully integrated components, from billing and scheduling modules to inpatient and ambulatory applications. But Epic is not simply plug-and-play software. It has to be built, or “personalized,” to fit the needs of each organization.

Over the summer and fall of 2010, YNHHs hired nearly 200 staffers and sent them to Epic’s campus in Wisconsin for training and certification. Then Team Epic, led by project director Lisa Stump; Steven Schlossberg, M.D., YMG’s chief medical information officer; and Daniel Barchi, chief information officer at the School of Medicine, settled into headquarters in Stratford, Conn., and began working nonstop on what became known as the “collaborative build.” Meeting regularly with a YNHHs Providers Advisory Group and subject matter experts well-versed in every conceivable aspect of the health care system from billing to bed planning, pharmacy consultation to patient care data, the team reviewed all aspects of the software with the people who’d be using it. At various points in the process, it was time for a “stoplight” vote on each part of the proposed Epic workflow. The vote was taken by a show of cards: green for “Okay, this will work for us,” and red for “Let’s stop and think about this.”

There were thousands of votes as everyone involved in the project weighed in and shaped the end result. In addition to creating a system that seemed to meet the workflow needs of its users, the collaborative build had another critical result. It brought people, many of whom had never worked together, out of their silos. “We’re building an EMR, but the true power of the Epic project may lie in helping us to form better teams that will transform our health care culture,” said Edmund F. Funai, M.D., former professor (adjunct) of obstetrics, gynecology, and reproductive sciences, and then a member of the Epic project’s interim leadership committee.

Their efforts were showcased in May 2011 at an event called the Work Flow Walk Through. This preview of the ambulatory application—there was a separate walk-through for the inpatient hospital side—attracted hundreds of future Epic users and left many favorably impressed by the potential power of the system. YIMA, the pioneer practice, prepared to go live that fall.

While Epic team members met with practice representatives and fine-tuned the software, there was hardware to be installed and there were extensive training sessions for everyone who’d be using the application. In addition, before the switch was flipped and the Epic login appeared on computer screens, staffers began what for many is an ongoing effort to abstract pertinent data from paper records and enter the information into a patient’s EMR.

A steep learning curve

The Epic era began on a rainy Wednesday morning, October 19, 2011, at YIMA headquarters on the third floor of the Yale Physicians Building. There were festive balloons, coffee and pastries, and enough Epic systems specialists in place to make the transition smooth and seamless.

It didn’t work out quite that way. As Leffell noted, the learning curve was steep. For example, right after go-live, productivity at YIMA dropped by about 50 percent. This was anticipated and factored into the implementation timetable. But the goal of returning to normal within a month or so eluded many YIMA physicians, nurses, medical assistants, and other staffers, as it would do in other practices.

In part, the decline in productivity was due to the sheer complexity of the software, which allows different ways to accomplish the same task. “As the very first Yale practice to go live, our transition to Epic was a struggle,” said Matthew Ellman, M.D., YIMA’s practice director. “But although some challenges remain a year later, we are now reaping the benefits of immediate and easy access to clinical results, rapid communication among staff and with patients, and the convenience and improved safety of e-prescribing.”

To be sure, working electronically and having to enter data via a keyboard on a computer screen rather than by hand in a notebook (or dictated into a tape recorder) is such a massive change in how a practice does business that slowdowns and snafus are inevitable. But some practices had easier transitions than others. Epic’s debut last March in orthopaedics was certainly not pain-free. “We walked through the fire,” said practice manager Connie Rinaldi. But the flames were more a simmer than a conflagration, and they didn’t burn for long because, Rinaldi continued, “We reached out to other departments to learn what worked, and we decided that we’d find solutions of our own to pass along.”

The strategy was a success, and almost all the providers were able to get back up to 100 percent of their pre-Epic productivity levels within a month. But there was a cost, noted Maureen Carey, R.N., who manages the nursing staff: someone had to enter all the new data that Epic requires, and the process could add as much as 15 minutes to each appointment. The extra work, Rinaldi explained, is being managed by shifting the responsibilities of the existing medical assistants. Sending now-superfluous file cabinets to an off-site storage facility has had an unexpected benefit. “Everyone now has adequate desk space,” she said. Moreover, Rinaldi and Carey expect the extra work to be temporary; as increasing numbers of patient records become part of the Epic system, the time-consuming data entries will no longer be necessary.

And computer makes three

Adding a computer to the doctor-patient encounter has not proven as disruptive as many providers had feared, said orthopaedic surgeon Jonathan Grauer, M.D. ’97, a self-confessed Epic partisan. “Everybody in the beginning was nervous that having to work on a computer while the patient was in the examining room would compromise the quality of the interaction, and it felt a little strange and awkward at first,” Grauer confessed.

But there are ways to blunt the oft-stated worry that the physician is taking care of a computer rather than a person, such as taking notes on paper and then transferring the data into Epic when the office visit is complete. In fact, there’s research about ways to minimize computer intrusiveness; YIMA was able to incorporate such findings into the design of its examination rooms because the practice was moving to new offices in advance of going live. The trick lies in maintaining a triangular setup, with the computer equipment set off to one side so that the monitor doesn’t get in the way of eye contact between doctor and patient.

Dickerman Hollister, M.D., a Greenwich oncologist, may even be taking a cue from sports bars by hanging a large monitor on a wall where everyone in the room can see what’s on the screen. “I can type pretty fast, and I can be on the keyboard and facing patients at the same time,” he said. “They can see what I’m doing and work with me. Epic definitely enhances our communication and better informs my patients about their care.”

The ability of the system to quickly generate office-visit summaries for patients, as well as useful health care information about a particular concern, has helped change doubters into fans. “The presence of a computer in the room is part of the price we pay for the portability of health care information,” said Grauer. “We’re all trying to find ways to deal with it.”

Indeed, there’s no longer any real choice. “EMR use is mandated by federal authorities for everyone who’s in the Medicare and Medicaid arena,” said Friedlaender, “so EMRs are going to be a part of our professional life. The real question we should be asking—and trying to answer—is how do we use them to maximize the quality of care we’re providing?”

There are a number of ways to address this concern: some of them local, others more global. The Epic implementation required everyone involved in the process to take a hard look at workflow. Working in Epic means following the application’s workflow and entering office visit data in a certain predetermined order.

“Epic imposes a discipline on a doctor’s daily activities that’s very beneficial, in both the short and long run,” said Leffell. Using the EMR has already resulted in improvements in such areas as the way calls from patients are received, routed, and acted upon; the thoroughness of documentation; and the turnaround time for notes. “We’re now able to get our notes into everyone’s hands the next day—it used to take a week or two,” said Grauer. “With Epic, the retrievability of all that information is just fantastic.”

Hollister, who logs in from home over morning coffee, explained that the EMR “makes me more efficient. It brings me up to speed before rounds and makes it less likely I’ll get surprised.”

And Friedlaender, besides touting Epic’s ability to provide 24/7 access to complete patient care information, offers perhaps the most compelling reasons of all to make the electronic leap. “Epic reminds us that we’re creating an electronic medical record that belongs to the patient—it’s not a private, inaccessible dossier,” he explained. “And the EMR allows us to keep track of how well we’re doing for our patients. If this transparency is threatening, then the anxiety is well deserved. As providers, we need feedback; and if Epic provides a nudge, so be it. In the end, we’ll be glad we have this powerful tool available to us.” YM

—Bruce Fellman is a writer in North Stonington, Conn.