Attendees
Anupam Goel (corporate)	Elliot Levine (Illinois Masonic)	Natalie Selk (Christ)
Sakhawat Hussain (Trinity)	Shilpan Patel (Good Shepherd)	Suneel Udani (Good Samaritan)
Christopher Jamerson(Children's)	Douglas Propp (Lutheran General)

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.