2019 Unified Epic Optimization & Upgrade High Level Timelines

1. 2019 Epic Upgrade & Instance AlignmentWomen & Children’s ImpactJennifer Ulrich, 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. 2019 Unified Epic Optimization & Upgrade High Level Timelines • PSJ Unified Epic & Upgrade Release: April 6-7 • Care Plan Upgrade: April 6 • Swedish Go-Live on PSJ Unified Epic: June 15 • Kadlec Go-Live on PSJ Unified Epic: August 17 • Last Sand Release for Prov, Swedish, and/or Kadlec Instances: Feb 19th • Build Freeze Feb 19 – May 7 (Sand will then release to PSJ instance only)

4. BETA Testing • Unified Epic and Upgrade Build will be completed and available for User Acceptance Testing: • Providence: Feb 13-March 1 • Swedish: May 16 – June 1 • Kadlec: TBD

5. Epic Learning Resources: March 18thEducation Materials Release

6. Role Specific Landing Page • One location for end user facing learning content organized into three categories • Epic Updates • Epic User Guide • New Learners • 144 roles across all Epicapplications

7. Epic Updates • Instance Alignment/Upgrade & optimization change summaries, new content highlights or other recent updates • Instance Alignment/Upgrade changes summaries • Role-based most impactful changes • Summary of change with links to more details where appropriate • Organization specific • PHS, Swedish and Kadlec

8. Epic User Guide • Reference material documenting system build, ranging from basic tasks to advanced topics (replaces current state tip sheets, quick start guides, job aides, etc. located in the Learning Library) • 4 organizational tabs • Exercises tab for roles with supportive self-directed learning scenarios • March 18th release: Getting Started content

9. New Learners • Summary of learning package activities for new users

10. High Impact Changes from OB Newborn Workgroup OB Newborn Workgroup leads: Jennifer K Ulrich Sara pompel Robin cothrell-tubbs Dr. Nicole Schmidt Dr. Katie Eastwood DR. Stephen Girolami With support from clinical subject matter experts & regional clinical informatics

11. Fetal Demise • Delivery Summary: Three Buttons for Living Status • Living • Fetal Demise >= 20 Weeks • Fetal Demise < 20 Weeks • Neonatal Demise Button Removed from Delivery Summary • Obstetric History has Neonatal Demise as an option in the Current Living Status

12. Invalid Delivery Type Warning • Can’t choose a Delivery Type of Vaginal < 20 weeks if Gestational Age is over 20 weeks

13. Delivery Summary • Removed ‘C-Section, Unspecified’ as a Delivery Type • C-Section, Unspecified will remain in OB History for use, if pertinent

14. Indications (for vacuum/forceps deliveries) • 4 Indications for Vacuum/Forceps deliveries: • Maternal indication • Fetal indication (changed from ‘fetal intolerance’) • Prolonged second stage • Others (see comment)

15. Shoulder Dystocia • Gentle downward guidance assisted by Maternal expulsive forces • Maternal pushing efforts were coached (removed: during maneuvers) • No fundal pressure applied

16. LIP/RN Delineation • Utilizing PSJH build where eight rows are bolded/italicized as suggested LIP documentation: • Pregnancy complicated by • Complications • C/S indications (primary and secondary) • Assisted Delivery indications • Forceps/Fetal Station • Vacuum/Fetal Station • Shoulder Dystocia present • Episiotomy, Lacerations, Repaired

17. Recommended Documentation • Upgrade Note allows us to utilize yellow yield sign and black text for recommended fields: • Delivering Clinician • Weight

18. Upgrade: Delivery Summary Report • To speed up clinician workflows, the Delivery Summary activity now shows reports instead of the read-only version that showed after Delivery Summary was signed. • If an obstetrician needs to update a signed delivery summary, they can still do so by creating an addendum

19. Maternal Fetal Triage Index (MFTI) • MFTI was developed by AWOHNN to help organizations triage obstetric patients • Visit AWOHNN’s website for more information and a short video describing the tool

20. Maternal Fetal Triage Index (MFTI) • End-users should utilize the OB Arrival Navigator to complete the MFTI Assessment • Using the MFTI Navigator Section automatically opens the Sidebar to the MFTI Report & filed data Banners

21. MFTI • After documenting all rows in the MFTI Assessment section, click “File Score” to calculate • A banner will appear denoting MFTI Level

22. MFTI Banners • The Banners correspond to the AWHONN tools: • Stat/Priority 1 • Urgent/Priority 2 • Prompt/Priority 3 • Non-Urgent/Priority 4 • Scheduled/Requesting Priority 5

23. MFTI: Flowsheet • There is also an MFTI Flowsheet that is better for reference than documentation • OB Triage Care Record Flowsheet will also show the Total MFTI Score • The AWHONN MFTI Protocol can be accessed by clicking OB MFTI Protocol in the Protocols Button at the top of the Navigator, or within the MFTI Flowsheet

24. Viewing MFTI Information • OB Greaseboards: LDR + Triage, Triage, and All Patients Tabs if patient has an ADT L&D Status of Assessment or C-Section • L&D Manager: LDR, LDRP if patient has an ADT L&D Status of Assessment or C-Section • Depending on Facility will show up for all maternal beds and also in OB OR • MFTI Index Report • Provider OB1 Reports Button

25. Naming Convention for Babies • The system standard for naming newborns is being updated according to this governance decision: • Last Name, Sex MomFirst Name • Warren, Girl MomJennifer • Numeric would be used only if newborn was a multiple • Warren, 1 Girl MomJennifer

26. Upgrade Impact to Baby Naming (Nova Note 641032) UPGRADE • In accordance with other SOGI workgroup changes we are taking an upgrade note that will show preferred name after patient’s legal first name, if a preferred name has been provided • Example: Warren, Stephanie “Steven” baby will inherit the mother’s preferred name: Legal Name = Stephanie Warren Preferred Name – Steven • For mother’s that have no preferred name entered, the baby will utilize mother’s legal name only Legal Name = Jennifer Warren Preferred Name = blank

27. Workflow Alert for Baby Naming UPGRADE • If a mother’s preferred name is entered after the baby is pended, then the names won’t match between mom and baby. • Example: Jennifer Warren was admitted and gave no preferred name. Her baby was pended, and admitted after delivery with this name: • A few hours after delivery the mother informed staff that she really prefers to be called Kathleen. Staff update Jennifer’s admitting information with a preferred name. Now mom’s name appears in Epic as: • Warren, Jennifer “Kathleen” • KEYPOINT: Babies should NOT be renamed after admission. This can have downstream impacts on Lab, Blood Bank, & more. Therefore, “Kathleen’s” baby remains admitted as Warren, Girl MomJennifer:

28. 592148 Maternal Advisory based on Newborn Information We can now show an Advisory in a Mother's Chart Based on Her Newborn's Information This BPA prompts you to order an RhIG workup, also referred to as a Rosette test.If ordered, the RhIG workup is sent to the blood bank. When resulted the pharmacy will prescribe an appropriate dose of Rhogam. 

29. 592148 Maternal Advisory based on Newborn Information If an RhIG workup is already done but no Rhogam has been administered, the nurse will see this BPA on the Discharge Checklist. This BPA is resolved by documenting a Rhogam administration, or selecting Not Indicated:

30. 562903 Stork Metrics Appear as Percentages IP OB Newborn Quality Metrics Dashboard previously showed data in the numerator over denominator format By displaying data in percentages it helps prevent any confusion that might have arisen from the metrics having different denominators, due to different groups of patients qualifying for each metric. Drilldowns into the data can still be done.

31. Addiction Recovery – OB Focused Order Set • The Addiction Recovery – OB Focused order set has been designed for use by any PSJH facility that has inpatient addiction recovery services • This focused order set is being created to be used in conjunction with the Antepartum Admission order set for pregnant patients that are being admitted to an Addiction Recovery Inpatient Treatment unit

32. Orders within Addiction Recovery – OB Focused Order Set • Lab – Lab orders will vary by location • Methadone will be available to Swedish addiction recovery unit • Buprenorphine (Subutex) lower and higher dose panels • Smoking Cessation orders • Withdrawal Medications • Other Medications

33. Naloxone for Discharge • A BPA was created to prompt outpatient orders for Naloxone upon discharge • It is triggered when the provider places a discharge order and the patient had the “Opioid use disorder management – OB” order, but no outpatient order for Naloxone is found

34. OB Insulin – June Release • Epic instance alignment presented an opportunity to look at how OB insulin is managed • Swedish utilizes an algorithmic (columnar) process whereas PSJH has traditionally used a standard infusion method • MFM Focus Group within Women & Children’s Institute has helped govern the OB Insulin build by defining glucose control ranges, and how to manage hypoglycemia, as well as defining the columnar algorithm • The new IV Insulin OB Columnar order set is intended to be used for antepartum and intrapartum patients • After delivery patients needing an insulin drop should be managed with the existing IV Insulin – Adult [1167] order set • DKA patients should be managed using the existing DKA [1745] order set

35. OB Insulin – June Release

37. Two Page PDF for OB Columnar Insulin Protocol

38. Other High Impact Changes for Epic v.2018 Upgrade & Instance Alignment Procedure Pass for Pre-op Care Plan Guides Sexual Orientation & Gender Identity (SOGI) / Preferred Names The Brain: A Nursing Activity for Better Shift Planning and Documentation Risk for Violence Multi-lingual AVS Code Status LDA & Wound Avatar including IRFO for Vaginal Packing

39. Disclaimer • See Epic Learning Resources for full details on these changes • The following slides are intended to give you a high level overview of nine 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 Women & Children’s. • Most high-impact projects have multiple clinical governance and upgrade committees that have been engaged

40. Procedure Pass for Pre-Op • It’s a powerful chart review filter, constantly updating the tasks needed with the most current information available • Procedure Pass is a dynamic worklist and interactive tool used to track required tasks that must be completed PRIOR to surgery to prevent cancellations and delays. • A few common tasks are automatically assigned. Other tasks can be manually added per local protocols • Some tasks complete automatically based on information in the patient chart. For others, the nurse marks the tasks as reviewed or not needed

41. What are Procedure Pass Tasks? • Tasks can include documents such as Orders, Consent, H&P, Advanced Directives. • Tasks can include tests needing to be performed such as lab tests, ECG and CXR. • Tasks can include required appointments, such as a Pre-admit Clinic visit or Total Joint Class.

42. Task Options • Nurses manage tasks in Procedure Pass as a way to communicate what tests are needed prior to the patient going to surgery • Labs are reviewed and results noted • Results from Care Everywhere will be noted • Outside records can be obtained and linked as well

43. Procedure Pass Integration Design for Inpatient Nursing More (Activities) > Pre-Procedure Navigator The Pre-Procedure Navigator will replace the Pre-op Checklist in Flowsheets, so all pre-op documentation exists in one location

44. Procedure Pass Integration for OB Nursing • Pre-Procedure available in OB Navigators • Use Tasks to add any applicable tasks like pre-op labs • The Pre-Procedure Navigator will replace the Pre-op Checklist in Flowsheets, so all pre-op documentation exists in one location

45. Deeper Look at Tasks: Labs

46. Deeper Look at Tasks: Spiritual Care and H&P Note

47. Pre-Proc Checklist Section of the Pre-Procedure Navigator

48. Clinical Practice Guidelines are now Care Plan Guides • Updated evidence and authoring methodology • New look and feel • One consistent format • New way to access • 100% Inpatient reviewed & revised • New topics! Key Point: A Care Plan Guide is a tool that reflects a synthesis of best evidence and practice that guides care without a “prescriptive” focus of a clinical practice guideline

49. Preview: 2018 Care Plan Format Key Point: The New Overview Care Plan includes Universal Goals like Prevent Skin Injury.

50. Future State will be to individualize at this point Current Prov instance workflow is to ‘select all’