Migrating Epic Electronic Health Records (EHR) system to public clouds, like Microsoft Azure, has clear advantages, such as significant cost savings, push-button scalability, and ransomware resilience. It's no wonder so many health systems are going down this path.
Problem is, Epic is arguably one of the most difficult workloads to move to a public cloud environment because of it's distributed nature. Epic is typically accompanied by a suite of co-traveler apps, which represents multiple vendors you have to work with to complete a migration. Additionally, Epic migration to Azure requires expertise in both cloud infrastructure building and management as well as Epic application management. Most healthcare organizations don't have the necessary expertise in house.
In this blog, we'll go over the major challenges – technical and management – organizations must overcome to complete a successful Epic to Azure migration.
Technical Challenges of Epic Migration to Azure
As you plan your Epic migration to the cloud, you will encounter several technical challenges. Here are some key areas where you can expect to devote significant effort to educate you and your staff as to the best way to overcome these obstacles.
1. Security in the Public Cloud
Security is handled differently in the public cloud, so it’s important to design your security strategy with these differences in mind. As is the case with all public cloud providers, Azure secures the platform —that is, the hardware and software that power the cloud — and, in most cases, the operating system too. Securing applications and data (valuables) is your responsibility (see figure 5).
However, Azure also offers services you can use to build your security infrastructure. These optional services address areas such as data protection, threat detection, identity and access management, compliance and data privacy, and application protection.
2. The Need for Interoperability
Interoperability of health information is key to effective care delivery in today’s diverse healthcare ecosystems. To take a recent example, the lack of space for therapeutic equipment forced many hospitals to transfer COVID-19 patients, requiring a swift and accurate transfer of medical records as well.
The big EHR vendors all claim to support interoperability, but challenges remain. Broadly speaking, there are three primary obstacles to seamless interoperability:
• Inconsistent coding. There is no consistent way of identifying a patient across the healthcare spectrum. The most common identifying data are name, date of birth, and Social Security number. However, this information can be coded in different ways in different systems leading to patient identification errors.
• Lack of messaging standards. Several standards development organizations have led collaborative processes with healthcare IT users to develop proposed standards, but there is no single agreed-upon standard for information exchange. Seemingly trivial differences such as mismatched fonts or custom data fields can require that information be manipulated and sanitized before it can be imported into another system.
• Information Blocking. While there are regular calls from industry groups and government agencies to end the practice, some EHR vendors continue to block certain kinds of information that they consider proprietary or charge a fee for transmitting the data outside the system.
Two Efforts to Standardize Health Data Sharing
• CommonWell, an alliance formed six years ago, operates a health data sharing network that enables interoperability using a suite of services aiming to simplify cross-vendor nationwide data exchange.
• Carequality, a recent initiative of The Sequoia Project, is a national-level, consensus-built, common interoperability framework to enable exchange between and among health data sharing networks. Nearly all major EHR vendors have aligned with at least one of these efforts.
All that said, Epic has a relatively good reputation for interoperability due to its range of tools for sharing data (see table 2). According to a recent study, Epic Systems is the first vendor to make real progress toward universal patient data sharing and interoperability.
3. Shadow IT
To a hospital CIO, shadow IT is as scary as it sounds. Shadow IT refers to the practice of bypassing IT rules and regulations about cloud usage and instead creating your own account — in effect, going rogue. Shadow IT can be quite the temptation; after all, anyone with a company credit card can start spinning up computing and storage resources completely unknown to anyone else in the organization.
Developers are perhaps the worst offenders because they are frequently under pressure to deliver working code; they may simply take matters into their own hands when local server resources are busy or not working.
Shadow IT can run up your cloud costs substantially, create holes in your security perimeter, and compromise compliance with HIPAA and other regulations.
Management Challenges
In selling the concept of an Epic migration to the cloud, you will encounter challenges on the business side too. Here are some of the more common ones.
1. Bridging the Skills Gap
Healthcare companies are scrambling to cope with a shortage of health IT professionals. A recent survey by the College of Health Information Management Executives (CHIME) found that 67 percent of healthcare providers are experiencing IT staff shortages. The shortage in skills is impacting the way CIOs run their departments, forcing them to recruit highly specialized staff who have in-depth
knowledge of the cloud and EHRs.
The good news is that most healthcare IT professionals can come up to speed on the basic knowledge they need to manage a public cloud Epic deployment with some outside help. When selecting an MSP or other third-party, look for one that puts an emphasis on knowledge transfer and collaborative work from the very start.
Cloudticity has had outstanding success using the “shoulder to shoulder” approach in which the organization’s healthcare IT staff are paired with MSP experts and obtain hands-on experience all along the way. Beware of vendors who want to do it all for you — that’s rarely a good deal no matter what they charge; it can lock you into a costly arrangement that compromises your ability to manage your outsourcing spend and respond to changes in the marketplace.
2. Overcoming Cultural Resistance
Migrating to the cloud is a disruptive event, so it’s no surprise that many organizations encounter resistance from their staffers. However, the real work of overcoming resistance starts at the top. Senior management in general — not just the CIO organization — must understand the reasons for moving Epic to the public cloud and the benefits they can expect to see. Therefore, the Epic migration leadership team must invest considerable time educating executives to build a coalition of support and enthusiasm for the migration.
With buy-in achieved at the top, the next step is engaging the people who will be directly affected by the change. Experience has shown that mandates from senior leaders are not effective; in fact, they can engender even more resistance. Instead, bring them on the journey through open forums where they can express concerns and receive informative and supportive answers. Providing training early in the process sends the message that you value your staff and are willing to invest in their success. If you adopt this approach, don’t be surprised to find that some of the most resistant employees become evangelists, which can greatly increase the prospects of a successful transition.
3. Managing Expenses
Migrating your applications to the cloud usually has cost benefits eventually, but early in the process, costs can actually go up for a variety of reasons.
For one thing, Azure deployments must be expertly tuned to ensure that resources are allocated and deallocated effectively, avoiding the case where unused instances remain provisioned and thus incur charges. Data transfers are another potential pitfall, because some cloud providers charge a per-gigabit fee when you move data out of the cloud. Therefore, applications that move large volumes of data between your data center and the cloud can drive up your cloud bill substantially. Applications that sync data between cloud and local data centers are particularly susceptible to this situation. Before finalizing on a cloud migration, you would do well to consult with a knowledgeable MSP who can help you navigate the different pricing options offered by the provider and fine tune your usage to keep costs down.
In the end, managing your cloud spend comes down to financial governance. Make sure that your MSP advises you on options such as chargeback, in which usage charges are allocated to the departments using the resources and thus catch the attention of budget-conscious department managers.
4. Setting Expectations
Perhaps the biggest potential pitfall on the business side of the house is unrealistic expectations. Promising too much and delivering too little is a recipe for ongoing skepticism in the executive ranks and sluggish adoption of new ways of doing things by the rank and file.
To avoid this hazard, think big and start small. Present the big picture of a cloudbased future Epic and then propose to execute a relatively limited proof-of-concept (POC) project — migrating one of the Epic test/dev/training environments is often a good place to start. Develop ways to communicate progress on the POC and setbacks to senior staff using dashboards and summaries that offer at-a-glance information about the trial project. Find an enthusiastic executive sponsor who can both advise and advocate at the highest level. Managing expectations may not be the most fun part of the job, but it can very well spell the difference between success and failure.
Next Steps
The migration of Epic Systems software to the cloud is inevitable and beneficial for healthcare organizations. To ensure a successful transition, partnering with experienced MSPs like Cloudticity, who specialize in healthcare IT, is essential. Schedule a free consultation with Cloudticity today to begin your journey to Epic on Azure.
