Through Epic Community Connect, healthcare organizations can provide “hosted” access to their Epic EHR to affiliated partners. Among other benefits, the relationship enables the host organization and the recipient partners to share the cost burden of the EHR. This “marriage” works, as long as host and recipients remain like-minded regarding the relationship. But what if they don’t?
Let’s consider a recipient health system that has been on a host health system’s Epic instance for more than 5 years. Service levels were not well defined in the beginning, so expectations were not met and over time the relationship has become strained to the point where the recipient organization is considering a divestiture, or “divorce.”
Following are a few of the important considerations for any recipient health system contemplating a Community Connect divorce.
1) Who will provide Epic technical support for the implementation and beyond?
Just like marriages of people, Community Connect marriages involve sharing chores, and they are not always shared equally. The biggest “chore” in a Community Connect relationship is Epic technical support. The recipient will sometimes outsource its Epic support to the host’s IT department. In addition to its own organization, the host’s IT department is also likely supporting other organizations, because economies of scale are achieved when those support resources are centralized.
When a host and recipient divorce, and before the implementation onto its own Epic instance begins, the recipient organization will need to consider how it will rebuild its Epic IT support team. Analysts, instructional designers, report writers, interface engineers, systems support engineers, and all the leadership and project managers that make up a functional IT department need to be insourced again. This can even include help desk personnel and informaticists – and don’t forget the third parties.
2) What will splitting third-party applications entail?
An Epic ecosystem can include hundreds of third-party systems implemented during the Community Connect marriage that will have to split. Migrating third-party systems completely from the host’s domain to the recipient’s can be a time-consuming and costly effort. Everything from getting new contracts, identifying support personnel, migrating all the information, and realigning integration with the single Epic instance takes coordination and resources – not to mention cooperation from the “Ex,” as many require waves of cutover for a smooth transition. There will inevitably be some operational workarounds required in the interim and possibly system downtime to consider.
3) Where do we have gaps in operational system design knowledge and how will we rebuild this knowledge in-house?
The recipient organization will also need to consider the wide range of operational knowledge needed beyond the IT team, including everything from facility structure (department, bed, accommodations, hospital and professional CDM, and fee schedules) required to enable efficient charge capture to clinical system design (content, order sets, care plans, and tools clinicians use every day). Often, the recipient sees the requests for changes to these processes as black boxes – change requests enter one side and are either denied or approved and completed. In most Community Connect relationships, while the recipient may be part of the revenue cycle decision-making relative to their facilities, the recipient typically does not:
- Own CDM
- Handle pricing
- Manage revenue integrity
- Fully manage legal medical record integrity
Picking up on our earlier example, the recipient organization has been relying on decisions handed down from the host regarding “how to run the facility” for five years, so any internal knowledge of how it is done is either gone or has become outdated. This combined set of knowledge and skills needs to be reassembled within the recipient organization, and it will take time. The recipient will need a plan for relearning how to lead, communicate system build and function, share implications of downstream cause and effect, and interpret regulatory requirements and guidelines that continuously evolve. The recipient will need people who can explain complex scenarios to executives and peers to negotiate change requests.
To further demonstrate the point, at one divorcing recipient, overall key performance metrics for go-live were looking fantastic (nearly all were back to pre-live baselines); however, there were $30M of claims that were not being worked and a significant number of logs that weren’t being posted. This presented a huge opportunity to improve the recipient’s bottom line, but because the health system was relatively small, it did not have the cash reserves or the in-house operational expertise needed to work the system. About 3 weeks prior to go-live, they had to lay off waves of managers, because they were short on money.
And let’s not forget the system skills to implement changes – the framework of analysts, informaticists, instructional designers, training specialists, and network of “super users” that carry the message to the masses. Managed services partners are often engaged to enable phases of progressive change in these responsibilities, although this strategy must also be carefully considered, planned, and executed.
The lesson learned here is to understand your organization’s weaknesses in terms of knowledge and skills and ensure there are good plans to build them back up. Forego the “nice-to haves” and focus on the skills and knowledge needed to be independent again.
5) What impact will splitting the system have on clinicians?
Splitting from one Epic system to two may seem simple; however, not all Epic systems are built the same (think master file record naming, foundation record use, internal system identifiers, etc.), so you can’t simply copy the full chart from the host’s Epic to the recipient’s Epic. To handle this, Epic uses “Exit Records,” where Epic bundles everything out of the legacy Epic system into a PDF and migrates that PDF to the recipient’s Epic attached to that Epic Serial Number (ESN). Keep in mind, the PDF is not searchable and acts more as an archive, as opposed to a usable document for clinicians.
6) What impact will splitting the system have on patients?
The impact to the legal medical record is another thing to consider – i.e., which clinical interactions belong to the recipient, which to the host, and more likely – which to both. This will take careful negotiations and decision-making about where the lines are drawn. The patient chart in Epic captures each of those interactions into a comprehensive medical record. If the divorce is not amicable, you could end up with “broken” patient records, where the visits at the host’s facilities are omitted from the recipient’s Epic instance. Obviously, this is not ideal for the patient.
Marriage – complicated to build, complicated to tear apart
As in any marriage, Community Connect partners may begin to ask, “What’s in this relationship for me?” Whether the relationship suffered a symptomatic growing apart, or a partner is allured by “greener grass,” be warned, divorce is not an easy way out. Becoming “single” again takes an immense amount of focus, determination, and perseverance. Among the questions to consider:
- Will we acquire the skills and knowledge required to be single again?
- Will we have the discipline required to live within our means?
- What will be the impacts, and will we have the fortitude to see the divorce through?
You can anticipate that, no matter what, not everyone will be happy. Expect internal groups to falter and question the decision for divorce. A thoughtful communication plan, addressing each of those audiences, calling out the trials and tribulations ahead will help everyone adjust to what is coming. Enlisting a consulting partner with Epic expertise and “divorce” experience who can serve as an intermediary and help you fully understand the implications and plan for them is also a good idea.
Contributors: Michael Totherow, Jason Lassen