Diane Salois-Swallow, until recently the CIO at Toronto’s Mackenzie Health, is currently Senior Advisor at the Mackenzie Innovation Institute (Mi2). In 2016, Diane was appointed Co-Chair of an expert provincial panel to develop evidence-based guidelines on integrating digital technology into professional practice at hospitals and other healthcare organizations. In 2017, Mackenzie Health was the first hospital in Canada to implement an Epic full-suite electronic medical record (EMR).

Diane is one of four panelists at Gevity and Divurgent’s co-sponsored symposium at eHealth 2019 on Tuesday, May 28 from 11:15 a.m. to 12:15 p.m. She recently spoke to Gevity about the transition to her current role and the challenges of pioneering an Epic implementation.

Gevity: Tell us a bit about your current role and the transition from being a CIO for more than 25 years.

DSS: In 1977, Mackenzie Health (formerly York Central Hospital) was a pioneer in computerized health care systems and the first facility in Canada to use an IBM Health Care Support (HCS) series of patient care applications. We continued that journey with the goal of implementing a full suite of an EMR and offering our patients access to their medical records through a portal. Our recent EPIC EMR system implementation enabled us to achieve HIMSS Electronic Medical Record Adoption Model (EMRAM) Stage 7 designation and, as a result, to measure clinical and business outcome improvements. It took many years to achieve this level of EMR adoption; once achieved, it was time for me to look at doing something different, so I offered my clinical and IT expertise to Mi2. I also wanted to be able to work part-time so I could do other things I like to do, such as sailing and golfing.

Gevity: Mackenzie launched its Epic EMR in 2017. What was the facility hoping to achieve and what was the outcome?

DSS: We had significant motivations. The first was to prepare for the replacement of the hospital information system (HIS) we were using at the time. We also had a very disparate system with several third-party applications. Our goal was to have a fully integrated EMR. Also, since we are building a new hospital site in Vaughan, we wanted to make sure our staff and physicians had at least 18 months of stabilization to be comfortable using the new system before the second site opened. The implementation took 15 months and was done on time, allowing the organization to focus on operational readiness for the new site, which will open in 2020.

Gevity: Were there any big surprises, either good or bad?

DSS:  A couple of years before the go-live, our organization established a strong governance structure with joint leadership and ownership of this strategic initiative between IT and clinical leadership and began planning for adoption. The biggest surprise was the commitment of our physicians, clinicians and leadership to adopt the system in their day-to-day work, especially Computerized Physician Order Entry (CPOE), voice recognition and Barcode Medication Administration (BCMA). From early on we sustained greater than 95 per cent compliance for both CPOE and BCMA. I was also surprised by the number of physicians who asked for training to personalize their application and by their willingness to help their colleagues; I was impressed by that commitment!

Gevity: What were the biggest challenges you faced?

DSS: One of the biggest challenges was staying on track to complete our go-live on time given that we had committed to a 15-month implementation (which is three months shorter than Epic recommends). Additionally, being the first Canadian organization to implement the full enterprise suite of applications presented many challenges. At the time, there was no expertise in most EMR applications in Canada so recruitment for certified staff and go live support was a challenge. We issued an RFP and found a company that helped us to find and certify local staff so we could meet our time target. An innovative initiative for go-live, in which we recruited summer students from “friends and family,” increased knowledge within Canada, which aided other organizations that implemented after we did. Another challenge was ensuring that we had all the technical components in place for assessing our technical readiness: all the pieces, such as Single Sign On (SSO), the network, wireless services and hardware devices at various locations, had to be in sync so there was only “one hand to shake.”  We spent a lot of time post go live to rectify some technical issues.

Gevity: How did you involve clinicians in your implementation? What was the impact to them?

DSS: Clinicians were involved all the way. Subject Matter Experts (SMEs) from all areas of the hospital, including physician champions from each department, were at the table; they had their say in how they wanted the application to be developed and adopted. Many of the physician builders received training and certification at the EPIC centre. They also wanted to ensure that we planned and committed to providing the emergency room additional support to ensure all the patients were seen on time while the physicians were getting used to the new system.

Gevity: Mackenzie was a pioneer for Epic implementations in Canada. What were the challenges specific to being the first to implement?

DSS:  A lot of the software needed to be Canadianized and adapted to our local environment. This required much more time to develop and test data for submission to several Canadian organizations such as the Better Outcomes Registry & Network, the Canadian Triage and Acuity Scale and the Canadian Institute for Health Information. We spent a great deal of time getting it right so we paved the way for other hospitals in Canada. We knew before we began our implementation that this additional effort would be required, given we were doing a full suite implementation. We also worked with other hospitals that had started but not completed an Epic implementation to Canadianize the software, which I think helped to ensure that it met the needs of all Canadian hospitals implementing Epic.

Gevity: There have been a lot of discussions lately about whether hospitals or organizations are too focused on EMRAM designation and that it doesn’t always tell the whole transformation story. How do you see that?

DSS: For us it was a pathway; it was a model or goal post that allowed us to measure where we were and where we were going. I believe there is significant value in achieving EMRAM 7, because it demonstrates successful implementation and adoption. To achieve EMRAM Stage 7, you need to show clinical outcomes, business improvements and sustained compliance. We reduced our COPD length of stay by 2.2 days. We also reduced our Door to Needle times from 54.5 minutes to 26 minutes, which has significantly improved our stroke patient outcomes.

Gevity: Do you think that we in Canada have the opportunity to avoid making some of the mistakes that have been made in the U.S., and if so, which ones?

DSS: In Canada, we don’t need to collect as much data as they do in the U.S. because they have different payment and funding systems. Many of the challenges in the U.S. are related to revenue generation and loss. I believe that in the U.S., physicians spend a lot of time entering data in their systems to meet regulatory requirements such as Meaningful Use. In our implementation, however, we only require physicians to enter the information we absolutely need because we knew data entry would burden them. We also replaced a lot of our third-party applications to have one integrated platform; that way the information flows from one application to another seamlessly. In addition, we have added tools such as voice recognition, portable devices and remote access to assist physicians with their workflow.

Gevity: What were the most important lessons you learned that you think other Canadian healthcare organizations that are either looking at implementing a new system or replacing an existing one could benefit from?

DSS: You must plan your implementation and adoption strategies early on. Implementation happens when you turn on the “switch,” but adoption requires ongoing sustained effort for workflow changes, optimization and end-user education. Persistently measure clinical outcome improvements. Declare EMR the top priority in the organization, which may mean cancelling or consolidating other meetings during the implementation or delaying other projects to ensure success. Learn from other organizations going through an implementation. 

Another important lesson learned is related to resourcing. Each organization that is live with EPIC has invested extensively for training and certifying staff. With other hospitals implementing, these highly trained resources are leaving for new challenges, placing the hospital that trained them at risk. I would like Ontario hospitals that are implementing Epic to collaborate on the staffing issue we are facing and figure out how we can assist each other.