An Epic Journey Gets Underway

The School of Medicine and the Yale New Haven Health System join forces to implement an electronic health record that is expected to lead to better care and outcomes.

When Yale School of Medicine (YSM) and the Yale-New Haven Health System (ynhhs) signed a multiyear contract with the Epic Systems Corporation in July to implement an electronic health records (EHR) program, the event marked the beginning of a process that Dean Robert J. Alpern, MD, termed transformational.

“Not only will the availability of an EHR change the practice of medicine, but when it comes to Epic, we will realize greater collaboration between the School of Medicine and the hospital,” said Alpern.

But getting to this point will involve, “an incredibly complicated process” said David J. Leffell, MD, deputy dean for clinical affairs and ceo, Yale Medical Group (YMG). The level of complexity exceeds anything we’ve ever attempted by orders of magnitude.”

An EHR is, in its most basic form, the digital equivalent of a paper chart. This comprehensive collection of information is portable—it can be accessed from a hospital computer or a clinician’s office or smart phone—and it can be searched and shared with patients and other doctors alike. (Community doctors affiliated with the health system will also be able to use Epic.) The EHR can contain everything from a physician’s notes to X-rays to a list of prescriptions—the Epic system will flag potential drug interactions, thereby improving patient safety—and using Epic’s patient portal, patients can see their records, order medications, schedule appointments, and even pay bills. Lost charts and illegible handwriting will become things of the past.

Implementing this system, which is expected to take at least four years and cost more than $250 million, will be aided by the arrival in October of Steven Schlossberg, MD, who will take up the new joint position of chief medical information officer at YSM and Yale-New Haven Hospital. Schlossberg, a urologic reconstructive surgeon, most recently served as the vice president and senior medical director for hospital-based and surgical specialties at the Sentara Medical Group in Norfolk, Va. But perhaps most importantly, he helped shepherd that health care organization’s Epic installation, which began in 2005 and is now being completed in Sentara’s eight hospitals. “It’s a work in progress,” Schlossberg explained, offering an inkling of what’s to come. “It’s always a work in progress.”

But one, Schlossberg added, with a huge payoff. “The Epic implementation helped us learn from each other, improve quality standards and patient care delivery and satisfaction, and deal better with the regulatory environment,” he said.

By the time Schlossberg arrives, Yale’s Epic project, currently directed by an interim leadership committee, will be moving into its beginning phases. According to David Smith, a YMG project consultant and a member of the interim team, the first group of trainees will travel in October to the Epic campus in Verona, Wis. Initially about 30 YMG people—doctors, nurses, information technology professionals, and business office administrators—will receive training on various aspects of the Epic application.

“This is not just an IT project,” said Smith. “Basically, anyone who has a need to interact with the patient or their chart will require a level of training and participation as the project unfolds.”

The stay in Wisconsin typically involves one and a half to three days of hands-on training, after which the trainees return to New Haven with a major project to complete in their specialty. After several weeks of extensive work and study the trainees return to Verona for several days to present their projects for evaluation and to complete an Epic certification exam, if it is required.

Every member of this first group is expected to have completed all training requirements by the end of this winter, said Smith. As training proceeds, work will also be under way in a critical but seemingly arcane area: the creation of an Enterprise Master Patient Identifier, or empi. “This is a key step,” Smith explains. “Currently, each of the organizations in the health system and YMG have a different way of uniquely identifying a patient, but in the near future as an integrated organization, we will need to assign a unique identifier—empi—to every patient that we’ve seen collectively in the past and will see going forward.”

Concurrent with the empi development, teams are figuring out how to find what Smith calls “meaningful and relevant” data in the electronic records that already exist in the hospitals and some of the YMG ambulatory practices. The information must then be converted into a common format that can be linked to the patient’s empi and eventually ported into the central Epic database. “EHRs can give us a handle on the quality and quantity of health care delivery—that’s the Holy Grail,” said Leffell. “The Epic system will help us better integrate clinical practice with clinical research.”

This step involves “significant challenges,” said Smith. “It’s all about standardization.”

To hammer out standard definitions and practices, doctors and lab technicians from each facet of the system will have to meet and agree on, for example, the standard definition of order sets, while their counterparts in various business offices will develop compatible billing procedures. The process will require, said Edmund F. Funai, MD, professor of obstetrics, gynecology, and reproductive sciences, and an interim leadership committee member, “an unprecedented level of collaboration. Physicians, nurses, IT specialists, business professionals, and others from across the system will be working together, most for the first time. We’re building an EHR, but the true power of the Epic project may lie in helping us to form better teams that will transform our health care culture.”

All of the training and teamwork comes together in the first half of next year when a cadre of newly certified experts from Yale and their Epic counterparts will start working on the “collaborative build.” In this part of the process, which Smith expects to take six to nine months to finish, Epic’s software will be configured for the workflow practices established at Yale.

The most obvious end result is an electronic medical chart that will be ready for use in YMG practices by late in 2012. Implementation at the hospitals will take place first at Greenwich, next at Yale-New Haven, and lastly at Bridgeport. The rollout schedule for community affiliates is anticipated to begin concurrently with the rollout to YMG practices.

As the implementation proceeds, Leffell believes the entire Yale health care system can benefit from the experiences, good and bad, of other organizations. In addition, what he calls the “pent-up energy of the faculty” will overcome the quite natural fear of change.

“This isn’t about computers—it’s about work flow and better patient care,” he said. “We’re very excited that it’s about to happen.”