An Epic journey

Date: September 16, 2011

Enterprise-wide, Johns Hopkins Medicine leaps into the electronic future of health care.

1 2

A universal electronic medical record will allow both patients and providers, such as internist Gene Green (left), instant, system-wide access to pertinent health information.

As a regional medical director for Johns Hopkins Community Physicians (JHCP), internist Gene Green was always on the lookout for ways to make patient care more efficient. The tool that served him best turned out to be right at his fingertips—the electronic database that contains all JHCP medical records.

Over time, an important pattern emerged as Green, now JHCP’s vice president of medical affairs, traced the electronic signatures entered by providers and staff members each time they took part in a patient’s care. What he found was a link between efficiency and teamwork, an important aspect of patient-centered care. The most productive sites, he says, were those “where the entire team was responsible for caring for the patient and the provider was able to delegate responsibilities.” 

Not only did Green’s electronic sleuthing lead to quality incentive bonuses for employees at exemplary JHCP sites, it uncovered a “best practice” model for serving patients that he has sought to replicate across the Community Physicians network. Had JHCP not migrated to an electronic medical records system in 2007, says Green, “I wouldn’t have been able to pick up on the link between teamwork and efficiency because I didn’t know who did what.”

With the 2013 launch of Epic, a software system that will integrate medical records across Johns Hopkins Medicine into a central database, all of the health system’s 1,700 specialists and primary care physicians will gain access to the same powerful tools available to Green and his JHCP colleagues. Whether the immediate goal is to build teamwork, monitor pediatric vaccination rates or remind diabetic patients to get eye exams, electronic record systems give health care workers a mechanism for elevating the quality of care, says Green, a co-chair of the Epic project’s clinical care work group.

As Hopkins moves toward a uniform electronic records system, Green marvels at the wealth of resources for patient-centered care that will emerge. “Not only will I be looking at the records of patients who have come into JHCP, I will be able to track them across Hopkins,” he says. “The number of places where caregivers touch our patients that I can see will increase by an order of magnitude.”

The Hopkins Medicine trustees recently approved a $100 million investment to activate Epic starting with the health system’s ambulatory care centers.  The endeavor comes at a pivotal point in the health system’s history, when rapid growth, financial challenges, regulatory obligations and health care reform demand a fundamental shift in medical and administrative practices.

“We can’t continue to grow and be efficient, safe and patient-centered unless we make this investment,” says Stephanie Reel, Epic task force and co-chair and the university’s chief information officer, vice provost for information technology.

Selected in part for its seamless integration of ambulatory and inpatient records, the Epic system is scheduled to be phased in across all care settings over a five- to six-year period, pending the approval of the Johns Hopkins Medicine and the Johns Hopkins Health System boards of trustees. When complete, Epic will have eliminated more than a dozen patient record systems across Hopkins institutions and transformed work routines for thousands of employees.

A paperless operation

Once Epic is installed, many specialists will enter information, lab orders and prescriptions on laptops rather than on paper charts for the first time. “We still have a lot of paper here in the ambulatory arena because we don’t have a way of creating electronic orders,” says Wayne Smith, the former senior director of information services for the Clinical Practice Association (CPA) and now the project director for the Epic implementation. Epic will allow all Hopkins Medicine clinicians to enter information in standardized computer physician order entry forms and other digital record systems. To avoid confusion, they’ll adopt terminology that is consistent throughout the enterprise.

As they consult a single electronic source for ambulatory and inpatient records, providers will keep track of patients’ progress as they move across different clinical sites. Epic will provide a single system for registration, appointment scheduling, patient accounting and billing.

With its rich store of real-time patient information, Epic will give providers a complete picture of all admissions and discharges, expediting bed management. Through their own electronic portals, patients will be able to see portions of their medical records, request appointments and review billing statements.   

To William Baumgartner, the other Epic task force co-chair, president of the Clinical Practice Association and Johns Hopkins Medicine senior vice president of the Office of Physicians, the universal electronic health record is essential to facilitating clinical integration throughout the system. “It’s going to help build relationships among the physicians, because they’ll be linked through Epic,” he says. “In fact, without Epic or a system like it, we wouldn’t be able to achieve that integration.”

While embracing the move to electronic health records, leadership was determined to ensure that the institution’s tripartite mission of patient care, research and education remained at the center of the exhaustive planning process. Some participants questioned Epic’s capacity to serve the needs of researchers and educators, Reel says. “Rather than a compromise for researchers and educators,” Reel explains, “Epic can be a foundation for their work, because patient data is the baseline for translational research and for the school of medicine’s new curriculum.”

Yet, plenty of challenges remain. “Epic is going to require a transformation in the way we use electronic systems, work together and embrace the technology,” Reel says. “There are lots of amazing opportunities, but they must be coupled with a lot of hard work. We must demonstrate we have the resolve to make it happen.”

Getting with the program

Along with executives, scores of administrators and clinicians have prepared a comprehensive plan and timeline for the Epic rollout. Pending board approval, leaders are eyeing an almost simultaneous launch of Epic on the inpatient units of Sibley Memorial and Howard County General hospitals, because their electronic health record systems are outdated and in need of a more immediate upgrade.

Because it is robust enough to meet upcoming federal regulatory requirements, the Sunrise clinical information system for inpatients at The Johns Hopkins Hospital will be among the last to migrate to Epic, most likely in five years, Smith says. For the time being, Johns Hopkins Bayview Medical Center and Suburban Hospital also will rely on their respective electronic record systems. At present, All Children’s Hospital in St. Petersburg, Fla., is not part of the Epic initiative.

This month, training begins for the 65 employees who were hired for the Epic implementation team. Once certified by Epic, team members in concert with clinicians and administrative teams will write explanatory content for the system, develop a training curriculum and fan out to train the providers and staff who will use the new system.

At the first of three “validation sessions” in December, hundreds of clinicians and staff, grouped by area of expertise, will work with the Epic team to identify remaining configuration needs.  In January, the Epic team will begin to make the necessary modifications. After the validation process is complete in August 2012, the team will develop the training materials that will prepare all ambulatory care givers and staff for an April 1, 2013, rollout.

 “Proper training is absolutely critical,” says Linda Kline, who left her position as senior director of patient financial services to become executive director of the Epic project. “We need all of our physicians and other clinicians to go through the training. We want them to be comfortable on day one.”

Strength in unity

By creating a central database for all patient records, Epic meshes with other enterprise-wide initiatives, including the newly established Community Division’s efforts to integrate Hopkins Medicine’s fragmented clinical components into a more unified whole.

Continuing efforts to improve patients’ access to Hopkins providers will also get a boost from Epic, Smith says. “Right now, patients across the health system are on multiple scheduling systems, which are complex, because they have expanded over the years in different clinical specialties. Now, we can create a new scheduling system as a baseline to improve simplicity and function for all specialties.”

Launching Epic across the system’s ambulatory care settings as well as Sibley Memorial and Howard County General hospitals will also allow Hopkins to meet “meaningful use” standards established by the Health Information Technology for Economic and Clinical Health (HITECH) Act. At stake are substantial Medicaid and Medicare bonuses for eligible providers and hospitals. Penalties await those who don’t meet the standards.

The enterprise-wide health record also will allow Hopkins Medicine to meet the October 2013 deadline for using ICD-10, a new national coding standard for medical diagnoses and procedures, before payers impose penalties

As he prepares for JHCP’s migration to Epic as part of the Ambulatory First rollout, Gene Green sees even greater benefits ahead. For example, for the first time, he will be able to search for patient records that were previously hidden in separate electronic systems or a specialist’s paper charts.

“I’m really excited that it will be easy to find electronic patient information from specialists that I used to have to search for outside the JHCP system,” Green says. “This system is truly patient-centric.”       

—Stephanie Shapiro