Opening Keynote: Donald M. Berwick, MD, MPP, FRCP

Improving clinical outcomes in surgery requires the ability to enact change and the means to measure results. The goal of this study is to document the efforts of a multidisciplinary team to build a fast track colon surgery program using Zynxhealth™ and to measure the impact of such a program using a clinical database. Methods: A multidisciplinary team was assembled to attempt to improve clinical outcomes related to elective colorectal surgery at a 300 bed independent academic medical center. Using Zynxevidence™ as a starting point to review the literature, the group decided to on several interventions in preoperative, peri-operative and postoperative care. This included building a Zynx™ based postoperative order set in our computerized electronic medical record. The American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP®) was used to evaluate clinical outcomes. Results The multidisciplinary committee convened on April 2009. By July 2009 a program was in place. Changes derived from Zynxevidence™ included: Sport drinks at midnight and 3 hours prior to skin incision, Hextend® use and goal directed fluid therapy, multimodal postoperative nausea and vomiting protocol, removal of nasogastric tube immediately after surgery, high flow oxygen, early feeding, and early ambulation. Seventy three patients undergoing elective colorectal surgery performed at Berkshire Medical Center from August 2006 to January 2009 were used as a control group. Forty two patients enrolled in the fast track colon surgery program were operated on from July 2009 to February 2010. Infection was 20.5% vs16.7%, Vent>48 hours 6 (8.2%) vs 0, sepsis 4 (5.5%) vs 0, OR return3 (4.1%) vs 0, LOS(days) 8.8 vs 6.5, 30 day mortality 2 (2.7%) vs 1(2.4%), No complications 52 (57%) vs 31 (74%) p<00.5. Conclusions: Zynxhealth™ was helpful in rapidly developing an evidenced based fast track colon surgery program. Using Zynx™ in conjunction with a clinical database (NSQIP®) documented success of a quality improvement program for elective colorectal surgery. This methodology speeds up the development of programs and allows for timely feedback of results. It has been applied to several other projects at our institution and has helped convince institutional leadership to further invest in surgical clinical databases and Zynx™.

In August, 2011 Northeast Georga Medical Center in Gainesville, Georgia implemented CPOE and electronic plans of care utilizing the Zynx evidience based tools. Initially the nursing and ancillary departments implemented evidence based order sets and plans of care using Horizon Expert Orders and Expert Plans of Care (HEO and HEP). The objectives of this presentation will be to share highlights of strategies used to achieve a 70% CPOE adoption rate within three months of implementation.

This project focused on improving the quality and safety of our patients by utilizing current evidence-based medicine principles to transfuse patients less often resulting in fewer complications, lower mortality rates and higher quality outcomes. Current medical literature supports utilizing a “trigger“ pre-transfusion hemoglobin of 7.0 g/dl for most routine, non-emergent transfusions. By incorporating this into an electronic order set and then mandating its use the overall transfusion rate declined, approx. 40%, as well as the percent distribution of patients with pre-transfusion Hgb>7.0, approx. 60%. The morality rate did not suggest an adverse effect if transfusing less often. Additionally, significant healthcare cost reductions were realized. The facility went from the 100% (most unfavorable) to the 9% (top decile) within 4 quarters with the Active Compare Group. Direct customer savings of approximately $588,000 were calculated using 6 month pre-implementation baseline vs. 12 month point implementation actual transfusion rates. This cost savings was only utilizing supply costs and did not incorporate staff time. The initiative was very successful leading to adoption and spread to other system facilities. It can easily be replicated and implemented in other facilities, even if they only use paper ordered set approach. It will also pave the spread to other clinical scenarios beside blood conservation. The main success factor needs to be medical staff acceptance of the blood conservation initiative. Once that is in place the content and format of the order set can be customized to fit their local practice as long as the evidence-based medicine concepts are the basis. If practice patterns don’t change significantly, then the medical staff may have to have a mandated use of the order set for routine, non-emergent transfusions to ensure the highest quality and safest outcomes for their patients.

In the advent of meaningful use requirements, organizations (EHRs, vendors) are drastically increasing flexibility for discrete data elements that can be exchanged across care settings and technology platforms via Health Information Exchanges. Implementing processes that optimize efficient and well-orchestrated patient transitions will become the underpinnings for developing a longitudinal care system. The use of evidenced-based order sets with evidence-based plans of care at the HIE level will be essential in the ability to manage chronic conditions, provide preventive care and quality improvement tools for patients across the continuum of care. As a recipient of one of four “Challenge Grants- Care Transitions”, we are pleased to demonstrate how Zynx will become a powerful tool to help coordinate care across these patient settings. HIE’s will offer the backbone to deliver meaningful clinical decision support in providing clinical rules. The presentation will focus on how clinical decision support would be beneficial by imbedding into HIE data consumption. Offering evidenced-based order sets with evidence-based plans of care “in the cloud” will help provide support with patient at discharge, medical reconciliation and prescription management. HIE’s will become the vehicle of understanding of a patient’s existential situation deriving from longitudinal interaction with clinical decision support tools between the physician and the patient and his family will become a crucial component of providing optimum care. Transitions between settings of care are well known as a frequent cause of medical errors that result in harm to patients. In addition, lack of coordination of transfers of care can result in unnecessary re-hospitalization when sufficient information about the patient’s condition and history is not available to physicians providing emergent care to patients. As part of the presentation we plan to offer insight on how Oklahoma is providing feedback to the Office of National Coordinator to help improve care transitions from acute care to nursing facilities.

Abstract: Many studies have been performed to show the importance of implementations, patient safety practices, workflow issues and their impact on clinical workflows for providers (licensed practitioners) using the CPOE in Electronic Medical Records. Different than above studies, in the current study we analyze the Utilization of CPOE Order sets for 3 hospitals of one IDN (Adventist Health System) using the same EMR’s with CDSS & CPOE for a fixed duration of one year (same dates of the calendar year). The results of order sets used were analyzed based on percentage of the total order sets used. Results showed Medicine & sub specialties order sets used the most (31.04%) followed by Anesthesia (30.75%), Admission Order sets (17.20%), ED (10.80%), Surgery & Subspecialties (9.04%), Interventional Radiology 1.04%, Peds/Neo (0.13%). The current presentation/paper discusses the breakdown of these above mentioned percentages/details, understating the reasons of the trends and how these trends of utilization can help the Medical Informatics leadership to understand the room for improvement in the development and restructuring of the content of these CPOE Order sets.

Avera Health(AH) is a health system with 29 hospitals in five states ranging in size from a 550-bed tertiary-academic medical center to a 6-bed critical access rural hospital. Utilizing a staggered go-live approach over a ten month period, AH implemented Avera Chart, a comprehensive provider-based EMR scope, providing Inpatient and ED CPOE, ePrescribing and template documentation, in all 29 hospitals. AH Physician Review Teams (PRTs) leveraged the power of ZynxOrder®, ZynxEvidence® and Zynx® Authorspace and Viewspace, to methodically create a library of over 450 standardized EBOS to support the rapid CPOE roll-out strategy and observed go-live and sustained provider-based CPOE utilization of greater than 80%. This lecture will share the concept of PRTs in rapid consensus building of evidence based order sets, required resources, encountered organizational and health-system challenges, and supporting EBOS maintenance.

Memorial Hermann, a System of 15 Hospitals, numerous outpatient facilities and over 4,000 providers has been partnered with ZynxHealth in the development and use of Evidenced Based Order Sets since 2005. During this time, and through many lessons learned, Memorial Hermann’s governance and change management processes have evolved and matured into models which are fast becoming integral and expected standards across the system. Memorial Hermann currently maintains 517 Order Sets containing approximately 2,288 unique orders and 33,077 order sentences. These Order Sets, after having been developed in AuthorSpace, reviewed in ViewSpace and approved for system wide use, are used electronically as Cerner Medical Power Plans in 9 Emergency Departments, 5 Acute Care facilities, 1 Heart and Vascular facility and 2 Rehabilitation facilities. In 2012, 139 of the above Order Sets will reach their expiration dates and go through a full system review cycle. In addition, 182 new Pediatric and NICU order sets are scoped for development by the end of March followed by 150 new Oncology Order Sets. MH will also implement CPOM at 4 more of their acute care facilities. As anyone who has ‘given it a go’ can attest, developing and maintaining Evidence based Order Sets whether in a multi-facility system or a single hospital, are not easy tasks. This discussion will focus on the methods of governance and change management that have been developed over time and proven to be successful at MH as well as tools used facilitate this multifaceted and ever changing undertaking.

Community Health Systems is faced with the unique challenge of providing Evidence Based Order Sets to more than 130 affiliated hospitals in 29 states across the nation. In addition, due to the varying degrees of readiness for CPOE among the facilities, these order sets will be deployed in an interactive PDF format first and then into five different EHR platforms. Evidence Based Order Sets are essential elements of Stage 2 Meaningful Use and CPOE criteria, and formulating the right governance structure was determined to be vital to this project’s success. Our governance strategy includes utilizing a team of Interdisciplinary subject matter experts to vet and edit the order set content that is then taken through specialty specific Physician Review Groups for final review and editing. The Physician Review Groups include physicians from throughout the health system to provide order sets that can meet the needs of all of our affiliated hospitals. Initially the order sets will be built with a standard in Zynx Natural Language in the Neutral Authorspace environment, which will be used for the interactive pdfs. The order sets will then be moved into a standard environment for each of our five vendor EHR platforms. Once the orders are ready for deployment, they will be submitted to a user group that focuses on a specific platform to ensure the essence of the order set has been captured and that it functions as intended within the EHR vendor system.

The purpose is to describe one organization’s journey to move from fragmented discipline-specific care planning to interdisciplinary plans of care (IPOC) supporting interdisciplinary care coordination. The process and lessons learned will be presented. The electronic health record (EHR) project vision at this multi-hospital organization was to replace a fragmented discipline-specific approach to care planning with an interdisciplinary model which promotes patient- and family-centered care and interdisciplinary team coordination through the use of evidence-based IPOCs. The journey began by setting the path in the direction of the project vision and by obtaining leadership support from all disciplines within the organization. This support included the necessary resources and freedom to investigate various care planning models and third party content vendors that would function well with the selected EHR. A rigorous selection process was developed and included an evaluation rubric consistent with the organizations’ vision, content vendor demonstrations, and consultation with other healthcare systems regarding their model of care and content vendors. The results from the selection process were presented to leadership and the selected third party content vendor was finalized. Planning the development of the IPOC content initially focused on the interdisciplinary language and format of IPOCs and subsequent integration of the EHR system. The restrictive nature of traditional nursing care planning language was abandoned in favor of a more universal medically-driven language including medical diagnosis, surgical procedures, and human response problems that would be acceptable to all disciplines. A style guide, which provides the framework for the language, content, and length of the IPOCs was developed and approved by an interdisciplinary practice and documentation council. A content review process was then developed that included interdisciplinary teams from specific service lines. The initial interdisciplinary team meetings often involved discovery and appreciation for the contribution each discipline has to the problems and goals contained in the IPOCs. The teams learned to speak the same language while exploring the difference between a multidisciplinary model and a truly interdisciplinary model. The teams became acutely aware of the shared responsibility of many interventions in the IPOCs and shared responsibility among disciplines’ goal attainment. Once a significant amount of contend was developed and the teams matured, a need was identified to develop a few select discipline-specific IPOCs that would become the vehicle to communicate very specific management within a discipline. Although this decision deviates from the ideal/perfect interdisciplinary model approach, care planning needs to be flexible to address the needs of complex discipline-specific clinical management. In conclusion, this organization remains committed to supporting an interdisciplinary care planning process using evidence-based IPOCs to facilitate interdisciplinary team coordination.The organization recognizes the value of a more flexible hybrid multi/interdisciplinary care planning process.

The purpose of the presentation is to share information on the success of our CPOE implementation and Clinical Decision Support achieving both Meaningful Use Stage 1 and improvements in patient safety and quality at 4 hospitals in the St. John Providence Health System. Using the Zynx Collaborative tools, Cerner EMR(Electronic Medical Record) Platform, and Ascension Health Collaborative starter order set content, we were able to successfully implement ~340 Order Sets/Cerner power plans and achieve a 70% CPOE adoption rate within the 1st week after Go Live. The presentation will outline the project team, governance, strategies for implementation, education tools, lessons learned and future recommendations. Specifically, information will be shared on how the project team used the Zynx tool to create system-wide order sets, capitalizing on twelve interdisciplinary clinical advisory groups to standardize and identify best practice patterns and include evidence-based links in the order sets. Emphasis will be placed on the governance structure, project management, change model used to promote adoption from early development through hands on training and post Go Live evaluation and optimization of power plans post implementation. Data was used to track milestone progress and reports generated to indicate usage and identify areas of risk or opportunity. The governance structure had two levels: An Executive Policy Group and an Operational CPOE Steering Group. Both groups will be described in detail. These groups were essential to establish the scope, prioritization of work, assignment of resources and eliminating any bottlenecks or delays in the process. Our High Reliability and 200 percent accountability philosophies drove the partnership between Information Technology, Zynx, Cerner and the Clinical Advisory Groups. This partnership provided the synergy to produce desired outcomes related to Meaningful use, quality core measures, and safety metrics. The presentation will include Dr. Ted Daniel, CMIO, Judy Avie, VP of Quality, Safety and Transformation, Dana Darocy, Process Architect and Medical Staff Transformation.

A phrase I have been using lately is “you hit what you aim at.” If you all you aim at is getting evidence-based order sets implemented, that is all you will hit. The reason we implement evidence-based order is to affect outcome. However, to hit an outcome, more than evidence-based order sets are needed, since not all evidence-based care is amenable to orders. To impact outcomes across the outpatient-inpatient continuum, and to deliver value, Vanderbilt is implementing a clinical decision support strategy that leverages multiple intervention points to impact correct care. The strategy is to leverage our full architecture to simplify content management, and to deliver evidence-based CDS to impact pharmacy (e.g. progression from low cost medication to high cost medication), clinical efficiency and workflow (e.g. correct referral and correct testing for effective clinical visits), and appropriate compliance with evidence-based care guidelines (e.g. dashboards and other decision support to ensure proper medications are prescribed, care delivered, or testing performed). Zynx Value+ is providing tremendous value to us to see pathways with new eyes, stepping beyond order sets to focus on outcomes. The challenge now is to implement, and to measure outcome and improve our care delivery. This presentation will outline the Vanderbilt architecture and approach to achieving high quality, cost effective care across the continuum.

In conjunction with Spectrum Health’s certification in Advanced Inpatient Diabetes issued by Joint Commission, a Requirement For I improvement was issued The requirement specific to the management of patients with diabetes in the inpatient setting state that an A1c is drawn at the time of admission unless the results of the patient’s A1c drawn within the last 90 days are know, or the patient has a medical condition or has received therapy that would confound the results. Our solution to this problem was to better utilize our automation to identify patients that may have diabetes. The process works by identifying patients based on use of an insulin powerplan. Insulin powerplans are used to treat patients with stress hyperglycemia and hyperglycemia with diabetes. If the powerplan is used the system asks the provider if they want to include Type 1 or Type 2 Diabetes Mellitus on the problem list by a discern alert pop-up. Once Diabetes Mellitus is listed on the problem list the electronic medical record is scanned to determine if an A1c is resulted within the last 60 days. If no results are found a discern alert pop-up asks the physician if they want to obtain an A1c. This will assure that a current A1c is available to providers and the patients. The intent of the rule / alert is to ensure that an A1c occurs 100% for each admitted patient with a diagnosis of diabetes, but give the clinician the option not to order an A1c if one was previously done at another institution, or other exclusion criteria is met. Diabetes_A1c_Monthly Month Year Num Den Rate 8 2011 690 803 85.9% 9 2011 566 708 79.9% 10 2011 613 769 79.7% 11 2011 597 736 81.1% Num: Patients who have had a A1c lab during the current encounter or 90 days prior to arrival. Den: Adult Inpatients diagnosed with diabetes, and currently on insulin or anti-diabetic medication.

Adventist Health System supported the creation and implementation of a clinical Interdisciplinary Plan of Care (IPOC) that promotes standardization in clinical practice and upholds the vision for AHS to become a preeminent leader in the coordination of interdisciplinary patient plans of care. AHS developed a patient-centered, evidence-based, interdisciplinary, electronic plan of care focused on promoting efficiency and effectiveness of the care process. And, with the fully deployed Cerner platform, standardized interventions are being suggested and documented. The clinical process of patient care includes assessment, establishing goals, planning, implementation, and evaluation based on diagnosis. This process is the foundation of clinical decision making and encompasses all significant actions taken by clinicians in providing care to all patients. Clinical standards of practice provide a guide to the knowledge, skills, judgment and attitudes that are needed to practice safely. The first phase of the project has helped to drive the reinforcement of these processes and standards in a more patient-centered approach. The current IPOC in our electronic health record now provides the following: 1) Access to evidence based information, articles on pathophysiology, and gathers data that can be mined by PowerInsight or other clinical reporting systems for clinical research 2) A practice environment in which outcomes can be measured and achieved 3) An environment that supports what is expected from professional clinicians to promote, guide and direct optimal practice 4) A framework for multidisciplinary clinicians to understand, collaborate and design /deliver optimal, comprehensive care. 5) Complements the computerized physician orders to create an environment of safety and enhanced clinical practice. In order to arrive at this juncture in patient-centered care, our content development began in August of 2010. We formed 9 committees of 70 content experts from our multi-state organizations. Over the course of 12 months, we developed and built 28 Condition/Procedure and 47 Patient Problem IPOCs within our electronic health record. The process involved hand-in-hand work with the informatics team to ensure that system functionality and documentation married with Zynx content and clinical decision support. The goal of our presentation will be to share our experiences and journey to becoming truly interdisciplinary. We will, also, discuss the fundamental building blocks needed to form a foundation for care planning within an electronic health record.

I. Life Prior to Zynx A. Multiple outdated versions of order sets with lack of evidence or standardization. B. Lack of gate-keeper for order sets C. Lack of standardized process for approving/implementing order sets, resulting in lengthy turn-around. D. Lack of input from ancillary areas other than Pharmacy. E. Nursing driven not Provider driven/based. II. The Journey A. Created an Evidence Based Information Coordinator (EBIC) B. Created Joint Operational Leadership Team (JOLT) including medical directors, APRN’s, Quality, Pharmacy, etc. C. Created Zynx Core team (included EBIC and Ancillary) D. EHR Specialists developed for roll out of Meditech 6.0 and have become invaluable to our Zynx process E. Communication plan, including monthly updates from CPOE Leadership Team. F. Identified resources to make it all happen G. Learned to take advantage of resources provided by Zynx. III. Detours and Road Blocks A. Changing the culture. B. Helping everyone understand the reason for change “The WHY” behind Evidence Based Order Sets, CPOE, and Meaningful Use C. Dealing with process issues (last minute requests, formatting, making sure old versions were not accessible, etc.) D. Dealing with people issues (people forgotten/left out, not engaged in the process, not onboard with the process) E. Trying to standardize by specialty area vs group. Blending practice styles and evidence. F. Right information at the right time to the right people. G. Challenges merging cultures from two hospitals. H. Complications with Order Sets 1. Order sets with documentation and communication combined. 2. Unclear definition of Protocols and Standing Orders. 3. Lack of standards per nursing unit. 4. Pre-Op, Post-Op, and discharge orders all combined on one order setI. Implementing best way to capture CORE/MU measures IV. Lessons Learned A. Unintentional exclusion of stakeholders B. No interdisciplinary check off C. Learning to evaluate and map out the process as there are nursing units that do things completely different D. Consistency in communication to staff and having it come from one centralized source. E. Overkill of the approval process V. Life After Zynx A. Providers drive the process and order sets designed through consensus. B. All ancillary areas are included in the process C. Open dialogue with other disciplines so we now have a team approach. D. Expedited and centralized approval and implementation process.

The purpose is to describe the main strategies used by this multi-hospital system to adopt interdisciplinary, evidence-based plans of care (IPOC) within an electronic health record (EHR). The EHR project vision at this organization was to provide a fully integrated, enterprise-wide, single patient EHR based on current science that supports and enhances patient safety, patient experience, interdisciplinary collaboration, and capacity/revenue management. To fully realize this vision from beginning to adoption, a cultural transformation was needed. Several strategies were utilized that included planning, restructuring, design, development, prioritization, implementation, and reevaluation. The strategies for a successful cultural transformation were defined as the Clinical Documentation Philosophy and Guiding Principle and provided the foundation to support the project’s vision. The vigorous selection process for an EHR system and the IPOC content that incorporated this philosophy was crucial. The organization’s plan of care process was transformed from a discipline-specific approach to an interdisciplinary care team model. Restructuring of the nursing clinical documentation and practice council to interdisciplinary approach and was the first step of the cultural transformation. This council was integral in the development of the style-guide for IPOC content. An analysis of the organization’s top DRGs was conducted to identify and prioritize IPOC content. Project management with strong evidence-practice expertise was employed. Additional innovative strategies used early in the journey included a definition of an interdisciplinary content review process. Education and training strategies for go live requires collaboration between clinical education and EHR-certified trainers. Education strategies have progressing from the skills needed for go-live survival to adoption of the EHR as a tool to enhance interdisciplinary practice. Feedback from EHR users was used to prioritize and facilitate new learning and served as the metrics to measure adoption and provided the focus for optimization and planning future EHR projects. In conclusion, innovative and multimodal strategies that are strategic and flexible are needed for the successful adoption IPOCs which drive patient care. Additional outcomes included a new appreciation of interdisciplinary practice, specifically the unique contribution of each discipline to improved patient outcomes.

Our journey began with the commitment to partner with Zynx in providing a system that delivers evidence based decision support for our team of healthcare providers. The formation of our Steering Committee was done early on and included members of nursing administration including our Chief Nursing Officer, Educational Specialists, Performance and Safety Improvement Coordinators and Clinical Nurse Leaders. A commitment was made early on by the Steering Committee to actively engage and support staff in the process. ..... The journey has not been seamless; there have been many competing priorities that have presented time constraints, work flow challenges which required refocusing and at times redesigning the work flow. What we believe has aided in our success to date, is two fold. First and foremost, organizationally our senior leadership team has supported and maintained this initiative as a priority. The second equally important driver of our success has been the continued engagement of our staff.

The primary goal of evidence based care development is to design highly sustainable and reliable decision making leading to improved clinical and financial outcomes. There are three important steps on the journey. The first phase involves a well-executed initial development plan. The second is gaining and/or preserving adoption by nurturing and building partnerships through the nexus of people, process and technology efforts. The third and final phase is a razor sharp and interdisciplinary drive towards quality through a shared understanding of how clinical decision support hardwires quality and a tangible understanding of how to apply such tools to achieve outcomes. CHS Three Phase Approach: Phase I -Initial Development: The evidence based care team completed a rapid cycle development plan moving from 1700 facility and physician based order sets to a system driven Shared Baseline approach focused on evidence based practice. We have implemented approximately 600 Shared Baselines across the ED and inpatient environments. Rapid cycle design for oncology and ambulatory is underway. Phase II -Adoption (Presentation Focus): Is geared towards three major tenets: •Focus on people - Concentrated effort on the continued maturity of system level service line design and governance teams, a focus on change management, physician engagement, and relationship development. Specifics on content governance approach, roles/responsibilities, and relationship to broader system governance. •Focus on process - Ensuring EBC facilitates the best process for patient care and physician workflow without sacrificing quality and safety. Specifics on content management operations and change management. • Focus on Technology - Clinical Transformation, optimization, improving physician experience. Making it so easy to do the right thing that success is a guarantee. Presentations to focus on how evidence based care order sets fit within post go live workflow optimizations and key lessons learned. Preparing for Phase III-Opportunity driven Performance Improvement: Ensuring that appropriate analytic efforts are in place.Establishing long standing partnerships across quality, IS, and the medical staff for continuous quality improvement.

The utilization of evidence-based care supported by health information technology that connects our clinicians with the right information when they need it to make the right decisions is part of the St. Joseph Health System strategic goals for Perfect Patient Care. In this presentation we will describe how a dedicated team of Clinical and Informatics Leaders were able to successfully develop 42 ZynxCare condition/procedure care plans and 33 individual problems in time to support the implementation of electronic documentation in 4 facilities in just 5 months. We will review how we developed our initial road map, incorporated check points, and dealt with the speed bumps. Finally, we will explain how we have welcomed 3 additional facilities to join us as we settle in for the longer journey which includes coordination with our Zynx Order Set team; as well as, other strategic care initiative partners.

Adventist Health West (AH) is a not-for-profit, faith-based system with 18 hospitals located in the states of CA, WA, OR, and HI. Use of Zynx for order set development, archiving and workflow has greatly facilitated the managing, customizing, and adoption of approximately 450 specialty-specific, physician-specific, and site-specific order sets. In this session we will demonstrate jumping up the hopscotch course and back: great ideas, that were not very popular and our process of jumping back to start. We will share more of our lessons learned, including: Brief or long? Subphase, multi-phase, sequenced or categorized? And how to address CDS in between? Interactive discussion during the session is encouraged.

This presentation will cover how one Network approached the standardization of Order Sets and Care Plans during implementation of an EMR. Innovative strategies to achieve standardization of care plan content, interdisciplinary collaboration, and improvement in the delivery of patient care will be discussed. Presenters will also discuss the slightly different approach taken with the standardization of order sets and the challenges, unintended consequences, and lessons learned. While Zynx helped the Network align the goals of the project with the implementation of the new Electronic Medical Record, there were major challenges faced in the initial phase for both care plans and order sets which included lack of standardization and a short time frame for customization, standardization, and integration into the EMR. In the development of the care plans leadership decided on a complete overhaul of all current systems to create an evidence-based, interdisciplinary, standardized method of care delivery. By using the Zynx tools, care plan teams were able to meet all project milestones as well as standardize content across the network. Order set development began by bringing physicians from several different facilities together to consolidate facility specific order sets into network order sets. Order set development has evolved over an 18 month period as project coordinators attempted to meet milestones using a variety of tools and processes. The eventual adoption of the use of the Zynx tools has allowed for increased ease of customization and collaboration in the build and standardization of over 300 Network evidence based electronic order sets. Both Order Set and Care Plan teams have found by leveraging the Zynx tools such as Author Space and View Space, teams were able to work efficiently and meet milestones more cost effectively during the scope of this project. Lessons learned post implementation is the need for strong leadership engagement throughout the process, the importance of using the Zynx content and tools, and the need to collaborate with both Zynx and the EMR vendor to ensure seamless integration of content and ease of use. As the Network moves forward with our EMR implementation and Phase II goals additional care plan and order set build and optimization will remain a primary strategic goal for the network. The same process will be used for customization and development of this content due to the ease of using the Zynx tools.

History of Zynx use at Riverside: Users are familiar with the processes/tools (Riverside subscribes to Zynx Ambulatory, Zynx Order, Zynx Plans of Care) Use of Zynx Ambulatory by Riverside Medical Group. They have weaved Zynx evidence into the very fabric of the ambulatory electronic medical record for use at the point of care. History of evidence-based order set development using Zynx Order and the deployment of CPOE (Across all acute care facilities we were at 84% CPOE for November) History of evidence-based Interdisciplinary Plans of Care at RHS prior to Zynx and outcomes achieved before and after deploying in Soarian

IPOC at RHS prior to Zynx and outcomes achieved before and after Understanding current processes, Involvement of bedside caregivers, Why aren’t these “Nursing Plans of Care”? IPOC development forced standardization, review and revision of policies, admission assessments and scope of care

MedStar Health is a 9 hospital health system consisting of both academic medical centers and community hospitals. It is in the midst of a multi-year initiative to implement the Cerner Millennium applications to all nine MedStar hospitals. Implementing Computerized Provider Order Entry (CPOE) has been the next step in MedStar's health IT strategy. MedStar has engaged an experienced clinical consulting team, Clinovations, to provide the content management and expertise for the rapid development of evidence-based, standardized order sets across the health system. With the aid of Zynx tools, MedStar has managed 40 specialty order set teams, has completed development of more than 275 evidence-based order sets, and has engaged more than 1000 providers in the process. These accomplishments were achieved over a mere 10 month period. Lessons learned include: use of site-specific clinical leadership to encourage participation; strategies for sharing best practices between academic medical centers and community hospitals; transparency of order set content using Zynx tools; strategies to manage order set development including various specialty stakeholders; management of broad audience review using Zynx ViewSpace; establishment of governance structures to expedite approval processes.

Don Berwick, MD, the outgoing Administrator for the Center for Medicare and Medicaid Services and previous President/CEO of the IHI, stated that it was going to be primarily up to health care providers (hospitals, clinics, physicians, nurses, administrators, boards, etc.) to ensure that the US heath care system can start to reliably provide the best quality of care for the lowest reasonable cost. We often talk about the ROI, but really we should be talking about the Value of the Investment when we deal with patient and population care. Being able to make use of the Zynx CMS Reimbursement calculator to help us more easily determine how much value (from a payer, patient, purchaser perspective) that we are actually providing -- utilizing evidence-based orders sets and other CDS modalities.

St. Joseph Health System (SJHS) has embarked upon a system-wide clinical effectiveness value initiative to improve quality and reduce cost through development of a comprehensive toolkit that provides point of care CDS tools including evidence based order sets with evidence links, algorithms, tools, and implementation plans- all part of a rapid spread model. As a multihospital system that includes critical access hospitals, specialty and tertiary care hospitals, the solution needed to be designed for flexibility. It had to be developed to allow for necessary adaptation based upon patient populations, operational resources, and a variable timeline for implementation of an EHR. The ability to integrate Zynx-SJHS standard order sets with CDS tools facilitated spread of order sets and drive care. The first regional clinical effectiveness initiative for stroke demonstrated a reduction in mortality from 6% (0.6 mortality index) to 3.96% (0.53), average length of stay from 3.48 (0.67 ALOS index) to 2.88 (0.63), while cost/case increased from $9,751 (cost/case index 0.97) to $9,591 (1.05). Next steps include continuing implementation of EHR and CPOE at additional hospitals to provide point of care CDS, monitor quality and cost metrics, re-assess and re-design tools if ineffective.

Here is a description