Old business - alert for contrast dye

Last month, the group asked for more information about what drugs might be included in an alert directed toward clinicians around potentially nephrotoxic medications if the patient had recently received intravenous contrast for a computed tomography procedure. The list of approximately 100 medications include metformin, gentamicin and other aminoglycosides, vancomycin, diuretics, ACE-I/ARBs, NSAIDs, cyclosporine, tacrolimus, and anti-neoplastics.

The group was interested in learning if the alerts could be stratified by perceived risk. In our current deployment of Multum, all drug-drug interactions are filtered so only the major contraindications display. The alert for these medications and contrast dye could be adjusted by potential risk. The risk of an adverse event may be more closely tied to change in creatinine before and after the test rather than a single creatinine value in combination with urine output.

The alert is intended to be a warning rather than a "hard stop" as there are times when the perceived benefits of the medication outweigh the risk of acute kidney injury.

Decisions & next steps

• Anupam to submit change request to Clinical Information Systems Enhancement (CISE) Committee for review.
• Anupam to ask Pharmacy team to consider developing more advanced logic to allow users to acknowledge higher levels of risk among specific patients.

Role of Physician Advisory Group (PAG)

Anupam is suggesting that this group serve as the approval body for

• Requests whose impact is limited to physicians, residents and Advanced Practice Clinicians
• Requests whose impact crosses multiple disciplines, including physicians and advance practice clinicians. In these cases, PAG would approve the work intended for their constituents and defer approval for other users to the appropriate supervisory groups

In-scope Hospital Outpatient Departments, Emergency Departments, Inpatient Settings including Sherman (separate Cerner instance) and BroMenn (MediTech), any workflows that affect these groups (e.g., cross-setting communication)
Out-of-scope Outpatient Clinics, Home Health
Request sources Advocate system service lines, specialty councils, multidisciplinary groups
Primary areas of focus
* Overall CareConnection user interface (e.g., menus, buttons accessible across the application user base)
* Chart review
* Order entry
* Documentation
* Decision support
* Communication among members of the care team
* Communication about electronic medical record changes

The group suggested it would be difficult to assemble standing committees to manage each of these areas regularly. When appropriate, PAG could nominate an ad-hoc group to review a specific question before making a decision.

PowerPlan work

PowerPlan consolidation work

In the Fall, the Clinical Informatics team will help manage a project to consolidate the hundreds of site-specific order sets into a single set of system PowerPlans to reduce unwanted variation from our sites.

The PowerPlans are more likely to be adopted if there is end-user input into their development and the content starts from the evidence. The group agrees to serve as the contact for site subject matter experts to help

• Provide input into reviewing the proposed content,
• Answering questions from site users about why and how the plan(s) were developed,
• Socialize the PowerPlans with specialty peers to increase adoption. One tactic would be to have site champions state "This PowerPlan saves me X minutes per patient."

Currently, the PowerPlan utilization reports only identify when a PowerPlan has been ordered. To help identify gaps in the PowerPlan adoption process, it will be helpful to develop reports to identify those cases where

• A PowerPlan was used, but should not have been, and
• A PowerPlan should have been used, but was not.

These reports could help target specific providers to better understand why a particular PowerPlan was not used.

Sequence of PowerPlan sections

The group discussed the relative merits and challenges of sequencing sections within a PowerPlan. The group felt it was reasonable to suggest a sequence of sections for admission PowerPlans that mirror the ADC-VANDIMLS mnemonic:

• Surgery/procedure (if applicable)
• Admit/level of care
• Code status (LET)
• Vital signs
• Activity
• Nursing
• Respiratory
• Diet/Nutrition
• Intravenous (IV) fluids
• Medications
• Laboratory
• Imaging
• Consults
• Rehabilitation Services
• Other

Symptom- or diagnosis-based PowerPlans may be better utilized if they were more consistent with the order urgency from the user's perspective (i.e., start with lab, imaging, medications). After that, the section sequence may differ based on PowerPlan intent. The group felt the benefits of custom group order outweighed the loss of standardization across PowerPlans.

Decisions & next steps

• PAG structure

  • Anupam to invite Sherman and BroMenn representatives to the group.
  • Anupam to contact Jane Dus to identify one or two advanced practice clinicians to serve on the group.
  • Anupam to contact Tom Hansen to identify one or two residents to serve on the group.

• PowerPlan consolidation

  • When the PowerPlan project is ready, the site physician representatives will identify relevant users at their sites to serve as subject matter experts.
  • Anupam to work with the analytic team to craft a strategy to consider reports to better understand appropriate use.

• PowerPlan section sequencing

  • For admission PowerPlans, use the sequence of sections above.
  • For all other PowerPlans, place the Laboratory, Imaging and Medications at the top. Some PowerPlans may benefit from custom sequencing based on the clinical indication.

Single discharge summary template

The Hospitalist service line has requested edits to the existing discharge summary templates to better meet the needs of our outpatient clinicians. Several years ago, Advocate developed a completely automated discharge summary. The feedback from the outpatient physicians has been that the compilation of data elements without physician descriptions was not helpful.

To reduce variation in the discharge summary creation process, the PowerNote, Dynamic Documentation and PC Touch templates would need to be very similar, if not identical.

Decisions & next steps
The group agreed on the proposed discharge summary template standardiztion.

• Anupam to submit the request to CISE.

Secure Texting (PerfectServe)

Many physician users complain about how PerfectServe interrupts them from completing their routine work with non-urgent notifications. Although some workflows ask the user if a message is urgent or non-urgent, it is not clear how PerfectServe routes those messages differently. Ideally, a secure messaging system would

• Ask the send about message urgency for every message,
• Update the user's PerfectServe mailbox without an interruption (e.g., change in badge or notification on the locked screen without a buzz or audible alarm). From a HIPAA perspective, PerfectServe has been able to modify notification to the locked screen with personal health information.
• Update the user's PerfectServe mailbox without an escalation for not seeing the message right away (e.g., like the PerfectServe notifications for patients admitted to the emergency department).

Decisions & next steps
* Anupam to work with nursing leadership to refine the overall communication policy among members of the health care team and mobile device policy over the next few weeks and present the content to this group.

Miscellaneous

Moving the meeting time

Lee Sacks has asked all leaders to clear the 8-9 AM block for site and system safety huddle meetings. The group agreed to move the meeting block to 7-8 AM.

CareConnection August change

The pediatric sepsis PowerPlan will begin with a nursing assessment. If the nurse believes the patient is at risk for sepsis, a team huddle will assemble and consider the pediatric sepsis PowerPlan as a starting point for diagnostic testing, intravenous fluids and antibiotics.

eviCore decision support

Good Samaritan is scheduled to go-live with the eviCore decision support product for advanced imaging with the September change date. Usability testing is scheduled for next week.

Provider directory consolidation

Advocate has employed a relaxed policy around consolidating provider accounts across our Advocate hospital sites. With the implementation of our system-wide Cerner registration process, we will need to drive our physicians with multiple accounts to a single account. The workflow for users who schedule cases in SurgiNet is more complex than the workflow for users without a SurgiNet schedule, but in both cases, there needs to be coordination between the physician user, Clinical Informatics and the Information Technology team. In all cases, the user needs to be logged off of Cerner for at least 24 hours.

Simpler way to access blood product administration

The Blood Products Task Force has this request on their list. The team is weighing possible options and will submit a request for build sometime in the near future.

Nuance Voice Recognition (Dragon)

Access to Dragon's Mobile Mic app

Several physicians are very interested in obtaining access to the app, but the monthly fee is not part of the existing Nuance contract. Users are being told that there are no funds to pay for the technology.

Access to Dragon within the Cerner application

• Some sites ((e.g., Good Shepherd) do not have access to the technology within Cerner.
• We do not have a process to access Dragon when CareConnection is down.

Decisions & next steps

• Meetings will be moved to 7-8 AM on the second Thursday of the month.
• Update group on next steps with provider directory consolidation at the next meeting.
• Anupam to follow-up with Beth Halperin on blood viewing request.
• Anupam to follow-up with AMG leadership team on understanding the process by which Dragon Mobile Mic app licenses are currently distributed.
• Anupam to obtain Dragon Medical One deployment schedule so users will know when to expect to access Dragon from within CareConnection (and CliniCare).
• Anupam to discuss strategy to access Dragon independent of our clinical applications in case of downtime.

Issues from prior meetings

[] If the signature + specialty request (with changing the resident's specialty with each rotation) and SmartTemplate work are performed by separate teams, then we will proceed down both paths simultaneously. Otherwise, we will work on the SmartTemplate request first before adding troponin in the daily labs SmartTemplate.
[] Anupam is still waiting to hear back from the Advance Care Planning Council about changing the requirement for a physical signature for LET orders.
[ ] Anupam to present electrolyte management to the ED Clinical Excellence Council to determine if this protocol could be applied in that setting.

Next meeting September 14th 0700-0800 hours CST.

Click here to see minutes from earlier meetings.

Feedback from upgrade and unexpected downtimes (PC Touch and CareConnection)

CareConnection Upgrade

Most of the medical directors feel that the Spring upgrade went relatively smoothly. Good Shepherd expects to migrate to the system TPN ordering workflow in mid-June.

PC Touch

Even after two years of use, the software still seems unstable. Any efforts to push adoption are stymied when clinicians cannot rely on the program to work on a regular basis. At a minimum, downtimes should be measured in minutes, not days.

[ ] Anupam to follow-up with Cerner team about obtaining additional assurances about PC Touch stability.

CareConnection downtime earlier this week

As part of a planned Lutheran General data center migration to multiple Uninterrupted Power Supply (UPS) connections, the switches were not set up as expected from the written schematic. In addition, the programs designed to re-direct users to the Kansas City instance of our clinical applications did not work as designed. The result was an unexpected downtime during the evening shift, a group who usually does not experience downtimes and is unfamiliar with downtime procedures. In addition to CareConnection, PACS, phones and every other clinical information system was unable for the 60-90 minute period. Lutheran General actually considered going on diversion during the downtime. The downtime exposed a lack of processes to help improve the organization's resiliency against unplanned events. Remediations include:

• Advocate has updated its schematics so the switches reflect the reality of what's been put in place.
• Advocate's core networking team will follow-up with Cerner to determine what changes can be made to the monitoring software so our users will be directed to the Kansas City data center when the next unplanned downtime occurs.

[ ] Anupam to follow-up with core networking and update the group when the software change has been made.

Communicating with end-users about changes

We continue to struggle with reaching out to users about electronic clinical system events. Illinois Masonic has a working model where Physician Informatics Committee (PIC) members attend the monthly meetings and disseminate the information to their colleagues. Other sites have either phased out or are considering phasing out the PIC meeting given poor attendance.

Change to default quantity on discharge prescriptions

Currently, Advocate does not permit users to enter more than 40 tablets on any electronic discharge narcotic prescription. Anupam was asked about reducing the number to 20 tablets to reduce the risk of diversion and addiction. One challenge with reducing the maximum number of tablets given is that some patients may end up coming back to the emergency room for another narcotic refill if they cannot follow-up with an outpatient provider in a timely fashion.

After a discussion of risks and benefits, the group agreed to change the default sentences within Cerner to a maximum of 20 tablets, but allow users the option to prescribe up to 40 tablets based on their judgment. Doug has also reached out to one of his colleagues in addiction medicine to see if they may be any potential ramifications from an addiction perspective with this change.

Moving from "stipend" to "volunteer" status

June will be the last month when the group will meet as medical directors with payment. The group agreed to continue the meetings scheduled the second Thursday of the month for now. There was some conversation about the financial challenges Advocate is currently facing. Although the medical directors provided some value to the organization, there has been no discussion of restoring the funding at this time. Based on the conversations among our senior leadership team, it is not clear if the financial savings from removing the medical director stipends will be re-directed back into Clinical Informatics.

Issues from prior meetings

[ ] Anupam to follow-up with CareConnection team about how we might better use front-line users to test changes to identify usability challenges.
[ ] Anupam did speak with Pharmacy Informatics team about options to reduce the frequency of low-value drug-drug and drug-allergy alerts. There may be a software fix to address the issue, but it needs to be tested. Doug would be interested in participating in any testing of a new solution.
[ ] Anupam to distribute electronic survey to our physician community for what library resources should be exposed within CareConnection.
[] If the signature + specialty request (with changing the resident's specialty with each rotation) and SmartTemplate work are performed by separate teams, then we will proceed down both paths simultaneously. Otherwise, we will work on the SmartTemplate request first before adding troponin in the daily labs SmartTemplate.
[] Anupam is still waiting to hear back from the Advance Care Planning Council about changing the requirement for a physical signature for LET orders.
[ ] Anupam to present electrolyte management to the ED Clinical Excellence Council to determine if this protocol could be applied in that setting.

Next meeting June 9th 0730-0830 hours CST.

Click here to see minutes from earlier meetings.