Apotti ProgrammeDeployment of Epic in Helsinki Area 2016–2020

How to work with customizing a shared EMR for different specialties? How to organize the work getting clinicians in front ?

How was the experience so far with EPIC ?

Apotti area covers

• 30 hospitals, including University hospital group (Helsinki University Hospital)

• 40 public health stations

• 50 social service offices

• 1,6 million citizens

Helsinki and Uusimaa Hospital District

• Two regions – 2.5 million citizens

• 12 hospitals

• 44,000 employees in the region will be using the system

• 46 municipalities can (at least in part) be linked up to the system

• 400 persons involved in the project organisation

• No social or home care included

Denmark: The Health Platform

Eastern Denmark

• Healthcare and social care services• Healthcare expenditure: 20 billion a year (9.5 % of GNP)

• Private healthcare service providers’ combined turnover: 3.5 billion a year

• Social care expenditure: 66 billion (32 % of GNP)

• Proportion of social care expenditure related to old age: 38 %

• Role of private sector providers is set to increase

• Challenges• Aging population

• Chronic diseases

• Almost 100 % Electronic Medical Record coverage

Background: Social and Healthcare in Finland

Epic Systems’ EHR software, the core of Apotti, is in use in some of the world’s top-rankinghealth care establishments

• Over 3 million users

• Over 45 million client portal users

• Over 360 organizations, including Kaiser

Permanente, Mayo Clinic, Johns Hopkins

• The best content is incorporated into the

Epic system and shared and updated with

the system to all users

→ The best practices in the world can be

easily adopted

Key facts about Apotti Programme

Apotti’smain objective

is to establish oneregionally integrated

client and patientIT-system for social and

health care

Apotti reforms Social and Health Care: Medication Process before Apotti

PegasosHealth center

Emergency

Lab

X-ray

Anesthesia

Operating room

Intensive care

Inpatient ward

Uranus

WebLab

Radu Agfa Pacs

GE CA

GE Opera

GE Clinisoft

Uranus

Pegasos

Uranus

= Information does not move, need for double documentation

Social services (nursing home)Effica Effica

GE Clinisoft

Health center

HUHD ED

HusLab

HUHD General Imaging

Anesthesia

Operating room

Intensive care

Bedded unit

Social admin

Medication check point

Changing color in the line describe that

the medication is changed.

Medication after Apotti go-live

• Specialized Care, Primary Care, Oral Health Care

• Elderly Care, Home Care and other Social Care Services

• Most of the Epic applications – clinical and administrative

• A lot of Finland specific functionality developed by Epic according to the

agreement

• Integration to national health archive KANTA and Prescription Center

• Finland specific coding and reporting

• Integrations to around 60 other systems

• My Chart client portal

The Scope

May 2012: Program starts as a common project owned by Uusimaa Hospital Area and 5 municipalities

Fall 2013 to fall 2015: Procurement and product evaluation period

• Over 600 social, health and ICT professionals take part in the procurement process

March 2016: 65 Apotti Associates (Physicians, Nurses and Social workers) start their work

April 2016: Contract between Apotti and Epic signed

• Value 384 million euros over 10 years

August 2016: Implementation begins

September 2016: Contract for infra services signed with Fujitsu

November 2018: First parts of system go live

Latest news:

• Over 400 employees working within the Apotti Company

• Apotti associated professional network consists of over 500 professionals

• Total number of end users is about 40 000

Key Facts about Apotti

Implementation time lines

2018 2019 2020

November

VANTAA:

oral healthcare,

substance abuse

services,

services for the

disabled,

employment

services

and family law

matters

700 users

May

VANTAA:

most of

healthcare,

family services

and services for

the elderly

2300 users

May

HUS:

Meilahti hospitals,

Skin and Allergy

Hospital,

Töölö Hospital,

Surgical Hospital,

HUS units of the

Malmi, Laakso, Aurora

and Herttoniemi

hospitals,

HUS Medical Imaging

12 500–15 000 users

October

HELSINKI

KIRKKONUMMI

KAUNIAINEN

TUUSULA

KERAVA

15 000 users

November

HUS PEIJAS

2 000 users

January

HUS:

Hyvinkää,

Lohja, Porvoo,

Jorvi, Raasepori,

Gynaecology

and obstetrics,

HUH Psychiatry

9 400 users

ONGOING SERVICE / PRODUCTION / FURTHER DEVELOPMENT

Areas of operational change

Guiding workflows

→Client and patient

safety

Utilisation of

knowledge

Electronic

services

Harmonized

practicesStructured

documentation

How to organize the work getting clinicians in front ?

• Workflows: How do clinicians work in Finland?

• Content: How can we help clinicians do their work more safely and effeciently? What kind of order sets, note templates and reports do theyneed?

• Training material and acutal training

• Testing

• Integrations: Where in the workflow do the clinicians need the data fromdifferent intergrated systems?

• COMMUNICATION

• OPERATIONAL READINESS

What did the clinicians do in Apotti?

How are clinicians involved?

65 Apotti Associates= Nurses, Physicians & Social Workers

working at Apotti Ltd.

Broad understanding of the

workflows and strategies in their

respective departments

Line of business

management

Regular meetings with

the leaders of their

departments

650 Subject Matter Experts

Experts of different disciplines

in organisations

Decisions on the

workflows and contents

of the system

Team around a

system application

Each Apotti Associate

belongs to an

application team

Direction / Adoption

Core

ACDC(Apotti Content Design

Conferences)

How did Apotti involve Clinicians?

Review, Build, and Approve “common”

content for all specialties

Review, Build, and Approve workflows

Review, Build, and Approve content needed

for different specialties

Epic has a standard way of doing it:

Problems in Denmark and in Finland ”The most important

decisions are done

when you know the

least about how the

system works”

”We did not

understand

what we were

deciding...”

FOUNDATION – CORE – CONTENT BUILD

ACDC (Foundation)

After ACDC

Apotti-Core-

Apartments

15 ACDC GROUPS 13 specialties groupPrimary careSocial care

Workgroups

1 Anesthesia

2 Abdominal Care

3 Cardiac/Pulmonology

4 Emergency

5 Head and Neck Centre

6 Inflammation

7 Intensive Care

8 Internal Medicine & Extended Care

9 Obgyn

10 Oncology

11 Orthopedics

12 Pediatrics

13 Primary Care

14 Psychiatry

15 Social Care

ONE ACDC-GROUP CAN HAVE MULTIPLE SPECIALTIES

Abdominal Care service line in HUH

Endocrinology and Parenchymal Diseases

Hepatic and Transplantation Surgery

Nephrology

Gastroenterology

Gastrointestinal Surgery

Urology

Vascular Surgery

Vantaan Go Live (11.5.2019) timeline

April May JuneMarch

11.5. at 04:00

Apotti GO Live in Vantaa

Primary Care and Social Care

12.4.

Cutover

training

28.3.

Cutover

training

16.4.

Go Live dress

rehearsal

8.4.–6.5.

Support models in place

6.–31.5.

Hyper care (extensive support)

1.–19.6.

Support continues

25.3.–19.6.

Go Live organization in place and working

25.3.–24.5.

Data conversion

8.4.–16.6.

Manual conversions

1.4.–30.4.

Manual conversion training and Kick offs

28.3.–5.4.

Building of

schedules for

end users

20.3.–7.5.

Log-in labs

11.5. → GL2

Intermediate workflows8.–11.5.

Cutover

1.4.

GLRA 123.4.

GLRA 2

25.4.

Cutover

Kick Off

27.4.

New Epic

version

11.3.–3.5.

End user training

12.3.–11.4.

Super user training

4.–11.5.

Health Care

Pre Go Live

29.4.–11.5.

Soc Care Pre Go Live

How was the experience so far with EPIC ?How did we succeed?

• Epic is used to working in silos/applications, but health care is an integrated process

• Medication goes from outpatient to inpatient to home care etc

• Scheduling, coding, billing and reporting is part of every process and cannot beseparated from clinical work

• Epic is very configurable –sometimes even too configurable…

• US Health Care workflows are not the same as Finland workflows

• Terminology and translation is hard and ”wrong” or ”new” terms can causeproblems

• Focus on core workflows and do optimization after clinicians know whatthey need

Greatest challenges during the build period

Patient transfer:

• New and complicated workflows

when the patient is moving between

different levels of care (ED to ward,

ward to operation theatre etc)

• Apotti should have followed Epic`s

guiding on how to support change

management, but did not because of

lack of resources and time

• Insufficient end user training with

incomplete system

Greatest challenges today (6 months after Go Live1)

Medication:

• Difficulties with integrations and workflows

with the national Prescription Center, both

technical issues and slow workflows

• Unsatisfactory configuration due to lack of

time and lack of co-operation between

different teams inside Apotti

• Easy to customize -> 76 different views and

lists in different parts of the system

• Inpatient and outpatient medication lists do

not communicate as clinicians are used to

• A lot of improvement still needed

Code capture:

• Registering administrative codes for billing, databases and more takes a lot of clicks

• Codes for are missing and end up in error work queues

• Code capturing needs to be intuitive and easy

• Hard stops?

• Secretary workflows are unclear

• Who does what?

Greatest challenges today (6 months after Go Live1)

InBasket:

• Professionals were not used to checking results through “email-like” InBasket.

• Technical issues with results routing

• Not enough change management before Go Live

• Inadequate end-user training → No clear understanding of the overall effect to daily work

Ordering:

• Computerized Physician Order Entry (CPOE) –good or bad?

• Epic Order Sets, Note templates and Favourites utilization is not on satisfactory level

• Personalization not on satisfactory level

Valley of death

• Change management

• Strong local clinical leadership

• Ability to make fast decisions and document them

• A certain level of detailed knowledge about the system is necessary

Wrap up