Welcome to the RUG n’ Roll Midwest & Great Lakes Regional User Group for Cerner Clients

1. Welcome to the RUG n’ RollMidwest & Great Lakes Regional User Group for Cerner Clients Milwaukee, Wisconsin April 30 – May 2, 2007

2. CPOE Implementation at Aurora Health Care:An Interactive Discussion Linda Holewinski,Lead Business Analyst, IS - CPOE Team Jeff Sievert, RPh, Pharmacist & CPOE Team Diane Ruediger, Business Applications Analyst Associate, IS - CPOE Team Cindy Tisinai, RN, MSN - Director, Patient Care Services and Chief Nurse Executive & CPOE Steering Committee

3. Objectives • Building Computerized Provider Order Entry (CPOE) • Provider Order Sets • Pharmacy Perspective • Training Providers in CPOE Use • Super Users • Physicians & Physician Extenders (Physicians’ Assistants, Nurse Practitioners) • Registered Nurses • Health Unit Coordinators • Allied Health Professionals • Implementing CPOE • Pilot Project • Structure - Process - Outcomes • Full House Implementation • Structure - Process - Outcomes

4. Aurora Medical Center-Oshkosh (AMCO) • Opened October 2003 • 84 acute care beds • Patient focused care model • All private rooms • 21,000 outpatient/ED visits/year • 250 physicians • 330 nursing staff • All digital radiology services • Specialty services in emergency care, family practice, internal medicine, oncology, pediatrics, rehabilitation services, surgery, women’s health

5. Power Plans Build for CPOE Linda HolewinskiLead Business Analyst - CPOE Team Aurora Health Care

6. Zynx Orderset development Evidence Concept Mapping Codesets Orderables Knowledge Compiler PowerPlan Build Tool Phases/Subphases Order Sentences Evidence and Reference Links Personal PowerPlans Initiate vs. Plan Status Change Concepts and “Gotch-ya’s” Moving Ahead Outline

7. Physician Ordersets in Zynx • Created in Zynx • Evidence-based • Multi disciplinary • Cross departmental • Cross enterprise • Standardized

8. Caresets vs. PowerPlans

9. CPOE Build Process • Ordersets created using the Zynx website tool • Concept CKI Mapping in Cerner • Export .xml file(s) from Zynx • Import .xml file into Cerner Knowledge Compiler • Reconcile the ordersets using Knowledge Compiler • Add/maintain ordersets using the PowerPlan Tool (DCP Tools)

10. Concept Mapping • Links Cerner Orderables to Zynx Orderables using Concept CKI numbers • Examples: • Orderables • Frequencies • Routes • Units of Measure • Meds use CKI from Multum • Binary files fromCerner • One to many vs. many to one

11. Knowledge Compiler Import from Zynx

12. Knowledge Compiler Reconciliation

13. PowerPlan Tool Window

14. Powerplan Functional Build Overview • Plan Level • Flexing • Hide • Versioning • Duration • Evidence • Category/SubCategory Level • Evidence • Order Level • Evidence Link • Offset • Order sentence

15. Functional Build Overview Cont’d… Subphases • “Plan in a plan” (nested) • Cannot have a subphase • Built the same as a plan (mark as “Subphase”) • Can be added only once per plan or phase • Can have Evidence Links • “Include” (known issue) • Durations • Can be ordered separately in the Plan Catalog

16. PowerPlan in Powerchart

17. Personal Plan Creation

18. Personal Plan Window

19. Powerplan Status • Planned Pending • Planned • Initiate Pending • Initiated

20. Known Issues and ”Gotch-ya’s” • Do not reconcile medications in the Knowledge Compiler • Picks up the first NDC that matches (may be Y- or Z-mnemonic) • Order sentences do not match appropriately • SPECINX does NOT integrate in PharmNet • Zero’s on import • IV Set problems on import • For Sub-phases that will be “Included”, MUST have at least one orderable in the sub-phase marked for inclusion. • Sub-phases can get “out of sync” (Cerner delete script to reconcile, does not work with 2005.02.53)

21. Known Issues, Cont’d…. • Cannot add comment to an IV set in the PowerPlan tool (Fixed in 2005.02.38) • Pharmacy/Physician Lock Server • Notes (Including “Persistent”) • Inability to see Order Comment on Order Sentence until the plan is in and “initiated pending” status

22. Known Issues, Cont’d…. • Personal Plan Issues • Establish guidelines! (orderables, frequencies, routes of administration, etc) • Auto-product select issues with incorrect details • Unable to maintain as a system – develop a process for notification • Order sentences are one-to-one • No subcategories • No Evidence • Zero’s in integer and decimal fields (known issue, fixed in 2005.02.61) • No sharing of plans, unable to use by others as “verbal”

23. Considerations for Moving Ahead • Implementation support (consider staff physicians and Residents) • Post implementation support (CPOE Support Specialists) • Multi-facility decisions up front • InBox and Security decisions • Remote access (from home, office) • Paper chart documentation • Printing of the Medical Record • Decision-making bodies (process redesign committees) • Post implementation ownership • Change management

24. Questions? lholewinski1@wi.rr.com

25. CPOE Pharmacy Implementation Jeff Sievert, RPH Pharmacist & CPOE TeamAurora Health Care

26. Product build Accurate assessment of products in inventory Care sets Match content in Power Orders Substitutions per P&T Formulary guidelines Physician input (ID, cardiology, ED) Write order sentences for each product Testing for correct content, autoselect, label content Pharmacy

27. Pharmacy • Maintenance • Fix / fine tune order sentences • New products • New order sentences • Physician input (may request new meds, new order sentences)

28. Pharmacyimpact • Very quick to verify orders • Impact on staffing (anesthesiologist orders-pre-op, RR, post-op, epidurals) • Formulary substitutions – automatic with CPOE • Autoselect : 90+% of orders autoselect, (some products autoselect turned off) • Start time defaults (need to watch closely to eliminate missed doses) • TPN (Caloric requirements VS presets)

29. Physician impact • Power plans—fast and complete orders • Personal plans—ability to customize orders (maintenance issues) • Speed of order input—computer savvy • Cancel/reorder—easy to change IV rate, new directions or parameters • Physicians input for new meds or order sentences • Pharmacy consult –specific orders for pharmacokinetics, can request pharmacy med reviews

30. Physician • Nursing communication –may contain medication orders, IV rate changes, dosing parameters • Surgery or ED orders—must be discontinued by OR or ED staff when patient transferred to floor • Lock-out issues • 60% of orders are entered via CPOE • Physician reluctance • Some physicians enter 80-90% • If difficulty in entering order or finding med—orders may then be hand written

31. Physician • Training, Training, Training!!! • Physician reluctance to training • Lessons learned during and after training useful for future training sessions • Have Pharmacist available during training

32. Questions? jeff.sievert@aurora.org

33. A Training Perspective on CPOE Diane RuedigerBusiness Application Analyst Associate CPOE Team Aurora Health Care

34. Outline • The Pilot at Aurora Medical Center - Oshkosh • End - User Training • The New & Improved Training Program • Physician Training • Lessons Learned

35. Spring 2006 - The Pilot • OB, Pediatrics, ED, Anesthesia (for OB) • Limited Trained Trainers • No dedicated Training Environment • Staff had limited experience placing orders • Ongoing Process Meetings

36. Paper Orders from within PowerChart

37. Our Task: Electronic Revolution

38. Does CPOE affect Process? Existing Process + = CPOE

39. Integrating Process into Training Paper • Orders • Notification of new orders • Requisitions • Preps • Communication NO • Will current training methodology work?

40. Fall 2006 – The Review • Created opportunities for practice • Decided upon ONE training region • Refreshed training environment • Created Computer Based Training Modules for staff

41. New Method: Start with paper • All classes will start with the same Introduction scenario • Presents information that attendees are able to demonstrate by doing independent activities. • Assures trainers that users will be able to comprehend new material – which is much more complex

42. Building on Complexity • Each part provides new pieces to the scenario followed by an activity – this allows instructors to introduce small pieces of new functionality at a pace attendees can follow along with • By the end of Part III attendees will begin learning about medication order entry

43. Introduction to Medication Order Entry

44. Introduction to Medical PowerPlans

45. Supplemental Class Scenarios • Each unit has 4 additional scenarios • They not only are ready for Medical PowerPlans, but also integration of Interdisciplinary PowerPlans • Attendees leave the session with a workbook, scenarios, Quick Tip handout, Icon/Button Bookmark and instructions on how to practice.

46. Lessons Learned • Understand the intended audience and boost skill sets before training commences • Have a stable training environment • Work with site to fully understand applicable processes • Provide the class with realistic scenarios to demonstrate understanding

47. Spring 2006 - The Physicians • Difficulty scheduling physicians • Two-hour training sessions • Limited Trained Trainers • Individuality in presentation of material • Limited use of Personal Plans

48. Fall 2006 - The Revision • Created and tested physician Skills Assessment • Three-hour training sessions • Developed Check-list for Training • Unsure of Personal Plan usage – dedicated time for Favorites Festival

49. Physician Skills Assessment

50. Provider Training Checklist