In our sponsored webcast on healthsystemCIO.com, Chad Brisendine, VP/CIO at St. Luke’s University Health System, and Erin Sain, COO at Galen Healthcare, discussed legacy support and staff augmentation during EHR transitions, specifically with St. Luke’s transition to Epic. The audience was very engaged and had quite a few questions, we’ve recorded all the answers below:

View the full EHR Transitions: Legacy Support & Staff Augmentation webinar

Q: How did/do you manage the change in patient identifier (MRN) and track all the places where it is used in interfaces to other systems? 

A: (Chad Brisendine) Our inpatient system is the source of truth for our MRN. We previously, prior to Epic, had consolidated our multiple systems into one EMPI, to be able to merge duplicates, both on the outpatient and inpatient side. We have a number duplicates and continue to try and resolve those. We’re looking at additional components outside of our Epic system to enhance those. There’s additional fields that we’ve been able to add in to continue within our electronic medical record numbering system to be able to help us support the matching and cross matching between all that within our MPI. Basically, when we go to do the conversion process, the simple part is that most of the demographics are maintained across, there’s several different fields that aren’t. I know Galen, part of their clean-up process is to handle that, prior to them being loaded, and then there’s a load process that goes along with Epic to import that into the system. There needs to be some additional questions answered by the organization like, what do they do for duplicate accounts? How do they identify and report them? Who manages them? We’re fortunate that we have a very robust system yet we still have a lot of duplicates in the registration process—big challenge.

(Erin Sain) Just to add on to the last thing Chad said, as part of the assessment that Galen would do, those particular questions for the organization would be asked, those are very important things for us to knock through, so I just wanted to highlight those questions that are unique to each organization and will change the scope of what we’re doing.

Q: Please review a past preparatory timeline for initiating and implementing the switchover. For example, how long does table building typically take? Can a staff member continue to effectively maintain current pt care and also perform needed implementation prep & other work? Average number of weeks/months before initial implementation of new system from start time? This organization is transitioning from one comprehensive but only semi-installed computer program with multiple enterprise features to another, more integrated provider computer platform, providing staff with current expectation of table building & initiate new computer program within a 4 month timespan. I believe this to be practically impossible. All thoughts appreciated!

A: (Chad Brisendine) So basically it sounds like there was an EMR or some system that was partially implemented, that some people are using but not fully, and then they’re going to put in a whole EHR, I’m making this up, across other areas and they want to know how long does it take to do the implementation or the migration of the data.

It’s typically not how much data but how many different components of the data you have. So it’ll all be around how many fields, tables and other aspects you want to transition, and how long does it take for that to be mapped and understood. Typically the energy is in the mapping exercise and figuring out the requirements, and then once that’s mapped and put together you can go as far back as that data lives. Then the question is about the quality of that data: Is it text-based? Is it a drop down? What’s the error component within those particular fields that you’re willing to pour it over? I know that’s not specific but I would say it could be anywhere from maybe 3-4 months to really study the analysis and then 6-12 months to transition.

(Erin Sain) So I’ll take it from a couple different perspectives, one’s the migration piece of it. We’ve seen projects on pretty short timelines but we’ve also seen them go anywhere from 9 months to 2 years. Then going back to what you said Chad, it really depends on what elements do you want converted and then specifically, what’s the timeline we’re looking at? Does it need to coincide with the go-live of your new EMR? All those things are constraints that determine what we can put in and how long it will take. In terms of the legacy application support, of how long does the switchover piece take, with the St Luke’s project specifically it’s a pretty long engagement that we’re working with you guys: 2 months were part of the kick-off; 3 months to get our team ramped up and in tune with all of your processes and documentation; and then we’re doing 15 months of full support for that project. I always hate saying it depends but it really depends on the project and what the organization wants involved as to what that timeline looks like.

(Chad Brisendine) I don’t think, in our transition, there’s anything else possible to convert—and you can say that yes or no Erin—but we pretty much went with the most components we think we can bring over without causing data quality issues.

Q: How many years of data did you convert and how did you make this determination?

A: (Chad Brisendine) We’re going all the way back to the beginning of the EMR period for us, so that’s roughly 2015. We have other components coming over from our hospital systems that have already been there for about 4 years because we took 2 years over. So normally we’ve been going around the 2 year mark. The physicians would like to see at least a couple years’ worth of data around labs, imaging, all those components. Erin, if you want to comment on what you typically see at other organizations.

(Erin Sain) Well it’s all over the board. Two years of current data and then the rest of typically archived, but again we see it all over the map with different organizations.

(Anthony) Is there sort of a best practice here in terms of how much data to convert, how many years?

(Erin Sain) That normally depends on the specialty. Most providers stick to 2 years, but they want it all, so it really depends. Typically, that’s part of the assessment that Galen does. We’ll come in and tell you what makes sense and then also we’ll tell you from a level of how many providers you have, does it make sense to do a data migration or is it better to do a chart abstraction. What we would say ideally is that 2 years should pick up the most relevant clinical data.

Q: What type of physician engagement model or governance did St Luke’s have in place to ensure providers were part of the transition, had a voice, and had some accountability in the success?

A: (Chad Brisendine) We’ve set up a governance structure with our physicians, so it’s multi-tiered. At the top is an executive committee that’s chaired by all the C-Suite folks, and then underneath that we have a revenue cycle governance, and then we have a provider governance that our CMIO leads with one of our CMOs. It has all our physician leaders from all our different specialties. It’s basically the chief or chair from each of those domains and they’re really a part of the decision-making process, what we’re doing and how we’re doing it. Then we’ve created sub-groups off of each of those. For example, our training program, we have different providers meeting with us off of that core group to make recommendations on what we’re going to do around training. We’ll put a program together with one of the chairs, we’ll provide them with a lot of the information, they’ll make some recommendations, then bring it up to the larger group for the approval. That’s how we’ve been working it. We have these things called decision documents for everything else that we do to help facilitate the decision making associated with that. We call it ‘provider-led and project team supported,’ which basically means that we’re going to do a lot of the heavy lifting but we’re going to have them be the real decision makers, the ones that are engaged, the authoritative source to say, ‘this is how we’re doing it, this is why we’re doing it,’ and then they can become the communication channel back to our providers on why we made the decisions that we made.

(Anthony Guerra) Very good, Erin, your thoughts on physician engagement during these transitions?

(Erin Sain) One of the things Chad and I both mentioned that, in terms of migration, is that we want to make sure the data is accurate and supports them in the best way possible, so their engagement is critical throughout this process. In addition to physician engagement we need clinical resources that are engaged but we also need to understand workflows, the way that the systems are configured so that we can maintain those once the new system is up and running. We don’t want to cause less efficient workflows once you’re moved to the new system, so physician engagement is very important from one aspect, the data, but then other resources from the client team are important as well.

Q: What was the transition schedule? Did you do ambulatory first or acute replacement? Would you do it the same way if you had to do it over?

A: (Chad Brisendine) I’m TBD on answering that question, we’re in the middle of our ambulatory now, we did acute first. We went all 7 hospitals big bang and now we’re rolling out ambulatory so I’ll come back and let you know. To date, we feel good about what we’ve built around it, I don’t know if I would understand what the pros and cons are the reverse way. It’s a question on the data. I wish we had the ambulatory data in there for the hospital side, I think the hospital side is going to provide us with some good data for the ambulatory side so if there’s anything that I’m going to learn it’s going to be  around that. The nice thing around the hospital side first is that a lot of our specialists are on the Epic system already, we’re still going to have to train them, but a lot of them are familiar with it, so we’re really bringing up the primary cares and then training for the ambulatory workflow. We feel that’s a positive benefit that they have that. The hospital implementation is challenging because it has a lot of the components but it also already has a lot of capabilities for ambulatory.

(Erin Sain) I’ll add that Epic themselves will recommend the acute side first over ambulatory. Typically, the acute or inpatient system is the source of truth, so from an operations perspective it’s easier to lead with inpatient data and then complement and match the ambulatory data to that.

Q: What particular contractual terms with the original EHR provider have you heard or seen proved missing or unclear once transition is decided or begun?

A: (Chad Brisendine) I wouldn’t say that we’ve had any issues with that at all and the only reason why is all our support and upgrades and everything. If Galen has had issues I’ll leave that up to Erin to comment on as they’ve been the buffer for us and we’ve had good support. I haven’t had to be involved with the vendor at all related to anything we’re not able to perform.

(Erin Sain) I’ll add that Chad and his group, their systems are on prim which we typically don’t see issues with, especially pulling the data out. When you have hosted environments sometimes it’s more difficult, a lot of the time we’re relying on source systems to provide us an extract.

(Chad Brisendine) What about Erin, just to comment on that, anything around support, with upgrades and such, from your angle? Any issues with not being able to get the latest version, or the right support we need in the development?

(Erin Sain) Stated simply you’re at the mercy of the hosted system as to what they want to do. A lot of times, what we’ve encountered is, the hosted system has found out that you’re moving away to a new system and they make it difficult to do any of that while you’re still trying to maintain things as is because you’ve got all of your providers on the old system. It definitely becomes difficult when you’re talking about the migration, like you said, upgrades to that system and how they support you.

Q: To what extent have health CIOs and their teams and advisers learned from the large quantity of non-healthcare IT transactions, best practices, and disputes? Are HIT leaders a bit myopic only considering intra-industry history and tips? As a CIO, do you think it’s best to just look within the healthcare industry for these types of transitions or can you get anything from looking outside?

A: (Chad Brisendine) I’m fortunate enough that we have a very experienced, non-healthcare industry CIO that sits on our board and we had a lot of chances to talk about the Epic transition. He’s been through a number of these massive transitions, a lot of the things that we’ve talked about today that we had already planned were the things that he thought were risky. He’s been very supportive of our process and plans and everything that we’ve done and we’ve put into place, both directly with me and with our board. So, I don’t think that there were any insights that he gained other than really understanding what our plan was around governance, operational engagement, data migration, data conversion. A lot of those same best practices that we’ve applied were applied in his vertical, which I would probably say that is one of the more advanced industry verticals that there are out there. I’d love to understand where we may have missed the boat but from his needle there wasn’t any.

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