Clinical Standardization ED Physician Documentation and CPOE Overview Brian Ingalls, MD

1. Clinical StandardizationED Physician Documentation and CPOEOverviewBrian Ingalls, MD

2. Welcome “The pessimist complains about the wind; the optimist expects it to change; the realist adjusts the sails.” -William Arthur Ward

3. Session Objectives • Understand: • About CHI’s ED CPOE and clinical documentation standardization • Scope of standardization • Process for content development and provider/clinician review • As leaders, what we need you to do • Answer your questions

4. The Clinical Standardization Project • Part of CHI’s OneCare Program to create a shared, universal electronic health record for each patient. • Clinical Standardization design teams are working to define clinical content, documentation standards and clinical workflows. • Teams are made up of physician, nurse and clinician experts from across the system. • The content and standards will be used to build both the Meditech 6.0 and Cerner advanced electronic health record (EHR).

5. Why One EHR? • Provide clinicians and staff with necessary tools and information • Improve patient safety and clinical outcomes • Enhance the patient experience • Eliminate duplication and waste • Better position caregivers for the future

6. Clinical Standardization Scope • Phase II design teams are developing clinical content for review. • Emergency Department CPOE • Pharmacy • Critical Care Plans • Emergency Department Nursing and Clinical Documentation • Perinatal Clinical Documentation

7. ED CPOE Scope of Work The Emergency Department CPOE team is creating standardized order sets for use in emergency departments throughout CHI. • Order sets are based on the top 50 ED discharge diagnoses from all CHI emergency departments. • Order sets will take into account localization to address site-specific needs and guidelines (e.g., state compliance, services provided).

8. ED CPOE Scope of Work, cont. • The content developed in these order sets will be the building blocks to future development of facility-wide order sets and CPOE in all patient care areas. • Standardization will allow us to achieve greater efficiency and quality in operations and patient care. • Acute care CPOE will be part of Phase III of Clinical Standardization; kickoff in April.

9. Clinical Standardization ED CPOE Design Team • Brian Ingalls, MD, Chattanooga, co-lead • Bill Sangster, MD, Denver, co-lead • Ron Lambson, RN, CIN, Denver, co-lead • Jack Geren, MD, Lexington • Paul Hildebrand, MD, Tacoma • Vincent Retirado, MD, Denville • Courtney Rosenthal, MD, Towson • Dave Running, MD, Lincoln • Kevin Smith, MD, Des Moines • Marc Smith, MD, Roseburg • Debbie Brining, RN, Tacoma • Melissa Morgan, RN, Little Rock • Mindy Walters, RN, Grand Island • Erin Edwards, RPh, Tacoma • Matthew Hubble, RPh, Des Moines • Jessica Neishem, RPh, Des Moines • Eric Wymore, RPh, Tacoma • Raecine Chaney, RN, Zynx analyst, Denver • Dee Munyon, RN, CIN/analyst, Denver

10. Team Resources • In addition to decades of combined emergency medical practice, resources include: • CHI-approved, evidence-based practices and existing documentation standards • eClinical reference solutions • Practice standards from ACEP, AAFP, AAP, ACS and ACOG • CHI core measures • Regulatory guidance from TJC, AHRQ, HIPAA, PQRI • Zynx Health • Analysis of current CHI Meditech and Cerner content

11. Order Sets Three Key Design Principles • Intuitive – So providers instinctively know where to find the orders they need. 2. Modular – Some order sets can be used for multiple patient types in conjunction with multiple order sets.

12. Order Set Design Principles, cont. 3. Mirror workflows and eliminate duplication – Once a provider sees a patient, the main order set will contain orders needed to determine a diagnosis. After that determination is made, a more specific order set is used for more specific treatments, medications or further diagnostic tests. Example follows.

13. ED GI/GU Work Up Main Diagnostic Work Up Order Set Initial Treatments, Medications, Diagnostics GI Bleeding subset N/V/D subset Pelvic Pain subset Antiemetic Meds subset GI Meds subset Pain Meds subset Additional Treatments Medications Diagnostics Additional Treatments Medications Diagnostics Additional Treatments Medications Diagnostics Additional Medications Additional Medications Additional Medications

14. How Order Sets Will Work The ordering provider always maintains control: • You can change order details from whatever is defaulted. • You can unselect orders that may be pre-checked. • You can add other orders that are not included in the order set. • It may be easier to simply place a single order rather than open an order set and search for the particular order you want. • You can use any modular order set for any patient.

15. Proposed Adult ED Order Sets • ED Acute CVA/Stroke – with subsets • ED Allergic Reactions • ED Anemia Workup • ED Arthrocentesis/Paracentesis/Thoracentesis • ED Behavioral Health – with subsets • ED Cellulitis/Abscess/Wound – with subsets • ED Chest Pain/Cardiovascular – with subsets • ED Endocrine/Metabolic – with subsets

16. Proposed Adult ED Order Sets • ED Fever – with subsets • ED GI/GU Workup – with subsets • ED HEENT – with subsets • ED Hypercoaguable Labs • ED Major Trauma – with subsets • ED Needlestick/Body Fluid Exposure • ED Neurology Workup – with subsets • ED OB-GYN – with subsets

17. Proposed Adult ED Order Sets • ED Orthopedics/Back Pain – with subsets • ED Respiratory/SOB – with subsets • ED Severe Sepsis/Septic Shock – with subsets • ED Workup Nonspecific – with subsets

18. Proposed Pediatric ED Order Sets • ED Peds Allergic Reactions • ED Peds Cellulitis/Abscess/Wound – with subsets • ED Peds Endocrine/Metabolic • ED Peds Fever – with subsets • ED Peds Fever Neonate/Young Infant • ED Peds GI/GU Workup – with subsets • ED Peds HEENT – with subsets • ED Peds Ingestion – with subsets

19. Proposed Pediatric ED Order Sets • ED Peds Major Trauma – with subsets • ED Peds Orthopedics – with subsets • ED Peds Respiratory – with subsets • ED Peds Seizure – with subsets • ED Peds Workup Nonspecific – with subsets

20. Your Role • Your feedback on the order sets is vital. • Order set Content Briefs are available for review at www.CHIOneCare.net. • Share this information with your teammates.

21. Reviewing Order Set Content Briefs • Check that the order set brief is evidence-based, accurate and complete. • Check that the order is intuitive and makes clinical sense with its flow of diagnostic choices. • Check for any needed additions, or for unnecessary order choices that could be deleted.

22. Two ways to provide feedback Leave a Reply section at the bottom of the ED CPOE page on CHIOneCare.net – your comment will be visible to everyone who views the page.

23. Feedback Click on the underlined email address listed at the top of each order set Content Brief.

24. For Additional Information Email: EDCPOE@catholichealth.net Website: www.CHIOneCare.net