Cleveland Clinic increases reliance on EHR to reduce 'technical debt'

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Dating back to the 1990s, the Cleveland Clinic was an early adopter of the Epic electronic health record system. This decades-long experience with its EHR has created both benefits and redundancies for the healthcare organization.

William Morris, MD, the Cleveland Clinic’s associate chief information officer, describes the Epic EHR system as the “central data hub” for the nonprofit, multi-specialty academic medical center that integrates clinical and hospital care with research and education. According to Morris, the EHR is integral to the way the Cleveland Clinic practices clinically and operationally.

“We have other ancillary systems but it’s by and large the big enterprise system,” says Morris, who notes that the EHR has been validated to HIMSS Analytics’ Stage 7 Electronic Medical Record Adoption Model in the ambulatory setting and Stage 6 EMRAM in the inpatient setting.

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At the same time, he contends that the EHR “in and of itself” is “just a digital repository—ultimately, it’s what you do with the technology in your ecosystem.”

Turning that data into knowledge and actionable insights is the goal, according to Morris. Toward that end, the Cleveland Clinic has created data-driven “risk scores” that alert clinicians when intervention is needed for patients. “We have a whole group called Quantitative Health Sciences or QHS in which we build direction models for our patients and populations,” he says.

QHS develops and tests state-of-the-art models for use in outcome risk calculators for cancer, cardiovascular disease, and diabetes—among other conditions—in order to help physicians determine the best choices of care for their patients.

“Do we deploy the algorithms within Epic or is it a black box outside of Epic? The answer is we do both,” says Morris. “We have several tools in our toolset that we can draw on. How we use those tools is predicated on the clinical workflow and the technical architecture that can best achieve the outcome.”

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While the Cleveland Clinic has pioneered new ways to integrate and enhance the use of its EHR, the organization is grappling with the problem of technical debt.

“If you’ve got two applications that do the exact same things, that is technical debt,” observes Morris. “Do you want to be spending your resources on both, or can you consolidate and use those resources to do the next opportunity that is unmet? That’s the classic innovator’s paradox. You want to be innovating but you also want to be retiring legacy when it gets folded back into your core solutions, so you can continue to innovate.”

Doug Smith, the Cleveland Clinic’s interim chief information officer, says that a top priority for the organization is reducing its technical debt.

“As an early adopter of Epic, we have accumulated quite a bit of what I’ll call technical debt. What I mean by that is multiple enhancements, bolt-ons, or revisions to the core application,” Smith points out. “We have to unburden ourselves of that. In Epic, it’s a return to foundation or a return to core.”

According to Smith, the Cleveland Clinic is working to reduce those redundancies so that “85 percent of the core functionality” comes from Epic.

“When you take an upgrade in Epic, they are always turning on more features and functions—most are optional and some are not,” says Smith. "What we look to do is shift away from being highly customized to being highly standardized. That’s the easiest way to put it.”

He contends that by reducing its technical debt the Cleveland Clinic’s clinicians will become more efficient “because they are adopting standard workflows that also exist in many other organizations—and, we’re more efficient in supporting it because we don’t take as long to validate or support an upgrade.”

“It’s a culture of continuous improvement and of constantly looking and seeing if there’s a better way to do it more efficiently, less costly,” concludes Morris. “We should be challenging ourselves if we’re investing in core applications to say ‘what are these bolt-ons and do they actually provide value? In some cases they do and in some cases they might be redundant and superfluous.”

In the end, he says Epic is the Cleveland Clinic’s partner. “We hold each other accountable,” Morris says. “We challenge them and it’s a healthy challenge. And, so, we will not be taking any (Epic) updates at face value. We have a process where we have clinical and operational vetting.”

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