Preparing for the implementa0on of the Epic EPR in Norway drawing on

experiences from Denmark

GunnarEllingsenUIT–TheArc4cUniversityofNorway

Tromsø

The Epic EPR

•  Epicisanintegratedsuiteofso@warewithfunc4onalityrangingfrompa4entadministra4on,throughsystemsforphysicians,nurses,pharmacists,radiologists,labtechnologist,andothercareproviders,tobillingsystems,integra4ontotheprimaryhealthsector,andafacilityforgran4ngpa4entsaccesstotheirowndata.•  BeingoriginallydevelopedfortheUSmarket,EpichasonlyrecentlybeenimplementedinEurope.

Epic in Denmark, Finland and Norway

• Denmark:2016•  Finland:2018• Norway:2021

Research ques0ons

• HowdidtheDanishhospitalsprepareforgo-liveandhowdidtheexperiencesa@ergo-livematchtheirexpecta4ons?• HowdidexperiencesfromtheEpicimplementa4onsinDenmarkinformtheNorwegianprepara4ons?

Method

•  Selectedprojectdocumentsarepubliclyavailable• Businesscaseandminutesfromkeymee4ngs.•  Thehealthauthori4esdosomeassessmentswhichareavailableinpublicreports.•  TheNorwegiancaseisbasedon4interviewsoftopmanagementintheHealthPlaVormconductedinOctober2018.

The Danish Case: Herlev and GentoHe Hospital (HGH) at the Capital Region

• ContractsignedinDecember2013•  EpicwentliveatHGHonMay21,2016• HGHhad949bedsand6449staff•  Stage3onEMRAM•  EUR375million

Expecta0ons

•  Eliminatepaperrecordsandreplacemanyexis4ngclinicalinforma4onsystemswithoneintegratedelectronicpa4entrecord

•  ItwasexpectedthatthemainbenefitsofEpicwouldbemoreefficientpa4entadministra4onandclinicalprocesses.

Adapta0on and configura0on

•  ToachievethesebenefitsEpichadtobeadjustedtomatchtheDanishhealthcarecontext.Theseadjustmentsinvolvedchangesintheuserinterfaceaswellastheunderlyingfunc4onality.

HGH experienced a number of problems aHer go-live (2016) Status report to the board of pa/ent safety, Capital Region, 12. august 2016

•  Referrals,admission-anddischargereportswerenotsentcorrectly•  Theiden4tyofunnamednewbornbabieswasdifficulttoestablishbecausetheyappearedas‘Unknown’,thatis,withouttheirmother’ssocialsecuritynumber.•  TheEpicdisplaysintheemergencydepartmentcausedproblemsforthestaff,whohaddifficultygaininganoverviewofthepa4entsandtheirstatus.•  Theintegra4onbetweenEpicandsomeofthemedicoequipmentmalfunc4oned,sodatawerenottransferredfromtheequipmenttothepa4ents’recordsinEpic.•  Theintegra4onwiththena4onalmedica4oncharthaderrors,suchasoccasionalduplica4onofmedicalorders,therebycrea4nguncertaintyandworkarounds.•  Manyblood-testordersremainedunsentbecausetheydidnotcomplywithnewrequirementstotheircontent,o@enwithoutthephysiciansunderstandingwhytheorderhadnotbeensent.

Delayed training (Report from the office of the Auditor General, 2018)

•  8weeksimplementa4onschedule•  TheuseofEpicstartedtwoweekslaterthanplanned,thatis,sixweeksbeforego-live.Thecompressedschedulewascausedbythedelayedcomple4onoftrainingmaterialsand,inturn,causedproblemscomple4ngthetrainingofallstaff.•  Thedelayswerecausedbyon-goingadjustmentstoEpic.Intheend,adjustmentstoEpiccon4nueda@ertraininghadstartedandmanyusersreceivedtrainingonaversionthatwasdifferentfromthesystemtheymetatgo-live.

Lack of cri0cal technical tests (Report from the office of the Auditor General, 2018)

•  Testswereconductedaweekbeforego-livebecausethefeaturestobetestedweredelayed.•  Thetestswerecomplicatedbyknownerrorsthathadn’tbeenfixedandtheyiden4fiednewerrors,including20inthecategoriescri4calandsevere.These20errorswerenotfixedun4la@ergo-live.•  ThetestofwhetherEpicproducedthesamedataforreimbursementastheoldsystemswasconductedthedaybeforego-liveandrevealedproblems;itwasdecidednottocomparethedataproducedbyEpicwiththosefromtheoldsystems.•  Inaddi4on,thefunc4onaltestofwhetherEpicfulfilledthespecifiedrequirementswaspostponedun4lOctober,fivemonthsa@ergo-live.

The benefits es0ma0on (Report from the office of the Auditor General, 2018)

• Anexpectedproduc4vitydipa@ergo-liveofonlythreeweeks•  Thebasisforthisop4mis4cexpecta4onisunclear

•  Asmuchas18monthsa@ergo-liveproduc4vityhadnotyetreturnedtobaseline

The Norwegian Case: The Health PlaVorm programme in Mid-Norway

•  Theprogrammeaimsatacquiringandimplemen4ngEpicforthewholehealthregion.•  Thecontractisplannedtobesignedin2019andthefirstimplementa4onareplannedin2021.•  Thereare3hospitalswhereofthelargestislocatedinTrondheimwithapproximately1000bedsand10500employees.•  ThecostoftheprogrammeamountstoEUR270million

Goals in the programme

11.11.18 14

• Improvecollabora4onbetweenthestakeholdersinthehealthcareservice• Reduced4mespentdocumen4ng• AcommonEHRforthewholehealthregioninMid-Norway.• The84municipali4eshavetheop4ontobuyintothesolu4on

Hospitals Nursinghomes

HomecareservicesGeneralPrac44oners

Replacement and integra0on

•  TheHealthPlaVormhasiden4fied80currentICTsystemsthatwillbereplacedbyEpic.•  Therearealso160integra4onsofana4onalcharacterthatwillbedeveloped.

• Whatarethekeyconcerns?

Organising par0cipa0on to create ownership and get the right func0onality •  “Whenwestartedtheacquisi2onproject,weinvolved400cliniciansfromtheen2rehealthcareserviceinMid-Norway,smallandlargemunicipali2esandhospitals(…)theypar2cipatedin301workshopsanddescribedwhatwasgoodwiththecurrentICTsystems,theircurrentchallengesandwhatwasmissing”

•  Theoutcomeoftheseworkshopsbecamethebasisfortherequirementspecifica4onincluding4000specificrequirements.

Ensure par0cipa0on of the 84 municipali0es in the region • Achallengeisthattheprogrammeisveryhospital-run.ItistheHealthAuthorityCentralNorwaythatownstheprogramme.EvenifTrondheimmunicipalitypar2cipates,themaineffortistoacquireanEPRforcentralNorway,andwefeelthatwemustensurethatthemunicipali2esaretakenintoaccount• Wemustensurethatthe84municipali2es“buyin”toEpicasearlyaspossibleinordertocreatestabilityaroundthesolu2on(…)weinvolveuser-representa2vesfromthemunicipali2esintheacquisi2onprocess.ThepurposeofthishasbeentoensuretheusersthatEpiccanbeadaptedtotheirneeds

Nego0a0ng demands with Epic

•  “WehadaverythoroughdialoguewithEpicinthespringof2018.Inthisperiod,weexperiencedthattheyreallyimprovedtheirunderstandingofwhatwewanted.Inthissitua2on,wealsoexperiencedthattheybroughtwiththemknow-howandknowledgefromDenmarkandFinlandthatwasusefulinNorway”

Dealing with the users’ requirements

•  Thenthevendor[Epic]wenthomeandstartedtoconsiderallourrequirementandrealizedthattheywouldendupwithaquitelargedevelopmentproject,andwheretheytoali[leextenthadconfronteduswithfunc2onalitythattheyalreadyhaveinthesystem.

• Andthentheycamebackusandshoweduswhattheyhadandsaid:“Ifyouwanttheofflinefunc2onalitythatwouldmeanTHISmanydevelopmenthours,butwhatwecanofferyounowaresomeadapta2onshereandnow.Ifyoucantellusonthisscreenwhatyouwantdifferentlywecanchangeittothemee2ngtomorrow”(...)theprofessionalsinthatfieldsaidthatthiswasgoodenough

Configura0on requires “physician builders”

•  ThecapabilityinEpictoconfigurethesystem,doesnotonlyextendtoEpicpersonnel.Similar,totheDanishcase,designatedcliniciansaresupposedtobeheavilyengagedinconfiguringandbuildingtheEpicsystems.i.e.designingfunc4onalityfortheirprac4ce.IntheEpicworld,thesearecalled“physicianbuilders”

A rigid implementa0on schedule

•  "Theyhaveaveryrigidand2ghtprojectplan.Theyhavephilosophyof:let’sjustgetthesolu2onupandrunningandlet’sbuildthecapabilityintheorganiza2ontounderstandthesolu2onanditspossibili2es”

•  “Aberthatyourunop2mizingprocessescon2nuously,whichyouasacustomermanageyourself…actuallyyouarebuildingthesystemyourself(...)youdon’thavetocallavendorwhohasno2metodoit”

Establishing a decision structure

•  TheDanesdidn’tmanagetotakedecisionstotheright2me.Andifthathappenstoalargeextent,thenEpicwillusetheirfounda2on(default)systeminstead…Andthenyouareofftrack

•  "Nowweareintheprocessofestablishingadecisionstructure(...)thatis,involvepeoplefromthelineorganiza2onsthatcanrespondtoalltheques2onswithina10daysno2ce.Epicwillprobablyraisesomethingbetween8000-12000ques2onswhentheystarttheimplementa2on"

Long-term effects and business plan

•  “IncomparisontotheDanishcase,theHealthPlacormhasnobusinesscasethatpromotesconcreteeconomicgains(…)Our”businesscase”ratherpointstoqualityrelatedtopa2entsafetyandpa2entsafety

•  “Butifwedothingsrightthenthereisapoten2alforefficiency-andeconomicgains”

Concluding discussion

1.  ComparedtoDanishcase,theNorwegiancasehasalargertransforma4vepoten4al,buttheorganiza4onalcomplexityishigher.

2.  Anuneasyposi4onbetweenEpicandtheclinicians(widespreaduserpar4cipa4onand4ghtdeadlines)

3.  Theuncertaintyaroundanextensiveformaldecisionstructure4.  Therecruitmentofphysicianbuilders5.  Standardisa4onfortheshort-termvsflexibilityforthelong-term6.  Lesspromo4onsofmeasurablebenefits(economyandefficiency)inthe

Norwegiancase