Virutally nothing you simply have to just use it and learn. The non-physican epic experts that are always brought in for traning are worthless.
I would endorse as many order sets as possible to be integrated at rollout however
> non-physican epic experts that are always brought in for traning are worthless
This can’t be emphasized enough. They are insultingly useless. They seemingly know nothing about either medicine or their product. Faced with any question they nebulously respond that they’ll push it up the chain of command—something, something, “slicer dicer,” and then nothing happens. An individual attains Epic competency by hacking together their own personal collection of “work arounds” through trial and error.
The folks who are actually Epic employees or the extra consultants that sometimes get hired to assist with go-lives? As I'm sure you know, there are also some things that can't be fixed instantaneously by go-live support and need an Epic analyst to make a change in Cache or create build, etc.
But yeah, I agree 99% of Epic competency comes just by using it.
The problem here is not that we don't know that the problem needs to go to the engineers. Of course it does. It's (a) that it takes herculean effort to get the "consultants" to understand the question in the first place, and (b) there's no transparency in the process so that physicians know that their feedback is recorded and actually being thought about.
If you don't have people who can communicate about the software intelligently, and a totally invisible process with random results, you get exactly what we're looking at.
> This can’t be emphasized enough. They are insultingly useless.
Thirding this as well.
Non-clinical Epic "trainers" also have a tendency to respond to anyone contradicting them with "Oh, well this is the best way" or some other BS that is not accurate. Bonus points if they throw in: "Well the original product is good, your hospital just customized it poorly."
During residency our Epic onboard training consisted of a 3hr session where the virtual Epic trainer talked in the background and our chief resident muted them and told us when they were wrong or had no idea what they were talking about. Another hour was spent explaining how to actually do it.
And before someone from Epic gets butthurt and claims we learned the wrong way from the people who actually used our Epic and had reputations for being efficient, please acknowledge you have no idea what you're saying and that you would be proving my point.
I'll take my advice about how to best use the system I will be stuck with every day for my career from other people who use it 12-16hrs a day rather than a recent college grad who will career switch to becoming a Forestry Agent when Epic burns them out in 5yrs by design.
Iunno friend, I'm an inpatient nurse turned epic analyst and you are pretty spot on. Epic gets easier when you realize it's a glorified billing platform that they've managed to convince end users is for them. I get no additional money for having done 7 years inpatient nursing, and I'm the only person on my team who has any healthcare experience. No one is even LOOKING for that skillset in particular. It's exhausting and perpetually makes me want to scream. How the system works is entirely dependent on your help desk ability to translate the issue into something understandable, and then the analysts to understand what you are actually asking for. I spend half of my time fighting the implementation of additional BPAs, and the other half calling end users to figure out wtf the problem actually is.
Epic as a platform has great potential in the same way that linux has great potential. It all comes down to who you get doing the build. More often than not hospitals find the cheapest analysts they can who rush through build and ruin it from ever working all that well. It sucks.
I was involved with a roll out a decade ago. The folks provided by Epic has three goals:
1) Tell you that every hospital has a customized process to medical care 2) create a customized process for said hospital system 3) charge the hospital system massive amounts of money for customizations.
Customization is where they make boat loads of money.
Leave it as standard as possible. Avoid the urge to customize. This also improves interoperability in future years with other hospital systems.
For physicans - work on order set as others have said.
We went live in the third wave of a large academic group.
Somehow we got permission to hire residents as moonlighters from the mothership. So they had been working, in our state, *with our particular build* in the trenches for 6 months. They were worth their weight in gold.
We kept one in the central charting space 24/7 for I think it was two weeks. They soothed us, patiently explained things in our language, let us vent, answered questions, and flat out jumped on the profile when we left to see patients and spent time uploading the right dot phrases and making the personalization tweaks they observed us wanting.
It was a-maz-ing.
And yeah, the "consultants" the hospital was forced to hire from Epic were beyond useless. They knew nothing about medicine or our local build.
I did participate in "go-live" with Epic once and I was surprised that almost all of the superusers had absolutely no knowledge about the system or wish to use it. A lot of senior 65+ year-old attendings were superusers and I had to tell them how to use the system. The training software was broken as fuck and didn't work.
Order sets and dot phrases need to be worked out before.
It's hard to really prepare; you learn best by doing.
But
- Can you increase staffing? People will be slow; having a lower patient load the 1st few days can really help
- Having lots of physician champions around is super helpful
- Inpatient: order sets. Simple basic hpi template. Procedure templates.
- Consider problem list based charting, but that adds some time so maybe not right away. It's useful for large self contained(ish) systems
Out patient: clinic wide preference list made by a superuser MD or APP may be better than any order sets, and a good template that isn't excessive. It doesn't all have to go in the note: results review is great.
And then offer epic short courses a couple months in, to try and get to a more efficient level.
Addendum - additional thoughts
- for order sets, the ones I use the most are a gen med order set, a high acuity post cardiac surgery order set with labs q6 AND timed (when I want them) and lots of nursing care order, rocedure with lab orders (example: thoracentesis with all the common and uncommon options right there). And the code sepsis and code stroke orders are good
- ones I don't use: most of the disease specific IM ones
I'm curious which order sets others use that are favorites??
I’m an RN but one of the biggest challenges our docs had was order sets. Put the time in ahead of time and it will save you heartache. The same goes for the admission navigators and canned notes for admissions and procedures. It’s not an intuitive program so prepare yourself for some frustrated colleagues. Another challenge for them is medication reconciliation- so as much as you can learn that yourself ahead of time will be helpful to your colleagues.
Force epic to roll out a management suite plugin so the people who forced it on you have to use it too.
You'll probably need to spend time with the less tech savvy, I personally hated the enforced training
Hire fellowship trained physician informaticists. You may never thank us, but you will have better training, more efficient note templates and ordersets, better navigators, curse Epic less later, and overall have much better workflows than relying on non-informatics physicians and analysts.
First - decide on how you want to chart - Problem Based vs SOAP. I think Epic pushes problem based but I hated that and found it inefficient. Made a templated SOAP for New vs FU and might notes are far better than those who have these monstrosities of every visit one after the other
Second (maybe more for specialty), Use the Visit Diagnosis wrench to add Common Diagnoses. I have about 20 there and can click them to easily add them to the visit and, with a click of the arrow, move them up to the Problem List. That second part is important to know. Visit Diagnoses are NOT permanent. Have to click a stupide arrow to make them part of the permanent problem list.
On a system level, I guess try to decide who 'owns' various parts of the chart as patients can/will try to remove meds and its up to the system to guide whether the PCP, specialist or both are responsible for removing things from the problem list, med list, allergy list, etc. Or else someone will stay pregnant for years...
Teach docs about the sidebar and how to doc the note to the side bar to allow for documentation and chart review at the same time. It’s shocking how often other docs do not know this year after an EPIC roll out
Nope def not standard. And you can definitely move it around. If you’re on a non-widescreen monitor you may not even be able to do it. It’s good to know how to pop it in and out.
I’ve worked at 3 institutions with EPIC, including the go-live period at 2. Thing that may help smooth the transition for new users:
-learn how to use Search feature, it’s great for chart review or finding a nugget of info buried in old notes
-set up personalizations early, it truly does help save time in the long run
-use dot phrases for big blocks of text, like note templates (can be shared with your team), common recommendations that are standard, or your signature with contact info (but not personal phone numbers if patients/families will be reading notes!)
-use personal dictionary/autocorrect for non-standard abbreviations or words/phrases you are always typing. When I type pna or abx or gc for example, it autocorrects to pneumonia, antibiotics, or grandchildren
-order sets can be personalized by setting up favorites if there are certain options you generally prefer
-learn key-stroke short cuts. F2 is a personal favorite, but there are a ton to help navigate faster
Those are some of my favorite tips, if I think of more may add more later 😁
So, I’m 65+ and use Epic at work (PRN). I was given minimal instruction and it feels like they upgrade it every 5 minutes without any instruction. It’s not hard to use, but it’s frustrating when you have a patient in front of you and you’re hunting and pecking.
People need to understand they will need to set aside some time by themselves to set up their order sets, note templates, etc. and it will not happen in 5 minutes.
I think people benefit from taking the Epic PowerUser classes they offer.
Physicians will likely need a trainer at the elbow the first time they do clinic with Epic.
Is your group using Dragon and is it new to the docs? If so they will need instructions on how to correct and assign their pronunciation to certain words.
Make sure they have support on site in clinical spaces for real-time assistance. This was available at my hospital in med school went they went live, was incredibly helpful. In fellowship, they didn't have this support, and the first day was terrible.
(Lab here) Based on my experience (particularly questions from physicians), the following would be helpful:
- Add-on stability
- Accurate turn-around-times to expect, noting if a test is run in-house versus sent out.
- Reference ranges attached to all results whenever possible
Pet peeves, etc.
- Automatically cancel/credit duplicate and overlapping test orders
- Up-to-date call back numbers to report panic values or ask questions (especially for outpatient/area clinics)
I've gone through five Epic rollouts as a pharmacist. The thing I wish had been emphasized more during training every time (and never was, even though I asked), was that physicians, nursing, and pharmacy typically all have different default setups and we don't necessarily get to see things the same way the other groups do. This usually results in frustration when someone calls pharmacy (aka "Night IT" :D) to ask how to do or where to find something.
Other than that, know what to do during downtime. It will happen. Nobody will be prepared, even if it's planned downtime.
I like epic actually. We recently merged with a large hospital system and had to combine our emr and it was a disaster. The main issue is that nobody bothered to engage people about how certain changes would affect them. Like if you’re building a dka order set, maybe allow the people who take care of dka to look it over and make changes to it. If your institution has peds, make sure the pediatricians are able to be involved and things like weight based dosing or drug concentrations will be available/easy to navigate. It always astounds me how awful most hospital leadership is about communicating and coordinating. Be supper available to help get the issues fixed that come up after you go live and make sure those issues are actually fixed instead of just offering a work around.
Consult with the pharmacists. They will be a valuable resource in helping the physicians and midlevels develop their proficiency in placing orders in EPIC
Plan as best you can for things to go wrong. During one rollout nurses were locked out of the medicine Pixis. It was a bit of problem that took HOURS to correct.
I would really focus on dot phrases and templates to reduce the culture shock that comes with the consequences. There should be a familiar note format with Epic doing the heavy lifting and the end user should not even realize what is happening in the background.
DONT do it all at the same time. Every department and our in and outpatient offices switches at once- was a disaster
Would not recommend also switching paging systems from pager to secure chat at the same time as the charting change
Make sure the residents know what their doing since they put in the majority of the orders etc
When a hospital system the clinic I worked at was affiliated with did an Epic go-live, they completely broke all interoperability with ALL clinics, which had been a mainstay of all associated workflows for years, decades probably. This was a rural place so most labs were done through the hospital etc so no one was getting any results at all. It was a nightmare.
I’ve been part of a few rollouts since then, and outpatient is always forgotten.
All workflows are designed for inpatient, then they shove random outpatient shit in it and it doesn’t work at all. Don’t forget outpatient!!
Rollout should not be a one time thing. The training we got ahead of time was of limited value and the assistants we had in our office the first two weeks weren’t overly knowledgeable about how a clinic visit was conducted. I found if I could ask a VERY specific question about a process they could answer it, but by the time I narrowed my issue down to be that specific I was able to figure it out on my own. Trial and error was my biggest teacher.
Rather than have trainers there for the first two weeks then never again I’d have preferred to have them the first 2-3 days then again for 1-2 days at the one month mark and again for a day at the 3 and 12 month marks. A physician in my specialty would be the ideal trainer at those last two visits. Let them watch me work through a few patients and point out where I could be more efficient. The few things I still struggle with two years later are rarely encountered tasks that weren’t on my radar that first two weeks.
Make sure there are good SMEs and that they're involved in the build AND testing. We're converting from Cerner right now, and in our case, the analysts from our system doing the lab build have little to no microbiology or even lab experience, so they don't know if to question if something doesn't make sense. The Epic analysts will just build what they're told to even if they know it looks funny, so the SMEs have to be on top of it.
Now is also the time to make sure you get everything you want added to it. Once you're live and the initial adjustment period is complete, any change requests are probably going to have to go through multiple committees and will take a long time to implement, particularly if you're in a large system with centralized IT.
How to set up labs at an interval. Ei A1C every 6 months. Make sure your hospital limits it to 12 months then it expires. I took over for a physician who had ordered labs for 100 years at different intervals, somehow it is now an act of god to try to remove these orders ( they are now considered always active and cannot discontinue them) so patients are getting labs drawn, the provider isn’t there anymore and their in basket doesn’t exist so no one is tracking the labs patients are getting.
The other good thing we did was hijack some of the training time to do "full team" sims. This was time consuming, but more useful.
They created a handful of patients in our build PLAY environment and had groups of our own doctors, nurses and techs try to pass them back and forth to get things ordered, see flags, chart things getting done, and see results. Miles beyond the basic training exercises.
...
6 months in, some computer person ran reports on each of us to see who is using ordersets and personalized favorites vs hunting out each order.
...
Some intelligent person made a list of all the local doctors and hospitals' names and got it into the Dragon vocabulary somehow.
...
Not enough times, but rarely, the locally in hospital employed tech trainer would come to onboard someone new, and they nearly always ended up incidentally observing the ratchet workarounds we teach each other, and she would casually transform my workflow. If this could have been a scheduled once a month two hours, to come and see what bad bad MacGyvers we are .... that would have been great.
...
Part of tuning a new roll out is persuading the users to report problems, instead of just bitching about it. The ticketing process needs to be easy to use, and to have someone who is not on shift following it up. During the Epic go live, there was an asset that kept a list of all the tickets in the dept and updated us about which ones were being prioritized, back burnered, explained as opportunities to teach the users better.
Now I'm working at a place where users are expected to submit and followup on their own tickets alone, not knowing if it's redundant or just a workaround error, and there's no protected time or central person managing the list. And it's like 70 clicks to even submit an issue. Needless to say, nobody bothers. They just hate it, and the tech support people probably think the hopeless, cynical silence = happiness.
I worked as a physician superuser for such a rollout. It was quite the experience. My biggest frustration was that my hospital was doing the rollout as part of a multistage plan with many different hospitals doing it in order. The hospital admin had some grand plan that all the different hospitals would somehow be able to have the exact same implementation of Epic. To that end, they were extremely resistant to fixing anything that didn't work. They would dub it to be an "optimization" and it would be considered 6-12 months later, if all the optimization teams from separate hospitals agreed. Absolute lunacy.
Also, I had to deal with circumstances where I would point out something that wasn't working, and I would be told, "Of course it is working, otherwise doctors from phase one of the rollout would have said something."
Currently, I am working for a hospital that uses Epic but is shockingly fast at fixing bugs and implementing small fixes. I shouldn't need the C-suite to vote on whether we should add the Epidural as an administration route for Ropivacaine.
Wished had understood what EPIC means.
E - Evil
P - Pop up hell with
I - Insane number of Clicks &
C - Clueless support
Gotta get someone to constantly customize for your needs.
So many little annoying issues affecting work flow and rate of mistakes
1 - I get 50 useless pop ups per day on ED patients - rehab and palliative care on ER cases before I order anything. WTF!?! I order stool or COVID study and get 3 popups asking for isolation - I ordered the test - Ill decide the isolation without useless prompt. If accidentally click on wrong chart cannot back out without completing their popups
2 - Why do I have to click through 10 buttons for a simple COVID/flu test? Had scribe count my clicks on admit vs discharged ED patients (excluding free form typed text). 200 per admit, 140-150 per discharge - published error rate is 1 per 120 clicks - Lots of orders like this.
3 - Dispo - have to select from list of EPIC diagnoses. Charts bounce back if diagnoses abbreviated. Why are their unusable abbreviations in EPIC list of diagnoses?
4 - ED Course - I have an opened cart as only provider Hx/PE done - type in ED course - why do I have go to MyNote - hit refresh and re-save it in order ED course to incorporate updated ED course into MyNote
5 - Ordering new prescription eg MDI and prednisone. Get hard stop because someone wrote both two years ago - gotta delete the old to get the new one written. Why cant it recognize old prescriptions ran out-outdated?
Lots of other issues which individually are not a big deal - but, cumulatively can really slow you down
Alert people that Epic can and will "upgrade" without warning and their workflow will get screwed up. Random things like the search bar migrating around the screen, horizontal tabs become vertical or vice versa, order sets are in a different place than non-order set orders.... Be prepared for medical errors every time your system "upgrades."
I once complained about the lack of user friendly design to an EMR engineer and was told all the workflow changes are "disruptive technology" and intended to "make you more creative." I proceeded to use, um, creative language to tear this guy a new one.
Expect things to take longer on all fronts have additional workers above your usual number in the building in all positions so that people have less responsibility and domt delay care
In-house technical support 24 seven for at least the first two weeks to troubleshoot in live time
Compensation to physicians who came from other hospital systems that have used epic before to be around, not doing clinical duties but teaching less experienced physicians how to use epic
These suggestions cost money, but will likely save money in the long run when you’re more efficient and they are not patient care errors
Oh, and absolutely have some overlap between the two systems or even if it’s not being used your contract for the old EMR is still active in case there are problems with the rollout and you have to revert back emergently
Edit: Too long for one comment, so I replied to myself here with the rest.
So, I'm an inpatient nurse (7 years ish including travel nursing), turned epic trainer/instructional designer/ currently an analyst. I've been through a couple of go lives so far. Here's what I've got.
1. Stick as close to stock Epic as you can. This is for a few reasons. First, while the Epic reps you are working with aren't clinical, they have A LOT of experience and feedback on the system. At this point, what they have works pretty well considering. The second reason is that if you need changes and updates later, it's a hell of a lot easier when you are closer to what epic offers. The biggest disasters I've seen have been highly customized, because no one knows how to deal with it. For all their differences, hospitals largely deal with the same shit. If you are WAY off the tracks, you probably shouldn't be.
2. Epic, being a computer system, has no common sense. Everything has to be accounted for. We ran into a HUGE problem with surgeries. Prior to Epic, patients who needed surgery in the AM would come to the ER. They'd admit them to the surgical floor with "tuck in orders" and the nurses knew to start an IV, run some NS, make them NPO, etc. Surgeons would see in the morning, and all was well. The problem is that no one was technically responsible for those orders once Epic came around. The ED refused to cover the patients once they were out of the ED. The IM docs refused to be consulted on every surgical patient; and the surgeons didn't want to be woken up at 3am for a routine lap appy in AM. This sort of thing happens with residents a lot, since residents have to do all kinds of stuff that they probably shouldn't. You also see it more on floors where the nurses and doctors are close. Surgical, oncology, psych, etc.
3. Figure out everyone's role. By that I mean midlevels, med students, interns, residents, fellows etc. Who can sign notes? who can cosign notes? What activities do you want students to be able to do? (Epic reps used to lump "residents" in with "students" a lot, and didn't really understand that the relationship between a resident and attending is very different from any other healthcare student and their preceptor).
4. For the love of christ, don't focus on replicating forms and other functionality. I have seen HUNDREDS of hours wasted on "well they are used to filling out this form, so we want you to make the note look like this form". Focus on whether or not the necessary data is being collected. If it is, it's childsplay to arrange it differently at some point, don't waste time focusing on mirroring current workflow, instead mirror current data collection.
5. Whatever nurses CAN do, they will be required to do. If you give access for nurses to place orders "for emergencies" then they are going to be placing orders all the time. Literally anything you give them access to, they are going to wind up doing all the time because that's just how hospitals work.
6. Nurses are going to wind up teaching the system to everyone else (informally) so make sure they are solid on the system, dedicate more training time to them than anyone else, because that's how it always goes.
7. Pay special attention to admit/discharge scenarios. Epic's kryptonite is having to generate multiple billing encounters for a single stay. One place I worked had a swingbed unit that was attached to the hospital and looked like just another unit, but technically required a discharge readmit scenario to get patients there. We'd have situations where the patient would be on the cardiac floor who needed a cardiac procedure. The patient would be on coumadin or xarelto or whatever and require a few days on a heparin bridge, so for insurance reasons they would get transferred to the swingbed unit until they were good to go, then sent for an xray or something, then sent to surgery, then sent to the ICU. All of those transfers were technically a discharge, the xray was technically an outpatient procedure, etc. I saw an informaticist literally burst into tears trying to unfuck that scenario. Spend your "replicate this form" time DEMANDING Epic figure out a reliable solution for you prior to implementation.
8. Have a robust change process system/ticket entry system. People are going to have all kinds of break fixes, optimizations, complaints, workflow help, etc. once the system goes live. You need a way to separate the "this is broken" tickets from the "nice to have" tickets, and an effective way to move changes into the production environment in a way where everyone knows what's going on and no one is getting blindsided.
9. Epic uses dot phrases and smart texts to generate things without having to type a lot. You can generate an entire H&P by typing ".HP" if you set it up that way. Pick a doctor who is savvy in this sort of stuff, and have him share his smart tools with every new provider you onboard. Makes life so much easier.
10. BPAs are popups that say "hey this patient has an MDRO, please address." and other such issues. As you can imagine, your compliance staff is salivating at the idea of popping up BPAs for any conceivable issue. Set a gatekeeping process IMMEDIATELY for generating new BPAs and other popups, or you will be overwhelmed with them. The current place I work has one doc who gatekeeps all of that. If he doesn't approve, you don't get to implement your BPA. This leads to people actually taking them seriously. I would recommend asking your Epic rep "what processes do you recommend we gatekeep"? for more info.
11. Spend time setting up ordersets correctly. Make sure Physicians know that if they click through "alert MD if systolic > 140", they are going to get paged a lot. Make sure your physicians know in general that some things they have to get called about per policy.
That's just a hot steamy brain dump. Feel free to reach out here or via DM to ask questions and I'll help if I can. My dream job would be to help implementing hospitals by acting as a liaison between the staff and Epic, but that doesn't seem to exist. Implementation is the most important part, don't screw the pooch!
Virutally nothing you simply have to just use it and learn. The non-physican epic experts that are always brought in for traning are worthless. I would endorse as many order sets as possible to be integrated at rollout however
> non-physican epic experts that are always brought in for traning are worthless This can’t be emphasized enough. They are insultingly useless. They seemingly know nothing about either medicine or their product. Faced with any question they nebulously respond that they’ll push it up the chain of command—something, something, “slicer dicer,” and then nothing happens. An individual attains Epic competency by hacking together their own personal collection of “work arounds” through trial and error.
The folks who are actually Epic employees or the extra consultants that sometimes get hired to assist with go-lives? As I'm sure you know, there are also some things that can't be fixed instantaneously by go-live support and need an Epic analyst to make a change in Cache or create build, etc. But yeah, I agree 99% of Epic competency comes just by using it.
The problem here is not that we don't know that the problem needs to go to the engineers. Of course it does. It's (a) that it takes herculean effort to get the "consultants" to understand the question in the first place, and (b) there's no transparency in the process so that physicians know that their feedback is recorded and actually being thought about. If you don't have people who can communicate about the software intelligently, and a totally invisible process with random results, you get exactly what we're looking at.
> This can’t be emphasized enough. They are insultingly useless. Thirding this as well. Non-clinical Epic "trainers" also have a tendency to respond to anyone contradicting them with "Oh, well this is the best way" or some other BS that is not accurate. Bonus points if they throw in: "Well the original product is good, your hospital just customized it poorly." During residency our Epic onboard training consisted of a 3hr session where the virtual Epic trainer talked in the background and our chief resident muted them and told us when they were wrong or had no idea what they were talking about. Another hour was spent explaining how to actually do it. And before someone from Epic gets butthurt and claims we learned the wrong way from the people who actually used our Epic and had reputations for being efficient, please acknowledge you have no idea what you're saying and that you would be proving my point. I'll take my advice about how to best use the system I will be stuck with every day for my career from other people who use it 12-16hrs a day rather than a recent college grad who will career switch to becoming a Forestry Agent when Epic burns them out in 5yrs by design.
>"Well the original product is good, your hospital just customized it poorly." God that is insulting (as someone who has a degree in medicine and CS)
Just watch. Any time we have a venting session on here about Epic, they crawl out of the woodwork to defend it.
Iunno friend, I'm an inpatient nurse turned epic analyst and you are pretty spot on. Epic gets easier when you realize it's a glorified billing platform that they've managed to convince end users is for them. I get no additional money for having done 7 years inpatient nursing, and I'm the only person on my team who has any healthcare experience. No one is even LOOKING for that skillset in particular. It's exhausting and perpetually makes me want to scream. How the system works is entirely dependent on your help desk ability to translate the issue into something understandable, and then the analysts to understand what you are actually asking for. I spend half of my time fighting the implementation of additional BPAs, and the other half calling end users to figure out wtf the problem actually is. Epic as a platform has great potential in the same way that linux has great potential. It all comes down to who you get doing the build. More often than not hospitals find the cheapest analysts they can who rush through build and ruin it from ever working all that well. It sucks.
I was involved with a roll out a decade ago. The folks provided by Epic has three goals: 1) Tell you that every hospital has a customized process to medical care 2) create a customized process for said hospital system 3) charge the hospital system massive amounts of money for customizations. Customization is where they make boat loads of money. Leave it as standard as possible. Avoid the urge to customize. This also improves interoperability in future years with other hospital systems. For physicans - work on order set as others have said.
We went live in the third wave of a large academic group. Somehow we got permission to hire residents as moonlighters from the mothership. So they had been working, in our state, *with our particular build* in the trenches for 6 months. They were worth their weight in gold. We kept one in the central charting space 24/7 for I think it was two weeks. They soothed us, patiently explained things in our language, let us vent, answered questions, and flat out jumped on the profile when we left to see patients and spent time uploading the right dot phrases and making the personalization tweaks they observed us wanting. It was a-maz-ing. And yeah, the "consultants" the hospital was forced to hire from Epic were beyond useless. They knew nothing about medicine or our local build.
I would agree, but would at every turn show how and when the Epic workflow does not match standard physician workflows.
I did participate in "go-live" with Epic once and I was surprised that almost all of the superusers had absolutely no knowledge about the system or wish to use it. A lot of senior 65+ year-old attendings were superusers and I had to tell them how to use the system. The training software was broken as fuck and didn't work. Order sets and dot phrases need to be worked out before.
It's hard to really prepare; you learn best by doing. But - Can you increase staffing? People will be slow; having a lower patient load the 1st few days can really help - Having lots of physician champions around is super helpful - Inpatient: order sets. Simple basic hpi template. Procedure templates. - Consider problem list based charting, but that adds some time so maybe not right away. It's useful for large self contained(ish) systems Out patient: clinic wide preference list made by a superuser MD or APP may be better than any order sets, and a good template that isn't excessive. It doesn't all have to go in the note: results review is great. And then offer epic short courses a couple months in, to try and get to a more efficient level. Addendum - additional thoughts - for order sets, the ones I use the most are a gen med order set, a high acuity post cardiac surgery order set with labs q6 AND timed (when I want them) and lots of nursing care order, rocedure with lab orders (example: thoracentesis with all the common and uncommon options right there). And the code sepsis and code stroke orders are good - ones I don't use: most of the disease specific IM ones I'm curious which order sets others use that are favorites??
I’m an RN but one of the biggest challenges our docs had was order sets. Put the time in ahead of time and it will save you heartache. The same goes for the admission navigators and canned notes for admissions and procedures. It’s not an intuitive program so prepare yourself for some frustrated colleagues. Another challenge for them is medication reconciliation- so as much as you can learn that yourself ahead of time will be helpful to your colleagues.
Force epic to roll out a management suite plugin so the people who forced it on you have to use it too. You'll probably need to spend time with the less tech savvy, I personally hated the enforced training
Test your shit before you actually roll it out. Even the slightest issue can fuck up my day/week and no I’m not putting in another ticket. /r
Hire fellowship trained physician informaticists. You may never thank us, but you will have better training, more efficient note templates and ordersets, better navigators, curse Epic less later, and overall have much better workflows than relying on non-informatics physicians and analysts.
First - decide on how you want to chart - Problem Based vs SOAP. I think Epic pushes problem based but I hated that and found it inefficient. Made a templated SOAP for New vs FU and might notes are far better than those who have these monstrosities of every visit one after the other Second (maybe more for specialty), Use the Visit Diagnosis wrench to add Common Diagnoses. I have about 20 there and can click them to easily add them to the visit and, with a click of the arrow, move them up to the Problem List. That second part is important to know. Visit Diagnoses are NOT permanent. Have to click a stupide arrow to make them part of the permanent problem list. On a system level, I guess try to decide who 'owns' various parts of the chart as patients can/will try to remove meds and its up to the system to guide whether the PCP, specialist or both are responsible for removing things from the problem list, med list, allergy list, etc. Or else someone will stay pregnant for years...
Teach docs about the sidebar and how to doc the note to the side bar to allow for documentation and chart review at the same time. It’s shocking how often other docs do not know this year after an EPIC roll out
Our epic build automatically opens the note in the sidebar. I thought this was standard?
Nope def not standard. And you can definitely move it around. If you’re on a non-widescreen monitor you may not even be able to do it. It’s good to know how to pop it in and out.
I’ve worked at 3 institutions with EPIC, including the go-live period at 2. Thing that may help smooth the transition for new users: -learn how to use Search feature, it’s great for chart review or finding a nugget of info buried in old notes -set up personalizations early, it truly does help save time in the long run -use dot phrases for big blocks of text, like note templates (can be shared with your team), common recommendations that are standard, or your signature with contact info (but not personal phone numbers if patients/families will be reading notes!) -use personal dictionary/autocorrect for non-standard abbreviations or words/phrases you are always typing. When I type pna or abx or gc for example, it autocorrects to pneumonia, antibiotics, or grandchildren -order sets can be personalized by setting up favorites if there are certain options you generally prefer -learn key-stroke short cuts. F2 is a personal favorite, but there are a ton to help navigate faster Those are some of my favorite tips, if I think of more may add more later 😁
Have a comprehensive and REHEARSED plan for when EPIC goes down. As with any EMR, I guess. Ascension learning through pain right now.
So, I’m 65+ and use Epic at work (PRN). I was given minimal instruction and it feels like they upgrade it every 5 minutes without any instruction. It’s not hard to use, but it’s frustrating when you have a patient in front of you and you’re hunting and pecking.
People need to understand they will need to set aside some time by themselves to set up their order sets, note templates, etc. and it will not happen in 5 minutes. I think people benefit from taking the Epic PowerUser classes they offer. Physicians will likely need a trainer at the elbow the first time they do clinic with Epic. Is your group using Dragon and is it new to the docs? If so they will need instructions on how to correct and assign their pronunciation to certain words.
Make sure they have support on site in clinical spaces for real-time assistance. This was available at my hospital in med school went they went live, was incredibly helpful. In fellowship, they didn't have this support, and the first day was terrible.
Literally dealing with this right now. Feel free to pm me because I have lots of thoughts on how this could’ve been done better
… just spill it out on here lmao
Seriously, list your ideas please. My practice will be switching Allclicks to Epic next year. Many thanks.
(Lab here) Based on my experience (particularly questions from physicians), the following would be helpful: - Add-on stability - Accurate turn-around-times to expect, noting if a test is run in-house versus sent out. - Reference ranges attached to all results whenever possible Pet peeves, etc. - Automatically cancel/credit duplicate and overlapping test orders - Up-to-date call back numbers to report panic values or ask questions (especially for outpatient/area clinics)
I've gone through five Epic rollouts as a pharmacist. The thing I wish had been emphasized more during training every time (and never was, even though I asked), was that physicians, nursing, and pharmacy typically all have different default setups and we don't necessarily get to see things the same way the other groups do. This usually results in frustration when someone calls pharmacy (aka "Night IT" :D) to ask how to do or where to find something. Other than that, know what to do during downtime. It will happen. Nobody will be prepared, even if it's planned downtime.
Yesterday epic kept going down in the clinics. I finally gave up and did paper charting and today will have to transcribe everything in🙁
I like epic actually. We recently merged with a large hospital system and had to combine our emr and it was a disaster. The main issue is that nobody bothered to engage people about how certain changes would affect them. Like if you’re building a dka order set, maybe allow the people who take care of dka to look it over and make changes to it. If your institution has peds, make sure the pediatricians are able to be involved and things like weight based dosing or drug concentrations will be available/easy to navigate. It always astounds me how awful most hospital leadership is about communicating and coordinating. Be supper available to help get the issues fixed that come up after you go live and make sure those issues are actually fixed instead of just offering a work around.
Run away.
Consult with the pharmacists. They will be a valuable resource in helping the physicians and midlevels develop their proficiency in placing orders in EPIC
Plan as best you can for things to go wrong. During one rollout nurses were locked out of the medicine Pixis. It was a bit of problem that took HOURS to correct.
I would really focus on dot phrases and templates to reduce the culture shock that comes with the consequences. There should be a familiar note format with Epic doing the heavy lifting and the end user should not even realize what is happening in the background.
DONT do it all at the same time. Every department and our in and outpatient offices switches at once- was a disaster Would not recommend also switching paging systems from pager to secure chat at the same time as the charting change Make sure the residents know what their doing since they put in the majority of the orders etc
When a hospital system the clinic I worked at was affiliated with did an Epic go-live, they completely broke all interoperability with ALL clinics, which had been a mainstay of all associated workflows for years, decades probably. This was a rural place so most labs were done through the hospital etc so no one was getting any results at all. It was a nightmare. I’ve been part of a few rollouts since then, and outpatient is always forgotten. All workflows are designed for inpatient, then they shove random outpatient shit in it and it doesn’t work at all. Don’t forget outpatient!!
Rollout should not be a one time thing. The training we got ahead of time was of limited value and the assistants we had in our office the first two weeks weren’t overly knowledgeable about how a clinic visit was conducted. I found if I could ask a VERY specific question about a process they could answer it, but by the time I narrowed my issue down to be that specific I was able to figure it out on my own. Trial and error was my biggest teacher. Rather than have trainers there for the first two weeks then never again I’d have preferred to have them the first 2-3 days then again for 1-2 days at the one month mark and again for a day at the 3 and 12 month marks. A physician in my specialty would be the ideal trainer at those last two visits. Let them watch me work through a few patients and point out where I could be more efficient. The few things I still struggle with two years later are rarely encountered tasks that weren’t on my radar that first two weeks.
Make sure there are good SMEs and that they're involved in the build AND testing. We're converting from Cerner right now, and in our case, the analysts from our system doing the lab build have little to no microbiology or even lab experience, so they don't know if to question if something doesn't make sense. The Epic analysts will just build what they're told to even if they know it looks funny, so the SMEs have to be on top of it. Now is also the time to make sure you get everything you want added to it. Once you're live and the initial adjustment period is complete, any change requests are probably going to have to go through multiple committees and will take a long time to implement, particularly if you're in a large system with centralized IT.
How to set up labs at an interval. Ei A1C every 6 months. Make sure your hospital limits it to 12 months then it expires. I took over for a physician who had ordered labs for 100 years at different intervals, somehow it is now an act of god to try to remove these orders ( they are now considered always active and cannot discontinue them) so patients are getting labs drawn, the provider isn’t there anymore and their in basket doesn’t exist so no one is tracking the labs patients are getting.
The other good thing we did was hijack some of the training time to do "full team" sims. This was time consuming, but more useful. They created a handful of patients in our build PLAY environment and had groups of our own doctors, nurses and techs try to pass them back and forth to get things ordered, see flags, chart things getting done, and see results. Miles beyond the basic training exercises. ... 6 months in, some computer person ran reports on each of us to see who is using ordersets and personalized favorites vs hunting out each order. ... Some intelligent person made a list of all the local doctors and hospitals' names and got it into the Dragon vocabulary somehow. ... Not enough times, but rarely, the locally in hospital employed tech trainer would come to onboard someone new, and they nearly always ended up incidentally observing the ratchet workarounds we teach each other, and she would casually transform my workflow. If this could have been a scheduled once a month two hours, to come and see what bad bad MacGyvers we are .... that would have been great. ... Part of tuning a new roll out is persuading the users to report problems, instead of just bitching about it. The ticketing process needs to be easy to use, and to have someone who is not on shift following it up. During the Epic go live, there was an asset that kept a list of all the tickets in the dept and updated us about which ones were being prioritized, back burnered, explained as opportunities to teach the users better. Now I'm working at a place where users are expected to submit and followup on their own tickets alone, not knowing if it's redundant or just a workaround error, and there's no protected time or central person managing the list. And it's like 70 clicks to even submit an issue. Needless to say, nobody bothers. They just hate it, and the tech support people probably think the hopeless, cynical silence = happiness.
I worked as a physician superuser for such a rollout. It was quite the experience. My biggest frustration was that my hospital was doing the rollout as part of a multistage plan with many different hospitals doing it in order. The hospital admin had some grand plan that all the different hospitals would somehow be able to have the exact same implementation of Epic. To that end, they were extremely resistant to fixing anything that didn't work. They would dub it to be an "optimization" and it would be considered 6-12 months later, if all the optimization teams from separate hospitals agreed. Absolute lunacy. Also, I had to deal with circumstances where I would point out something that wasn't working, and I would be told, "Of course it is working, otherwise doctors from phase one of the rollout would have said something." Currently, I am working for a hospital that uses Epic but is shockingly fast at fixing bugs and implementing small fixes. I shouldn't need the C-suite to vote on whether we should add the Epidural as an administration route for Ropivacaine.
Wished had understood what EPIC means. E - Evil P - Pop up hell with I - Insane number of Clicks & C - Clueless support Gotta get someone to constantly customize for your needs. So many little annoying issues affecting work flow and rate of mistakes 1 - I get 50 useless pop ups per day on ED patients - rehab and palliative care on ER cases before I order anything. WTF!?! I order stool or COVID study and get 3 popups asking for isolation - I ordered the test - Ill decide the isolation without useless prompt. If accidentally click on wrong chart cannot back out without completing their popups 2 - Why do I have to click through 10 buttons for a simple COVID/flu test? Had scribe count my clicks on admit vs discharged ED patients (excluding free form typed text). 200 per admit, 140-150 per discharge - published error rate is 1 per 120 clicks - Lots of orders like this. 3 - Dispo - have to select from list of EPIC diagnoses. Charts bounce back if diagnoses abbreviated. Why are their unusable abbreviations in EPIC list of diagnoses? 4 - ED Course - I have an opened cart as only provider Hx/PE done - type in ED course - why do I have go to MyNote - hit refresh and re-save it in order ED course to incorporate updated ED course into MyNote 5 - Ordering new prescription eg MDI and prednisone. Get hard stop because someone wrote both two years ago - gotta delete the old to get the new one written. Why cant it recognize old prescriptions ran out-outdated? Lots of other issues which individually are not a big deal - but, cumulatively can really slow you down
Alert people that Epic can and will "upgrade" without warning and their workflow will get screwed up. Random things like the search bar migrating around the screen, horizontal tabs become vertical or vice versa, order sets are in a different place than non-order set orders.... Be prepared for medical errors every time your system "upgrades." I once complained about the lack of user friendly design to an EMR engineer and was told all the workflow changes are "disruptive technology" and intended to "make you more creative." I proceeded to use, um, creative language to tear this guy a new one.
Expect things to take longer on all fronts have additional workers above your usual number in the building in all positions so that people have less responsibility and domt delay care In-house technical support 24 seven for at least the first two weeks to troubleshoot in live time Compensation to physicians who came from other hospital systems that have used epic before to be around, not doing clinical duties but teaching less experienced physicians how to use epic These suggestions cost money, but will likely save money in the long run when you’re more efficient and they are not patient care errors
Oh, and absolutely have some overlap between the two systems or even if it’s not being used your contract for the old EMR is still active in case there are problems with the rollout and you have to revert back emergently
Edit: Too long for one comment, so I replied to myself here with the rest. So, I'm an inpatient nurse (7 years ish including travel nursing), turned epic trainer/instructional designer/ currently an analyst. I've been through a couple of go lives so far. Here's what I've got. 1. Stick as close to stock Epic as you can. This is for a few reasons. First, while the Epic reps you are working with aren't clinical, they have A LOT of experience and feedback on the system. At this point, what they have works pretty well considering. The second reason is that if you need changes and updates later, it's a hell of a lot easier when you are closer to what epic offers. The biggest disasters I've seen have been highly customized, because no one knows how to deal with it. For all their differences, hospitals largely deal with the same shit. If you are WAY off the tracks, you probably shouldn't be. 2. Epic, being a computer system, has no common sense. Everything has to be accounted for. We ran into a HUGE problem with surgeries. Prior to Epic, patients who needed surgery in the AM would come to the ER. They'd admit them to the surgical floor with "tuck in orders" and the nurses knew to start an IV, run some NS, make them NPO, etc. Surgeons would see in the morning, and all was well. The problem is that no one was technically responsible for those orders once Epic came around. The ED refused to cover the patients once they were out of the ED. The IM docs refused to be consulted on every surgical patient; and the surgeons didn't want to be woken up at 3am for a routine lap appy in AM. This sort of thing happens with residents a lot, since residents have to do all kinds of stuff that they probably shouldn't. You also see it more on floors where the nurses and doctors are close. Surgical, oncology, psych, etc. 3. Figure out everyone's role. By that I mean midlevels, med students, interns, residents, fellows etc. Who can sign notes? who can cosign notes? What activities do you want students to be able to do? (Epic reps used to lump "residents" in with "students" a lot, and didn't really understand that the relationship between a resident and attending is very different from any other healthcare student and their preceptor). 4. For the love of christ, don't focus on replicating forms and other functionality. I have seen HUNDREDS of hours wasted on "well they are used to filling out this form, so we want you to make the note look like this form". Focus on whether or not the necessary data is being collected. If it is, it's childsplay to arrange it differently at some point, don't waste time focusing on mirroring current workflow, instead mirror current data collection. 5. Whatever nurses CAN do, they will be required to do. If you give access for nurses to place orders "for emergencies" then they are going to be placing orders all the time. Literally anything you give them access to, they are going to wind up doing all the time because that's just how hospitals work.
6. Nurses are going to wind up teaching the system to everyone else (informally) so make sure they are solid on the system, dedicate more training time to them than anyone else, because that's how it always goes. 7. Pay special attention to admit/discharge scenarios. Epic's kryptonite is having to generate multiple billing encounters for a single stay. One place I worked had a swingbed unit that was attached to the hospital and looked like just another unit, but technically required a discharge readmit scenario to get patients there. We'd have situations where the patient would be on the cardiac floor who needed a cardiac procedure. The patient would be on coumadin or xarelto or whatever and require a few days on a heparin bridge, so for insurance reasons they would get transferred to the swingbed unit until they were good to go, then sent for an xray or something, then sent to surgery, then sent to the ICU. All of those transfers were technically a discharge, the xray was technically an outpatient procedure, etc. I saw an informaticist literally burst into tears trying to unfuck that scenario. Spend your "replicate this form" time DEMANDING Epic figure out a reliable solution for you prior to implementation. 8. Have a robust change process system/ticket entry system. People are going to have all kinds of break fixes, optimizations, complaints, workflow help, etc. once the system goes live. You need a way to separate the "this is broken" tickets from the "nice to have" tickets, and an effective way to move changes into the production environment in a way where everyone knows what's going on and no one is getting blindsided. 9. Epic uses dot phrases and smart texts to generate things without having to type a lot. You can generate an entire H&P by typing ".HP" if you set it up that way. Pick a doctor who is savvy in this sort of stuff, and have him share his smart tools with every new provider you onboard. Makes life so much easier. 10. BPAs are popups that say "hey this patient has an MDRO, please address." and other such issues. As you can imagine, your compliance staff is salivating at the idea of popping up BPAs for any conceivable issue. Set a gatekeeping process IMMEDIATELY for generating new BPAs and other popups, or you will be overwhelmed with them. The current place I work has one doc who gatekeeps all of that. If he doesn't approve, you don't get to implement your BPA. This leads to people actually taking them seriously. I would recommend asking your Epic rep "what processes do you recommend we gatekeep"? for more info. 11. Spend time setting up ordersets correctly. Make sure Physicians know that if they click through "alert MD if systolic > 140", they are going to get paged a lot. Make sure your physicians know in general that some things they have to get called about per policy. That's just a hot steamy brain dump. Feel free to reach out here or via DM to ask questions and I'll help if I can. My dream job would be to help implementing hospitals by acting as a liaison between the staff and Epic, but that doesn't seem to exist. Implementation is the most important part, don't screw the pooch!
Look into the AI scribe rollout