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Jason Fish, MD

Assistant Clinical Professor,
General Internal Medicine & Health Services Research

When did you first use Epic? I began using electronic health records at the Garden Grove Kaiser Permanente facility when I was working 16 hours each weekend doing per diem work in the after-hours and urgent care centers. I was a participant in the roll-out of Epic.

What do you like best about the system? I really liked the system in that it combined all aspects of patient care into a single medical charting system, and it is a relatively easy system to use. I really like how the system intergrates all aspects of patient care. For example, the active (chronic and acute) problem list ties into order entry diagnoses, which then can be brought into one's notes in the assessment and plan with a simple command. And, the snapshot patient overview page is automatically updated from each encounter.

In what ways did the EHR enhance your practice? How did it help other health professionals in your office? There's no question that it enhanced it. Here are two things that were especially helpful: 1) Note writing was much easier, being able to pull in trends of values or latest studies with simple commands. I also thought diagramming was very easy -- illustrating rashes or skin findings, or identifying key joint inflammation (which Rheumatology already does on paper which I imagine would be great for them in Epic); and 2) Communication with other physicians. You could send the [patient] encounter to the in-box of another doctor with a note about your concerns or follow up. And that's all part of the medical record. I really liked the way the system enhanced how doctors could communicate with one another.

What did you find was the most challenging part of the transition to Epic? Setting up the templates (such as ROS and PE templates) or "dot phrases" that allowed you to quickly pull in data or insert commonly used phrases. For example, I would discuss patient risks and benefits, which I added into my notes. In Epic, I could quickly add this to the bottom of a note by simply typing a quick dot command and the text would be inserted.  It takes time to build up those templates. Once you have them set up well and thoughtfully, things will go well, and it's also easy to edit them. First, you may spend eight hours in training. Then when you have the person [patient] in front of you, you start sweating. Once you get it, though, things go much more smoothly. Another challenge was transitioning to panel management thinking. The training did not really address this and I found many of the clinical personnel struggled with this. For example, Epic allows for ways of identifying groups of patients who need special attention (namely, those due for particular services or who need increased surveillance and medication management). However, we struggled with how to execute this in Epic in an easy manner other than going patient by patient, which was not efficient.

What suggestions do you have during training and rollout? Training will be critical and a slow rollout is imperative. We spent one to two full days in training learning the system. However, while this was helpful to understand the system and its requirements, the real work came when trying to customize the system to meet the needs of my personal patient care. This step takes time and could benefit from practicing with some "mock patient encounters." That's where the physician can use the EHR with someone who is role-playing as a patient. It will also be critical to have truncated schedules initially to allow for appropriate building of the templates as well as having an Epic expert and local clinical champion available. When you have a patient in front of you, you start sweating as you try to use the system. Having these experts around you helps alleviate this anxiety and facilitates the building of thoughtful and useful templates. We took almost four weeks of truncated schedules and expert availability before going back to normal schedules. I also think there would need to be a focus on particular content that is relevant to each division's clinical focus. For example, for me, focusing on individuals and on my panel of patients is key to my success as a primary care physician. Focusing the training and building of the customized system on both of these areas would be critical for my success, and I imagine that there are other areas that would be relevant to other clinical disciplines.

What advice would you give to new users? Really use the Epic experts. I think that's critical. Set it up right, think through it, and things will go well.

If you had it to do it all over again, what would you have wanted done differently regarding the readiness and training approach? I think Kaiser did a great job of training us. I do think there should have been a little more effort to identify users who may struggle more initially and provide some additional training, or provide a little more one-on-one time with the experts. I also think there should be some clinical champions that are available as well. It would have been nice to have some clinical personnel who were trained and experienced who were available to help others, rather than us all in the same boat at the same time.

Any additional comments? We need a repository of all the things we are learning to share with people (like a compendium or newsletter, with lessons learned today and/or new tricks and tips for success) that goes out every day during the rollout. Then it could go out monthly for the first six months.