Thank you to everyone who joined me for grand rounds at Seton Hospital this morning. Posted here are the slides from my talk, “Social Media and Your Practice, Ready or Not”. Happy socializing —
On September 1st UCSF Medical Center turned on electronic health information exchange with our Epic electronic health record. It’s an important step forward and one of the features of electronic health records I’m most enthusiastic about. It has the power to improve health not just at our own institution but wherever our patients go. We had hoped to enable this as part of our June 2nd inpatient big-bang go-live, but decided to wait 90 days to make sure some final details were fully hammered out.
Epic has two levels of electronic health information exchange, “CareEverywhere” for exchanging information between Epic customers, and “CareElsewhere” for more limited exchange with a non-Epic EHR. For now we’ve turned on CareEverywhere, connecting us with participating northern California providers like UC Davis, Stanford, and Palo Alto Medical Foundation, although there’s no geographic limit within the United States for where records can be shared. (With their particular sense of humor, Epic presented this week at their annual meeting on the future “Intergalactic” sharing of health records, emphasizing the point with photos of the Curiosity Rover and The Netherlands) Our first exchange was at 10am on the 1st when we electronically received records for an ill youth hospitalized at UCSF who had previously received care at Stanford, and we had a dozen exchanges in the first 7 days.
Like always, we only share health information between institutions after getting written permission from our patient. The large majority of patients want their health information shared electronically with other physicians and hospitals when we need it to provide safe and appropriate care, as long as we are sharing securely. In my experience, my patients are surprised to learn even major hospitals have largely remained isolated islands of information. When I collect permission from a patient to obtain their records from a hospital across town, patients are usually surprised and discomforted to learn I didn’t have access to it already. Health care is far behind other industries in this kind of information integration, and fixing this in a hurry is a centerpiece of the federal government’s standards for health IT implementation.
For the last few decades health records have been shared primarily by telephone and fax. We call the primary physician’s office (for example) and if we actually reach the physician immediately, we usually get their best recollection of the patient off the top of their head, followed by more complete information by fax hours or days later if at all. If the patient was recently hospitalized, getting that hospital record requires work from that hospital’s medical records department, seldom a 24/7 operation, and it arrives as a thick, grainy, often disordered, fax-of-a-copy-of-a-scan of the original record. This helps, but the information has to be manually transcribed in to our own record, which is only as accurate and complete as any 10-fingered process.
With electronic health information exchange, sharing patient records is more secure and more accurate. The electronic point-to-point connection between institutions is encrypted and the identity of the patient is confirmed electronically between the EHRs. The patient’s health information arrives immediately in our EHR instead of on the tray of a fax machine some unknown number of hours later. A physician on our receiving end reads and validates the electronically exchanged information before incorporating it in to our own record. The exchange is at the level of data instead of pieces of paper, and so discrete information like medication lists, drug allergies, problem lists, and other pieces of history can be synchronized between the institutions.
Unfortunately we’re still not able to exchange information with San Francisco General Hospital or Kaiser Northern California, two providers with whom we share many patients. Kaiser Northern California has been on Epic for years, but does not to participate in electronic health information exchange. San Francisco General is moving fast on implementing its own electronic health record, and we look forward to connecting with them when the capability on both sides is ready.
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.
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.
The next piece of functionality we aim to turn on is health information exchange. Epic calls this “CareEverywere” for data-level exchange between Epic customers and “CareElsewhere” for the exchange of CCD documents with non-Epic EHRs. Once we throw the switch on CareEverywhere we’ll be able to exchange data with other Epic customers, including our fellow University of California Medical Centers in Sacramento (UC Davis), Los Angeles, and San Diego, and with our respected colleague-competitors at Stanford. Health information exchange will be a signature advance in our service to the community, but at first the clinical impact will be modest because we share relatively few patients with these sites. Of the main regional health care systems, we share the most patients with Kaiser-Permanente, San Francisco General Hospital, and the City-operated Department of Public Health clinics. However, although Kaiser-Permanente is also an Epic customer and participated in health information exchange in Colorado, their northern California region opts against health information exchange outside the Kaiser system. San Francisco General Hospital and the DPH clinics are underway with their own (non-Epic) EHR projects, and I hope to see us sharing CCD documents with them once the technical ability on both sides is in place.
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.