Epic Upgrade & Instance Alignment Surgical Impact

1. 2019 Epic Upgrade & Instance AlignmentSurgical / PeriOp ImpactCourtney Talbot, Sr. Clinical Informatics Architect - System

2. Disclaimer: Please note that based on feedback from Validation and User Acceptance testing changes to the build were possible after the development of this presentation.Therefore screen shots available in the presentation may not represent the final build delivered.

3. Role Specific Landing Page • Learning Home Dashboard (LHD) in Epic. • There is a link in the LHD to the external Learning Home site • One location for end user facing learning content organized into three categories • Epic Updates • Epic User Guide • New Learners • 144 roles across all Epicapplications

4. High Impact Changes from Surgical/ProceduralWorkgroup Surgical/Procedure & Anesthesia Workgroup leads: Courtney Talbot Jennifer K Ulrich James Arndt Lam Johnson Ben Hall Dr. Ellen Derrick DR. Brian Chen With support from clinical subject matter experts & regional clinical informatics

5. Overview of Large Surgical Instance Alignment Projects Not at Hoag

6. Overview of Large Surgical Instance Alignment Projects (continued)

7. Surgical Signed & Held Order Contexts • A new feature has been added to help identify which signed and held preop orders apply to a patient's future surgeries and procedures. • When a surgeon or proceduralist signs preop orders, whether the case is scheduled or not, the Review Context window appears. • The surgeon selects the case and the context is assigned

8. Surgical Signed & Held Order Contexts • When the preop nurse releases the orders, all signed and held orders are grouped by context (surgery or procedure name) • It is easy to select and release the orders that apply to the current surgery only • This context will also help other nurses avoid releasing signed and held orders for future procedures throughout the patient's hospital stay

9. Surgical Signed & Held Order Contexts • When the preop nurse releases the orders, all signed and held orders are grouped by context (surgery or procedure name) • It is easy to select and release the orders that apply to the current surgery only • This context will also help other nurses avoid releasing signed and held orders for future procedures throughout the patient's hospital stay

10. Surgical Signed & Held Order Contexts:Unscheduled Procedures • If you are entering your preop orders for a case that has not been created or scheduled, when you click sign, the Review Context window prompts you to type the surgery or procedure. • In the Procedure field, type the name of the procedure. • Click Accept. The context is assigned and your orders are signed and held. • The procedure you entered shows as the order context.

11. Surgeon Discharge Note Containing Smart Data Elements (SDEs) • This project brings Smart Data Elements (SDE) into SmartTexts or Smartlinks • SDEscontain post procedure documentation elements required by the Regulatory Compliance department • Smart Data Element (SDE) can be mined into reports • Notes in Scope to contain Smart Data Elements: • PHS BRIEF OP NOTE • PHS GEN OPERATIVE REPORT • HOAG BRIEF OPERATIVE NOTE • HOAG OPERATIVE NOTE • SWE - POST PROCEDURE • Reports in scope that will pull data out of the Notes: • 24-hour Post-Operative Report • Brief Post-operative Note

12. Optime Tracking Events New/Updated Events in the Aligned Instance: • NEW: Ready for Transport (PreOp): • On the All Events grid • Facilitates reporting and communication when patient is pre-op in distant location • NEW: Incision Closed (IntraOp): • Added to IntraopQuick-event Buttons • Added to Intraop sidebar progression buttons • Will be used for Swedish PACU Paging instead of 'Alert PACU' • UPDATED: Procedure End (IntraOp): • This event replaces ‘Procedure Close/End’ • Added to IntraopQuick-event Buttons • Added to Intraopsidebar progression buttons • Allows specificity for procedures that have long gap between closure & end of procedure (ex. Neuro) • Able to track some ANE Events & trigger activity in PACU (assign nursing at closure)

13. Timeout/Safe Surgery Checklist: Timeout Types • Changes to Timeout Types: Addition of TIPP (Team IntraOp Procedure Plan) timeout type

14. Timeout/Safe Surgery Checklist: Pre-Incision • Changes to Timeout Pre-Incision: • All team members stop activities and conversation • Fire Risk Assessed / Protocol Initiated • Overlapping surgeries

15. Timeout/Safe Surgery Checklist:Debrief • Changes to Debrief: • Clean Closure Protocol Followed • Wound Protector (Alexis, Gelsport) Used

16. Timeout/Safe Surgery Checklist: GI Timeout • Changes to GI Timeout: Add ‘Allergies Reviewed’ to shared Universal Procedure Time-out used across Sedation Narrators (Endo, Inpatient, ED, CV, IR)

17. Bariatric PreOp & PostOp Ordersets • Bariatric PreOp Orderset Highlights: • The Bariatric PreOp orderset is new to Providence • Swedish and Providence providers worked to create a Bariatric PreOporderset for the aligned instance of Epic • The Bariatric PreOp orderset has been reviewed by the Digestive Health Institute (DHI), and Pharmacy representation from the DHI. • The Bariatric Preop order set includes the standard preop order set sections, however the Preoperative VTE prophylaxis section includes a Pharmacologic VTE Prophylaxis order with multiple options.

18. Bariatric PreOp & PostOp Ordersets • Bariatric PostOp Orderset Highlights: The Bariatric Postop order set contains the standard sections found in all postop order sets with some differences. • The Diet section contains Advance diet as tolerated for stapled procedures, non-stapled procedures, and same day surgery. • The Nursing section includes the Specialty Bed, Non-Invasive Adult Ventilation, and Bedside Glucose orders. • The Medications Other section includes changes to the antibiotics (as part of another project). The Antihypertensive section includes Hydralazine. • The Ancillary Services section includes the following additional orders: • Patient May Use Own Home CPAP/NPPV • Inpatient Consult to Case Management • Diabetes Consult (Inpatient) • Pain Services Consultation

19. Preadmit Navigator: Overview • Dynamic Navigator: • Phone Call workflows (no Preadmission appointment) • Clinic Visit workflows (Preadmission appointment) • Benefits: • Changes in the navigator are intuitive per the appropriate workflow • Only displays relevant documentation, when possible • Decreases navigator size • Allows better reporting for staff productivity • Impacted Users: Preadmission Nurses

20. Preadmit Navigator Changes: Phone Call Interviews

21. Preadmit Navigator Changes: Clinic Visit

22. PreadmitNavigator: Interview • Visit Start: Enter the exact time that the Interview starts. This will assist with productivity calculations. • Special Needs: This information will populate to the case. From the preadmit appointment, you will be directed to enter this information directly on the case

23. PreadmitNavigator: Screenings (added) • Cardiac: Revised Cardiac Risk Index • .RCRI= Smartphrase associated with the Cardiac Risk screening

24. PreadmitNavigator: More Screenings Preadmit Toolbar: New “More Screenings” Three tabs in More Screenings: 1. Pre-Anesthesia 2. Psych 3. Geriatrics

25. PreadmitNavigator: Patient Planning & Wrap-Up

26. PreadmitNavigator: Wrap up Visit End: • This section calculates the total time spent interviewing the patient • It uses the Visit Start Time & the Visit End time to calculate the Total Visit Time NOTE: In Procedure Pass, the “Interview Complete” task will automatically complete when the “Visit End” time is entered

27. PreadmitNavigator: Wrap up Pt Refused AVS & Preview AVS: • After Visit Summary (AVS) is now available to give to the patient after a preadmit visit • Same AVS that is used when Discharging the patient after surgery • Patient can refuse the AVS and it can be documented if needed • Add the Medication information for day of surgery using the .PREPROCMEDin Discharge Instruction text field & complete the note (using F2) • That information will flow into the AVS for the patient to take home

28. Preadmit Navigator: Wrap up

29. PreadmitNavigator: Patient Planning • Care Coordination: • Used to mark patient as needing Provider Evaluation (if applicable at your site) & enter the Date • Communication tool with Nursing and Anesthesia • Displays the name of the author automatically • Used for Preadmit visit coordination

30. PreadmitNavigator: Patient Planning • Preadmit Notes: • New Note Type to enter/view information specific to Preadmit • Available in Chart Review > Note tab .RCRI Note: The Preadmit Note Type can be added Procedure Pass as a task and linked into that view, so all preadmit documentation is visible across care areas

31. Preadmit & Anesthesia Staff • Preadmit: Anesthesia staff can assess a version of the Preadmit navigator, directly from the StatusBoard Procedure Pass: Anesthesia staff will be able to access the Procedure Pass activity Note: Surgeons will not have access to Procedure Pass, this is future optimization

32. Other Preadmit Providers • For mid-level providers supporting PreadmitClinics: • The same Preadmit Navigator and Procedure Pass activity used by Preadmit nurses will be available for them in addition to their visit Navigator • The hospitalists, nurse practitioners, physician's assistants must be logged in the Preadmit Clinic context to get the correct navigators

33. Procedure Pass & Inpatient Nurses • The Pre-Procedure Navigator will replace the Pre-op Checklist in Flowsheets • All preop documentation exists in one location • The New Pre-Procedure Navigator will be available under the MORE menu • Impacted Users: Inpatient Nursing, including Peds, NICUand OB • This has been socialized to Nursing CDTs: • Inpatient Nursing • NICU • Pediatrics • OB

34. Other High Impact Changes for Epic v.2018 Upgrade & Instance Alignment ECTWorkFlow Standardized Neurovascular Procedure Note Templates Sexual Orientation & Gender Identity (SOGI) / Preferred Names Risk for Violence Multi-lingual AVS Code Status LDA & Wound Avatar Care Plan Guides Blood Born Pathogen Orderset Sheath Management

35. Disclaimer • See Epic Learning Resources for full details on these changes • The following slides are intended to give you a high level overview of ten high-impact changes that will come with the 2019 Epic Upgrade and Instance Alignment • Other changes will also be seen with this upgrade • The following projects were not directly managed, nor clinically governed, by Surgical / Procedure Focus Groups. • Most high-impact projects have multiple clinical governance and upgrade committees that have been engaged

36. ECT Workflow: Ambulatory Psychiatric Provider • The Ambulatory Psychiatric provider will access the ECT flowsheet by clicking on the Behavioral Health activity and clicking the ECT tab • There are two topics: Historical ECT Procedures report and ECT • Previous ECT Procedure information will display on the Historical report • Provider documents recommendations for the procedure on the ECT flowsheet and files

37. ECT Workflow: Overview • The ECT Workflow has been redesigned to include the use of a flowsheetfor the Psychiatric provider in the ambulatory and procedural settings • The flowsheet will capture recommendations for pre-procedure, intra-procedure and post- procedure medications and the procedure settings • An Anesthesia sidebar report has been created for the anesthesiologist to review the recommendations. • A Historical ECT Procedure Synopsis report was created so the provider can see the longitudinal view of the ECT’s.

38. ECT Workflow – Anesthesia Side Bar • Anesthesiologist will be able to review the recommendations from the Psychiatric provider by using the side bar report. • The last filed data will display

39. Standardized Neurovascular Procedure Note Templates These Procedure Note (SmartText) Templates are included in this work: • Impacted Providers: • Cerebrovascular neurosurgery • Interventional providers

40. Sexual Orientation/Gender Identity (SOGI) Overview 2018 Upgrade Changes • SOGI Phase 3 focuses on improving the patient experience and on better supporting patient-centered care. You can already capture nuances in patients' sex and gender, that goes beyond their legal sex, in Epic today. • There are new updates throughout the system to use and show patient’s gender or sex assigned at birth instead of legal sex when appropriate. The Sex field in Demographics now displays areas to capture Gender identity, Sex assigned at birth, and Sexual orientation. • There are also updates throughout the system that make it easier for users to see a patient's preferred name, such as in Patient Lists, Headers, Chart Review , Reports or InBasket. This is especially important for transgender or nonbinary patients, but also helps improve the patient experience for any patient with a preferred name that differs from their legal name. • SmartLinks have been updated to retrieve a patient's titles and pronouns based on the patient's gender identity. • MyChart Patients can now view and edit more on the new Personal Information page, including: preferred name legal sex, sexual orientation, gender identity, and sex assigned at birth. • Baby Names now display the mothers preferred name as part of the baby naming convention.

41. Epic v.2018 Upgrade Notes and SOGI Committee Decisions Better Support for Patient Preferred Names in Epic 561082 • Display both First Name and Preferred Name where possible Better Support for Transgender, Intersex, and Nonbinary Patients in Epic 561390 • In columns and reports, do NOT use Epic updates to replace legal sex with gender id • Have columns and reports display both legal sex and gender id information where possible SmartLinks Now Show Sex and Pronouns Based on Gender Identity 608365 • Updated SmartLinks now respect incongruence and preferred pronouns Copies of Sex SmartLinks Now Show "Boy" or "Girl" instead of "Man" or “Woman” 631112 • .sex should display “adult” or “child”

42. Updates to StatusBoards • Name columns display both First Name and Preferred Name

43. Updated Headers and Reports First Name and Preferred Name both appear in header Updated Report headers display complete information

44. Updated SmartLinks now respect incongruence and preferred pronouns

45. Risk for Violence • New FYI Flag ALERT titled Risk for Violence • Will trigger- • Separate alert in Headers • Banners on Landing Pages • PAF columns with Icons Note- Use will be defined by the individual ministry and governed by local policy Why? Violence towards healthcare workers is a nationally recognized problem

46. Patient Header & Banners Example in the Patient Header: • Banner will display in all Surgical Navigators > Communication section, including: • Preadmit • Preop • IntraOp • Phase II Discharge • Professional Exchange Example of Banner in Preop Navigator:

47. Risk for Violence – StatusBoards

48. Who can activate this FYI Alert? • Access to place the FYI risk for violence alert: • Nurse Managers (should include House Supervisors) • Nurse Executives • Clinic Managers • Security • Social Services • Case Managers

49. Risk for Violence: Operational Considerations • While operational practice around the use of this tool is out of the scope of this project, here are a few identified considerations. • This is adjunctive to local policy and procedure. • Local policy should consider: • Define who meets criteria for this Alert • Define who will place the alert on patient charts • Define criteria for removal of alert

50. Multilingual AVS • Multilingual AVS provides the ability to print a patient discharge or instructions in languages others than English • Includes rule based verbiage for: immunizations, sleep apnea, smoking cessation, Warfarin, Aprepitant, Sugammadex, methotrexate, designated care providers, antibiotics, and call 911 verbiage • Swedish currently provides multilingual AVS’s. Providence provides multilingual in Ambulatoryonly. • Epic cannot translate certain pieces of information: procedure names, medications, free text notes BENEFITS • Improved patient experience • Standardization of care and documentation • Approximately 10% or more of our patients have documentation that a language other than English is their preferred language