December 26, 2007

An Epic Challenge
By Elizabeth S. Roop
For The Record
Vol. 19 No. 26 P. 14

The University of Iowa Hospitals and Clinics has created what it hopes is a stress-free environment to help staff tackle a monumental effort to convert its information system in record time.

For most people faced with the task of replacing a facility’s much-loved—and highly customized—legacy information system with an all-in-one vendor product in two years, fun would most likely be the last word they use to describe the process.

But the Epic Project Team at the University of Iowa Hospitals and Clinics (UIHC) is not made up of “most people.”

Despite being charged with deploying Epic’s clinical application system at the 762-bed tertiary care teaching facility in 28 months while simultaneously maintaining the existing legacy system, the project team hasn’t been intimidated. Instead, it has applied its “having fun while working hard” philosophy and taken an approach that has won over skeptics, kept things progressing, and injected a healthy dose of laughs into what is now known as “The Epic Project.”

The keys were to design an approach that would ensure everyone worked cohesively as a team, communicated, and were both positive and creative. What they wound up with was a fun, frugal implementation revolving around a movie, theater, and musical production theme conveyed through a number of creative tools designed to set expectations, build relationships among team members, foster open communication, and keep the project team motivated.

“It’s hard to get stressed out when you’re humming a tune,” says Kristy Walker, UIHC’s director of clinical applications and healthcare information systems. “It’s a little way to break the stress. Our philosophy is ‘have fun while working hard.’ It helps to keep balance and respect for coworkers. That’s not new with the Epic project per se, but it helps us to be successful with this aggressive schedule and task we have before us.”

Aggressive is probably an understatement. The deployment UIHC is attempting to accomplish in two years has been taking other facilities as long as one decade. The entire project is being handled internally by 35 teams involving more than 375 people representing clinical, IT, and more than 175 other key resources.

Adding to the challenge is the fact that because the clinical staff was already accustomed to automation, it was critical to have a full accompaniment of tools ready for go-live.

“Our end users have a huge dependency on the electronic prodding, templates, orders, and prescription sets that they’re accustomed to, so there is an incredible amount of build,” says Walker. “The number of parameters we are going to have downloaded from bedside devices at go-live will be Epic’s largest count.” It will also be Epic’s largest amount of data transferred from a legacy system.

“That makes the two-year timeline we started off with feel even shorter,” says Mary Jo Duffy, assistant director of clinical applications and healthcare information systems.

And all that comes after a nine-month vendor selection process that itself was “pretty aggressive because we needed buy-in from the entire enterprise for this project to be successful,” says Walker. “All represented stakeholders needed to support the philosophy of the Holy Grail system that could do everything for everybody. To step through that process in a timely manner required processing in a very structured, uniform mode.”

Rules of Engagement
The first step in that structured approach was to develop “rules of engagement” that serve as the project’s guiding principles, including the following:

• Patient-centered.

• Use best practice models when possible.

• Standardize when possible.

• Minimize customization.

• Avoid paralysis by analysis.

• Perfect is the enemy of good enough.

• Go-live is not the final step.

• Hit every milestone.

• Soon is not a time.

• Hope is not a plan.

• Be positive and creative.

Defining rules of engagement and guiding principles wasn’t an entirely new concept at UIHC, although for the Epic project, “we really took it to the next level,” says Duffy.

To demonstrate its commitment to the rules and as a way to kick off the project, the team had them printed on notepads distributed throughout the facility. Doing so also served to remind everyone within UIHC of the facility’s patient-centric focus, which is at the heart of the switch to Epic.

“Institutionally, we have tried to be very patient-centered. When we are looking at challenges or where there is disagreement on resolutions, maintaining focus on the objective of safe, quality patient care makes it easy to come to agreement of method and path,” says Walker. “It helps us resolve that negotiation of how we should be doing things. That is why we wanted to make sure that was at the top of our list.”

“Soon is not a time” and “hope is not a plan” were included to address the potential for indecision to stall progress. In addition, because they were transferring from a legacy system that had been highly customized over years of use, “standardize where possible” and “minimize customization” were put in place to remind everyone “that things are going to be a little different, but that it’s going to be OK,” says Duffy. “We just wanted to give everyone that little heads-up that we were going to be standardized where possible.”

Adds Walker: “It’s really nice that they’re taken to heart. Every time there is a challenge or we’re negotiating between different players’ opinions, [applying the rules] helps resolve it quickly. The guiding principles really have helped, not in a dictatorial way but [to foster] a collaborative spirit throughout the house.”

She cites an example where clinicians were struggling to determine which terms for order frequency would be used in the new system. The “standardize when possible” rule was quickly called into play by the physician leadership, which determined the terminology included in the Epic Model System would be the standard.

The rule “provides people [with] something simple to follow,” says Walker. “Historically, with our internally developed legacy system, people could overanalyze forever. We knew that was a risk coming into the Epic Project, which is why we made it one of our guiding principles. With a two-year timeline, we couldn’t afford long, drawn-out, ongoing deliberations.”

Creative Communication and Collaboration
The rules of engagement weren’t the only creative tool being used to build a cohesive team and communicate with the entire UIHC staff. Microsoft Office SharePoint, a collaborative intranet site, is used to let the facility’s staff stay abreast of the project’s status. Monthly speaking points called “Epic at Iowa” and incorporating a Ben Hur theme are also used for updates. Plus, a countdown to go-live is posted to SharePoint.

Enterprisewide sharing of the Epic Progress Report keeps everyone accountable for its success and helps to heighten attention to risk management. “We put [that] out there … to let them know where we are” with the project, says Walker.

Epic and UIHC staff team members have read/write access to the Epic Project SharePoint site so they can update progress reports and share information, minimize duplication of documents, and save space on e-mails by sending a link rather than attached files.

A key message within all communications is the Peak Analogy, based on New Rules for the New Economy — 10 Radical Strategies for a Connected World by Kevin Kelly. The concept centers around the idea that scaling a higher peak often means crossing a valley of less fitness first, and a clear view of the future should not be mistaken for a short distance.

Another challenge was to bring the 35 separate task force teams into a single, cohesive unit. UIHC did this with a project kick-off celebration dubbed “The Dawning of a New Era,” the theme song for which was a rewrite of “Aquarius” called “Epic Upon Us.”

During the event, team members participated in “speed teaming” to help members of the Epic, clinical, and technology teams get to know each other. Similar to speed dating, “It was a fun way to get people talking to each other,” says Duffy.

An in-house communication campaign was also launched under the “Our Epic Production” theme to convey the following key elements:

• An epic is characterized by great length, multiple settings, heroic characters on a quest, and large numbers of characters.

• The UIHC implementation has the same characteristics as an epic; the impact is gigantic.

• UIHC’s heroic quest includes improved care and service for its patients.

• The number of people responsible for its success is enormous.

Other aspects of the Epic Production include the following:

• events for celebration, training, and announcements featuring free popcorn;

• lobby posters of epic movie productions altered to reflect the implementation;

• “sneak previews” in cafeterias and during rounds and reports;

• the use of a movie clapboard graphic for buttons, product tie-ins, and fliers;

• “Learning Clips,” two-minute YouTube videos developed by each project team and posted on SharePoint with the intention of generating excitement and positive energy for the project;

• “easy” buttons in every conference room; and

• CHARMS, or Clinical Application Division Honor Awards and Recognition Medals, designed to recognize exceptional efforts with fun “badges,” such as the Ancillary Technical Support Award and the Dashing Dashboard Award.

“It’s contagious when you do things like that,” says Walker, adding that even the mandatory training sessions will carry the epic production theme. “It just makes it a little bit more fun,” she says. “You’re still doing training, but it’s a little more lighthearted; it’s not as stressful. When in a positive environment, the learning and collaboration is just more successful.”

The easygoing approach has even been applied to status reports in the form of the Epic Project Train. When things are on track, the status is the engine car pulling the train; successful milestones are celebrated in the party car; when help is needed, it’s signified as flying off the back end and hanging on to the caboose; and trouble is conveyed as tied to the railroad tracks of an approaching train.

“You don’t have all that negative baggage about something doing poorly,” says Walker. “There is no baggage about hanging onto the back of the caboose. It is projected as a state where everyone rallies around to help out.”

An Epic Success
The rollout won’t be complete until 2009, but the success of the creative, fun, and frugal approach UIHC has taken to its aggressive implementation project is already noticeable in how well the teams are working together to resolve differences and the input coming from all areas of the facility.

“It helps that IT and clinicians have already been working collaboratively for a number of years. It helps to have that trust factor because we’re at the point now where things could be scarier, but it’s going alright,” says Walker.

She notes that even Epic has noticed a difference with UIHC’s approach. Facilities transitioning from an internally developed system to a vendor product typically experience a high level of turnover and dissatisfaction among the development team, but this project has been greeted positively.

“The important thing is that the enterprise agrees that this is the appropriate tool for patient care and that it is used consistently across the board,” says Walker. “Caring about the people you’re working with and caring about your end product helps you stay motivated, makes the hard work doable, and lends itself to an environment where you can maintain a positive outlook.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.