If you travel to a developing country, you might be surprised by the ubiquity of modern – and the lack of legacy – technology. That’s because, as SingularityHub explains … “in developing countries, particularly African ones, millions of people are skipping the technological evolution process, leapfrogging over now-obsolete technologies and going straight to modern fixes.”

As more Canadian healthcare organizations look to undertake major transformation initiatives such as implementing new or updating existing clinical information systems over the next few years, it might not be possible to leapfrog entirely over the well-documented challenges and frustrations that American healthcare organizations have experienced in their longer history with implementing electronic medical and health records systems, but it’s certainly possible to explore and apply some of the lessons they – and our own Canadian “pioneers” – have learned.

On May 28, 2019, at the 2019 eHealth Conference in Toronto, four senior healthcare IT executives (two from Canada and two from the U.S.) shared their experiences implementing the EHR software Epic using a “big bang approach” at various hospitals and healthcare systems as part of a symposium co-sponsored by Gevity Consulting Inc. and Divurgent. (To view the recorded session or clips, click here.)

The four – Dr. Sarah Muttitt, Vice President, Information Management and Technology and CIO at Toronto’s SickKids; Diane Salois-Swallow, until recently the CIO at Richmond Hill, ON’s Mackenzie Health, and now Senior Advisor at the Mackenzie Innovation Institute; Lou Capponi, Vice President and Chief Medical Informatics Officer at Denver, Colo.-based SCL Health; and Dennis Loftus, Senior VP and CIO at Riverside Health System in Virginia – provided a number of extremely valuable insights into the drivers that served as the impetus for their implementations, the approaches and methodology that worked well for them and what they might do differently given the benefit of 20/20 hindsight. As part of this exchange, each outlined how their implementation has contributed to better quality care for their patients and more efficient and effective processes for their organizations.

The following are some of the top takeaways from the discussion.

Key drivers, expectations and benefits

The decision to undertake a major business and clinical transformational initiative, especially in healthcare systems with multiple sites and facility types, is typically driven by a host of unique needs and conditions.

Single, integrated system and the interoperability imperative

Diane Salois-Swallow of Mackenzie Health spoke of how Mackenzie needed to replace an aging health information system and several third-party applications.

Virginia-based Riverside Health System, as well, was grappling with a host of multiple and increasingly unmanageable systems used by the organization’s acute care, ambulatory, emergency and long-term care departments. The organization’s Epic implementation eliminated a number of internal interoperability challenges and facilitated much easier sharing of clinical/patient records externally with other healthcare organizations. “In the State of Virginia, we’re lucky because we have about eight to 10 large healthcare systems and virtually every one is on Epic,” Dennis Loftus said. “That means it is unbelievably easy to share records seamlessly from one organization to another. We’ve also implemented the Epic home health and the hospice modules and our care managers just love the ability to see the complete continuum of care for any patient throughout the whole state of Virginia.” Since Riverside’s go live just under two years ago, it has shared more than three million records – those coming in and out – with all 50 states, he added, although interoperability remains a challenge for organizations to share data with providers and organizations not on the same platform.

In the U.S., health information exchanges, which allow doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient’s vital medical information electronically, have been used as a means of bridging the interoperability gaps for healthcare providers and systems on different EHR platforms; in Canada, Canada Health Infoway has developed a concept of an interoperable EHR that will facilitate the sharing of data across the continuum of care, across health care delivery organizations and across geographical areas. But, Sarah Muttitt said, there are still many ongoing challenges to sharing information across multiple EMRs.

For SickKids, which had more than 130 different best-of-breed systems and databases, the need to consolidate was a clear driver, but it was equally important to be able to provide a better experience for the families of their young patients, especially the 10 to 15 per cent of those they share with the Children’s Hospital of Eastern Ontario (CHEO) in Ottawa, with whom SickKids partnered on their Epic implementation. Most of those shared patients, explained Dr. Sarah Muttitt, were also the sickest and their cases the most complex, and by implementing a shared EHR, the patient experience was not only smoother but safer.

Harnessing the power of clinical data

At Colorado-based SCL Health, Lou Capponi, who has participated in numerous EHR implementations, highlighted his multi-decade quest at a number of large healthcare organizations to produce data that could be used to gain insights into and improve patient care and business processes. “I was looking for data to guide and promote change within the health system, and in the three organizations I’ve been in, that’s only really been achieved in one of them, and that’s because most people are not thinking about the end product as data you can use to manage costs, manage quality, improve health and drive value, he said. “They’re thinking just about getting the information in and taking care of the day-to-day transactions in a hospital. We’re seeing that now where we’re using that data for very exciting things like artificial intelligence to guide and predict.” But, he added, organizations need to define in advance the data they will need and how they will use it: by developing a data strategy aligned with your business strategy, you will be better equipped to be able to use that data to drive clinical and business process improvements.

Measuring and managing improvements

Other benefits the speakers identified include reduced costs and the ability to measure business and clinical performance and improvements. Despite the initial $100 million outlay for the associated software, training and resource costs, noted Dennis Loftus, Riverside has received just over $1 million back as a result of being under budget and through Epic’s good install program (a rebate that can be applied to future Epic costs by, according to Johns Hopkins, meeting requirements related to several indicators of a successful installation, such as the percentage of staff who pass proficiency assessments and the frequency of communication with Epic, as well as other key indicators) and additional credits for coming in under budget.

For Mackenzie Health, which achieved Electronic Medical Record Adoption Model (EMRAM) Stage 7 certification, certification enabled the organization to benchmark its progress. Level 7 is important because it measures adoption, Diane Salois-Swallow explained.

And while the topic of physician burnout seems by now inextricably linked to any discussions of EHR implementation and adoption, Dennis Loftus offered an interesting perspective. Although Riverside has scored well on post-implementation physician engagement assessments, the health system’s physicians are still “just as frustrated as every other physician out there on the physician burnout side,” he said. Although physicians in different areas might have loved their individual, best-of-breed EMR, they were still frustrated by the lack of interoperability with other internal systems pre-Epic. More importantly, he added, it wasn’t good for patients, especially from a continuity of care, medication safety and reconciliation perspective. “So the physicians were very frustrated then and they’re very frustrated today, but they recognize they are on the right course.”

The benefit for Canadian organizations, he added, is that vendors are now course-correcting on their earlier EHR development approach of “checking off every box” to comply with U.S. regulations such as Meaningful Use, and improving their products to make them less onerous for providers to use.

Unparalleled methodology

 “The Epic methodology impressed me more than any methodology has impressed me in my entire career,” Dennis Loftus observed. “I’ve been involved in implementing so many systems, and I was surprised at how good, how mature and how solid Epic’s methodology has become today.”

Diane Salois-Swallow agreed. “I wish I had been exposed to that methodology earlier on in my career. I think we would have been a lot more successful. It’s very structured, it really works and it can only lead to success at the end of the day.”

Lessons learned

Determine your data governance strategy before it’s too late.

One of the most important pieces of advice for those embarking on an EHR implementation is to design and develop a data governance strategy at the outset. That will help you avoid some of the challenges SickKids experienced. “We’ve been really challenged,” Sarah Muttitt said. “I think we designed largely around ease of use, convenience and adoption but we didn’t have that level of maturity around data itself. We’re paying a little bit for it now but has it ever exposed some of the things that we didn’t know! It has actually created a bit of momentum around data governance, data quality and data integrity.”

Have an optimization roadmap.

SickKids’ system is “rock-solid” and working exactly as it was designed, noted Sarah Muttitt – just not exactly how people want it to work. “It’s all optimization and that is a lifetime journey,” she said. The key is to determine what can be achieved on an annual basis, taking into account finite capacity and infinite demand.

The truth is that Epic could be optimized forever, added Lou Capponi. The key to success is in setting the expectation that changes to the system will be driven by your organization’s strategy, not just by what people discover that they want as they use the system. “That’s very difficult for me as a CMIO, because for 10 years, people have been asking for things and we do some of them and [not others], and what I’m doing right now is to … focus on really strategic projects that are going to have an outcome directed at a specific problem.”

Plan for talent development and retention.

Healthcare organizations are investing heavily in procuring and training the best and the brightest to implement their EHRs. Typically, those resources tend to move on to the next big project, especially if the location is more convenient. Dennis Loftus, who reported that Riverside Health’s previous average turnover rate of two to three per cent is now “bouncing around at five to seven per cent,” says organizations should do their best to make their workplace a great place to work and grow. But they should also consider forming teams with more than just the “whiz kids” who can ace Epic’s aptitude test, he said. “I probably would have placed a little more value on some of those people that have been with Riverside for many years that may not have scored quite as high.”

Lou Capponi agreed, noting that taking a strategic approach to hiring resources – determining your core requirements and the areas that can be staffed more flexibly to accommodate turnover – will help ensure greater stability with your EHR implementation.

In a previous Q&A with Gevity, Diane Salois-Swallow also noted the challenge Mackenzie faced in retaining staff after training and certification. “Each organization that is live with EPIC has invested extensively for training and certifying staff,” she said. “With other hospitals implementing, these highly trained resources are leaving for new challenges, placing the hospital that trained them at risk. I would like Ontario hospitals that are implementing Epic to collaborate on the staffing issue we are facing and figure out how we can assist each other.”

However, noted Sarah Muttitt, Epic is not a project management company. “They do not manage projects. They have a methodology that they squeeze into your proposed timeline, but do not think you are not going to need strong project management to manage task dependencies and mitigate risk. Invest on the project management side.”

Wrap-up and most important single piece of advice?

Lou Capponi: Plan for getting data out of the system.

Sarah Muttitt: Ensure that your implementation is the single most important initiative in your organization. It’s difficult to persuade people to give up other high-priority projects but it’s essential to really focus on getting this done and done right. It takes strong governance, strong executive leadership and a lot of negotiation.

Diane Salois-Swallow: Measure your improvement at the onset – and keep measuring your benefit realization.

Dennis Loftus: Invest in your people and control your costs as you go through the project.

Looking for additional resources?

To read a pre-conference Q&A blog post with each panelist, visit:

·       Lou Capponi: SCL Health VP and CMIO Louis Capponi: Epic offers powerful and sophisticated tool with increasing predictive powers

·       Dennis Loftus: Budgeting, physician builders and go-live support all key to epic implementation success, says Riverside VP and CIO

·       Sarah Muttitt: Epic go live is just the beginning of a long-term commitment

·       Diane Salois-Swallow: Epic implementation at Mackenzie Health part of an advanced clinical transformation