Running Head: DESIGN AND IMPLEMENTATION OF DISEASE...

Running Head: DESIGN AND IMPLEMENTATION OF DISEASE-SPECIFIC ORDER SETS

FOR STROKE AND HEART FAILURE 1

Design and Implementation of Disease-Specific Order Sets for Stroke and Heart Failure

Madhvi Jayarao and Nicole Bammel

DL- 406, Northwestern University

March 15, 2014

Design and Implementation of Disease-Specific Order Sets for Stroke and Heart Failure 2

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M. Jayarao, N. Bammel

Table of Contents

Introduction ..................................................................................................................................... 3

Background Information ............................................................................................................. 3

Stakeholders, Goals, and Objectives ........................................................................................... 3

Information System Inventory .................................................................................................... 6

Intervention Selection and Workflow Opportunities .................................................................. 7

Change Management Plan ........................................................................................................... 9

Action plan .............................................................................................................................. 9

Communication plan.............................................................................................................. 11

Implementation and go-live support ...................................................................................... 11

System Design .............................................................................................................................. 12

Design Document and Architecture .......................................................................................... 12

Intervention (Content) Specification ......................................................................................... 13

User Interface ............................................................................................................................ 15

Input to the system ................................................................................................................. 15

Output to the system .............................................................................................................. 17

Knowledge Engineering ............................................................................................................ 18

Evaluation ..................................................................................................................................... 19

References ..................................................................................................................................... 20

Possible Journals for Publication .................................................................................................. 21

Appendix A ................................................................................................................................... 22

Appendix B ................................................................................................................................... 29

Heart Failure Order Set Screenshots ......................................................................................... 29

Stroke Order Set Screenshots .................................................................................................... 32


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Introduction

Background Information

Continuum Health* is a 375 bed hospital and healthcare system with a primary service area

that covers 9 counties in the Northeast. The system owns a medical group comprising of over 150

physicians spanning all specialties as well as a network of over 250 non-employed physicians that

are credentialed with the system to provide inpatient care.

In late 2013, in an effort to be recognized in the region for the level and the quality of care

delivered for Stroke and Heart Failure patients, the organization has decided to pursue accreditation

status as centers in excellence through the Joint Commission for Stroke and Heart Failure.

There is considerable evidence that accreditation programs improve the process and

delivery of care thereby improving clinical outcomes. In an effort to meet the standards of care

required for accreditation, we are proposing the hypothetical development and implementation of

electronic health record (EHR) - based disease-specific order sets in the acute care inpatient

setting. These order sets will facilitate compliance with two accreditation programs: Primary

Stroke Center Certification though a partnership between The Joint Commission (TJC) and the

American Heart Association/American Stroke Association and advanced certification in Heart

Failure through the Joint Commission. The order sets will be designed to provide evidence based

material though Zynx Health and will also incorporate the required core performance metrics to

obtain and maintain accreditation.

Research suggests that implementation of standardized order sets, templates, or protocols can

improve compliance with recommended processes of care- such as Venous Thromboembolism

(VTE) Prophylaxis, Statins, angiotensin converting enzyme inhibitors (ACEI) or Angiotensin II

receptor blockers (ARBs) on discharge can significantly improve patient outcomes.

Disease- specific order sets promote adherence to clinical standards by making best

practices easy to follow by applying clinical decision support at the point of care improving

consistency of treatment, patient safety, reducing patient mortality and hospital costs through

decreased lengths of stay. Additionally, order sets also assist in transitions of care amongst

various care teams during patient care. Evidence based orders decrease the chance of errors and

enhances best practice implementation over the course of time.

Since the organization is already live on EHR and currently using generic order sets for

broad categories (e.g. Generic Medicine and Generic Surgery) for delivering care, the

development of disease- specific order sets will assist providers in meeting current standards of

care and clinical protocols.

*Continuum Health is a fictional entity


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Stakeholders, Goals, and Objectives

Stakeholders Pertinent CDS Activities

Committees

Order Set Committee Develop best practice and evidence based order sets as needed.

Drug and Therapeutics

Committee Reconcile treatment options with existing pharmacy formulary

Review and identify potential contraindication and drug

interactions.

Quality and Patient Safety

Committee Review and analyze performance measures on a regular basis

to improve treatment plans.

Medical Executive

Committee Overall oversight and approval committee for all medical and

clinical activities.

Involved in final approval of order sets developed

Personnel

Clinical Information Systems

Implementation Team(s):

EHR Build team

Zynx Health build team

IT technical team

Clinical analysts

Clinical trainers

Involved in the design and implementation of the order sets.

Responsible for clinical training.

Providing system and network support

End-users:

Physicians

Midlevel’s

Nurses

Represented at the Order Set Committee to develop and

approve clinical content built into the sets.

Promote the use of order sets organization wide

Involved in actual use of the order sets for clinical

documentation of patient episode

Hospital administration Not involved in actual design and implementation of the order

sets but are vested in the favorable outcomes in terms of

improved patient care, decreased length of stay, decrease cost

of care and improved reimbursements.

Chief Informatics Officer

(CIO) and Chief Medical

Informatics Officer (CMIO)

Vested in the successful design and implementation of new

functionality with minimal disruptions to existing workflows.

Chief Medical Officer

(CMO) Vested in keeping physician satisfaction high which is

achieved by adequate physician participation in the

development and training of the order sets as well as minimal

disruptions to the workflow.

Invested in the success of the new functionality and subsequent

use of the new order sets.

Consumers

Patients Directly benefit from improved clinical care and best evidence

medical practices

Empowered patients that are engaged in their own medical care

due to better patient education resources.


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Goals Focus Areas Clinical goal Objective

Improved

patient care Emergency

Department

Acute care

inpatient floors

Stroke center

Clinical

Decision Unit

(CDU)

Medication

safety

Transitions of

care

Early recognition,

intervention and follow-up

in accordance with clinical

practice guidelines

Improve patient care hand-

offs to other units and

facilities (skilled nursing

and rehabilitation)

Improve patient

outcomes

Reduce mortality and

morbidity

Decrease improper

follow-up of test results

Meeting

regulatory

requirements

Meaningful Use

Stage 2

Heart Failure

and Primary

Stroke center

accreditation.

Improve performance to

achieve optimal

performance.

Analyze and use

standardized performance

measure data to continually

improve treatment plans

Meet performance measures

for reporting purposes and

the maintenance of

accreditation

Demonstrate the application

of and compliance with

clinical practice guidelines

published by the AHA/ASA

or equivalent evidence-

based guidelines

Achieve Meaningful

Use Stage 2

Accredited as a

Primary Stroke Center

and as a Heart Failure

center

Development

of specialized

care teams

Organization

wide

Preventive Care

Early intervention for

Stroke patients

Appropriate post discharge

follow-ups

Reduce response times to

alerts

Improved workflow and

alert system for clinicians.

Rapid response times

of the specialty teams.

Improved patient

outcomes

Decreased readmission

rates

Better educated

patients

Decreased

readmission

rates

Post discharge

care plans

Schedulable orders in order

sets ensure patients have

post discharge follow-ups

within 7 days of discharge.

This is a requirement for

Heart Failure.

Improve patient

outcomes by

proactively

Improve All clinical Encourage the use of Providers will be able


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providers

knowledge of

stroke

providers

evidence based guidelines

for the management of

Stroke and Heart Failure

organization wide

to educate their patients

more because of their

greater knowledge

Information System Inventory

System inventory component Rationale

Hardware/Network There is no additional requirement for hardware

since this is added functionality to existing

system and network capabilities

Software/ application

Zynx Health module Module to be installed and tested.

Order sets

Naming convention Using established naming conventions to

maintain consistency and allow users to quickly

and easily locate order sets

Style Guide (EHR and Zynx Health) Using a style guide consistent with organization

wide standards reduces development and

training time. This also makes the new orders

easier to use because they are alike in

appearance to other existing order sets.

Master vocabularies (EHR and Zynx Health)

for clinical terminology, ICD-10 codes, CPT

codes and drug names

Reconciling both vocabularies will make

integration between the two systems seamless

functionality. This would also reduce the amount

of time spent building order sets in two separate

environments.

Existing Heart Failure and Stroke

documentation inventory

Leveraging existing paper-based or

documentation templates to ensure appropriate

and the most updated content is built.

Resources

Order set committee Oversight committee that will oversee the

development, implementation, and training for

the new order sets developed. The participation

of Cardiology and Stroke Center champions

would be a requirement for the new orders. The

orders are then to be vetted by pharmacy to

ensure drug names listed are part of the

organization’s formulary.

IS technical resources IT tech staff to load and integrate the Zynx

Health platform to the Zynx administrators’

desktops and ensure that there is adequate

integration between the two systems in terms of

networking and accessing evidence based links.

EHR Order Set Build Analysts Analysts to build the evidence based order sets

that are built based on Zynx Health


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Zynx Health Build analysts (Project Manager

and Coordinator)

Analysts to build and maintain evidence based

order sets in Author space for migration into

EHR

Clinical trainers Trainers to conduct hands-on training and

demonstrations for all providers in the inpatient

setting.

Intervention Selection and Workflow Opportunities

Currently the Cardiologists use a general cardiology order sets for their Heart Failure

patients; while the Stroke team use general medicine order sets to document a patient encounter.

These order sets are generic and require the clinicians to often enter orders in free text since the

existing orders are not condition specific. Furthermore, clinicians often forget to document

reasons why they choose not to follow a certain treatment plan effecting the organization’s

compliance with the performance measures required for accreditation. The use of generic order

sets also makes it very difficult to capture the essential performance measures that are required

for reporting.

Creation of the new order sets would not significantly impact the current workflow of the

clinicians since the organization is already using the EHR for computerized physician order entry

(CPOE). To ensure minimal disruption to workflow, we intend to utilize existing documentation

templates/paperwork as well as the existing style guide and naming convention that has been

utilized for existing EHR based order sets. To further minimize disruptions to current workflow,

an extensive training plan has been developed that provides clinicians with hands on training as

well as demonstrations at department meetings. The new order sets also capture key performance

measures which make data abstraction for reporting purposes easier.


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While order entry is not a new workflow for the clinicians, the use of evidence based

medicine content is new functionality that is being implemented organization-wide with these

specific orders. The providers will have to select the disease-specific order sets when they are

documenting care for Stroke and Heart Failure patients.

Order Set (OS) Creation Process (gaps presented in bold; yellow = needs attention; red = needs urgent attention)- Adapted from Zynx Health

Sta

ge

4.

Ap

pro

ved

/

Re

lea

sed

Sta

ge

3. R

evi

ew

Sta

ge

2. P

rep

pe

dS

tag

e 1

. D

raft

Define Roll-out (based on unit/group)

EXAMPLE: 1. ED

2. Hospitalist

3. ICU

4. Surgery

5. OB

6. Peds

Pharmacist to prep the OS for meds:

1. Remove non-formulary items

2. Make reccds on top 1-2 meds

3. Move evidence-based formulary

meds to bottom of OS and ask SME to

review

Identify top

admission DRGs

(20-25) for each

unit/group

A. Check if there is a

hospital approved OS

on paper and

B. Check if there is a

Zynx template

Report findings to C-Suite and physicians to

enhance adoption of OSs

Identify “additional” OSs for

workflow

1. MD workflow (eg, AM labs, CT

contrast)

2. Nursing workflow

IS to build OS in

AuthorSpace

(using Zynx

template, if

available)

Zynx Project Manager (with

clinical background) to

prep the OS: 1. Remove all

horizontals, 2. Remove all

Nursing/Unit protocols

Define Horizontal OS Roll-out:

1. Venue-specific

2. Disease specific

3. Convenience

Interdisciplinary teams to prep OS (or define standards):

1. Nursing

2. Lab

3. Radiology

4. Dietary

5. PT/OT/RT

6. Blood bank

7. Case Management/ DC planning

Use ViewSpace:

SME to provide initial

review of OS and

changes are made

based on SME input

IS to customize

OS based on

CPOE build

principles

Establish Ground rules for

OS creation:

1. No pre-checked meds

2. 1-2 pages (optimal)

3. 80-20 rule

4. 1-2 choices per med

Schedule OS review session with “core” team:

1. Physicians (Champion, SME, super user

physician, naysayer), 2. Nursing, 3. IS

(including nursing informatics), 4. Pharmacy, 5.

Quality, 6. Zynx project manager, 7. Other

Physician Champion to

lead discussion around

key clinical issues and

enforce ground rules

ViewSpace for

“core” Team

feedback, with

final decisions

made by SME

arbitrator

ViewSpace for larger

physician audience:

1. 2 week review, 2.

Customized email with

clear instructions and

tutorials. Final decisions

made by SME arbitrator

IS to build/integrate

order set in CPOE

(integration may

involve mapping of

Zynx terms to CPOE

terms)

Create associated

comorbidity

linkables (when

appropriate)

Measure order set use and order item

utilization, and trim order sets based on actual

utilization data

Measure clinical and financial

outcomes based on OS use versus

non-use

Approval process

(eg, P&T, Med

Exec)

Identify SME

arbitrator for

each OS

Define OS

scope (eg,

pneumonia vs.

CAP/HAP/

HCAP; AMI vs

STEMI/NSTEMI

Define order set

structure/Section

headings (eg,

ADCVANDALISM)

Develop/finalize

CPOE order

catalog (>80%

complete)

Inventory and

proritize

current order

sets


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Change Management Plan

The implementation of new disease specific orders sets designed to deliver evidence

based care and capture key performance measures represents a change in workflow. To ensure

successful implementation, it is important to have a detailed change management plan that

addresses the impact of change and the potential barriers to successful implementation.

Action plan

Identification of the stakeholders

o A key element is to identify and communicate with stakeholders effectively to get

their buy-in and engagement early in the project.

o An effective way to get stakeholder buy-in is to understand their needs and

concerns to ensure adoption.

o Work together to develop a key messages to communicate to different

stakeholders as well as identifying key champions for each area to carry the

messages throughout the organization.

o It is important to communicate why the change is occurring, what it means to

them, how it effects to them and how the change will benefit them. Often the lack

of communication is the biggest barrier to implementations.

Stroke/ Heart

Failure

workflows

activated

Access

EpicCare

Select patient

and review data

Navigate to orders tab and enter

order name.

(Option to ‘Favorite’ order set if

orders are routinely used by the

provider)

Select order,

enter data, sign

and confirm

order

Clinical

documentation

and order entry

complete

Orders are dropped

to the appropriate

work queues and

action taken

Outcomes and performance

measures are populated and

measured.

Patient present with symptoms of heart

failure to the Emergency department/ direct

admit

Proposed order entry workflow


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Assessing the environment and the need for change

o In order to achieve accreditation distinction, the organization is required to

demonstrate a higher level of care for specific diseases by meeting and reporting

specific sets of performance measures. The need of disease specific order sets was

identified and requested by the physician champions from each area to ensure that

the organization is able to meet these requirements.

Rollout timeline

o Establishing the rollout and timeline for all the various phases of build, testing,

training and implementation is critical for the success of this project. Since the

enhancement is added functionality to existing EMR capability, this will be a

single organization-wide roll-out.

3/3/2014 5/14/2014

4/1/2014 5/1/2014

3/25/2014

Order set committee approval

3/31/2014 - 4/4/2014

Zynx Health order set build3/3/2014 - 3/21/2014

Development of order set content

4/7/2014 - 4/11/2014

Epic Order set build

4/14/2014 - 4/16/2014

Order set testing

4/22/2014 - 5/6/2014

Training, tweaking and testing

5/14/2014

Go-Live

Tentative rollout and timeline

Hospital Administration

Order Set Committee, Quality and Paitent Safety,

Medical Executive Committee

Clinical IT Implementation Teams

End Users:

Physicians, Midlevels, Nursing,

Ancillary areas

Patients


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Prior to Go-Live, it is important to test the new orders to ensure that the orders are getting

routed accurately and validate the data abstraction is accurate.

The training plan should allow providers hands-on training to allow them to test and

review the orders. This also gives an opportunity to identify inaccuracies or workflow glitches

ahead of the Go-Live. Additionally, training should be supplemented by departmental

demonstrations.

Communication plan

Most often than not, communication plans are not adequate and the knowledge of new

changes or functionality does not reach the staff that are working on the floors. Therefore, it is

important to ensure that the key players are included in the communication plan. The

communication should continue through all phases of the project from planning to

implementation. Communication can take many forms; through email, intranet news, specific

newsletters, EMR log-in page alerts, faculty meetings and department meetings. Lack of

awareness/ communication can halt the implementation of even the most well built and tested

systems if providers are not aware.

Implementation and go-live support. The change management plan should also include

Go-Live support on the actual Go-Live date. Even with extensive training, providers sometimes

find it hard to navigate the system at Go-Live. It is important to ensure that a representative of

the build team and super-users are at hand to ensure that there is support readily available at hand

to minimize disruptions in workflow.

Assessment

Environment and the need for change

Planning

Stakeholders, workflows, barriers, building, testing

and training

Implementation

Go-Live

Monitoring and controlling

Performance measures and order set functionality

COMMUNICATION


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System Design

Design Document and Architecture

The design document for this CDS intervention will be updated as an iterative process. It is

expected that the document will constantly change as the project progresses and will be continuously

updated and maintained; often in real time. These documents will be updated weekly by the

implementation team and progress shared with key leadership as the order sets are being developed and

for maintenance purposes.

End Users

EHR Application Server

EHR DatabaseData Storage

and retrieval

Ancillary Services

Laboratory

Pharmacy

Radiology

Internet

DESIGN ARCHITECTURE

Zynx Evidence

Database


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The design document will serve as a future working document that can be used for future

implementations as well as a knowledge base document that various team members may utilize

to understand the reasons/ steps to implementation. The design document consists of the key

tasks that need to be performed within stipulated time frames.

Intervention (Content) Specification

The main goals of implementing the specialized order sets are twofold; improving patient

outcomes by standardizing patient care and to meet regulatory requirements.

Standardizing patient care significantly improves patient outcomes by ensuring the

patient receives the most updated clinical care as backed by the latest clinical research in a timely

% Complete Task NameDuration

(days)Start Finish

Resource

NamesKey Activities

60% Strategy and Planning Phase 15 Mon 3/3/14 Fri 3/21/14 MJ,NBAchieve stakeholder consensus on the objectives of

the project.

100% Establish Scope 2 Mon 3/3/14 Tue 3/4/14 MJ,NB

85% Develop project plan 2 Wed 3/5/14 Thu 3/6/14 MJ,NB

75% Prepare business case 5 Mon 3/10/14 Fri 3/14/14 MJ,NB

0% Approve Project 3.5 Mon 3/3/14 Thu 3/6/14 MJ,NB

65% Design Phase 15 Wed 3/26/14 Tue 4/15/14 TBD,MJ,NBEstablish project environment for the development and

deployment of the order sets.

100%Establish core project implementation team and project

team environment5 Wed 3/26/14 Tue 4/1/14 TBD,MJ,NB

75% Produce communication plan. 2 Wed 3/26/14 Thu 3/27/14 TBD,MJ,NB

65%Define EMR integration strategies to align timelines and

resources with EMR implementation.3 Wed 3/26/14 Fri 3/28/14 TBD,MJ,NB

25% Define paper based order set approach. 2 Wed 3/26/14 Thu 3/27/14 TBD,MJ,NB

25% Define order set maintenance model. 2 Wed 3/26/14 Thu 3/27/14 TBD,MJ,NB

50% Prepare order set style guide. 2 Wed 3/26/14 Thu 3/27/14 TBD,MJ,NB

5% Build Phase 21 Mon 3/31/14 Mon 4/28/14 TBD,MJ,NBConstruct and approve order sets within the scope of

project.

100% Collate existing paper order sets, remove redundancy 1 Mon 3/31/14 Mon 3/31/14 TBD,MJ,NB

0%Reconcile paper order sets with Zynx Health evidence-

based content2 Tue 4/1/14 Wed 4/2/14 TBD,MJ,NB

0%Assign order sets to members of the order set

development team to build initial draft2 Wed 4/2/14 Thurs 4/3/14 TBD,MJ,NB

0% Draft initial order sets (Zynx AuthorSpace) 2 Fri 4/4/14 Tue 4/8/14 TBD,MJ,NB

0%Send initial drafts out for review and feedback (Zynx

ViewSpace)2 Tue 4/8/14 Wed 4/9/14 TBD,MJ,NB

0%Collect and collate reviewer comments, send changes to

builders for revisions5 Wed 4/9/14 Mon 4/14/14 TBD,MJ,NB

Follow strict timelines with reminders and close follow-

up to help ensure participation and prevent delays

0% Obtain consensus on initial order set drafts 2 Tue 4/15/14 Thu 4/17/14 TBD,MJ,NB

0%Perform extended review of order sets, revise and update

order sets3 Fri 4/18/14 Tue 4/22/14 TBD,MJ,NB

0%

Review by order set development team, department

heads, medical executive committee, and other members

responsible for final approval

3 Tue 4/22/14 Fri 4/25/14 TBD,MJ,NB

0% Deploy Phase 10 Tue 4/29/14 Fri 5/9/14 TBD,MJ,NBDeployment of completed order sets throughout

organization.

0% Communication of order set deployment 1 Tue 4/29/14 Wed 4/30/14 TBD,MJ,NB

0% Deploy enhancements to EMR (if applicable) 3 Tue 4/29/14 Fri 5/2/14 TBD,MJ,NB

0% Perform end user training 5 Fri 5/2/14 Wed 5/7/14 TBD,MJ,NB

0% Go Live 1 Thurs 5/8/14 Thurs 5/8/14 TBD,MJ,NB

0% Maintenance Phase 5 Mon 5/12/14 Fri 5/16/14 TBD,MJ,NBEnsure order sets reflect latest best practices in patient

care and knowledge.

0%Establish order set review cycle for organizational

feedback and incorporation of industry best practices2.5 Mon 5/12/14 Wed 5/14/14 TBD,MJ,NB

0%Communicate and deploy modifications to organization

and end users2.5 Wed 5/14/14 Fri 5/16/14 TBD,MJ,NB


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manner. Additionally, the Primary Stroke Center will have a specialized Stroke team that

responds to all acute stroke alerts organization-wide since time is the most important factor for

improved outcomes. Order sets ensure that patients receive the most relevant patient education as

well as follow-up plans in a timely manner resulting in better hand offs between providers and

decreased re-admission rates.

Regulatory requirements for the Joint Commission require that the organization

demonstrate meeting individual performance measure sets for each specific accreditation for a

year (sample size is based on the number of patient admitted with the specific DRG codes) prior

to application for accreditation. To ensure that the providers are documenting the requirements,

these measures are pre-built into the order sets and are designed as required entries. The

providers are required to select options in the order sets or free text alternative choices or reasons

why they choose not to prescribe a medication or treatment option.

Furthermore, the use of the order sets would also bring the organization closer to meeting

Meaningful Use (MU) Stage 2 requirements of using CPOE for more than 60% of all orders

placed.

Stroke Performance Measures (The Joint Commission, 2014)

Measure ID # Measure Short Name

STK-1 Venous Thromboembolism (VTE) Prophylaxis

STK-2 Discharged on Antithrombotic Therapy

STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter

STK-4 Thrombolytic Therapy

STK-5 Antithrombotic Therapy By End of Hospital Day 2

STK-6 Discharged on Statin Medication

STK-8 Stroke Education

STK-10 Assessed for Rehabilitation

CME

requirements

Accreditation required: All provides are required to complete 8 CMEs on Stroke

related care per year.

Heart Failure Performance Measures (The Joint Commission, 2014)

Measure ID # Measure Short Name

HF-1 Discharge Instructions

HF-2 Evaluation of LVS Function

HF-3 ACEI or ARB for LVSD

CME

requirements

Organization specified: All providers are required to complete 5 CMEs on Heart

Failure Care per year.

Order set development requires the use of Zynx Health Starter sets (See Appendix A).

These starter sets may be customized to each organization’s individual requirements. The orders

are edited in Zynx’s online platform, AuthorSpace, before being shared with the Order Set

Committee for approval. The Order Set Committee comprises of key stakeholders as well as the

Stroke and Heart Failure Center Medical directors and key participants from across the

organization. These edited orders are then viewed online on Zynx’s ViewSpace. Reviewers can

make comments regarding the orders. Once all edits and comments are received, the orders are

edited to include all changes before being approved for implementation.


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The new workflow would require physicians to select the new disease specific order sets.

The order sets are designed to include the latest treatment and test options based on evidence

based clinical guidelines. Where appropriate, links to the latest evidence are available if a

provider wants to refer to the most recent guidelines and research supporting a recommendation.

The provider would be required to pick the required check boxes or document reasons why not

as appropriate.

Once the physician signs off on the order, it drops to the appropriate workqueues

allowing each area (e.g. lab, pharmacy, radiology and imaging) to know that there are orders for

patients that need to be completed. If discharge orders are placed, this alerts the case managers

that the patient is ready to be discharged and the appropriate follow-up care needs to be set up

prior to patient discharge. Since the order sets already include the performance measures, it

becomes easier for data abstraction for reporting purposes and to identify weak areas that need

further education or training.

User Interface

Input to the system. The order sets are designed such that some options are pre-selected

(such as NPO until Dysphagia Screen) to ensure that certain tasks are being completed. Figure 1

below is a screen shot that illustrates what the order will look like to a clinician. While some of

the options are pre-selected, the physicians are able to un-select an option and document reasons

for doing so. Fields with a blue circle with a white ‘x’ in it tells the physician that there are some

details in the order that need to be completed and the order set cannot be signed until these

details are addressed. While the disease- specific order sets include options for the latest

evidence based treatments and testing protocols, a physician also has the ability to enter alternate

drug preferences. If this routine preference for the physician, the user is able to save these as

favorites to expedite the ordering process in the future. The advantages of this functionality are

Screenshot of part of the proposed Stroke order set (please refer to Appendix B for full sets)


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that the options are pre-selected and once the preferences are saved, this enables the physician to

double check the orders before signing off on them.

Figure 1: Beginning of Order Set

Figure 2 below shows the medications section of the order set. The dropdown arrow on

the right hand side of the screen allows the physician to change the order sentence. If they do not

want any of the order sentences listed, they have to option to edit the details based on their

preferences.

Figure 2: Medication section of order set


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Output to the system. There is minimal output from the system. However, if a patient

has a documented allergy, potential drug interactions, or if a duplicate medicine has been

ordered, a pop up alert will appear for the physician to either decline the medication because of

the allergy or document reasons to override and allow it. Additionally, links are built into the

system so that physicians may directly click on the reference symbol and be taken directly to the

material should they choose to (Figure 3). Since each of the new orders are disease- specific, the

order sets provide the most current and relevant options for treating a patient. While the orders

are self-explanatory, there are certain key ‘hard-stops’ that are incorporated into the order sets.

These ‘hard-stops’ require the physician to select an option or document reasons for non-

selection prior to signing off on the orders.

Figure 3: Screen shot of access to evidence- based material when clicking the blue ribbon.

Since, this is an enhancement to the existing EHR; the amount of disruption to workflow

is anticipated to be minimal. The new order sets are easy to get accustomed to since it contains

basic check boxes and drop down menus. The order sets are further customizable so that the

users can change visual preferences (font size, background color, etc.) to allow for easy reading

and use. Figure 4 below shows the screen the physician will see before they sign off on the

orders


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Figure 4: Physician sign off screen

Knowledge Engineering

The decision to implement enhanced order sets for accreditation status was brought to the

attention of leadership by the medical directors of each center of excellence. The directors

thought the most effective and efficient way of ensuring that key performance measures were

captured and that clinicians followed the most current evidence based medicine; was to

implement disease specific order sets. These order sets were designed to ‘steer’ providers by

making it easy for clinicians to follow established protocols.

The clinical leads then developed and reviewed the most current evidence based order

sets available through Zynx Health to determine applicability within the organization. Once a

consensus was achieved, the orders were then built by the build teams into the EHR for

implementation.

The established protocol for the organization is to edit and review implemented order sets

at a minimum of every year to ensure that the orders are current with the most recent guidelines

based on an established review and maintenance schedule. The order sets are reviewed on a

rolling calendar schedule to be able to effectively stagger review over the year. Since these are

disease specific order sets, sign off on the updated orders also needs to be obtained from each of

the medical directors of the Stroke and Heart Failure Centers. The orders will then be reviewed

by the Order Set committee and compared with the Zynx order sets to identify any new evidence

that needs to be incorporated into the order sets.

However, Zynx Health also notifies the appointed point person on the organization side if

newer evidence that is associated with a particular order is available. This serves as a trigger for

the point person to contact the appropriate department heads to determine if the change is

appropriate and necessary. Finally, performance measures have been incorporated based on the

Joint Commission’s core performance measures. This makes data abstraction efficient since all

the key elements have already been developed.


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Evaluation

Prior to Go-Live implementation, the order sets need to be tested to check if they were

built correctly with the proper content and performance measures. Part of the testing would

include verifying if the orders ‘drop’ to the appropriate workqueues (i.e. laboratory, pharmacy,

radiology) once they are signed off by the physicians. Recursive routing will be done on the units

to ensure the orders are being directed to the proper areas for review.

Additional verification of correct order build would include confirming that the orders are

functioning as designed, if the links in the order sets are going to the correct evidence-based

references, and if the appropriate hard stops and alerts are occurring in various simulations.

The design study to validate the build and determinate the clinical efficacy will occur on

a monthly basis post the order sets Go-Live. These measures will be compared to base-line

metrics prior to the Go-Live. Measures of success would include improved patient outcomes,

satisfaction, and key performance measures.

Conclusion

Implementation of this CDS will assist the organization in achieving accreditation status

through The Joint Commission as centers in excellence for Stroke and Heart Failure. Once the

new CDS is developed, the implementation of the new order sets organization-wide is expected

to be seamless.

The implementation of these specific disease-specific order sets for Stroke and Heart

Failure will serve as a framework for the future development of similar orders organization-wide.

The development of disease- specific orders will assist the organization meet requirements for

performance measures reporting, additional certifications/accreditations, and improve overall

patient satisfaction and outcomes.


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References

Ballard, D., Ologa, G., Fleming, N., Heck, D., Gunderson, J., Mehta, R., . . . Kerr, J. (2008). The

impact of standardized order sets on quality and financial outcomes. In B. J. Henriksen K,

Advances in patient safety: New directions and alternative approaches. Rockville:

Agency for Healthcare Research and Quality.

Bobb, A., Payne, T., & Gross, P. (2007). Viewpoint: Controversies surrounding use of order sets

for clinical decision support in computerized provider order entry. Journal of the

Americal Medical Informatics Association, 14(1), 41-47.

Byers, J. (2011, September 28). Getting to know your order sets. Retrieved from Clinical

Innovation + Technology: http://www.clinical-innovation.com/topics/practice-

management/getting-know-your-order-sets?nopaging=1

Chang, K., Noormohammad, S., Snell, A., & McCoy, J. (n.d.). "Bride to CPOE" using

standardized electronic clinical order sets. Zanett Healthcare.

Handler, J., Feied, C., Coonan, K., Vozenilek, P., Gillam, M., Peacock, P., . . . Smith, M. (2004).

Computer physician order entry and online decision support. Academic Emergency

Medicine, 1135-1141.

Jao, C., & Hier, D. (2010). Clinical decision support systems: An effective pathway to reduce

medical errors and improve patient safety. In J. Chiang, Decision Support Systems (pp.

121-138). Intech.

Nolin, J. (2013, June 14). Overcoming barriers to implementation of order sets. Retrieved from

Advance Healthcare Network for Health Information Professionals: http://health-

information.advanceweb.com/Columns/Directions-in-Analytics/Overcoming-Barriers-to-

Implementation-of-Order-Sets.aspx

Osteroff, J. A., Pifer, E. A., Teich, J. M., Sittig, D. F., & Jenders, R. A. (2005). Improving

outcomes with clinical decision support: An implementer's guide. Chicago, IL: HIMSS.

The Joint Commission. (2014). Specifications manual for fational hospital inpatient quality

Measures. Retrieved from The Joint Commission:

http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_

quality_measures.aspx


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Possible Journals for Publication

The Healthcare Executive, Journal of the American College of Healthcare Executives

(ACHE)

Healthcare Information and Management Systems Society (HIMSS)

PubMed

Journal of the American Medical Informatics Association (JAMIA)

Journal of the American Medical Association (JAMA)


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Appendix A

Sample Starter Order Set for Zynx Health

Heart Failure-Diastolic-Admission to Med Surg

General

Precipitating factor

Patient condition

Vital signs

Resuscitation status

Activity

Ambulate

Bed rest

Bed rest with bathroom privileges

Bed rest with bedside commode

Up ad lib

Up to chair

Nursing Orders

Assessments

Assess pain

Cardiac monitor

Measure blood pressure, orthostatic

Measure height

Measure intake and output

Measure weight

Contingency

Notify provider specify parameters

Interventions

Apply anti-embolic stockings (graduated) Evidence

Intermittent pneumatic compression Evidence

Peripheral venous cannula insertion/management

Urinary catheter initiation/management

Urinary straight cauterization

Patient/Caregiver Education

For patients with heart failure who smoke, a smoking cessation intervention (e.g.,

counseling) should be given Evidence

Education, smoking cessation Evidence

Education, heart failure

https://www.zynx.com/ASNextGen/general/TransferToEvidence1.aspx?Parm1=0&Parm2=184106177105008031120089&Parm3=189891&Parm4=103160075139085238020193&Parm5=005069196211216127217032





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Diet

Diet, diabetic

Diet, fluid restricted

Diet, low cholesterol

Diet, low fat

Diet, low sodium

Diet, regular

NPO

Tube feeding

Respiratory

Blood gas, arterial

Oxygen via nasal cannula

Oxygen via nonrebreather face mask

Oxygen via simple face mask

Oxygen via Venturi mask

Pulse oximetry

Laboratory

Cardiac Markers

Creatine kinase, MB isoenzyme (CK-MB)

Creatine kinase, total (CK-total)

Troponin-I

Chemistry

For patients with heart failure undergoing active titration of heart failure medications or

receiving IV diuretics, serum creatinine, serum electrolytes, and BUN concentrations

should be measured daily Evidence

Blood urea nitrogen

B-type natriuretic peptide (BNP) Evidence

B-type natriuretic peptide, N-terminal prohormone (NT-proBNP) Evidence

Calcium level, serum, total

C-reactive protein (CRP), quantitative

Creatinine (Cr), serum

Ferritin

Glucose, serum, random

Magnesium (Mg) level, serum

Phosphorus level, serum

Thyrotropin (TSH)

Thyroxine (T4), free





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Hematology

Complete blood cell count with white blood cell differential

D-dimer

Partial thromboplastin time (PTT), activated

Prothrombin time (PT) and international normalized ration (INR)

Panels

For patients with heart failure undergoing active titration of heart failure medications or

receiving IV diuretics, serum creatinine, serum electrolytes, and BUN concentrations

should be measured daily Evidence

Basic metabolic panel

Comprehensive metabolic panel

Electrolyte panel

Hepatic function panel

Lipid panel

Renal function panel

Therapeutic Drug Levels/Toxicology

Digoxin level

Urine studies

UAIF

Diagnostic Tests

Cardiology

For patients with suspected diastolic heart failure, LV systolic function and diastolic

function should be assessed to aid in diagnosing diastolic heart failure Evidence

12-lead ECG

Echocardiogram, transesophageal Evidence

Echocardiogram, transthoracic Evidence

Radiology

General Radiography

Radiograph, chest, 1 view

Radiograph, chest, 2 views

Nuclear Medicine

Nuclear medicine, cardiac, blood pool, gated, rest or stress, planar (MUGA) Evidence

Medications

Angiotensin-Converting Enzyme Inhibitors Evidence

Captopril- 6.25 milligram orally 3 times a day

Enalapril-2.5 milligram orally 2 times a day

fosinopril

5 milligram orally once a day








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lisinopril

2.5 milligram orally once a day


quinapril

5 milligram orally 2 times a day

ramipril



Angiotensin Receptor Blockers Evidence

The evidence for the use of an ARB is conflicting Evidence

losartan



Beta-Blockers Evidence

For patients without contraindications who have diastolic heart failure and a previous MI,

a beta-blocker should be used Evidence

Bisoprolol-1.25 milligram orally once a day

Carvedilol-3.125 milligram orally 2 times a day

metoprolol succinate SR 25 mg 24 hr tab

0.5 tablet orally once a day

1 tablet orally once a day

DVT Prophylaxis: Low-Dose Unfractionated Heparin Evidence

heparin

5,000 unit subcutaneously every 8 hours

5,000 unit subcutaneously every 12 hours

DVT Prophylaxis: Low-Molecular-Weight Heparins Evidence

Dalteparin-5,000 unit subcutaneously once a day

Enoxaparin-40 milligram subcutaneously once a day

DVT Prophylaxis: Reminders

For acutely ill patients without contraindications who are hospitalized with heart failure,

VTE prophylaxis with LDUH, an LMWH, or a factor Xa inhibitor should be used; for

acutely ill patients hospitalized with heart failure who have a contraindication to

anticoagulation, IPC or graduated elastic stockings should be used Evidence

Immunizations: Influenza Virus Evidence

Screen for influenza vaccine Evidence

influenza virus vaccine, inactivated

0.5 milliliter intramuscularly once











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Immunizations: Pneumococcal Evidence

Screen for pneumococcal vaccine Evidence

pneumococcal 23-valent vaccine

0.5 milliliter intramuscularly once

Aldosterone Antagonists

spironolactone



Analgesics: Opioids

morphine

2 milligram intravenously once



Anticoagulants: Vitamin K Antagonists Evidence

For patients with heart failure of nonischemic origin, avoid the routine use of warfarin

Evidence

For patients without contraindications who have heart failure and chronic or documented

paroxysmal atrial fibrillation, warfarin should be used Evidence

Warfarin-5 milligram orally once a day

Antipyretics

Acetaminophen-650 milligram orally every 4 hours as needed for fever

Calcium Channel Blockers Evidence

For patients without contraindications who have diastolic heart failure and symptom-

limiting angina, a calcium channel blocker should be used Evidence

amlodipine-5 milligram orally once a day

diltiazem-30 milligram orally 4 times a day

verapamil-40 milligram orally 3 times a day

Diuretics: Loop Evidence

For patients without contraindications who have diastolic heart failure and volume

overload, treatment with a loop diuretic should be used to control peripheral edema and

pulmonary congestion, especially if the response to thiazide diuretics is inadequate, or for

patients with more severe volume overload Evidence

Monitor creatinine, serum electrolytes, and urea nitrogen concentrations carefully,

especially during active titration of diuretics or while on IV diuretics Evidence

bumetanide


0.5 milligram/hour continuous intravenous infusion














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furosemide


10 milligram/hour continuous intravenous infusion



torsemide


20 milligram intravenously once loading dose

5 milligram/hour continuous intravenous infusion maintenance dose



Diuretics: Thiazide and Thiazide-type Evidence

For patients without contraindications who have diastolic heart failure and volume overload,

treatment with a thiazide diuretic should be used to control peripheral edema and pulmonary

congestion Evidence

Monitor creatinine, serum electrolytes, and urea nitrogen concentrations carefully, especially

during active titration of diuretics or while on IV diuretics Evidence

chlorothiazide



Chlorthalidone-12.5 milligram orally once a day

Hydrochlorothiazide-25 milligram orally once a day

Metolazone-5 milligram orally once a day

Indapamide-2.5 milligram orally once a day

DVT Prophylaxis: Factor Xa Inhibitors Evidence

Fondaparinux-2.5 milligram subcutaneously once a day

Laxatives: Stool Softeners

docusate sodium-100 milligram orally 2 times a day

Potassium Supplements

potassium chloride-10 milliequivalent intravenously once administered over 1 hour

potassium chloride SR 10 mEq cap-1 capsule orally once a day

Reminders

For appropriately selected patients with heart failure, consider treatment with an HMG-

CoA reductase inhibitor Evidence

For patients with hypertension, consider the use of an antihypertensive agent (e.g., ARB,

ACE inhibitor, aldosterone antagonist, beta-blocker, diuretic) Evidence

There is inconclusive evidence for the use of a cardiac glycoside Evidence









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IV Fluids

Dextrose 5% with 0.45% NaCl

Dextrose 5% with 0.9% NaCl

Sodium Chloride 0.45%

Sodium Chloride 0.9%

Consults

Consult to cardiology

Consult to case management

Consult to dietitian, adult

Consult to discharge planning

Consult to disease management

Consult to social services

© 2010, Zynx Health Incorporated


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Appendix B

Heart Failure Order Set Screenshots

Figure 1-1

Figure 1-2


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Figure 1-3

Figure 1-4


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Figure 1-5

Figure 1-6


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Stroke Order Set Screenshots

Figure 1-7

Figure 1-8


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Figure 1-9

Figure 1-10

Figure 1-11


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Figure 1-12

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