We’ve been live on Epic now for a little over 1 month. Our newly-minted interns started work on June 21st and a flock of new upper-year resident physicians and fellows began July 1st. One of the most enjoyable aspects of practice at UCSF is the phenomenal quality of students and trainees we attract, and as hoped, our new trainees have taken to the EHR and computerized provider order entry especially smoothly. In some respects they are more comfortable with the workflows than the senior trainees who directly supervise them because the new arrivals have no prior expectations from how things at UCSF used to work. We also have the advantage that something like one-third of our new trainees come from a hospital system that was itself an Epic customer.
Total call volume to our “provider” (physician, NP, and PA) and general help desks, starting with the go-live date.
The interaction between Epic CPOE and our lab and radiology systems continue to have some challenging wrinkles. Epic offers an integrated laboratory system called “Beaker” and a radiology system called “Radiant”. (Epic likes to give cute names to its software components) For reasons of project scope among others, we chose to stay with Sunquest and IDX/Rad for lab and radiology (respectively) for the time being. Although these are each leading systems and widely used elsewhere, the workflow integration between Epic and these ‘outside’ systems remains a work in progress in edge-case scenarios.
The only workflow to date we’ve backed out of is using Epic to satisfy the CMS requirement for an attending physician to document their face-to-face evaluation of an inpatient to qualify them for home care. We built this in Epic as an ‘order’ with all the required elements, and the Case Manager could tee this up (‘pend’ it in Epic jargon) for the attending’s review and signature. For reasons of workflow and the competition for attention, we’ve backed off on having this be electronic for now and reverted to the paper form.
We’ve been live on Epic in inpatient now for two weeks and we’re cautiously very happy with our results. Direct entry of orders by physicians is stable at just over 90%, with the balance being orders written on paper in settings we planned for (chemotherapy and pediatric TPN) and verbal or telephone orders. We’re digging in to our live data on verbal and telephone orders to see how they cluster and how we can continue to reduce them. Revenues remain within the margin of variation, and our near-term clinical metrics (door-to-floor, average length of stay, etc) are unchanged to slightly improved. The very interesting clinical outcomes, like rates of medication error or risk-adjusted mortality, await more data.
Our knottiest workflows in the system are what Epic calls (a little strangely) “Hospital Outpatient Departments”. These are facilities that serve both inpatients and outpatients, like interventional radiology and the endoscopy suite, and so require a mix of inpatient and outpatient workflow and software. If the patient needs full anesthesia for the procedure, as is often the case with child patients, you have a triple-intersection of complexity. In our paper-based prior existence this was all smoothed over by smart people with lots of institutional knowledge and the right relationships. They knew how to get anything done. In preparing for an integrated EHR we put a great deal of effort in to analyzing this work prospectively, but the magnitude of change brought by automation has had unintended effects. No surprise, and we’re crunching through all those processes again with the benefit of experiencing the system in real life, and the problems continue to look solvable.
Meanwhile our clinicians continue to ask deeper and more interesting questions about the system, moving from “How do I get my job done?”, to “How do I manage this complex discharge?”, and on to “Our Division wants to start publishing custom packages of SmartLinks and we want to send people to Wisconsin. Whom do we talk to?”
Still in its early stages at UCSF, one week old as of today, is inpatient documentation centered heavily around the Problem List. This has been used by some providers in the ambulatory setting over the last year, but is now being used nearly universally on hospitalized patients. Rather than writing an assessment and plan as free text at the bottom of an admission, progress, or consult note, each relevant item on the hospital Problem List will now have a unique assessment and plan note written specifically about that item.
This has several potential beneficial effects:
1) Sharpening a physician’s diagnostic thinking.
2) Improved continuity-of-care and ability to review a patient’s chart. Currently, if a patient named Bob has COPD and you want to find out what has been done over the last ten years for his COPD, you have to sift back through every old note in the chart, looking for the ones where COPD was discussed. Very time-consuming. With the Problem List approach, Epic allows you to “View All Notes” for any given item on the Problem List. This means that with a single click, you can conjure up every assessment and plan note written specifically about Bob’s COPD, whether from the ED, ambulatory clinic, or inpatient setting, going back through time.
We think this is a very powerful tool and are excited to see it begin to improve care.
Its our 7th day live on Epic in our inpatient areas, and at 1522 we lost commercial power. The rumor so far is that PG&E has had a substation go down and power is out for several blocks at least. Our clinical areas are equipped with multiple layers of emergency power and are fine, as is our phone bank for supporting clinicians, but here at the Command Center in UC Hall we’re in the dark for now.
Update – the word on Twitter is that power is out all the way to 19th Avenue (we are at 3rd Avenue) with 11,000 customers blacked out.
We’re five days in to our go-live and continuing to maintain all our expected workflows on the system. Our CPOE rate hit 90% today, the balance being orders written on paper for expected reasons (Pediatric TPN and Chemotherapy) and telephone or verbal orders. Our ED door-to-floor time is about expected, neither better (yet) nor measurably worse. Revenues are within the margin of variation.
Below are the trouble tickets called in to our service desk broken out by category. As anticipated the large majority of issues are users whose security is not set up perfectly for their role. Security settings in Epic are very customizable and, it has to be said, enormously complicated. When I took the Epic security class in Madison it reminded me of the nephron.
Next in the stack is “optimization” which for now doesn’t count as trouble, and third on the list is printing. With the incredibly powerful things we can do with technology, like order and document extracorporal membrane oxygenation on a premature infant clinging to life, I find it remarkable that printers everywhere continue to be such a pain. No amount of rigor and testing (and we did a lot of testing) here or elsewhere can seem to entirely decomplexify them.
More power than the early 20th century had planned for.
We’re now 96 hours live on the system with two weekend days and two weekdays under our belt.
From the beginning we made CPOE mandatory with the exception of chemotherapy protocols and pediatric TPN. We had 1669 calls to the support line on the first weekday (Monday) and 677 Tuesday. We’ve had 4,167 concurrent staff members in the system at its peak to date, including clinical and non-clinical users, and 16,446 orders entered electronically in Apex (Epic) in the last 24 hours.
We took over two large office suites on the campus for the support effort. One houses the service desk that receives calls, the other is the “Command Center” for the applications team. Both these groups are in UC Hall, built in 1917 and the oldest building on UCSF’s Parnassus Campus. Our facilities department had to wire in an auxiliary power distribution panel to accommodate the electrical load. We also have two support resource rooms for drop-in help and training, one inside the cafeteria and once just adjacent to it.
Before flipping the switch and releasing a live system into the wild, you build and rebuild, meet and discuss, plan and prepare, train and cajole. You think you have a good idea of how your end users will interact with the system. Then you go live. And thousands of people start using the system. Those people provide more eyes, ears, and brains in front of the system, trying to get their daily jobs done. Just as water cuts its own path through sand and stone, cleverly, but purposefully meandering towards a final destination, so do the users. They are endlessly creative, figuring out ways to use the system that often could not have been anticipated and that are often ingenious. In a system that is both as deep and broad as Epic, there truly are many ways to do any one thing. So, it is often worth sitting back and watching what people figure out for themselves before jumping in to try to teach them “the right way” to do something, because hey, we might learn a better way.
Our medical informatics group likes baseball metaphors, and we’ve described the Monday just past as the home opener. Our ambulatory practices were in full swing using Apex (Epic) for registration and billing for the first time. With a large influx of new administrative users to the system we’ve had an uptick in users needing changes to their security setup, but worked through that volume during the day and evening. The spike in call volume around mid-morning briefly stressed parts of our voice telecom system (of all things). On the clinical side, the first full day using Apex for anesthesia and OR operations went remarkably smoothly; more later on the extraordinary efforts of Dr David Robinowitz and many others to implement this newer module of Epic at UCSF.
On the inpatient side, we’re refining aspects of the discharge process and the collaboration between physicians and case managers. Fewer than half the patients hospitalized at UCSF receive their primary care here, so we work hard to bridge the gap between our inpatient and specialty services and the care patients receive in their own communities. We plan to implement CareEverywhere, Epic’s health information exchange, which will go part of the way toward tightening those connections electronically.