One Institution’s Experience With Implementation of EPIC/Beacon: Lessons Learned

The University of Colorado Hospital (UCH) has seen incredible growth over the last 10 years, and in 2009, hospital leadership made the decision to replace multiple interfacing systems with “EPIC”-EPIC Systems Corporation’s flagship product. This decision meant that the University of Colorado Cancer Center would need to replace its previous oncology electronic medical record (EMR) with EPIC/Beacon.

The University of Colorado Cancer Center is a National Cancer Institute Comprehensive Cancer Center that in 2012 had 4,500 new patients and 54,000 patient visits. The clinical arm of the Cancer Center currently has approximately 500 employees involved in both the inpatient and outpatient operations. All clinical operations for the Cancer Center occur at UCH or its satellite facilities.

Implementation of an EMR is never an easy task, but it can be made more palatable through detailed functional and technical planning efforts on the front end. Getting the appropriate users (physicians, nurses, pharmacists) to spend time in these planning efforts can be one of the biggest challenges-but one that must be met to ensure success. The Cancer Center, Ophthalmology, and Solid Organ Transplant services were among the last clinics to go live because each required the added layer of a specialty EPIC module for their respective service. Beacon is EPIC’s oncology module; it allows physicians and other providers to create treatment plans and supportive care regimens based on standardized protocols but also allows for easy modification. The treatment and supportive plans must be built in advance of the go-live.

The Culture Shift

It is often said that “culture eats strategy for breakfast.” Implementing a new EMR in a busy clinical environment can be impossible without initial buy-in and commitment from the key stakeholders and users. Human nature makes change difficult, and users are often reluctant to give up their current workflows. In an effort to create a high-functioning EMR that would serve both clinicians and patients well, the mantra for the institution became “why not EPIC?” UCH began to work with EPIC implementation experts, system analysts, physicians, and other clinical staff to make the vision of one common medical record a reality. Broad-based institutional commitment and internal marketing helped provide the activation energy needed to propel the project; their importance cannot be overstated.

Detailed Preparation

Beacon Tips & Tricks

Place all medications related to a patient’s oncology treatment in Beacon and everything else in “meds and orders” in EPICare. The orders flow differently through the system and should be segregated for the cleanest patient record.
Spend the time to build treatment plans that follow NCCN guidelines. All treatment plans can be easily modified to suit the needs of a specific patient. Starting with an NCCNrecommended treatment plan ensures that every physician has a good base plan to work from.
Physicians should sign all orders in the treatment plan; they can be modified on the day of treatment if necessary.

The Cancer Center was scheduled for go-live on July 24, 2012; both EPICare (EPIC’s general hospital application) and Beacon were to deploy concurrently. Nine months prior to go-live, several EPIC workgroups were formed, including key representatives from each oncology clinical area, to discuss current workflows and how those would be replicated in the new system. Each workgroup went through the EPIC workflows step-by-step to validate the new process against the current workflows. Members of each group were given notecards (pink [meaning “will not work”], green [meaning “could work but needs addional investigation”], and yellow [meaning “works-move forward”]) to be used for voting on each process. If more than 50% of a group voted either yellow or pink with regard to a particular process, that process had to be re-evaluated before it could be considered ready for successful implementation. This approach continued for several months until all the oncology workflows had been validated and approved. This process brought to light several workflows that needed to be evaluated on a deeper level prior to go-live. It is important to understand that implementation of a new EMR does not fix current workflows, and in fact will often amplify existing problems.[1]

Oncology Chemotherapy Treatment Plan Conversion

UCH spent one full year prior to go-live in preparation for using Beacon. A team of practitioners was assembled that included physicians, pharmacists, nurses, and research and IT personnel to work through the validation and building of the chemotherapy treatment and supportive oncology care plans. The previous chemotherapy administration system included over 600 unique treatment protocols, but many were redundant and could be retired or modified to provide standardization. Each plan required a revalidation to determine its adherence to the current evidence-based treatment/standard of care and thus the necessity of its conversion to Beacon. It is important to note that each member of the validation team-with the exception of the IT personnel-had no change to their daily workload; validation was an added job duty for already maximized team members. This created another level of difficulty in expediting the process of revalidation. A Sharepoint website[2] (a Microsoft collaboration tool) was developed and used as the repository for all aspects of the go-live preparation; the site’s dashboard listed individuals and their current treatment plan validation workload. This provided a central location for monitoring the current status of the project, the work of individual team members, and progress toward the goal.

The validation process was split into tiers: Tier 1 (T1) validation was completed by a pharmacist and a member of the research team; Tier 2 (T2) validation was done by the oncologist. The role of the pharmacist included checking medications and dosing in each treatment plan. The research role (for protocols that were part of a research study) was to validate the treatment plan against the requirements of the study. T2 validation included reviewing the treatment plan and making any recommendations for modification. If the plan required changes, it was sent back to the developers and then sent back through T1 validation.

Tips for Successful Implementation of Any Oncology EMR

Involve physicians. Physicians must be engaged and involved in the building of the system and workflows in order to be able to utilize the system successfully. They are the primary users of the treatment plan module and must be integral members of the development team. Physician buy-in is critical to the successful development and implementation of any EMR.[3]
Standardize workflows. Standardizing workflows across all practice areas allows teams to help each other rather than having to turn to the system to address issues. Having “standard work” be a part of the implementation is critical and allows for a more efficient operating environment post go-live.
Streamline faulty processes. Implementation of an EMR will not fix broken workflows. It will however, highlight the issues in a way that can often paralyze patient care. If an organization can spend the time before an implementation to address and streamline workflow issues, the EMR should result in an overall improvement in the efficiency and safety of clinical care.[4]
Accept that any EMR has limitations. No system will provide every user with all the functionality desired, and this must be accepted at all levels across the organization. It is hoped that when an EMR is evaluated by hospital leaders, they take into account all the most important aspects of patient care, from treatment to billing and everything in between.
Carefully evaluate your IT department and resources prior to go-live. System knowledge is critical to successful deployment, and IT staff must have the skills to support the new and existing systems. It is also important to plan for optimization after users have settled into using the new EMR. In the year leading up to an implementation, users are focusing on daily workflows and are not able to address the more specific needs of a specialty or department. Planning ahead and building resources for optimization into the process allows the institution to maximize the knowledge base and create the best system possible. Staff can become system experts and continue to work with representatives from the software vendor to address issues that simply could not be addressed prior to implementation.

In January 2012, a Beacon UCH Project Manager was recruited to ensure that all treatment plans were appropriately validated by the July 2012 deadline. The process slowed for two primary reasons: (1) pharmacy and research did not have staff with enough dedicated time to review protocols in the required timeframe, and (2) physicians were not aware they had work to do on the final T2 validation step and often needed prompting and assistance to utilize the validation systems. The treatment plans were built into a test version of EPIC, which proved difficult to use since formal Beacon training had not occurred. A group formed by the Project Manager met weekly to evaluate the progress, re-engineer the process, and keep the validation moving forward in order to meet new deadlines. The re-engineering included committing specific pharmacist and research time for validation and setting up a workflow that made IT personnel available for physician assistance. A pager was dedicated to the IT staff and passed around so that one member was always available to assist a physician whenever he or she was doing protocol validation. An analyst could assist over the phone or in person if necessary. Weekly analysis of the progress and dedication of time for personnel to assist in the revalidation process made a significant difference in meeting the new deadlines. The validation process continued after the go-live and still continues today for all new treatment plans and modifications to existing plans.

Another important aspect of implementation was the conversion of active patients from the existing EMR to “EPIC/Beacon.” This required all patients on active treatment to have a treatment plan assigned in the Beacon test environment. The test environment was then converted to production at go-live. Having the treating oncologist do the actual patient conversion provided an excellent training opportunity and was an integral part of the preparation. Physicians who had a larger number of patients on existing active treatment spent more time doing conversion and consequently were more adept at using the system on the first day of go-live. The physicians used their knowledge from training and the assistance of moderators to successfully convert over 600 treatment patients to Beacon within the 2 weeks prior to go-live. The conversion had a significant positive impact on patient care following the Beacon implementation.

Ready for Launch

Go-live was scheduled for Tuesday, July 24, 2012, for the Cancer Center, Ophthalmology, and Solid Organ Transplant services, which included over 18 separate outpatient clinics and the Cancer Center infusion center. The institution of an EPIC command center fully staffed with trained analysts allowed for quick access to assistance. The command center was also used as the central repository for all system-wide issues that required additional development. Several months prior to the go-live, clinics reduced provider schedules up to 50% to allow additional time for working with the new system and for making the required changes in clinic workflows. This allowed the clinics to implement new workflows and learn to use the system without significantly delaying patient care.

Dedicated EPIC analysts were assigned to each clinic-several analysts if necessary, depending on the size of the clinic. The analysts’ role was to assist the clinical staff and physicians with any system questions and to alert the command center when larger system issues were discovered. The analysts were physically located in the clinic from its opening to its closing each day, and they often stayed past closing to assist with larger issues. Each clinical area was provided with large Post-it notes hung in central clinic locations where any team member could write and post a question or problem. This eliminated duplication of questions and allowed answers to be posted for use by the team. Daily 15-minute huddles occurred in each clinical area; these huddles included the Chief Information Officer, EPIC Project Manager, Chief Medical Information Officer, Subject Matter Experts from other practice areas already live on EPIC, the Practice Manager, and EPIC analysts. The huddles provided a forum for discussing issues encountered in the clinics. Often, questions could be answered during these stand-up meetings; more challenging questions were forwarded to EPIC’s central office, depending on EPIC’s ability to provide a solution. Issues related to workflow were addressed by the Subject Matter Experts and Chief Medical Information Officer.

Looking Backward

Overall, the implementation went well for UCH, albeit with some lingering workflow and system issues. One such issue was Beacon’s inability to provide a single location where a clinical snapshot of a patient could be viewed. The system required too many mouse clicks and different screens in order to see the chemotherapy treatment flowsheet, lab results, height, weight, oncology treatment, blood administration, and orders for a given patient. This issue was corrected within 60 days of go-live. Representatives from EPIC worked to provide the oncology team with a new feature called “Synopsis,” which provides one location where all the pertinent information can be seen; this is particularly valuable for the Cancer Center infusion center.

Any EMR implementation can be fraught with problems and unintended consequences, but these can be minimized with thoughtful preparation. One year focused on an implementation seems to be the “sweet spot” for time well spent on predevelopment: more than one year and you may experience redundancy in development, given the length of time until implementation; less than one year and there is not enough time to complete the tasks necessary for a smooth go-live, and that can affect patient care.

A recent survey of the medical oncologists and oncology nursing staff at UCH showed that 71% of physicians feel Beacon has made patient treatment easier for providers. UCH had an existing oncology EMR; however, integration of the new oncology EMR (Beacon) with the full EMR (EPICare) has made it easier for the care team to see the whole patient record (imaging, pathology, etc) and to access all information when making treatment decisions. Well over half of the nursing staff feel Beacon has made it easier to provide safe care for patients; they cite the ability to see the whole patient record.

Financial Disclosure:The authors have no significant financial interest in or other relationship with the manufacturer of any product or provider of any service mentioned in this article.

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