1 Use of the Epic Electronic Health Record for Comprehensive Clinical Research Management at Duke Iain Sanderson, BM, BCh, Denise Snyder, MS, RD, Terry Ainsworth, RN, MS, ACNP, Cory Ennis, MS, Julie McCauley, Fabian Stone, MBA, MHA, MT, Leigh Burgess, MHA, MEd, MA, Beth McLendon-Arvik, Pharm.D, Colleen Shannon, JD, and Mark Stacy, MD. Duke Medicine, Durham, NC.
2 Disclosure Dr. Iain Sanderson has no relationships with commercial interests. Learning Objective Understand the steps to implementing a management system for clinical research as part of the Electronic Health Record in a major academic medical center.
3 Topics A few facts and figures about Duke Clinical Research Describe our implementation of Epic 2012 for research administration at Duke Planning, training, testing, go-live Current state and CTMS plans What next?
4 Duke Medicine Facts and Figures 3 Integrated hospitals using a single instance of Epic 2012 Duke University Hospital 924 beds (live June 22 nd 2013) Duke Raleigh Hospital 186 beds (March 1 st 2014) Duke Regional Hospital 369 beds (March 1 st 2014) 16,318 employees >7,000 simultaneous users of Epic (Epic s largest big bang go-live) 2013 Clinical revenues $2.54B, 1.2m outpatient visits 2013 Total research revenues - $651m 2013 NIH funding $284m - ranked 10 th 2012 Industry funded research $215m (DCRI ++)
5 None of that Counted for Very Much, With Substantial Risk. Clinical Systems Discovery Start Research Systems Discovery Start Go-Live Aug Aug June Epic was coming whether we were ready or not
6 Our existing systems would be swept away.. Retiring Systems No paper system for scheduling, orders, billing!
7 Drivers in our Implementation No interfaces possible with Velos eresearch or eirb Robust split charge billing mechanism for research and standard of care charges Robust study and subject registry Improved role based security Compliant and efficient research workflow Platform for BPAs, MyChart etc Support central management of research through Duke Office of Clinical Research (DOCR) Explored and found considerable functionality for managing clinical studies in model Epic 2012
8 Model Epic 2012 Research Functionality, but also with an Order Set for each study Protocol *Study Cycles As an Order Set = New in Epic 2012 * = Duke configuration choice, not a customization
9 Desired Result Systems Integration and simplified workflow for Research. Retiring Systems Epic becomes the reference study and subject registry. Enrollment, visit schedule, study drugs, orders, documentation and revenue cycle managed in Epic. For over 1000 users Epic
10 Initial Timeline.. Clinical Systems Discovery Start Research Systems Discovery Start Current State Research Calendaring and Ordering Workgroup Future State Validation RAC RAC RAC RAC Aug 2011 Aug Sept Oct Nov Dec Jan Feb
11 harge code CPT Charge code CPT Excel Study Grid Research Revenue Cycle Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Order Set/ Beacon build Standard Of Care Study Calendar Study Sponsor
12 Research Workflow Validation February 6th Stop Light Evaluations 90+ Subject Matter Experts and Stakeholders from across the Research Enterprise A success based on Feedback.
13 Epic and Research - Timeline Send DOCR staff for Epic order set certification Maintenance Build Validation Feb 6 th Billing Calendar And Smart Set Build (ongoing) Wave 4 Go Live June 22 nd Feb Mar Apr May June July Example build Curriculum development Super User Training Train 800 CRCs
14 Which Studies need Order Sets and 4047 Active studies in eirb Billing Calendars by Go-live? Excluding: Exempt studies No CRU oversight (i.e. DCRI) Data analysis only Retrospective Studies Completed but data analysis ongoing Completed but subject follow-up High Priority Non-oncology 552 High Priority Oncology (Beacon) CRU feedback: External sponsors Recent enrollment? Total Enrollment? PRMO feedback: Active after June 2013? 1. High charges AND IDEs 2. Blue grids (other payers) 3. Striped grids Charges > $40, Yellow/green/pink grids 6. Two color grids 7. One color grids
15 Epic Build for Research Had to define the build workflow and coordinate across build teams RSH record, study calendar, order set, Beacon Protocols Created a war room team of co-located staff 6 staff from DOCR 8 staff from PRMO (Revenue staff) Contractors 4 order set builders, 2 willow builders, 1 coordinator 2 Beacon build team contractors 500+ study calendars on time But Order sets and Beacon protocols were much harder. A $2m investment over 18 months
16 Order Set Build Progress Build burndown up to go-live 16 stage build, validate, QA and release process
17 Training Three course curricula required to support Epic clinical research: Clinical Research Coordinator (410 staff) General Researcher (read only access) (438 staff) Research Billing and Compliance (35 staff) All users would need 4 hours Introduction to Epic classroom training as well as specific training 64 staff needed dual role training. Required steps Develop curriculum, secure resources, train, go-live and maintain A $165k investment
18 Other Preparations for Go-live Go live and training website and materials Tip Sheets, videos, command center information PI research order sign off instructions CRC training documentation Testing needed to create test scripts Town Halls, Research Wednesdays, and a communication blitz Create the command center and staff it Cut over activities (500 appointments, 2000 security profiles, 9000 enrolled subjects) Go-live June 22 nd 2013
19 Go-live June 22 nd 2013 Command Center
20 Where are we now? We did successfully implement a new workflow for over 1000 people at the core of our research enterprise Some issues with compliance for study linking to visit schedules, but we can measure that for the first time and retrain. Split billing with a complete revenue cycle for research Study-related totals since 6/22/2013: 1,978 active research studies in EPIC 14,805 enrollments 25,803 encounters Duke Office of Clinical Research (DOCR) established as central administrative/operational body for research support Epic as a Clinical Research Patient Management System
21 What have we done? Concept of CTMS functionality at Duke has changed. Clinical Care Epic EHR CTMS Study registry Non billing risk study registry Subject Registry Randomization Consent repository Study Financial Management Research appointments Accrual Based Accounting Research Orders Sponsor Invoicing Study Calendaring Volunteer Subject registry CRC workflow Adverse event management Split Billing Electronic Data Capture Reporting Study sample management Reporting across all studies
22 Duke Office of Clinical Research Epic: Clinical Research workflow Clinical Studies, Subjects, Research Charges, MyChart, BPAs RFD EDC: REDCap RFD SAP: FCs Click eirb Studies, Named Personnel Daily Export Studies, Subjects, Charges EDW/ Research Management Data Mart: All Velos data, All Epic data, All eirb data, All Reporting, (NCI reporting) Duke s Planned CTMS Landscape Custom Interface Velos eresearch: CTMS All clinical and nonclinical study registry, All subjects registry, Volunteer registry, Sample tracking, Invoicing, AE Management, Financial mgt ETL
23 What Next? Integrate Epic with Velos eresearch for non-clinical research subjects and advanced CTMS functionality Leverage EPIC functionality for research Best Practice Advisories for recruitment Smart Forms, Retrieve Form for Data Capture for MyChart patient questionnaires and device data capture Provide services for these through the Duke Office of Clinical Research
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