An Epic Newsletter

"I just admitted a patient using Epic, and it was beautiful."

So said Dawn Grinenko, M.D., assistant professor of medicine and director of the hospitalist service at Shands at UF, upon admitting what turned out to be the first Shands patient using the Epic electronic medical record system.

Epic went live at the Shands at UF, Shands Vista and Shands Rehab hospitals at 7:20 a.m. on May 14. (At Shands Jacksonville, Epic will go live in September.)

Job 1 for UF&Shands is to ensure safe, high-quality care for our patients. The very first action item in the quality component of our strategic planning process was the decision to implement an electronic medical record, or EMR, across ambulatory and hospital care, and across our Gainesville and Jacksonville campuses. The decision to proceed — a $100 million commitment over five years — was approved by the Shands Board in Gainesville and Jacksonville in September 2009; Epic was chosen as the vendor in November 2009; Kari Cassel was recruited as the UF&Shands CIO in December 2009; and the inpatient Epic installation began in January 2010.

Now, after an extraordinary effort touching virtually every clinical faculty member, resident, student and staff member, and working at lightning speed by the standards of most EMR installations, inpatient Epic has been successfully launched.

Some of us remember a time before the World Wide Web. Before personal computers, laptops, cell phones and iPads. Before word processing and electronic spreadsheets. Before Google, Facebook and Twitter. Before PubMed, WebMD and UpToDate. Before retail shopping, ticket ordering and "research" on just about anything online anytime, anywhere. It‘s been an amazing journey, equivalent historically in our times to the Industrial Revolution before us.

But where has this technology been in our health care system? Up until a few years ago, the average supermarket — with bar coding, supply chain management and store cards that tracked your purchases — had more information technology than most physicians‘ offices and hospitals, where you had to write out the same demographic, insurance and medical history information over and over. Now that‘s changing; we are embarking on a journey that begins with the electronic recording of health information but leads to higher-quality care, better health outcomes, improved education and training, and improved knowledge about care processes and outcomes that, in turn, leads to further enhancements of disease prevention, diagnosis and treatment.

Part of our early success with inpatient Epic on the Gainesville campus is a consequence of the lessons already learned in implementing Epic at our ambulatory faculty practice sites. (In Jacksonville, the faculty practice had previously implemented an electronic medical record, which will transition to Epic in 2012.) By the time May 14th rolled around, Epic had already been implemented at more than 26 UF Physicians practice sites and at Shands HomeCare, with more than 2,000 active users. In addition, almost all UFP providers have begun electronic prescribing, and the Epic MyChart patient portal pilot has successfully linked almost 1,500 patients to the practice in a secure online format, where they communicate with the practice team, request appointments and receive test and Xray results from their physicians. So, when the go-live date for inpatient Epic arrived, attendings and resident physicians were already facile with navigating Epic and entering data in the EMR, allowing the team to focus training on those aspects of Epic that differed between the outpatient and inpatient environments.

That said, on the first morning there were still some snags to be resolved around device connectivity (e.g., the ability to see imaging studies or fetal monitoring strips online) and order entry (which worked for attendings but not for residents). Many issues have arisen, large and small: On the first day, there were more than 900 calls to the "command center" for help. With greater experience, the number of calls has waned, but we want to encourage more inquiries, pushing us to create the best system possible for our patients.

Indeed, a wonderful thing has transpired over the past week. In each department, there has been a buzz of activity around the nuances of taking care of patients using Epic. There were few regrets about how the system couldn't do certain things, and little yearning for paper and pen; rather, there has been small group learning in real time — the way the medical educators say it's supposed to happen — and email shout-outs to others for help with using Epic as applied to specific types of patients and circumstances. Solutions appear, often due to the ingenuity of another member of the department figuring out how to deal with a similar problem. The solution is communicated, and then goes viral.

I'm sure that the above description doesn't fit everyone's experience, and that I will hear from those with specific problems that have been particularly intractable, but the energy and spirit that I have observed from so many, whose clear goal is to figure out ways to make Epic work on behalf of improved patient care, is clearly palpable.

Epic supports our quality goals in patient care, improves our research capabilities and overall operational performance, and will be embedded in our educational curricula for our students. As stated by Donald Novak, M.D., professor of pediatrics and the physician liaison whose herculean efforts with faculty and staff have contributed greatly to our overall success: "Everyone realizes the long-term payoff is going to be very big — improved patient care, improved patient safety and improved access to records for patient care and research. The beauty of this is that what we will achieve in enhancing patient safety will also create tremendous efficiencies for the health care system, which will find their way back to the patient. But in the short-term, we have just reached the mountain, which is 'Go Live.‘ We are focused on getting people comfortable with the system and informing them about what is going to happen next."

Veronica Carr, R.N., M.S.N., a nursing information services coordinator, says Epic will improve communications immensely. "Today, when a patient comes to the emergency department, their information doesn‘t easily move along with them. If they are admitted to a floor in the hospital, we have to start all over collecting data – we get their weights again, we ask them about their medications, personal/family health histories and allergies," Ms. Carr says. "With all the areas of the hospital or clinic the patient travels through, I‘ve heard patients say, 'I‘ve already answered that question six times.‘ The clinician must say, 'I am sorry, but we have to ask you again.‘ With Epic we are finally going to a place where we don‘t have to ask patients the same things over and over. Instead we will be able to look at the record and be able to talk about their history, name their medications, confirm whether the patient is still using the medication and ask if they are taking anything new. It demonstrates to the patient that we are informed, and we will be. I think Epic is going to dramatically improve our customer service and improve patient safety."

Jeremy Archer, M.D., a pediatric cardiology fellow with the Congenital Heart Center, first learned the Epic system while he was a pediatric resident at the University of Vermont. He says the challenges of learning a new system gradually give way to the realization that it is a valuable tool. "Having all of a patient‘s data in one system in inpatient and outpatient settings is very powerful. I particularly like the ability to create templates which standardize the information that caregivers collect," Dr. Archer says. "It helps remind you to do everything necessary for a complete and thorough patient interaction. At first, the system can be challenging, but it‘s always challenging to learn a new system. After several months, people get used to working with it and increasingly appreciate the benefits. But for the new people entering our health-care system, it will be the standard approach. A new group of residents will be coming in July, and they will be the ones who will take to Epic most easily and probably wind up as the best at using it."

Likewise, Barbara McNamee, M.B.A., a director in the department of surgery, knows from experience the power of an electronic medical record. "Having participated in Epic implementations at my previous institution, I was eager to start the process at UF as I had seen firsthand the benefits of the program," Ms. McNamee says. "Embarking on this culture change, our department admittedly had mixed feelings of enthusiasm and trepidation, but as the opportunities for standardizing patient care, eliminating redundancy and ensuring billing compliance became evident, trepidation waned and enthusiasm increased. Our department is committed to realizing the full potential of Epic and is aligning resources to ensure continued success in each phase of implementation."

An important goal for UF&Shands is to improve the university's ability to do science, to make discoveries, to publish results and to translate those results into improved care and improved health through the Clinical and Translational Science Institute. Epic will also add value to that effort. "The launch of Epic is a precursor to many of the giant strides we hope to make in advancing clinical and translational research at UF&Shands," said David Nelson, M.D., director of the UF CTSI. "The combination of EPIC, the integrated data repository project and universal informed consent for all patients will allow us to harness the collective power of our clinical data to improve the health of our communities. In the future, with more data available, we can more rapidly transform scientific discoveries into medical advances."

Dr. Marvin Dewar has been the architect of the Epic installation in the UF physician practices. He comments: "It is great to have the continuum of care data available for everyone in one place — from initial patient information collected in the ambulatory visit, to admission information, to discharge information. Having a truly interdisciplinary record where every clinician can see what any other clinician has done and not duplicate work or tests is helping us to deliver safer, more effective clinical care."

Dr. Juan Vilaro, chief resident in Internal Medicine, said: "It's going much more smoothly than we had expected. We believe it's better for our patients and it makes us so much more effective as residents. And it's great to finally see emergency, outpatient and inpatient information all in one place! I'm looking forward to being a fellow here and making this system work for me."

Installation of Epic has been coordinated under the watchful eye of Kari Cassel, UF&Shands CIO. She summarizes it this way: "Going from paper to electronic is one of the largest and most important changes that can occur in a clinical organization. An EMR positions an organization for the future. The systems are far from perfect and today we must adapt our processes to work with the system. Over time, we will adapt the system to our workflow. Our goal is to embed EMR technology in our health care delivery and our health sciences education curricula so that EMR becomes core to how all of our health care providers deliver care. The EMR will provide us with the tools necessary to improve continuously."

Soon after Epic went live, Epic on the iPad using a free Citrix app was discovered. Presto — a fully functional hand-held version of Epic! Although a view-only version of Epic for the iPad was in the works as a future element of the Epic roll-out, news of the fully functional Citrix app spread like wildfire, and hijacked the original plan. Soon, iPads appeared everywhere and the IT team ensured that they were registered and secure. Now, all of a patient‘s health information is in the palm of a hand. William Riffee, Ph.D., dean of the College of Pharmacy and well-known technophile, put it succinctly: "How cool is that?"

Forward Together,

David S. Guzick, M.D., Ph.D. Senior Vice President, Health Affairs President, UF&Shands Health System