An Epic Achievement
In 2019, in pursuit of seamless interoperability, open access to clinical data for advanced analytics and research, and an enhanced patient and provider experience, a large academic health system made the strategic decision to implement Epic’s electronic health record (EHR) and revenue cycle systems across its enterprise. The organization includes twelve acute care hospitals, three acute care children’s hospitals and a pediatric rehabilitation hospital, a large behavioral health network, ambulatory care centers and surgery centers, geriatric centers, comprehensive home care and hospice programs, imaging centers, fitness and wellness centers, and retail pharmacy services. The organization’s strategic partnership with a university makes it an academic healthcare system, and the affiliation offers a comprehensive cancer center. The organization is a large private employer, with more than 37,000 employees, 9,000 physicians, and 1,000 residents and interns.
Setting a Solid Foundation
Pre-implementation planning is an important phase in any large-scale implementation. During this time, the organization has an opportunity to get organized, set up decision-making structures, validate scope, and establish guardrails for implementation ahead of the arrival of the vendor’s implementation team. The client organization established seven guiding principles for their implementation program and relied heavily on them, reinforcing them at every turn. Although these are different for every organization, this organization’s principles included ones addressing patient engagement and clinician and staff satisfaction, for example.
The Planning phase is also an opportunity to review and ensure the accuracy of the budget. Early on, Impact Advisors was asked to conduct a high-level analysis of the
organization’s implementation cost model to identify potential risks from both staffing and budgetary/cost perspectives. After it became clear that the model was deficient in several areas, Impact Advisors was asked to recast 5 and 7-year total cost of ownership models for the implementation of Epic.
Cost modeling required an in-depth look at the timing and timeline of the implementation across the expansive organization. Leadership opted for a phased implementation, with certain hospitals, specialties, and medical groups going live in pre-defined “waves” over three years. The decisions of who and when were based on things like current EHR, size and complexity of the facility, as well as consideration of other competing initiatives.
Grouping the facilities lessened the administrative burden on providers who see patients at more than one hospital. Since the groups of hospitals were generally based on legacy groups and those using the same systems, fewer providers had to work in multiple systems. Grouping the facilities this way also assisted the centralized service teams who were already used to working in multiple systems. A comprehensive staff transition process was put in place to progressively migrate staff from legacy systems to Epic.
During one of the first critical phases, client subject matter experts (3,300 nurses, physicians, pharmacists, medical school staff, and other stakeholders) organized into 62 discipline-specific workgroups and councils to make interdependent decisions about scope, functionality, workflow, and configuration of the system. These workgroups and governing councils would play significant roles in both system design and operational readiness.
The Need to Pivot
As with every healthcare organization, the arrival of COVID in early 2020 impacted the client’s priorities, and many of its team members shifted their attention immediately to site preparedness and patient care. By Q4 2020, COVID’s impact on SME and resource availability made it clear that the original timeline was no longer realistic. Client leadership decided to pause, evaluate, and develop a modified plan, leveraging guidance from Impact Advisors’ experienced team.
Changes in scope required a second timeline adjustment and wave restructuring. The planning team closely examined the facility groupings and wave sequence and reordered based on when heritage systems needed to be replaced, including the cost associated with replacing sooner vs. later. COVID’s persistence would require more adjustments over the next two years, ultimately lengthening the timeline to include six waves spanning five years.
"We were impressed by Impact Advisors’ partnership with us. The consultants worked elbow-to-elbow with our people, sharing best practices and demonstrating a genuine desire to see us succeed. When choosing an implementation partner, we wanted a firm that delivers high quality services and the best talent, and that’s what we got.”
The Benefits of a Waved Implementation
With a typical “Big Bang” implementation, all facilities go live together, the command center opens and provides break/fix support, and the team eventually switches focus to optimization, and then upgrades. With the phased approach, activations were scheduled approximately every 6 months, which meant the team would be working to stabilize the facilities that just went live, all while planning the next activation. Although more complicated, this approach allowed the implementation team to incorporate lessons learned with each wave, including streamlining go-live metrics and honing go-live procedures.
Operational engagement and change readiness structures and processes saw some of the biggest enhancements as waves progressed. In fact, the processes and tools worked so well for this client, Epic incorporated some of the elements into their standard playbook for future implementations. Key to success was the constant reinforcement of the project being Operations-led and IT-enabled. To this day, the team is working on ways to better expose this shared responsibility with dashboards and metrics on support tickets and within workgroup structures.
The Importance of Operational Engagement & Change Readiness
Developing ownership and acceptance of the newly implemented system can be particularly challenging at a large, multi-facility organizations. From the beginning,
there was a concerted effort to set the expectation that the implementation of Epic was not an “IT project” but a collaboration between Operations and IT – a shared
responsibility.
Within three weeks of Impact Advisors’ arrival on the project, the team was able, with the support of the executive team, to set up critical workflow walkthrough sessions, in which operational stakeholders examine Epic workflows and how the Epic system can impact or improve existing workflows. Socializing redesigned workflows among the key decision-makers is critical to the optimization and adoption of the new system.
As mentioned, operational engagement evolved with each wave. For the first couple of go-lives, the client deployed executive “Site Leaders” who met regularly with the Epic project team and were tasked with getting their site’s personnel registered for (and available to attend) training. They were also responsible for ensuring their technical teams were keeping up with technical dress rehearsals and assigning someone to communicate high-value system changes. With the next
two waves, the team implemented a more comprehensive engagement and readiness process that increasingly focused on the site leads taking full ownership of change readiness for their respective sites.
Another notable shift was when the standard command center huddles became “patient safety huddles” during the later go-lives. Client leadership started each meeting with the question, “Are our patients safe?” which effectively gave context to the issues reported in the meeting and short-circuited “the sky is falling” reports typical at go-live huddles.
Achievements and Other Value Adds
As the team prepares for its final wave of go-lives scheduled for September of 2024, they can look back on some truly epic accomplishments (see box below). In addition to successful implementations across the organization, there were a few other notable successes.
- Epic Gold Stars x 3: Early on, client leadership made achieving Epic Gold Stars a strategic priority. (Epic’s 10-tiered Gold Stars system rates how much of Epic’s available functionality, including upgrades and enhancements, a health system goes live on). In 2022, theirs was the first organization to go live at a Gold Star Level 10, and then they did it again in 2023 and 2024. Completing two major implementation waves in a year while achieving Gold Star Level 10 was made possible through the effective partnership between IT and Operations.
- System Standardization: The significant amount of merger and acquisition activity in the industry has made enterprise standardization a common challenge among today’s health systems. Like many of the large, merged organizations, this client expected the move to a single, enterprise-wide EHR platform would help drive the desired standardization – and it has! It has also revealed existing inefficiencies and even a few foundational element gaps. The clinical and revenue cycle teams have been successfully working together to resolve these challenges and other optimization opportunities that are critical to realizing Epic’s full potential and value.
- Managing System Enhancements: Balancing a multi-wave implementation, go-live support, optimization, and upgrades requires close management of operational priorities. This client implemented a comprehensive enhancement evaluation and approval process for acute clinical workflows. To date, the program has implemented 20,000+ enhancements. The team leveraged a fully integrated (into Epic) Service Now (SN) instance to manage the requests, which made the capture of important details (screen, computer, location, etc.) very easy and efficient. The reporting and dashboards utilized within SN were pretty basic at first, but the team was able to enhance these tools over time and the communication of performance and progress was very valuable. Impact Advisors also created a custom Excel-based reporting tool that allowed the client to fully analyze and report real-time Orion data outside the web application, including task completion, overall count of tasks completed by date, remaining open tasks, and more
Multiple Waves of Success
Wave 1: First Medical Group – May 2021
Highlights included:
- Successfully deployed ~11,000 devices
- Executed a hybrid training strategy in the face of ever-changing COVID protocols
- Developed project plans and tools that could be used in future deployment waves
Wave 2: Second Medical Group, Medial School, and First Hospital – October 2021
Highlights included:
- Converted over 103,000 appointments in two days
- Brought over 260 outpatient departments live
Wave 3: Acute Hospitals, 50+ Outpatient Centers, and Cancer Center – June 2022
Highlights included:
- The first go-live involving all service lines, including several highly complex workflows
- A “soft go-live” of 400 Cadence users involving the manual conversion of 4,000+ appointments (and validation of ~27,000auto-converted appointments) from eight heritage systems and some paper departments
Wave 4: Outpatient Medical Groups – October 2022
This activation was complicated by the acquisition of a key cardiology practice from a competing organization – one with which the project team wasn’t able to engage until mere days before go-live.
Wave 5: 3 Acute Care Hospitals and the Final Medical Group Practices – October 2023
With this go-live, the organization is now using Epic in 11 of 12 acute care hospitals, the cancer center, and in 100% of the combined medical group. This major milestone also added 12,000 more users to the Epic system, which was the target for officially retiring its legacy system.
Wave 6: Last Acute Care Hospital, a Hospital within a Hospital, and Behavioral Health Care – September 2024
The final wave of go-lives will include an acquired hospital (the first facility without any legacy system alignment to the organization) and a specialized children’s hospital—essentially a hospital within a hospital. With 15 different locations, this hospital includes a state-of-the-art inpatient and rehab facility, numerous outpatient facilities, and a long-term care facility, all with unique workflows that the team is combing through now. And finally, wave 6 will include the Behavioral Health service
line, which has required subject matter experts to ensure the client’s Epic build/workflow complies with state/federal regulations.
“Impact Advisors listened and challenged, kept me aware and proactive, and helped me avoid ‘rabbit holes.’ They also did a good job of telling us what not to do and what might not be good for [us]. I found real value in that.”