Jim Turnbull, CIO at Salt Lake City-based University of Utah Healthcare, said he had been able to avoid the pressure of meaningful use.

"My last two employers have done (or are in the midst of) Epic rollouts from revenue cycle through EMR/CPOE, "he said. "We've been lucky to roll these out in a staged manner over a period of several years, without a lot of MU pressure on the accelerator."

This has helped to protect the organizations financially, and not expose them to the inherent risks that come with a big bang.

The first rollout – at the Children's Hospital in Denver – was in the early years of Epic's entry into the inpatient market space, from roughly 2003 to 2006. The current rollout started in 2009 and will conclude with the replacement of the major inpatient applications this year.

"In hindsight, I guess we are always reminded that these are complex endeavors, and that the process and culture change is much more significant than the technical challenge," Turnbull said. "Another thing that still seems common in the industry is that EMR projects are considered 'IT projects.' As we know, they are anything but!"

Back to Maine Medical Center
Accenture's Safavi says he's not familiar with the circumstances at Maine Medical Center. However, it's not uncommon, he said, for the IT team to suffer fallout from an implementation that does not go off as expected.

"Lots of things can happen, but the most common is surprise," he said. "It generally exposes an organization around either lack of planning or a cultural issue. You often see the IT organization want to go faster than the clinical organization, and the clinical organization will be unprepared or unwilling."

Those cases create a difficult problem for leadership and boards, who face answering, "What is more important here? Is it managing the pace and cooperation of our stakeholders, or is it managing the economic cost of the transition?"

"That's the job of boards and leaders to figure out," said Safavi. "There's no one answer. Every answer varies with the organization."

It made sense to select Epic for inpatient care, MaineHealth's Blumenfeld, told me in 2010. The Epic EHR was then already rolling out at MaineHealth's owned and affiliated medical practices.

Rather than a best-of-breed approach that many CIOs espoused in years past, most now see more merit in a single vendor approach. Blumenfeld is among them. "The end user interface stays consistent across all venues including ambulatory and inpatient, and the information that's in the repository is integrated in a way that only a single database can do," he explained.

The goal, said Blumenfeld, is to have a more integrated workflow, a more integrated presentation and more integrated data set.

"This also helps, by the way, when we start to talk about measuring the quality that we deliver and population health efforts – making sure people get their flu shot or making sure everyone gets aspirin after a myocardial infarction," he said. "Those things are greatly aided by our ability to capture all the data in one big bucket and then analyze it to improve the care we deliver."

"We found that Epic has a great reputation and ranks high on things like the KLAS rating and generally receives very high marks from the other systems that have adopted them in recent years," Blumenfeld said.

A couple of years later, when he and his team were preparing for the rollout at Maine Medical Center, he said Epic was enjoying so much popularity because, unlike other EHR companies, Epic had grown, but not through acquisition, thereby avoiding the integration problems that often come with patching disparate systems together.

When Blumenfeld spoke with Healthcare IT News Associate Editor Erin McCann a couple weeks prior to the scheduled Dec. 1, 2012, rollout at Maine Med, he brought up the famous Gartner curve.

"You know where you start out and everyone's very excited, and you go for a week or two: 'This is great; this is really cool,'" he said. "Then you start to notice all the problems, and you fall into the valley of despair. That usually happens a month or two into the project.

"Then by three or four months, you're coming out of the valley of despair, and people are starting to say, 'Wow, this is OK, you know, I can live with this.' Then by seven or eight months, it's, 'Wow, I don't know why I ever didn't live with this.' That's when you start getting the real benefits of an electronic health record."

The Maine Medical Center nurse who spoke with us about charge capture issues is still waiting to see those benefits. Meanwhile, she said, she is concerned about best practices and lack of training.

Most nurses had three four-hour courses, with some specialty nurses getting an extra course. Some of the courses were led by Epic employees, but most were by nurses taken off the floor, trained on the system and then sent back to teach the other nurses.

"It didn't follow a workflow at all," she said. "It was really sort of patchwork." Moreover, she said, when people had questions about the workflow, they really weren't addressed. "I felt we were not educated well at all. When we actually went live, it was scary. People did not know what they were doing."

The nurses did not know how to enter orders appropriately. "There were huge gaps of people not knowing how to put orders in and not knowing how to do really important things like blood administration, how to order the blood. We were never taught any of those things."

Nurses have learned how to do some of those entries by now, she said, but there are so many ways to do the exact same things.

"One person will show you one thing; another person will show you something different," she said. "There're eight different ways to do the same thing. Every day, you feel like, 'I don't know if I did this admission right; I don't know if I entered any of my documentation right. There's a lot of discrepancy in how we were taught to document."

"The change is a wrenching one," Blumenfeld told Healthcare IT News in that interview before the rollout this past December. "It's wrenching for the physicians, it's wrenching for the nurses and it's wrenching for the support staff, the financial people, the operations people. Everyone has to do things differently than they did before. So it's a big, big change for any hospital to go to an EHR."

Healthcare IT News Managing Editor Mike Miliard and Associate Editor Erin McCann contributed to this story. It was first published in the July 2013 print issue.