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Sunday, July 28, 2013

An EPIC Tale. Portending an EPIC Fail?

One of my compadres sent me this link the other day.


In the Boston marketplace, Partners Healthcare is is replacing 30 years of self developed software with Epic. Boston Medical Center is replacing Eclipsys (Allscripts) with Epic. Lahey Clinic is replacing Meditech/Allscripts with Epic. Cambridge Health Alliance and Atrius already run Epic. Rumors abound that others are in Eastern Massachusetts are considering Epic. Why has Epic gained such momentum over the past few years?

Watching the implementations around me, here are a few observations:

1. Epic sells software, but more importantly it has perfected a methodology to gain clinician buy in to adopt a single configuration of a single product. Although there are a few clinician CIOs, most IT senior management teams have difficulty motivating clinicians to standardize work.  Epic's project methodology establishes the governance, the processes, and the staffing to accomplish what many administrations cannot do on their own.

2. Epic eases the burden of demand management. Every day, clinicians ask me for innovations because they know our self-built, cloud hosted, mobile friendly core clinical systems are limited only by our imagination. Further, they know that we integrate department specific niche applications very well, so best of breed or best of suite is still a possibility. Demand for automation is infinite but supply is always limited.   My governance committees balance requests with scope, time, and resources. It takes a great deal of effort and political capital. With Epic, demand is more easily managed by noting that desired features and functions depend on Epic's release schedule. It's not under IT control. 

3. It's a safe bet for Meaningful Use Stage 2. Epic has a strong track record of providing products and the change management required to help hospital and professionals achieve meaningful use. There's no meaningful use certification or meaningful use related product functionality risk.

4. No one got fired by buying Epic. At the moment, buying Epic is the popular thing to do. Just as the axiom of purchasing agents made IBM a safe selection, the brand awareness of Epic has made it a safe choice for hospital senior management. It does rely on 1990's era client server technology delivered via terminal services that require significant staffing to support, but purchasers overlook this fact because Epic is seen in some markets as a competitive advantage to attract and retain doctors.

5. Most significantly, the industry pendulum has swung from best of breed/deep clinical functionality to the need for integration. Certainly Epic has many features and overall is a good product. It has few competitors, although Meditech and Cerner may provide a lower total cost of ownership which can be a deciding factor for some customers. There are niche products that provide superior features for a department or specific workflow. However, many hospital senior managers see that Accountable Care/global capitated risk depends upon maintaining continuous wellness not  treating episodic illness, so a fully integrated record for all aspects of a patient care at all sites seems desirable. In my experience, hospitals are now willing to give up functionality so that they can achieve the integration they believe is needed for care management and population health...
I have to say that, given that my particular REC project turf was almost exclusively small doc shop outpatient EPs, I've never gotten to kick the Epic tires or even watch it in action. It may be a perfectly fine, usable, featiure-rich project with great vendor support behind it for all I know.

Critics are not difficult to unearth, though. Foremost among the high-profile target is the Epic CEO herself, an Uber-geek straight out of Central Casting, but all the more notable for her gender.

An Interview With The Most Powerful Woman In Health Care
Zina Moukheiber, Forbes Contributor

Judy Faulkner might not be a household name yet, but in the health care industry, she’s simply known as Judy. She is the founder and chief executive officer of Epic Systems, a privately-held $1.5 billion (2012 revenue) company that sells electronic health records—a position that makes her one of the few self-made women on the Forbes billionaires list. Her customers are top medical centers, such as Cleveland Clinic, Geisinger Health System, and Johns Hopkins. She wields enormous influence. Almost half of the U.S. population will have its medical information stored in Epic digital records when hospitals finish installing them.

Faulkner, rarely, if ever, grants interviews. A year ago when I profiled her, she refused to speak. Because Epic shuns publicity and press releases, it is perceived as aloof; and criticism leveled at Epic regarding its business strategy is rarely challenged by the company. In a phone interview from Epic’s seat in Verona, Wisconsin, Faulkner acknowledged that.

Forbes: A year ago, you declined to be interviewed, what made you decide to talk now?

Faulkner: I’m recognizing that when we were small, we could stay under the radar, but now it’s harder. I get so many requests for interviews. If I talk to everyone, we can’t do our job with our customers and work on our software. It would be hard to stay focused.

I was an undergrad math major, and a grad student in computer science. I’m hugely introverted, not atypical of math majors. It’s not something I love [being in the public eye]; it’s a personality thing. I like to go around, and people not knowing who I am. I like to keep some privacy, be a normal person.

Forbes: With success comes visibility, plus you’re a woman who’s a computer scientist, who coded the original software for Epic. It makes for a good story.

Faulkner: If you line up the CEOs of major [electronic health record] companies, the CHEESI group–I came up with that to remember them all: Cerner CERN -1.97%, HBOC (now McKesson MCK +5.29%), Eclipsys (now Allscripts), Epic, Siemens , IDX (now part of General Electric GE -0.16%), what’s the primary difference? It’s funny, visually I’m the one woman, but I’m the only one with a technical background. That’s the main difference.

Forbes: Many things are said about Epic by competitors, but also by customers. One of them is that Epic is a closed system: it’s difficult to exchange patient information with other electronic health records; it’s hard for third-party vendors to integrate with Epic, and the technology is old. Is this totally wrong?
Read on...

The hits just keep on coming.
Judy Faulkner: Criticism that Epic system stymies interoperability 'unfair'
May 17, 2013 | By Dan Bowman
Responding to criticisms that Epic's electronic health record systems are closed and, thus, difficult to integrate with third-party vendors, CEO Judy Faulkner, in a rare interview granted to Forbes, called such accusations "totally wrong."

In fact, Faulkner referred to Epic as "the most open system I know," saying it's designed as a database management system.

"Database management systems need to allow their users to mold it to what they need," Faulkner told Forbes. "We interface with speech recognition, imaging, medical devices, lab, patient education content, user authentication and hundreds of different vendor systems."
Faulkner said claims that the company does not value interoperability are "unfair," adding that Epic systems were interoperable before government regulation came into play.

She also took a jab at the recently formed CommonWell Health Alliance in the Forbes interview.

Faulkner raised concerns about CommonWell at a Health IT Policy Committee meeting last month, saying that not initially being invited to be part of the alliance caused her to have doubts about its motives.

"What is it?" Faulkner, a policy committee member, asked rhetorically at the meeting. "Is it a competitive business? Is it a service? Will it be favoring those who started it and using those who did not start it as the means to feed the business? What components of business will be in it? Will it sell the data? Will there be patents?"...
Faulkner referred to Epic as "the most open system I know," saying it's designed as a database management system. "Database management systems need to allow their users to mold it to what they need."

OK, so, does this mean you'll share your RDBMS database dictionary with everyone?

Didn't think so.

Interesting Forbes article comment here in the wake of "Who Says Chief Information Officers Can't Lose By Choosing Epic?"
John Stokes: I think you are only beginning to scratch the surface of the difficulties providers and institutions face with regards to making a rational, informed decision about EHRs, and about the true, long-term total cost of ownership.

For any new EHR installation there is at least some form of “double hit”: The product cost and the lost productivity cost.

In contrast to the comment above that “there are literally thousands of other causes of decreased revenue immediately following ANY [EHR] implementation”, Epic stands out as the only EHR for which there is now a track record of failing hospitals immediately following their EHR implementation. A mere coincidence? No. It is because Epic’s execution and business strategy imposes and requires new, permanent, and massive increase in the fixed cost of operations of the organizations that they partner with. These are simply not sustainable. What are two of these “hits”?

The Epic product cost: The software and licensing is only a small part of this. The major costs come is in the massive time and funds spent on training, support, configuration, updates, and salaries of a large number of new full-time staff that the institution has to hire permanently (50 new FTE for a small hospital; 150+ new FTE for a large academic institution). At 100k with benefits, that is 5 to 15 million a year in new fixed operational costs.

The Epic productivity cost: No other EHR other than Epic requires 18 to 24 hours of full-time training for highly educated physicians to become ‘basic’ end users. This is a huge loss of time (two to four days) that physicians are not compensated, nor taking care of patients. As the prior commenter stated “Any responsible EMR vendor will suggest a lighter schedule in the first few weeks of a new system to allow staff to get acclimated”. To be precise, Epic recommends a 50% reduction in clinical workload during this “acclimation”, and then recommends a 25% reduction for at least several more weeks. Epic states that providers should be back to their baseline productivity after six months to one year. However, the reality is that after a year of using Epic, most physicians never recover their full level of efficiency, and are experiencing at least a 10% productivity hit. What are the financial costs of this?

A typical physician will see 40 to 50 patients a day, or 5-6 per hour in clinic. That leaves about ten minutes per patient for an entire encounter, including history, examination, prescription writing, and counseling the patient (including the new Meaningful Use required data entry requirements, etc.). So even as little as one or two minutes more per patient adds up quickly – lengthening the workday by one to two hours. With a loss of productivity of only one hour per day (above) at $100 per visit, that represents six patients, or $600 /day. At that rate the physician is losing $10k/month. Multiply that by the number of physicians working in your practice group or community hospital and you get millions in losses each month.

This loss of physician time may also be measured as an opportunity cost of seeing an additional five to ten patients per day. With all of the strains on the healthcare system, a shortage of primary care doctors (made acutely worse by an influx of 38 million newly ‘insured’ patients entering the system under the ACA) – can we really afford to waste the most valuable and essential asset of the entire healthcare system: physicians’ time?

Note that most of the 5800 hospitals in the US are not large, well endowed academic medical centers with both alumni and government giving billions to prop them up. Epic’s market is only those hospitals with at least 100 million to spend, which is some 200+ hospitals in the US. The remaining 5500 hospitals? They run on a razor thin margin of 1-2%, and where a few million here or there is enough to put them deep into the red. Epic is very selective in picking clients only that fit their one and only criteria: deep pockets.

It would be convenient to dismiss Epic’s role in the financial demise of a growing list of hospitals in the United States. Unfortunately, these are not coincidences. This is a real and consistent pattern, and correlates the physicians comments and surveys on usability. [Ignore the trade association surveys sponsored by the vendors under HIMSS and KLAS - these are meaningless technical specifications and laundry lists of features].

The arguments that Epic provides for failure is that is was ultimately the end-users fault. Yes, those stubborn, unteachable doctors who went through 24 years of formal education – through college, graduate, and postgraduate study and training – who happily use their smartphone, tablet, and laptop to do manage virtually every aspect of their life on the web. But we can’t get those doctors to learn how to use a 1992 vintage thick client with nested dropdown menus seven layers deep. Will Epic lead the way and take usability seriously? Or it will it continue to be a risk to the financial health of the institutions it is supposedly helping?

We live in dangerous times in HIT. In a few years, when the $27 billion subsidy program for EHRs dries up and the mad gold rush for EHR implementation is over – it will expose many more hospitals that over-extended themselves with their choice of Epic. I must concur with Ryan Champlin. That is a dangerous choice.

John Stokes: After reading my followup post here comparing the cost of two statewide hospital networks (Maine with Epic at $366 million; West Viginia with VistA at $8 million) there must be some fundamental reason that CIOs are willing to spend thirty times more for a product than another product.

Is Epic actually “better” than any other EHR? What do the end users have to say about Epic?

This survey on usability is directly from physicians (not via a vendor-sponsored surveys such as KLAS or HIMSS that emphasize vendor attributes such as ease of implementation, or length of feature lists).

These are ordered from lowest to highest rating.

EHR Overall Usability Rating (number of raters)

AHLTA 2.64 (49)
Siemens Soarian 2.73 (15)
Cerner 2.93
GE Centricity Enterprise 2.96 (57)
McKesson 3.1 (88)
Allscripts 3.06 (3)
Meditech 3.08
Partners Healthcare 3.34 (25)
EpicCare 3.51 (148)
Greenway 3.83 (69)
VistA: 4.06 (124)

This survey shows that usability of EHRs has gotten *worse* since Meaningful Use regulations came into effect in 2010. One factor may be that EHR vendors have focused their development efforts to satisfy these requirements rather than the requirements of their end users.

Note also that survey results of VistA were mostly from the VA, where they are using a non-Meaningful Use certified EHR. It appears that while commercial EHRs devote their energy to winning the buzzword compliance awards from KLAS, VistA remains steadfast on its commitment to its physicians.

Now, to your question. VistA is the #1 ranked EHR and more cost effective by a factor of twentyfold.

I can only guess that the reason CIO’s choose any system over VistA:

(1) lack of information: the VA does not have a marketing department
and get and and publicize its system.
(2) lack of vision: an institution does not see the value in open-source, in taking ownership of their own intellectual property and information infrastructure, in building internal capacity to support this, and in supportin their own user-driven innovation. They would rather outsource this to a proprietary vendor.
(3) lack of name brand recognition: The CIO does not want to get blamed for a failure, so chooses a big name company. (This is obviously untrue: how can you say the VA and its 1400 clinics and hospitals running VistA is not a large enterprise)
(4) lack of clinical and technical expertise: The CIO does not have the combined technical and clinical knowledge to appropriately assess EHRs, and therefore has to depend on superficial demos, marketing materials, word of mouth, or responses to RFI (which are simply marketing brochures, sans slick pictures).

Again, these are only guesses, but based on many observations. 
Whatever one thinks of this commenter's views, they comprise a refreshing, considered respite from the endless onslaught of bumper sticker quality anti-Health IT naysayers.

Epic's "Usability" assessment in the America EHR survey.

Interesting. a 4.01 high for "Document a progress note for each encounter."

You have to register an account with American EHR (free) to get at the full report for all surveyed systems.


Why Epic's market dominance could stifle EHR and health IT innovation
Brandon Glenn

Epic has attracted several notable critics, who warn that its market dominance could have harmful effects on the future of health information technology, EHRs and even patient care. Worse, these critics warn, Epic has achieved much of its market dominance on the backs of taxpayers.

Epic is the nearly undisputed king of the electronic health records world.
About 40% of the U.S. population has its medical information stored in an Epic electronic health record (EHR), and the company often sits atop research firm KLAS' rankings of best-available EHR systems.

Epic has plenty of big-name clients who've spent tons of money installing its expensive systems: $700 million from Duke University Health System; $700 million from Boston's Partners Healthcare; $150 million from the University of California, San Francisco; and $80 million from Dartmouth-Hitchcock Medical Center in New Hampshire, Forbes reported last year.

So it's not surprising that such a high-profile company has attracted several notable critics, who warn that its market dominance could have harmful effects on the future of health information technology, EHRs and even patient care. Worse, these critics warn, Epic has achieved much of its market dominance on the backs of taxpayers - courtesy of $35 billion in federal subsidies paid to hospitals and doctors to purchase EHR systems...

Aside from the taxpayer subsidies Epic has indirectly received, what really rankles the company's critics is Epic's lack of interoperability with other EHR systems, meaning that's it's a "closed" system that doesn't share patient data particularly well with doctors or hospitals who don't use Epic's software.

"If Epic (already based on an antiquated technology -- MUMPS) decides to maintain an essentially closed system, and to drive all innovation internally, this could prove stultifying, limiting the development of novel ideas, and forcing the many high-profile adopters of Epic to accept stagnation or pay the staggering costs of switching," wrote physician-scientist David Shaywitz in Forbes.

In other words, the "closed" nature of Epic's systems - coupled with its dominant market position - could mean that Epic ends up setting the defacto standards for EHR systems, effectively stifling innovations that its competitors might develop in the EHR market. That, in turn, could lead to Epic's big hospital customers - and those hospitals' patients - being frozen out from advances in EHR technology. ..

Then there's the question of to what extent American taxpayers are helping to subsidize Epic's market grab, courtesy of EHR incentive payments outlined in the Obama administration's 2009 stimulus bill. It's not a coincidence that the privately held company's sales have been skyrocketing in recent years, up to $1.2 billion in 2011, double what they were four years prior, according to Forbes.

It's also no coincidence that Epic and other major EHR players lobbied the federal government hard for the subsidies, and those companies "have reaped enormous awards because of the legislation they pushed for," The New York Times reported earlier this year.

Executives at smaller EHR companies say the legislation cemented the established companies' leading positions in the field, making it difficult for others to break into the business and innovate, according to The Times...
??? Ya think? I don't think Judy does.
Helping enrich Faulkner is ... a piece of government legislation [Meaningful Use] that subsidizes the adoption of electronic medical records, by paying millions to qualifying hospitals... Faulkner is also the only head of a company to sit on a government-appointed policy committee that makes recommendations on standards for the exchange of patient information.
- Epic Systems Tough Billionaire


Google "Epic EHR." Here are the first, above-the-fold responses I got.

Gotta love it. Paying for positioning. I bet Judy Faulkner could care less about all these ankle biters.

Below, gotta love this stuff as well (rolls eyes).


New on SBM
[T]he new CAM buzzword these days to explain why quackery “works” is epigenetics. Basically, whenever a proponent of alternative medicine uses the word “epigenetics” or “quantum” to explain why an alternative medicine treatment “works,” what he really means is, “It’s magic.” This is a near-universal truth, and even the most superficial probing of such justifications will virtually always reveal magical thinking combined with an utter ignorance of the science of quantum mechanics or epigenetics.

More to come...

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