In June 2024, two Boston-area hospitals went live with transitions to unified Epic EHR platforms. As part of the Harvard Clinical Informatics Lecture Series, chief medical information officers from Beth Israel Lahey Health and Boston Children’s Hospital recently discussed the benefits of the transition and some of the challenges they faced along the way.
“It was funny for us to go live at the same time, because I’m sure all the Boston-area hotels were booked with Epic support,” said Terrance Lee, M.D., M.P.H., associate chief medical information officer at Beth Israel Lahey Health.
The stories that Lee and Chase Parsons, D.O., M.B.I., chief medical information officer for Boston Children’s Hospital, told about their processes, governance and challenges overcome before and during the go-live paralleled each other in many ways, including a focus on whittling down the number of third-party applications and migrating data from legacy systems into Epic.
Parsons explained that Boston Children’s has satellites across the Boston area and close relationships with the Pediatric Physicians Organization of Children’s, which is a large independent ambulatory outpatient practice that has been on Epic for a long time. It shares patients with Dana Farber Cancer Institute on an instance of Epic. And it shared an instance of Cerner with Franciscan Children’s Hospital. Franciscan went live on Boston’s Children’s Epic instance in October.
Boston Children’s had been using Cerner since 2007 for its clinical EHR. “We had a hybrid system where we had Epic for registration and scheduling, and Cerner for the front end for clinicals,” Parsons explained. “We had 398 custom applications or integrations with our EHR. We had a custom interface for billing. For instance, our patient portal was a hybrid of the Epic scheduling, so patients could see when their visits were, with the Cerner clinicals, so patients could see their lab data. We have a central data warehouse, which was a data repository for all those systems and it still exists today.”
In spring 2022 Boston Children’s made the decision to move to Epic, and the project kicked off in January 2023. “We really wanted to strengthen our system integration to ensure that as the EHR matures, as we mature as an organization, that we’re able to maintain and strengthen our integration to our third-party systems….and make sure that it’s all one integrated system,” Parsons added. “We want to ensure that patients are able to self-schedule, which is is still being optimized at this time, and that they can quickly schedule appointments, and that the lead time for patient access is improved.”
Boston Children’s also wanted to integrate with research, which, prior to last June, had been outside of the clinical systems, and conducted through other processes — either custom applications or on paper, in some instances. “We want to maintain our safe and quality care as we care for our complex patients, and ensure that we enhance equity and the patient family experience and the team and provider experience as well,” he said.
In late 2022, Boston Children’s began to form its governance structure to look at its legacy data. “We had to decide what data we need in the future, and what will be our approach to making data available within our Epic instance from our Cerner days,” Parsons said, “then also ensuring that we had institutional and operational alignment on key decisions that we needed to make during our Epic implementation.”
They started off by looking at the current state of their third-party and custom applications. “We had nearly 400 of those, and we went through them, application or integration by application or integration, row by row with all of the institutional stakeholders prior to the go-live of the Epic project,” he remembered. “And we had Epic involved. We had to know, does Epic meet the needs for this solution? If not, what are the gaps and what will we be losing out on? Or is there a different third party that we should be using or should we maintain this custom application we have?”
They were able to whittle it down to around 100 third-party or custom applications today.
Part of the pre-work was getting funding from the project to ensure that they had enough physician subject matter experts. “We had over 100 physicians who were receiving funding from the project to be closely involved with responsibilities like clinical content design, training their colleagues prior to go-live, communicating their needs to us in IT and communicating changes locally during the project,” Parsons said.
One example of a big project was adopting an electronic consent process across the organization, and IT got project resources to develop the electronic consents. Today they’re pretty widely used across the institution, although paper consents are used in some spaces as well.
The governance structure had executive sponsors who are chief medical and chief nursing officers, as well as a steering committee, which was a place to bring escalations so that they could ensure the right resources were in the right places at the right time. It also involved many workgroups across the organization that reported up escalations to their relevant body.
The clinical work groups mainly reflect the different Epic modules. For instance, orthopedics had their own work group to configure Bones, which is the Epic product for orthopedics, and oncology configured the Beacon module for the oncology treatment plans. Decisions for each work group were based on an Epic project management tool called Orion.
Outside of those workgroups that align with Epic modules, they also had all of their ambulatory specialties and inpatient specialties configure content in quick sprints so that they had the right templates and some smart phrases that they brought over from legacy order sets. As part of the Epic implementation, they reviewed all Epic clinical decision support and then decided which ones were appropriate for moving forward, and which decision support they had in Cerner that they needed to built out in they Epic system.
Data conversion and archiving
Boston Children’s brought over three years of most types of data from Cerner into the Epic instance. “At the end of this month, we should have all of our scanned documents from the past three years available in Epic from Cerner,” Parsons said. “Over 8 million documents or PDFs are being brought over to finish that work up now, but most of the data was available on day one of Epic go-live there.”
The training for the go-live involved a lot of personalization, and it was meaningful for clinicians to learn the Epic workflows from their peers. “One thing to say about training is that I wish we had a better idea prior to starting our training who was practicing precisely where — which doctor worked in both an inpatient and ambulatory setting, which ones were just inpatient, and which ones crossed specialties, like which doctor worked in the ICU and in the ED, because training was really personalized to their clinical workflows, and we had to do a lot of reorganizing and reassigning training so that we could understand who was still deficient in their training before go-live,” Parsons added.
The go-live went smoothly, he said. “As far as our full clinical systems go, we went down for a few hours after midnight and then came back up with our Epic system. On June 1, we went live with our Epic system. We continued in-patient care, and we did have slightly reduced capacity over the first few weeks of our go-live, as far as clinics went, but really quickly went back to normal capacity, and we even had some complex surgical procedures completed overnight.”
The go-live at Beth Israel Lahey Health
The implementation at Beth Israel Lahey Health was called “OneBILH.”
As Lee explained, the background is that Beth Israel merged with Lahey Health in 2019 and the combined organization has 14 acute hospitals. In developing a blueprint for the future, one of the foundations was a unified EHR. The organization has over 39,000 employees, including 4,700 physicians. “We have a gigantic primary care arm on top of our specialties as well as home health,” Lee said, “so we knew that the foundation for a lot of the work that we want to do for the future was it would be driven by a unified system.”
Lee described the legacy EHR situation as fragmented. “We had at least 13 large EMRs and many, many other different instances here. We even had a couple instances of Epic already in our system, and many instances of eCW in our primary care space. All of our users clearly saw the use case for this.” Patients in primary care would go to the acute hospital to get their diagnostic testing and be on a different system. “Everyone was really anticipating this change, which actually made change management easier, he said.
Lee noted that in contrast to Boston Children’s, Beth Israel Lahey Health is doing a phased approach. They went live on June 1 at their biggest hospitals, including Beth Israel. They also had to bring sites that were already on Epic onto the OneBILH configuration.Then in fall of last year, they went live with another wave at the community hospitals affiliated with Beth, Israel. They have a third wave coming up this year. “On September 6, we’re going live with another hospital at Mount Auburn, as well as our hospital in New Hampshire,” he said.
Just as at Boston Children’s, reviewing third-party applications was a big task and needed to be done thoughtfully, Lee said. One big principle of the implementation, he said, is “Why not Epic?” If there is an integrated tool, they chose to implement that instead of retaining niche solutions. For ones they did want to retain, they needed to make sure that they had an integration with Epic. For the ones that they chose to replace or retire, they need to extract that data and put it into Epic.
One of the top issues around go-live is identifying the resources to help with data conversion and validation. “Data conversion is a big, big, big deal,” Lee said. “We converted five years of data into our system here, but it’s very time-intensive, on the back end, and a lot of users don’t realize what we in informatics do to prepare this conversion. We want to map that data. We need to validate that data. A lot of that on our side was done by our informatics team. We had to identify those clinical and administrative folks who can help us manually abstract some of that data that we’re not converting automatically. Even determining the scope of what we’re converting and what we’re not is tricky, because it’s a moving target, and you’re not going to satisfy everyone. So we really had to make thoughtful decisions on what’s highest yield and what needed to be manually abstracted.”
Almost like a mini-go-live within a go-live was the switch-over to one secure chat messaging platform. It meant comprehensively going through every department and understanding what their communication strategy is and moving them over, Lee said.
The OneBILH mantra about training was: “no training, no access, no kidding.” Everyone up to the executive and hospital leadership level supported this idea, Lee said. “Everyone understood the importance of the training, but also the limitations of the training. You’re not going to retain everything from those hours there, but it’s important to get that foundation and get your feet wet here, but also continue that post-training with other readiness activities.”
As at Boston Children’s, mapping people to the right roles for the training was very challenging, and that’s something that has been a lesson learned, Lee said. “After our wave one and wave two, we’re getting better at it, and hopefully our wave three will be even better.”
Post go-live issues include medication reconciliation, both in the ambulatory space and inpatient space, making sure they are getting prescription refills out, and stabilizing the way they are able to order labs. “Also, making sure we’re routing results to the right folks at the right time has been tricky, and we’re working through that,” Lee said, “and as always, watching our hospital charges as well.”
