A Patient-Centric Database

I've been thinking a lot lately about patient registries, accountable care networks, and Healthy Planet-type stuff. Personal fact: I'm prone to think up conspiracy-theories and am, at the macro-level, a glass-half-empty person. When you put the two together, it makes this blogger concerned about the future of healthcare.


"With the Patient at the Heart" is printed on the back of Epic's business cards, and emblazoned proudly on company vehicles. I've worked at different organizations that had similar slogans about patients being first and foremost and the most important thing. The underlying sentiment with these slogans is that each patient is a unique individual, and each patient deserves personalized care.

Healthy Planet (and its primary drivers, Obamacare and MU) are active obstacles to that. No longer is Joe Smith a relatively healthy male and a compliant patient with diabetes whose lab tests happen to run slightly abnormal, he's now the 37th entry on the list of patients with an A1C over 7. He's been on that list for a year now, and gets a letter every month saying he needs to come in for a checkup. Mr Smith's doctor is worried, because even though Joe is healthy and doing everything to correctly manage his diabetes, the lab tests run high enough that the doctor gets dinged on his metrics. The doctor is therefore considering dropping Mr Smith as a patient.

Enter Accountable Care Networks. Now, not only is Medicare tracking all your stats, but your employer is too. And because your employer is paying the hospitals, your employer has a vested interested in your health. The healthier you are, the cheaper it is for your CFO, and those savings can be passed directly to the stockholders. Taken to its logical conclusion, given equal experience, equal qualifications, and identical answers during the interview, it's going to be the younger/skinnier/male candidate who gets the job. Age/Gender Discrimination will morph into Health Discrimination.

Discuss below. Are my fears irrational? Is your organization re-working existing teams to meet a growing list of reporting needs that must be available in prod yesterday?

Interview-ish article with Judy Faulkner

Courtesy of Healthcare IT News: Epic CEO Judy Faulkner talks EHR Interoperability, Need for a National Patient ID, Physician Productivity

The comment "Unique patient ID has to happen" intrigued me, because that's patently untrue.


Consider:

• We already have a national ID: Social Security Number. However, that doesn't account for recent immigrants or tourists. 
• It's possible that every single person living on planet Earth may visit the United States at some point and while visiting may need health care. 
• You'd need to be able to account for >7,000,000,000 people (and counting). 
• Tourists may visit the USA multiple times and years apart, and they can't be expected to remember an MRN.
• A national ID does no good if the potential exists for one patient to have multiple IDs. Within a single hospital, Patient Merge gets used all the time. If you've ever had to deal with Patient Merge AND Care Everywhere, then you know the problems that arise when a hospital can't match the person to the chart. Multiply that by the entire nation. Or the entire planet. 
• Biometrics are unique and they can't be forgotten because they don't have to be remembered in the first place. 
• A national (international?) database of biometric information with bi-directional interfaces to every hospital system will need to be created and maintained.
• Remember Obamacare?

That seems a good place to stop. Discuss. 

EHRs Suck

And I think this video summarizes why quite nicely. The youtube comments (surprisingly) are intelligent and worth a cursory glance.

The video promotes #letdoctorsbedoctors, which in turn promotes athenahealth. I glanced at the athenahealth* website, and their demo looks an awful lot like Epic with a sleeker UI. I'm not exactly sure what they're offering, unless it's an "out of the box" version of Epic. Every feature in the demo is available in Epic, but in Epic it requires tons of analysis, build, debugging, and rebuilding.

Given the similarity to Epic, I'm curious to see how many of athenahealth's employees used to work in a certain cow pasture in Verona.

EHRs do suck. And with all of the MU regulations, EHRs are never going to get better. The government requires reportable data, and that requires data entry. Unless "exam room stenographer" becomes a new job title, doctors are the only ones able to enter all the data that the government wants. The other option is for the government to get out of the way (aka "deregulation") and let doctors be doctors.

*I'm assuming that the lower case and lack of spacing is part of their trademark. Unless you're e.e. cummings, you should use proper punctuation and capitalization.

By Request, Epic's Severance Agreement

Some comments on my first post alluded to a severance agreement. I promised to post it when I received it, so here it is:

The full text:

SEVERANCE AGREEMENT AND RELEASE

Regardless of whether I sign this agreement, I will be paid my normal salary and for my unused vacation accrued through my last day of work, subject to Epic's policies on pay upon termination. (Only add this language if you would not pay out unused vacation)

If I sign this Agreement and abide by its terms, my last day of work at Epic will be ________, 20__ (The "End Date"). For that End Date to be in effect and to receive the severance benefits described below, which are in addition to anything owed to me, I must sign and return this agreement to epic no later than _______, 20__. Prior to the End Date, I will fulfill my commitments to Epic in a professional and timely manner, including abiding by Epic's policies.

Epic will provide me with severance in the form of continuation of my base salary in effect on the End Date, less standard payroll deductions and withholdings, for ____ (__) weeks. The first installment of severance will be provided to me on Epic's first normal payroll date following the End Date that is at least seven (7) business days after Jennifer Peterson in Human Resources receives my signed agreement.

Although my receipt of severance pay and other factors may affect my unemployment insurance benefits, if I am awarded such benefits, Epic will not appeal that award. If I am denied such benefits, Epic also will not appear at any unemployment insurance appeal tribunal hearing unless required by law.

I am not entitled to any other severance, benefits, vacation , paid time off, leave, equity interest, bonus, commission or other payment, compensation, or consideration of any kind (including, for example, that Epic will not match any 401(k) amounts contributed by me in 2012), except those expressly described in this agreement. I have been paid all other compensation owed and for all hours worked except those expressly described in this agreement. I have been paid all other compensation owed and for all hours worked except as described in the first paragraph above, received all leave and leave benefits and protections for which I am eligible, and haven't to my knowledge suffered an on-the-job injury for which I haven't already filed a claim.

I agree not to reapply for or seek employment with or at Epic.

I generally and completely release, and promise not to sue, the Company with respect to any and all releasable claims I may have against the Company. The "Company" includes Epic, it's affiliates and subsidiaries, and its and their past and present officers, directors, employees, agents, owners, insurers, predecessors, successors and assigns. This release does not apply to any claims that may arise after the date I sign this agreement or any claims that cannot be released under applicable law. Otherwise, the release claims include all claims, whether or known now or later discovered, whether based on contract, tort, statute or otherwise, which arise out of or are in any way related to any events, acts, conduct or omissions occurring prior to my signing this agreement, including claims for future damages allegedly arising from the continuation of the effects of any such events, acts, conduct or omissions. For illustration only, the released claims include any claim arising out of (1) alleged discrimination of any type, (2) my Epic employment, agreements, compensation or benefits, or the termination of employment, or (3) any federal, state or local law, regulation, ordinance or order concerning the employee relationship, compensation or benefits, or the termination of employment. Nothing in this release is a waiver of a right to file a charge or complaint with administrative agencies such as the federal EEOC that I cannot be prohibited from or punished for filing as a matter of law, but I waive any right to recover damages or obtain individual relief that might otherwise result from the filing of any such charge with regard to any released claim.

This agreement represents the entire agreement between Epic and me, and it completely supersedes any prior or simultaneous oral, written, or implied agreements, statements or understandings concerning its subject matter. This agreement doesn't supersede my continuing obligations under the Epic Employment Agreement, including for example obligations relating to confidentiality, intellectual property or non-competition, or other continuing obligations that I have to Epic under any other agreement.

This jiggered some memories I had of when Epic tried to get me to repay the moving costs that they incurred by employing me. I told them I would do no such thing, and they let the issue drop.

Epic's Principles, Part 10

Epic's 13 principles
1. Do not go public.
2. Do not be acquired.
3. Expectations = reality.
4. Keep commitments.
5. Be frugal.
6. Have standards. Don't do deals.
7. Create innovative and helpful products.
8. Have fun with customers.
9. Follow processes. Find root causes. Fix processes.
10. Don't take on debt for operations, no matter how good the deal.
11. Focus on competency. Do not tolerate mediocrity. 
12. Teach philosophy and culture.
13. If you disagree, dissent. Once decided, support.

We've arrived at the final installment, and the one I'm least qualified to write about, as my tenure at Epic predates this principle.

Business books describing streamlined, high-functioning teams or companies generally agree that there is value in hearing all viewpoints regarding a given issue. Leaders don't always have the best view of what's happening on the ground, and smart leaders like to know if they're rapidly progressing to a cliff. Also, a team cannot be high-functioning if its members are working at cross purposes. Once the decision-makers have had their say, the team must unify their efforts. This is a sound business principle, and a good idea.

However, this requires that leaders be able to admit that they're wrong. I don't think Epic's leadership has that ability. Those stillborn ideas that I remember from staff meetings were never spoken of again, and no documentation existed in the first place. I can't imagine any of the power holders at Epic admitting that they thought developing a Farmville-esque Facebook game about healthy kids* was a good idea. For dissent to be valuable, leaders have to listen to it, and to listen to it means they have to acknowledge that they may be wrong. Epic's culture doesn't permit the rank and file to question authority.

I saw this article about the Pontiac Aztek, and it seems appropriate.

The 13th principle is a good goal, but I don't see how Epic can actually follow it--they'd have to change a lot about their culture and philosophy to make it happen. It's admirable that Epic has considered it, and that Epic is encouraging it (at least on paper), but I don't see their cultural inertia changing directions any time soon. On behalf of all current and future Epic employees, I'd love to be proved wrong here.


*I remember Judy talking about this idea several times over a period of a couple months.

Epic's Principles, Part 9

Epic's 13 principles
1. Do not go public.
2. Do not be acquired.
3. Expectations = reality.
4. Keep commitments.
5. Be frugal.
6. Have standards. Don't do deals.
7. Create innovative and helpful products.
8. Have fun with customers.
9. Follow processes. Find root causes. Fix processes.
10. Don't take on debt for operations, no matter how good the deal.
11. Focus on competency. Do not tolerate mediocrity. 
12. Teach philosophy and culture.
13. If you disagree, dissent. Once decided, support.

If Epic actually meant "philosophy and culture" as it's understood by most people, then it's an abject failure. But if they meant "Drink the kool-aid until you drown in it," then they're doing pretty well. Paraphrased as "Teach Epic's philosophy and culture," then the principle makes perfect sense.

Epic has a particular philosophy and culture which many businesses don't adhere to, so the business philosophies that new Epic employees just spent 4-6 years studying in college don't always apply. Epic has to instruct these new employees in the specific way that Epic runs. Sometimes Judy provides this instruction bluntly in the monthly staff meetings, at other times the employee just picks it up by diffusion.

One of Epic's unique business philosophies is that "it's better to hire someone with no relevant experience and train them from the ground up than to hire a seasoned software developer and have them unlearn everything so they can do Epic development." As flawed as I think that belief is, it is fully in tune with Epic's philosophy, and it is definitely taught.

I'm drawing blanks on other examples of Epic's philosophy. Add your own in the comments.

As for Epic's culture, they don't teach this as explicitly. In theory, it's laid back (e.g., no dress code) and  flexible (work hours). In practice, there is a distinct dress code that successful Epic employees follow--nice blue jeans and at minimum, a nice-looking "casual" shirt. Holey sweat pants and Packers jerseys might work once in a while if worn ironically, but if you show up every day looking like that, you're not going to work there long. The flexible hours (as I've written before) amount to "Come in as early as you'd like before 9 am, and stay as late as you need to after 5 pm." You either learn the culture and drink the kool-aid, or you leave the company.

Epic does teach its philosophy, but it doesn't teach its culture. You're expected to learn and follow both.

Epic's Principles, Part 8

Epic's 13 principles
1. Do not go public.
2. Do not be acquired.
3. Expectations = reality.
4. Keep commitments.
5. Be frugal.
6. Have standards. Don't do deals.
7. Create innovative and helpful products.
8. Have fun with customers.
9. Follow processes. Find root causes. Fix processes.
10. Don't take on debt for operations, no matter how good the deal.
11. Focus on competency. Do not tolerate mediocrity.
12. Teach philosophy and culture.
13. If you disagree, dissent. Once decided, support.

Principle 10 is interesting--it used to be "Don't take on debt, no matter how good the deal," but apparently Judy had to buy some buildings on credit. It's nice that day-to-day fiscal responsibility is a priority, but unfortunately, I'm in no position to know how well Epic is doing on that. The company is privately owned specifically to keep this kind of information out of the public.

Epic gets a bye on this one, due to my lack of insider information.

Because of that, you get a twofer this week. "Focus on competency. Do not tolerate mediocrity." As with most things, Epic takes an inconsistent approach to this.

Judy most assuredly does not tolerate perceived mediocrity in its employees, but she sure is happy to have the least mediocre EHR out there. There's a difference between Best and Least Bad. Epic is adequate, but the volume of user complaints and bug reports preclude any claims of excellence. Epic does try, though; they're just hampered by how they enforce their ban on mediocrity.

I'm talking about how Epic churns and burns through its employees. New employees are trained to a level of adequacy, then left to sink or swim on their own. If they start to sink, rather than fish them out of the pool and enroll them in swim lessons, Epic lets them drown.

Most business knowledge that I've come across (google: retraining vs replacing employees) advocates that retraining is the more sound business decision. In terms of lost productivity and monetary expense, replacing costs more. Consider Epic: When I was there, communal wisdom stated that it took about 9 months for a TS to become self-sufficient after being hired. Retraining the under-performing employee should take about a month or two of concentrated effort. Replacing that employee starts the 9 month counter over. If most people are leaving sometime between 1.5 and 2.5 years, then the customer is getting minimal competency from their TS.

If training were better, and could be compressed into a shorter time frame, that would help Epic live up to its principle. Get the employee competent faster. If Epic retrained the underperformers--time management skills, prioritization, troubleshooting shortcuts, etc--then they wouldn't have to give up 9 months of non-productive time. Epic wouldn't have to pay that new employee for 9 months on the promise of only a couple months of productivity after that.


While Epic tolerates mediocrity in their product, they are quick to fire mediocre employees, which is a no-tolerance response. Epic has historically struggled with getting its employees the right training, and Epic never retrains. Competency is assumed, never questioned, and never corrected if necessary. There's little proof of a focus on competency. Epic fails on this principle.

Epic's Principles, Part 7

Epic's 13 principles
1. Do not go public.
2. Do not be acquired.
3. Expectations = reality.
4. Keep commitments.
5. Be frugal.
6. Have standards. Don't do deals.
7. Create innovative and helpful products.
8. Have fun with customers.
9. Follow processes. Find root causes. Fix processes.
10. Don't take on debt for operations, no matter how good the deal.
11. Focus on competency. Do not tolerate mediocrity.
12. Teach philosophy and culture.
13. If you disagree, dissent. Once decided, support.

"Follow processes. Find root causes. Fix processes."

This one has always bothered me from a semantics angle. What is the Epic Employee to do with the knowledge of the Root Cause? Why was the employee told to find it? What if the process wasn't the root cause of the problem? I would have rephrased it to "Follow processes. Find root causes of problems. Fix root causes."

Epic has a lot of processes that need fixing, and since several of these processes have been flawed for the better part of a decade (at least), it's clear that Epic has no interest in fixing them. The most obvious example of this is their HR practice. Epic follows the practice of hiring the best and the brightest of the inexperienced. Shortly after the employee becomes competent with solo work, the load gets bigger until the employee either buckles under the strain or decides that the strain isn't worth it. At that point, the employee starts looking for work outside of Epic, taking all that experience with him.

The root cause of that problem is firing the employee instead of investing in their growth. Since Judy has gone on record at a staff meeting to lament their employee retention numbers, she could kill two problems by fixing one root cause.

Then there's the problem of Epic's development. Everyone who's gotten a peek behind the curtains knows that Epic's code base is held together with chewing gum and baling wire. A bona fide Patient Safety Escalation comes out every other week, and there are about a dozen Care Concerns each week.

Development processes were followed; Epic has numerous checklists for that. Problems were introduced into the product. Root causes were discovered by the Patient Safety committee. The problems were fixed after the fact (mostly), but the processes that allowed those issues into the software weren't modified.

The root cause of a given PSE is relatively easy to discover, and the code change required to prevent that specific problem from occurring in the future is manageable. However, the root cause of Patient Safety issues in general hasn't been looked at. How can Epic prevent buggy software from going out? I've heard suggestions (and posited some of my own), but nothing has changed.

While Epic talks a big game about fixing processes, they don't really deliver on that.

Epic's Principles, Part 6

Epic's 13 principles
1. Do not go public.
2. Do not be acquired.
3. Expectations = reality.
4. Keep commitments.
5. Be frugal.
6. Have standards. Don't do deals.
7. Create innovative and helpful products.
8. Have fun with customers.
9. Follow processes. Find root causes. Fix processes.
10. Don't take on debt for operations, no matter how good the deal.
11. Focus on competency. Do not tolerate mediocrity.
12. Teach philosophy and culture.
13. If you disagree, dissent. Once decided, support.

Epic has a slide, so I guess that's got to count for something.

Seriously though, there's a fine line between having fun and frivolously wasting money. UGM walks that line nicely. There are loads of customer-centric events that (to me, at least) never appeared to be gross misuses of money. For customers visiting Verona's campus, Epic follows this principle pretty well.

However, for Epic employees visiting customer sites, fun with customers usually isn't a priority. While visiting Epic staff could suggest going out for a meal during lunch or after work, many Epic customers prefer that visitors' time be devoted more to resolving issues than extra-curricular socializing. Given various legal and ethical issues around vendors paying for clients' meals and vice-versa, the Epic employees that I've dealt with are doing the right thing, even if it's not necessarily following Epic's 8th principle.

Out of 8 principles so far, Epic's actually following 3 ½ of them (and two of those are gimmes).

Epic's Principles, Part 5

 Epic's 13 principles
1. Do not go public.
2. Do not be acquired.
3. Expectations = reality.
4. Keep commitments.
5. Be frugal.
6. Have standards. Don't do deals.
7. Create innovative and helpful products.
8. Have fun with customers.
9. Follow processes. Find root causes. Fix processes.
10. Don't take on debt for operations, no matter how good the deal.
11. Focus on competency. Do not tolerate mediocrity.
12. Teach philosophy and culture.
13. If you disagree, dissent. Once decided, support.

"Create innovative and helpful products." Having recently spoken to some brand new Epic users, I could have some fun with the "helpful" part of this, but since I did drink the kool-aid pretty heavily for my tenure at 1979 Milky Way, I'll abstain from most of the snarkiness.

When used well, I do think Epic is really helpful. As a MyChart user, it's great to be able to see my lab results whenever I feel like it. It's convenient to schedule appointments without having to wait on hold on the phone. As someone who's watched clinicians ooh and aah when they were able to see other providers' notes on their patients, it's obvious that Epic can be helpful.

However...
A couple of things have to align for Epic to be helpful: The customer has to have implemented the software correctly, and Epic's code has to work. It's not a principle, but it's shown at every staff meeting: "Rule #1: Software must work. Period." Judy used to enjoy mentioning how the Cerner CEO thought that was a personal dig directed at him, but I've seen enough Patient Safety Escalations and Care Concerns coming from hastily coded Epic software to say that Epic is guilty of breaking Rule #1, too.

Software that doesn't work isn't helpful. When Epic works, it's beautiful, but when it doesn't work it's downright dangerous. Epic needs to work on the safety of its products. That, in turn, will increase the helpfulness factor.

I'll give Epic half credit on the helpfulness bit of Principle 7. As for innovation, there's a good mix of innovation and stagnation happening in Verona.

On the one hand, they haven't done much that's truly groundbreaking since taking over the entire industry. Their new products are primarily focused on providing an Epic option for specialty software that used to be sold by best-of-breed vendors. On the other hand, MyChart is really cool, as is Haiku and Canto.

Meriam-Webster defines innovation as merely an improvement over something existing. By that definition, Epic is constantly innovating, as their software is consistently getting better over time. However, my own exacting standards demand more. I feel that innovation needs to be more earth-shattering, like what the iPhone did to the cell phone industry. Giving patients easy access to their own health records was that kind of game changer. There's a Chronicles quote that says "Talent hits a target that no one else can hit. Genius hits a target that no one else can see." MyChart was genius. Beaker, Phoenix, Beacon, Thumper or iHeartHearts or whatever they're calling Cardiant now--those  all stem from talent. Innovation requires genius, in my book.

tl;dr: Epic does a pretty good job with innovation and helpfulness, by the dictionary definitions. I wish they would do more and try harder to be more helpful and innovative.

Does Judy know what happens at her company?

A coworker of mine showed me this article: Healthcare IT News: Go-live Gone Wrong. It details a couple of organizations that had huge monetary issues after going live with Epic. Apparently, no one told the clinicians that they'd have to take charge of some of their billing workflows (e.g., Charge Capture), therefore the hospitals had huge budget shortfalls.

It brings to light an old problem with Epic: lack of training. I'm not sure what Epic provides for trainers at customer sites, but this shouldn't have even been an issue--Epic's implementation staff should have covered this in their project plan. However, Epic doesn't always provide IS for existing customers. Everyone has a TS, but they certainly aren't trained in any kind of project management skills--I don't think it was just me, but during my tenure TS received no training (there's that word again) in project management. We weren't even given a book on the subject. Project Plans are just not something TS know about. The tools given to IS at the start of their new employee orientation are geared to helping new customers and getting someone with no healthcare experience a chance of successfully completing a large-scale multi-million dollar project.

I don't know any specifics about these implementations other than what's in the article--I don't know if it was an IS or a TS who screwed up. I do know that Epic is giving itself a bad reputation with this kind of thing. Training is, at its core level, a somewhat rapid way of imparting experience. As the target audience of this blog can attest, Epic has a problem with giving anyone more experience than the bare minimum necessary. While I don't know if it was an IS or TS who failed here, I'm >80% certain that that employee had less than two years of Epic experience. Anyone who had been there longer would have known better and this wouldn't have happened.

And that brings me to Epic's biggest problem: its turnover rate. Whether its from employees getting burned out and leaving on their own volition or the employees being forced out--there is an unmistakable dearth of experience at Epic. My current employer, when I started working here, had an experienced TS. We've been live on Epic for a while, and the TS had been at Epic for most of that time. That TS had seen the changes Epic had gone through, been through the transition from table-based order transmittal to rule-based, helped us with our build decisions and, in short, knew the differences between our system and Epic's Model. Well, that TS left, amazingly without exhibiting any outward signs of burnout, and was replaced by a fresh out of training newb. Two years later, after dealing with I don't know how many "I don't know" responses on weekly issues calls, the replacement has burned out and left. We're now on our third TS in as many years, and the replacement's replacement shows all the outward signs of being new, as well.

From a personal standpoint, the team feels betrayed by Epic. I know my customers from my TS days felt that way when I was pushed out and replaced by newer folks. (They told me as much when I asked if I could use them as references.) It's a problem that has been going on for years now, and based on Judy's high and mighty rhetoric about how much support Epic customers receive, I get the impression that no one in her circle actually has the boots-on-the-ground perspective--or maybe they're too scared to tell her.

The current impression at my organization is that Epic doesn't care about live customers. New, implementing customers are great, and Epic will move mountains to make sure things are done right (or not, I've heard interesting things about Duke's implementation). But existing customers adding new clinics and new hospitals can figure it out themselves. Epic's already got their money.

My advice to Judy, if she (or her delegates) are reading: You actually need to retain your staff. Free health insurance and a month-long sabbatical aren't enough--you will have to quit firing people. It is not, in fact, easier to train someone new than to re-train someone with experience. Experience matters to your customers, and Epic's lack of it is starting to show.