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Readers Write 11/7/11

November 7, 2011 Readers Write 23 Comments

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

The Other Side of Epic
By Vince Ciotti


It’s almost gotten boring to read about another large hospital or multi-IDN picking Epic. It’s as if they have no competitors in the high-end market, which is silly. Mckesson Horizon, Siemens Soarian, Cerner Millennium, GEs Centricty, and Allscripts / Eclipsys Sunrise all have equal or better functionality. What they don’t seem to have is a back door to sell a hospital’s C-Suite through the medical staff, an insurmountable advantage Epic has due to its ambulatory roots.

Having assessed a number of Epic hospitals and having several CIO friends relay their Epic experiences recently, I think it’s about time someone listed the many weaknesses of Epic instead of just more glowing testimonials (to be sure, every vendor has their strengths and weaknesses: one could list many things wrong with other vendor systems too.) This “other side” is intended to open the eyes of those who are considering Epic just because everyone else is.

  • Rookie implementers. Epic hires fresh college graduates for their implementation consultants (IC), a practice that saves them a fortune in salaries and gives them malleable candidates to learn “the Epic way.” Unfortunately, these ICs are terribly naïve when it comes to hospitals and do poor work on site, mainly sitting in their offices and looking up questions in “Epigoogle,” their search engine. A hospital would be far better off with veterans that have many installs under their belt, plus several years working in healthcare, to know the many challenges that make hospitals one of the most difficult industries to automate.
  • “Epic” costs. Epic charges huge sums for their software and implementation services, just like most other vendors — equal to or greater than license fees. However, there are internal costs that make an Epic budget just that: dozens of hospital FTEs from IT and every user department who need to travel to Verona for many weeks/months of training and testing. Factor in their salaries and the cost for replacement temps and the re-training for inevitable turnover and you can understand why clients like Kaiser and Sutter reported budget overruns of 2-3 times their initial cost estimates.
  • The “Epic Way.” Time and again I have heard from CIOs who have gone through an epic install (lower case intended) that the only way to make an Epic implementation successful is to not change the system, but rather adopt your workflow to EpicCare. This is silly in light of the mega-bucks Epic charges. Vendors like Cerner and Siemens pride themselves in adopting their system to their clients’ workflow through screen painting and workflow engines. How can Epic dare charge so much, yet be so inflexible?
  • What hardware? Like Meditech (which Epic seems to have copied many bad ideas from, like all employees having to live near headquarters, running up hospital travel costs), Epic does not sell hardware. It is your responsibility and good luck that you buy enough to achieve decent response times. Any problems, just call Dell or IBM and buy more servers. Contrast that with more sensible vendors like Eclipsys and GE that sell hardware and negotiate reasonable system response time guarantees where they will buy more servers if needed. And Epic’s proprietary Cache’ database does take many minutes to run even simple reports.
  • Interfaces. What, you thought Epic was integrated? Well that’s true, except for “minor” applications like ERP (AP, GL, PR, HR and Materials). Even the smallest vendors in the industry — such as CPSI, Healthland and HMS — include functional, totally integrated ERP suites, let alone leaders like Meditech and Paragon. CPSI even offers totally integrated PACS and time and attendance modules. Many of Epic’s ancillary department systems are relatively weak compared to specialty vendors. For example, their Beaker LIS can’t hold a candle to SCC Soft Computing or Sunquest, and their ED suite pales in comparison to A4 or MedHost. So, you better add an interface engine, servers, and analysts to that bloated budget.
  • Physician training. Physicians love the fact that they see the same Epic EHR in their practice as they see in the hospital, but for two minor problems. First, the Epic build is different for ambulatory versus inpatient order screens, so physicians have to learn two ways of entering orders, responding to alerts, etc. Second, they have to sit through 12 to 18 hours of training classes – factor those hourly expenses into your budget (physicians are not exactly low paid!) At least they don’t have to fly to Verona for weeks of indoctrination like your poor users and IT staff.
  • High ratings. Epic has the highest ratings KLAS has ever seen, but think back to all the dozens of IT and user department staff who spend weeks and weeks getting brainwashed on the Epic way. How do you think QuadraMed or Keane’s scores would look if they required their clients to send dozens of FTEs to their headquarters for months of training or testing? And it they didn’t cooperate, they wouldn’t qualify for “good” software maintenance rates, running up their budgets even more. Is it cause or effect?

Well, I could go on, but I doubt Mr. HIStalk will publish much more heresy. Indeed, if he even publishes this, I’ll admire him even more than I do today, as no one in HIS circles seem to challenge Epic these days.

Again, every HIS vendor has their strengths and weaknesses. I could go on for pages of weaknesses about any vendor, not just Epic. It is just sad that everyone seems to conform to only praising Epic while ignoring these and other weaknesses. Anyone else have the nerve to join me in calling for more rationality when dealing with the Epic “cult?”

Vince Ciotti is a principal with H.I.S. Professionals LLC.

They’re Killin’ “Me”
by Richard E. and Joy Goodspeed

11-7-2011 8-25-24 PM

My colleagues present themselves with an air of professionalism both in dress and in conduct. However, they look sloppy when they forget some grammar basics in speech and emails. My biggest pet peeve is that they are killing “me.”

They don’t understand what happens to the first person singular personal pronoun (“I”) when it follows a preposition. If the pronoun is alone behind that preposition, they get it right, but when it is part of a group of two or more, it is usually wrong.

Grammar rules may be a little hard to understand, so I’ll illustrate with some examples.

Say I invite Tim to go to HIMSS with me. I tell you, “I invited Tim to go to HIMSS with me.” Good. Inga decides to come along to keep us out of trouble. I say: “Inga went to HIMSS with Tim and me.” My colleagues would say “Inga went to HIMSS with Tim and I,” and that’s bad grammar (killing “me,” . . . get it?). How do I know it’s bad? Take Tim out of that last sentence. Are you going to say “Inga went to HIMSS with I”? Of course not. “Inga went to HIMSS with me.” Sticking Tim into the middle of the action doesn’t change the need for “me.” The pronoun is the object of “with” (a preposition), so it’s got to be “me.”

Now you’re on a project, and you’re telling your partner about a physician who came to a project meeting to make a complaint. “The radiologist complained to the project team and me.” Right! Now you’re catching on. It’s not “the project team and I,” as it would not be “to I” if you were the only one there. “To me” and “to the project team and me” are both correct.

This discussion is all about the “objective case.” It makes sense that you use the objective case for the object of a preposition. However, “I” also changes to “me” when it is the object of a verb.

Suppose you are going to take Tim to the new ER. “I’m taking Tim to the ER.” There’s nothing hard about that. Along comes Inga. She’s going to take Tim to the ER, and you can come along. You tell Jane about it. “Inga’s taking Tim and I to the ER” Oops! No, no. You’re killing “me” again. You and Tim are now the object of a verb (to take), and you have to use the objective case. “Inga’s taking Tim and me to the ER.” We use the same criterion for the case of that pronoun that we used when it was the object of a preposition: take “Tim and” out of the sentence. In your most ungrammatical of moments you wouldn’t say “Inga’s gonna take I to the ER.”

Keep thinking about objective case (and quit killing “me”).

Joy Goodspeed is a senior integration analyst with Sarasota Memorial Healthcare of Sarasota, FL.

Passionate People Perform
By Peter Longo

Another day, another conference call. “OK, we have everyone on the line and we are ready to review our ACO strategy that will affect v5.5 and the ICD 10 but we can’t forget the FFS model or the FQHC needs as we build the HL7 exchange. With the eMPI not ready, the focus should still stay on the CSI program and promote the current CCD standards that hopefully won’t affect the DR on the COF for client CPHR or the CPQs …” (do we use too many acronyms?)

With all this work selling software that enables physicians and nurses to deliver high-quality healthcare, we still can feel removed from the impact on a patient’s life. Yearning to be reminded, a group of dedicated sales professionals felt the need to get directly involved with delivering care and service to people in need, volunteering at Wheels For Humanity.

11-7-2011 8-30-03 PM

Wheels For Humanity (I guess that is WFH) is an organization that is dedicated to supplying wheelchairs to incredible people who are unable to walk for many reasons and who can’t afford mobility. Generally, they spent their young lives being carried from place to place. Painfully, the time comes when they no longer can be carried, and they are left to stay in their rooms. Recipients of these chairs are given the joy of mobility, but equally importantly, they are given dignity.

We work in an industry that is focused on the patient. This live experience stands as a pivotal reminder that the patient should be the center of everything we do. Many of the wheelchairs will be sent to places like El Salvador, Indonesia, and beyond. This whole operation is possible through donations and volunteers wanting to make a difference. Volunteers with a passion to help others.

11-7-2011 8-30-56 PM

The one thing our industry is not short on is passion. It is incredible to see so many individuals passionate about improving healthcare. I don’t think anyone can find an industry with a rivaled passion toward helping others. I am pretty sure there is no acronym for passion.

Please take a moment to read more on Wheels For Humanity.

Peter Longo is vice president of sales with Allscripts.

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Currently there are "23 comments" on this Article:

  1. I really wonder if Mckesson Horizon, Siemens Soarian, Cerner Millennium, GEs Centricty, and Allscripts / Eclipsys Sunrise all have equal or better functionality than Epic… Maybe they do, maybe they don’t. Given many organizations are completely giving up on those platforms to move to Epic – I doubt it.

    For sure, MDs and CIOs like what Epic says it can provide – a single integrated system – inpatient and outpatient built around the patient by a private company that doesn’t want to get into areas that are not its core competency such as hardware or ERP software.

    For that, I guess they are willing to deal with the inexperienced implementation staff and their ‘epic way’, high costs, and the complexity of the software configuration, maintenance, ongoing releases and end-user training.

  2. I am not in the EMR business so I don’t care if Epic or another vendor dominates the market. However, Epic seems to be doing a lot of things better than its competitors because customers are voting with their dollars. Seems like either Epic really is better (for now) or the vast majority of customers are irrational, deluded sheep. The simple explanation is that, right now, Epic is better for most hospitals. As a vendor that has to work with hospitals that have a variety of EMRs, the Epic facilities seem happier and less dysfunctional. We’ll see if this can be sustained as the number of facilities they have to bring up becomes more than they can handle.

  3. God Bless You, Vince!

    Here’s Epic’s business strategy:

    You pay them to train their implementers on on Real World Healthcare Workflows.

    Then you get to pay them again after your insall is only partially successful and your CIO has been fired. So you get new leadership and another perpsecitve on how the system “really” should work. (Yeah more consultant money towards a “slight redesign”.

    Then, after you’ve spent $120 – $160 million you have to say it’s great because you’re so far in the hole if you say anything else it is, as Vince wrote, an act of heresy.

    And if you want to talk about interoperability, well, you might as well start believing in Santa Claus and Unicorns again……….

  4. One of the most legitimate limitations of the Epic Ambulatory EMR is there lack of functionality to meet the needs of various specialty physicians in terms of functionality. This is generally a fair criticism of every major ambulatory EMR vendor but there ability to meet the needs of say of an ophthalmologist (e.g., various integration with hardware in the office) are very limited compared to other major ambulatory EMR vendors such as NextGen or specialty-specific vendors.

  5. Why must all criticism of Epic end up looking like a paranoid, self-righteous screed? There are plenty of legitimate problems, but when you stomp around and pretend like you’re some kinda French Resistance fighter speaking truth to power, it just gets ridiculous. People criticize Epic all the time and aren’t considered “blasphemers” for having done so, especially on this site. “Brainwashing,” and “indoctrination,” really? And you intended to be taken seriously? Post #4 shows us how a reasonable person gives reasonable criticism.

  6. Vince forgot one major disadvantage of Epic: their workflows! Endless clicking, leaving a trail of bread crumbs and hoping to be able to find your way back.

    With that said their strengths outweigh the many weaknesses.

    1. First and foremost, they act as a partner – the nickles and dimes are spelled out and the same for everyone. Would you rather go used car shopping with a few of the other vendors (contracts range from list price to a 70% discount).

    2. Single code base (not quite the same as integrated). No “internal” HL7 interfaces between modules or re-entering info into a module that was integrated by updating the marketing materials.

    Simply a case of being the best based upon pitiful competition!

  7. Don’t forget that “Stork” is really re-packaged Obix sold as integrated at the same standard as the rest of Epiccare. They also license other software applications like Imprivata and preferentially tie those programs into their own system. It’s not really a single-sourced integrated database the way they advertise. The only difference between them and other vendors is really the centralized, closed, controlled model they have. Judy’s way or the highway

  8. Vince, you give way too much credit to Epic being able to successfully brainwash that many people. Sure, Epic’s not perfect, by any stretch. They’ll tell you that. They also tell you that new modules are going to be rough. They also tell you they focus on systems around the patient and less so in other areas.

    I think the basic difference is that Epic is comfortable with themselves and telling their customers what they can and can’t do for them.

    Why the attitude and anger? Seems odd.

  9. As a taxpayer I find it ridiculous that our money is being used to buy Epic under the guise of lowering costs and better healthcare. In essence it is like the real estate crisis where we helped people buy something they couldn’t afford/cost justify in the first place?

  10. I agree that any observation about Epic that is not glowing is somehow viewed as negative or flawed. I do work with the system and am unimpressed with the implementors. Just a statement based on my observation so feel free not to bash me too.

  11. Quick correction to post 8. The Stork application is part of the same codebase as all of Epic’s modules, and isn’t “repackaged Obix” as claimed. Not sure where that impression came from. Epic does have some client-side integration with Obix to display fetal monitor strips, so that might be the source of the confusion.

  12. Epic is satisfying a need that is probably attractive to CEO’s and CIO’s everywhere – safety. If everyone is selecting Epic, then everyone can’t be wrong and therefore neither am I. Epic is satisfying the needs of the many at a nice profit for themselves. What will be interesting is to see if they can keep up. There have been many anecdotes about Epic’s inability to do reporting to meet meaningful use. And other concerns and comments that keeping up with growth is inhibiting innovation. As Vince said, every company has their positives and negatives. We’ll just have to wait and see

  13. I’d like to particularly address the issue of workflow. Whether you purchase Epic, or any other EMR, your processes and workflows will change – and that’s a good thing.

    If they were purposefully engineered in the first place, you’ll want to re-engineer them anyway because you can’t separate the process and workflow from the strengths and weaknesses of the tools that you use as part of those processes. As the tools change, the optimal processes change, too. For the same reason that when you go to buy food, you don’t pound horseshoes onto the tires of your car, when you implement a new medical record system, you don’t follow exactly the workflows of the old system.

    Now, can EMR vendors do a better job of meeting you halfway? Absolutely. But at the same time, you need to be cognizant of the fact that your existing processes weren’t carved into stone tablets atop Mount Sinai. Anytime there is a change in either the requirements of your business or the capabilities of your tools, your processes and workflows will almost certainly change. The organizations that are the most successful are those that embrace the change as an opportunity for improvement.

    I remember one particular client I consulted for. I was trying to define one particular process, and I was at a loss as to why certain steps existed. At first, nobody could tell me what they were trying to accomplish, but as I dug deeper and deeper, I found the answer – that process was originally designed to work around a limitation in their EMR. Not their current EMR. Not their last EMR. The EMR before that one. They hadn’t needed it for years, but kept doing it because it’s “how they did things”.

    The net result was a process where one person filled out a form that duplicated other documentation, it changed hands twice without being acted upon, and then the last person shredded it. Everyone in the chain assumed that someone else was using the form for something.

  14. I agree with much that is included here but I think Vince misses a few points although I totally agree about the Epic way. I am amazed at how many large organization are willing to let this happen.

    As far as shortcomings, reporting is abysmal and requires an excessive amount of effort (unless one is totally ‘Model’. This is a huge burden on IT staff. Second, Intersystems is a private company that is even more secretive than Epic – just try to dig into them.

  15. So you are saying that Epic working people so hard they burn out after 2 years and randomly firing the people that make it longer than that for no reason whatsoever means they have inexperienced people and the customer suffers?

    No way!

  16. I was just looking through the list of Stage 7 hospitals and noticed that almost all of organizations use Epic. Given Vince’s comments about all vendors being equal, wouldn’t you expect an equal distribution. Maybe HIMSS is in on the conspiracy too …

  17. Epic’s success is driven by their culture and their focus. That’s what differentiates them. They may or may not have the best product in all areas, and they have their issues. However, Judy built a strong culture from day 1, which eventually permeated throughout her clients, including, and most importantly, the physicians. She stayed focused on building a strong foundation for her product and then just kept building on it. She didn’t acquire, go public, or build a big consulting arm, because she didn’t want the distraction. She chooses her clients based on their ability to succeed, and has been careful not to grow too fast or too far. She listens to her team, and she listens to her clients, and they trust her. Her mission is to connect the earth, not get richer. She’s already rich on realestate alone! And while she’s doing all this, she is giving back to her community on a daily basis.

    In my opinion, as long as they continue to focus and retain the culture, they’ll be at the top of the leader board for a long time. No disrespect to the other vendors, because there are some great products and people out there. However, Epic is in a completely different league right now. And for those of you who have not been to Verona to tour the campus, I highly recommend it.

  18. Well – Yes, Vince is promoting a discussion on EPIC. But at least the other article by Mr. Longo is promoting the well being of the patient.

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