As of March, Penn Medicine is live on Epic enterprise-wide, wrapping up what has been an almost decade-long process.

Penn began rolling out Epic electronic health record at its ambulatory sites as far back as the late '90s – finally completing the outpatient implementation about seven or eight years ago. In March, the academic medical center switched on its inpatient, hospital billing and home care systems. 

That has required a bit of a balancing act when it comes to ensuring physicians and nurses are using the EHR to the best of its capabilities, said Scott Schlegel, associate vice president for EHR transformation at Penn Medicine.

"Basically we were living with two different worlds," he said.

At first, the idea with the ambulatory implementation was to eventually transition staffing and resources to post-rollout EHR optimization.

"But we never really stopped implementing: We continued to implement and we never got around to optimization," he said. "So the problem that we had was that our physicians were never really trained after they got their basic training and they developed good or bad habits individually."

One of the key tasks for Schlegel's team was "to do some remedial work to tighten up on the ambulatory side – the ones that have been live for a little while – and then mesh that with the newly minted users on the inpatient side."

So far, that work has been going very well, he said. His team comprises so-called advanced provider educators who focus on targeted efforts to ensure clinicians are using the EHR optimally.

"We've been tasked to create optimization infrastructure, and a transformation infrastructure, that leverages the EHR to help us achieve our business goals and clinical care goals," said Schlegel. "Those are our marching orders."

Good governance is key

As is often the case, a sound strategy is essential to make such outreach work: "We have a very strong governance group, and we set our optimization efforts around those governance-set priorities and needs," he said.

"Because our EHR is the backbone of basically everything we can get done on the operations side, we leverage other groups that are already in place. They may be quality groups, they may be existing policy governance groups or enterprise governance groups."

Schlegel's colleague Philynn Hepschmidt said it's critical to have a balance of stakeholders at the table for any successful optimization outreach.

As associate executive director of EHR integration and clinical optimization, Hepschmidt is charged with making Epic work well across Penn Medicine, teaming with various leadership across the organization to come up with strategies for better IT use.

With those groups, "there's a mix of clinical folks from various care settings, in addition to administrative roles, which creates the balance you need in order to make appropriate decisions," she said.

Schlegel said a three-part balance – "a physician, a nurse and an operations person" – had been extremely valuable to crafting smart optimization strategies that meet the needs of the specific staffers.

Crucially, he said, the efforts are led by the operations department – in close partnership with information services – and are focused both on improving both individual usage of Epic and enterprise-wide functionality challenges.

"One of the uniquenesses with us is that we do not sit in IS," said Schlegel. "We sit in operations but partner very closely with IS."

He said there were some "challenges that were unique to us in the beginning," with regard to "sorting out what role people had, and where we draw lines and things like that."

He sees the optimization team as "a bridge between operations and IS," allowing each to play to its strength while maximizing the chance that EHR optimization efforts will stick.

"We've sort of helped facilitate that by pulling various groups together to leverage the existing infrastructure to get some stuff done," he said.

Hepschmidt says one recent education strategy they've implemented at Penn Medicine is pop-up "genius bars" where any troubleshooting question is on the table.

"The topics are focused on the things we can do right then and there which help to make charting or searching for information in the chart easier," she said. "They've gotten some questions about reporting, where to find them in the chart and also questions about which reports are useful. This is an area of education we will need to continue to develop."

The team is considering teaming up with Penn's Faculty Wellness Committee, which runs a project with a similar concept, said Schlegel. "So one day we may have, 'How to best use your Outlook email.' And then another day it would be an Epic-focused one, where we would explore how to use quick actions, or how to use your mobile app."

Extracting value from expensive systems

Schlegel says EHR optimization is important for many reasons, especially when it comes to getting clinical and financial returns from some very expensive IT systems.

"One of the things we have struggled with – and I think a lot of places struggle with – is with our senior leadership saying, 'Show me the value of this investment.' We invested almost $200 million in Epic, and we're not alone there, I know. So what do we get from it? Some folks might just regard it as the cost of doing business. But our (execs) are really pushing for how do we leverage this system to get some of that money back."

Some of that ROI can be achieved right away, of course, "with the normalization and standardization of workflows," he said. But Penn Medicine wants to go well beyond that.

"My background is in practice administration and I work very closely with physicians – with, how can we measure your improvement in productivity or charting efficiency or something like that, as a result of our intervention," said Schlegel. "How do we make you happier? How do we shorten your day and help you make it to your soccer match without having to worry about charting at 10 o'clock at night."

So Penn Medicine uses Epic's provider efficiency data, which tracks nearly everything a physician does in the EHR.

"Our trainers will look at that prospectively and figure out, you can easily see who's logging in at 10 o'clock at night and closing their chart," he said. "This was a very popular thing. It doesn't represent more dollars, per se. But in this day and age, with providers feeling more and more put-upon, this was included as a faculty wellness activity.

"Now we're getting some pressure to go a little further and really identify some process measures that we think are helping – and we're using that PEP data to drive that," he added.

One doesn't have to be at a large and well-resourced academic medical center to embrace optimization projects such as these. Even those providers with more modest staff sizes could pursue similar initiatives on a smaller scale.

"We started with a very small group," said Schlegel. "We began with four, added two eventually, and then added more as we went on. We did a little leg work to try to figure out what the top clinician complaints were, at first, then we supplemented that with data, which was fairly doable. You could just as easily do this in a practice of five or 10 people."

Whatever the size of the provider organization, the importance of EHR optimization efforts has to be communicated to C-suite and clinical staff alike, he said.

"We said, 'This is as important as passing a Joint Commission audit, or the next Medicare mandate that comes down the road.' And I think our organization did a pretty good job of recognizing that and escalating it.”

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

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