Using Templated Info

New York Hospital Queens

Why we signed up to be a pilot:

• To help develop and adopt best practices for CDS performance improvement
• To serve as a starting point for assessing CDS at NYHQ, which has had CPOE since 2006 and has a plethora of order sets and MLMs.

How we are using the template (teams/roles/processes involved):

• The hospital's Anticoagulation Task Force has completed and reviewed the completed template.
• For purposes of this CDS project, we are evaluating VTE prophylaxis for the medicine and surgery services. In the future, OB/GYN and orthopedics will be reviewed, as well.

Benefits/learning resulting from this use:

• The workflow template helps identify the relevant particular stakeholders and CDS interventions.
• As NYHQ rolls out its ambulatory EHR, the workflow template can be extended to span the continuum of care, e.g. ambulatory surgery, outpatient VTE prophylaxis for atrial fibrillation.
• Similar to a cause-effect diagram, the five rights template can be used to drill down on selected CDS interventions to assess if the information, person, intervention format, channel, and time in the workflow are optimal.
• Outcomes can be followed with the VTE clinical quality measures for meaningful use (http://www.cms.gov/EHRIncentivePrograms/Downloads/MU_Stage1_ReqSummary.pdf):
  • VTE prophylaxis within 24 hours of arrival
  • Intensive Care Unit VTE prophylaxis
  • Anticoagulation overlap therapy
  • Platelet monitoring on unfractionated heparin
  • VTE discharge instructions
  • Incidence of potentially preventable VTE

Hennepin County Medical Center

Why we signed up to be a pilot:

• Joined the collaborative because of strong interest in healthcare innovations and emerging delivery models. Have limited resources to pursue process and content of certain CDS initiatives. Easier to do in a collaborative.

How we are using the template (teams/roles/processes involved):

• Flow Diagram – High level CDS documentation and strategy design/analysis (VTE collaborative: Content owners – the decision makers, Clinical Champion, CDS team, Performance improvement, CMIO, CMQO)
• CDS Grid – Detailed documentation of deployed CDS and proposed CDS (CDS team, Includes clinical champion)
• Five Rights Grid – Not yet using although this process occurs ad hoc during the CDS design/build/test process.

Benefits/learning resulting from this use:

• Flow diagram is very useful to frame high level discussions and document the necessary components for a gap analysis.
• CDS grid is the gap documentation and naturally feeds into priority planning (within a CDS project)
• Five rights seems too academic for our VTE Collaborative group but may be useful for the CDS team and long term documentation/tagging. This documentation is critical for sharing among sites.
• It is difficult for many end users to bridge the gap b/t the template (flow diagram) and their workflow. This phenomenon seems to be inversely proportional to their experience with the content build process in the EHR.

Veterans' Adminstration

Why we signed up to be a pilot:

• To evaluate how a template for CDS could support quality improvement in a setting with advanced electronic systems
• To explore the use of the CDS template to help outline processes for including patient perspectives in disease management

How we are using the template (teams/roles/processes involved):

• Identifying new processes to enhance clinical care based on the Patient Centered Medical Home model and patient empowerment
• Identifying potential and current CDS tools that can support these processes
• Recognizing areas where existing tools could be optimized and areas where new tools need to be developed

Benefits/learning resulting from this use:

• Useful in establishing an overarching plan for best practice for diabetes care in VA
• Helpful in identifying roles of various health professionals and specific CDS tools to support them
• Provides a roadmap for a long-term project allowing for incremental improvements and CDS development around specific tasks

University of Pennsylvania - Outpatient

Why we signed up to be a pilot:

• We have been involved in medical home practice redesign for several years now. Three Penn practices have been participants in the Southeastern Pennsylvania Chronic Care Initiative where diabetes management was a focus of our practice transformation efforts. We were interested in using a structured approach to analyzing our efforts, to help evaluate what we have done so far, and what we need to do going forward in terms of population management and stratified care management as we spread the processes to other primary care practices.

We have used the template in three ways:

• To deconstruct our activities to date, and to pull together activities which have occurred in several practices into a single map of our efforts. For example, how we have used patient lists among our nurse practitioners has been somewhat variable both across and within practices. We also found that we needed to further conceptualize our care management and population management activities that occur outside individual patient interactions. This is the area where most of our current CDS activities are, and the 5 Rights discussion allowed our clinicians and IT specialists to flesh out these aspects of our processes. In this regard we asked to have letter Z added to the template to reflect non-encounter based activities CDS Activities. The activities in Z are expanded in further detail in Population Management
• We used the template to think through and refine CDS for our Health Maintenance alert. We added a separate Mammography alert for MA/RN
• We recognized three levels of CDS Activity: Active, Passive & Substrate. The backbone clearly displays active alerts. We have added green bars as an example to indicate the start and duration of passive alerts. We have highlighted in yellow activities in which discrete data may be captured which serve as the substrate for CDS triggers

Benefits/learning resulting from this use:

• The exercise of categorizing and describing our strategies has been very useful and demonstrated the importance of stepping back from "the weeds' to get the big picture of where our efforts are going. We have been working with our processes for several years now, and the need to reinforce consistency and learn from our experience re what is working (or not) is clear. Since we are bringing up several new practices on the PCMH, the benefit of sharing experiences, and taking advantage of some of the newer tools and capabilities in EPIC was particularly evident. We were also able to identify the areas of opportunity (like the need to increase patient engagement).

University of Pennsylvania - Inpatient

Why we signed up to be a pilot:

• Hoping to participate in development and refinement of tool that can allow our CDS group at Penn to better recognize opportunities where CDS can improve care processes or outcomes.

How we are using the template (teams/roles/processes involved):

• Our CDS leadership at Penn in the outpatient and inpatient settings met to review how we each integrated a CDS project into the template. The exercise gave us an opportunity to discuss the strengths and limitations of the tool.

Benefits/learning resulting from this use:

• For VTE prophylaxis, we realized that although we had a system in place to assess patients risk of VTE on admission, and a system in place to track whether or not patients were on VTE prophylaxis and whether they received their scheduled doses, we did not have a system in place to monitor patients risk of VTE throughout their stay, such that if their risk were to change, we would not recognize this and would not adjust therapy accordingly.

Lehigh Valley Health Network (LVHN)

Why we signed up to be a pilot:

• LVHN has a strong interest in PI and applying standard work to our care processes
• We have people active in the world of CDS and in the Society for Hospital Medicine collaboratives
• We wanted to share our experiences and learn from others

How we are using the template (teams/roles/processes involved):

• Will present the in-pt templates (Generic Workflow backbone and Target-related Workflow) to the CDS Committee in December. Goal will be to use the templates to guide discussion and decisions regarding PI opportunities and potential CDS interventions.
• Intention is to work toward adoption of the templates at other committees (Med Exec Comm, Care Management Committee, Departmental PI/QI Committees) as a standard communication and planning tool

Benefits/learning resulting from this use:

• Using the shared library to learn how other organizations are approaching similar problems
• Increase awareness/understanding at LVHN of the capabilities/limitations of our clinical information systems.
• Improve understanding at LVHN of the full capabilities of CDS ("the toolbox is more than just alerts and order sets")

Texas Health Resources

Why we signed up to be a pilot:

• Commitment to advancing electronic health records pursuit of creative methods to improve patient care
• Desire to collaborate with others in developing a template aimed at improved CDS strategy planning and outcomes
• Learn and provide input to assist others

How we are using the template (teams/roles/processes involved):

• Utilizing as a workflow roadmap for CDS intervention development, implementation and evaluation
• Evaluating template for value and potential enhancements

Benefits/learning resulting from this use:

• This graphic tool is a holistic mechanism to consider CDS interventions within:
  • The entire workflow versus in isolation
    • complimentary versus contradictory
    • supportive versus disruptive
    • invisible guidance versus annoyance
  • Technical build
    • Unintended interactions between CDS interventions
      • Example: Each level of care - new VTE risk assessment / prophylaxis
        • Alert must not consider if ordered previously
• Promotes workflow analysis of 5 Rights of CDS- information, to the right person, in the right format, through the right channel, at the right point in clinical workflow.