2019 Epic Instance Alignment and Upgrade Lab Focused Overview

1. 2019 Epic Instance Alignment and Upgrade Lab Focused Overview Joleen Borg, PSJH Sr. Clinical Informatics Architect

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. Epic Migration 2019 Timeline

4. 2019 Unified Epic Optimization & Upgrade High Level Timelines • PSJH Unified Epic & Upgrade Release: April 6-7 • Care Plan Upgrade: April 6 • Swedish Go-Live on PSJH Unified Epic: June 15 • Kadlec Go-Live on PSJH 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 PSJH instance only)

5. Epic Learning Resources: March 18thEducation Materials Release

6. Epic Learning Resources Website • Learning material categories • Epic Updates • User Guides • New Learners • Available March 18 – site will be updated at that time, will include lab rolls • Website Link • https://epiclearning.providence.org/Content/Home.htm?tocpath=Home|_____0 Available March 18th

7. 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

8. 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

9. 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

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

11. Epic Beta Testing Environment • Available • Providence Feb13 • Swedish May16 • Kadlec July • Available for informatics and end users to test new features before their released to live environment • Access Instructions https://community.providence.org/sites/LearnLib/LLNurSupMstr/BETA_How_to_Access.pdf

12. Instance Alignment – Lab Work Group

13. Lab Work Group IA Themes • External Lab Results – April 2019 • Bloodless Program/Blood Product Refusal – May 2019 • Design in progress • Specimen Navigator – Swedish – June 2019/Kadlec – August 2019 • Design in progress

14. External Lab Results Transplant screen shot not yet available

15. Instance Alignment - Other

16. Shared Items Instance Alignment • Isolation Orders and Workflows • Bloodborne Pathogens & Post Exposure Prophylaxis • Risk for Violence Swedish Only • Adult CSF Order Set • Bronchoscopy Specimen Order set

17. Isolation Orders and Workflows Description: (Executive Summary) Highlight of Impactful Content and Process Changes and Caveats for use: • For Nursing, the changes in workflow are large. However, the new build will reduce the degree of alerting that they currently see. • For providers, there will now be linked isolation orders for C diff when diagnostic testing is first ordered. This process is automated in the order panel, so their change trauma is less, but they need to be made aware of the changes. • Early, and correct, isolation precautions are key to infection prevention while trying to minimize barriers to care. This theme incorporates lessons learned to facilitate isolation orders and accompanying workflows while reducing complexity when multiple precautions are indicated. More accurate C. diff identification and management is supported. • All RN service lines are affected. • All Providers need to be informed. • As Infection Prevention is central to patient and caregiver quality and safety, and part of multiple performance measures, system-wide communication needs to highlight the important changes via Nursing Education and Chief Medical Officer channels. Users Impacted & Groups to Inform:

18. C. diff 2 Step Test & Isolation Order Panel

19. Fast Track - New C. diff 2 Step Lab Test – Impacted Facilities 5 Swedish Medical Centers included, but going live June 15.

20. Personal Preference List Updates • Isolation Theme & C. diff Fast Track require updates to personal preference lists • Both projects going live on April 6 • Isolation Theme: • Moving from a single orderable to a panel that bundles the lab test and isolation order • Impacts all acute facilities on PSJH unified instance of Epic • C. Diff Fast Track • 25 labs moving to a new 2 step C. diff test • Impacts relevant/related acute and ambulatory facilities

21. Bloodborne Pathogens Post-Exposure Prophylaxis Orderset Description: (Executive Summary) Highlight of Impactful Content and Process Changes and Caveats for use: • Lab evaluations are updated to current recommended diagnostic tests. • Medications and decision support for HIV, Tetanus and Hepatitis B post-exposure prophylaxis are updated. • Updated Post-Exposure Prophylaxis lab testing and medication options in the new OS will facilitate management of risky blood exposures. • The new OS can be used for all patients seeking care, including employed caregivers. • ED, Women & Children, PeriOp and Acute Inpatient CDTs will need to be informed to socialize the availability of this new OS. Users Impacted & Groups to Inform:

23. Patient at Risk For Violence Flag • New FYI flag titled Risk for Violence • Documenting the flag generates an alert to caregivers that a patient has a risk for violence • Alert displays in Patient header, schedules, lists and reports

24. 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

25. 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

26. Swedish Only for June 2019 • Adult CSF OS • Bronchoscopy Specimen OS

27. Adult CSF Order Set (Swedish-only) Description: (Executive Summary) Highlights of Impactful Content and Process Changes and Caveats for use: • Reduces need for repeat lumbar punctures • Providers are directed to wait for results of basic CSF testing before ordering additional studies. This point should be mentioned in the change notice, summary documents, and discussed with clinical and operational groups • Most of the lab orders are ‘unit collect’ which will be a workflow change for Swedish providers. • Contains robust clinical decision support • Aligned with, and promotes, best practice, patient safety and high quality care • An updated Swedish Adult CSF order set, facilitating timely and appropriate work-up of CNS infections and hemorrhagic processes. • This will be restricted for use at Swedish-only initially. • Future roll-out to the unified build will be dependent on lab resources. • ED providers: ED CDT • Acute care providers: Acute Inpatient Care CDT • Intensivists: Critical Care CDT • Infectious Disease specialists: Infectious Disease CDT • Integrated Informatics Council (IIC) • Clinical Informatics: Collaborative Learning Session • Swedish Lab Users Impacted & Groups to Inform:

28. CJD specific instructions and link to surveillance form

29. Bronchoscopy Specimen Order Set (Swedish-only) Description: (Executive Summary) Highlight of Impactful Content and Process Changes and Caveats for use: • Proceduralists should become familiar with the OS prior to the procedure. Clinical decision support for specimen orders will be provided based on the patient’s clinical presentation and immune status. • Upon completion of the procedure, the bronchoscopist will utilize the orderset to first identify anatomic location, then address the specific intervention performed. • This process may be repeated multiple times for pathologies in varied locations requiring different methods for collection • This is a complex OS. Any issues with content and workflows must be promptly addressed. • The complex process of ordering post-bronchoscopy specimens will be simplified with the new Bronchoscopy Specimens Orderset. • Users will benefit from orders that link specimen location, procedure/method used and specific diagnostic tests in a single, easy-to-use OS. • Use of the OS should streamline evidence-based specimen ordering, reduce variation and improve efficiency and patient outcomes. • Lab resources require that this be deployed at Swedish-only initially. • Swedish providers who perform bronchs • Procedural Unit Nursing staff • Critical Care and Pulmonary unit staff • Lab processing, Anatomic Path and Lab Clinical staff Users Impacted & Groups to Inform:

30. Beaker Specific Upgrade

31. Summary of Themes/Notes • 577504 Enter Multi-Category Results and Check Abnormality for Cytology Interpretations and Other Tests in Beaker • 590796 It’s an Open-and-Shut Case (Prep Worklist) • 558279 Clinicians See a Comment When Stain Results Change • 567216Improved Phlebotomy Collection Workflows in Rover iOS • 577236 Collection Questions come to Rover • 592600 Print Patient Labels No Longer Appears in Rover Patient Summary

32. Beaker Anatomic Pathology • No need to use “Other findings” to document the additional result • Will trigger a re screen automatically where “other findings” was not able to • Quickly confirm the block and slide tasks • Color coded buttons to allow selection of all tasks of a type at once • Ability to add notes and flags as the case, specimen, and task level • Hover over icons in task line to read documentation left by others • 577504Enter Multi-Category Results and Check Abnormality for Cytology Interpretations and Other Tests in Beaker • 590796It’s an Open-and-Shut Case (Prep Worklist) • Multiple category selection possible on discrete results in the Case Result • Updated look for Case Prep Worklist

33. Illustrations • Insert Screen Shots • Demonstrate or Enter User Workflow

34. Illustrations • Insert Screen Shots • Demonstrate or Enter User Workflow

35. Microbiology • Faster and more comprehensive notification to the provider when the stain itself has changes • 558279Clinicians See a Comment When Stain Results Change • When results of a stain are changed or appended after the result has been sent to the patient chart, a standard comment explaining that change is added to the chart

36. Illustrations • Insert Screen Shots • Demonstrate or Enter User Workflow

37. Rover • Closer match to the workflow in Hyperspace • Accessioning preview to see how orders will be grouped into specimens • Visibility to tube order • Edit tube types • Collection Questions appear when associated with a test similar to Hyperspace • 567216Improved Phlebotomy Collection Workflows in Rover iOS • 577236Collection Questions come to Rover • 592600Print Patient Labels No Longer Appears in Rover Patient Summary • New collection screen makes specimen collection workflows more efficient and helps ensure phlebotomists take the minimum amount of blood necessary

38. Illustrations • Insert Screen Shots • Demonstrate or Enter User Workflow

39. Illustrations

40. Upgrade

41. Shared Upgrade • SOGI • Baby Naming Convention • Secure Chat – Pilot – FYI only – no impact to Lab Staff for pilot

42. SOGI Project Goals 2017- 2018 • Make Epic more inclusive of sexual and gender minorities • Help clinicians make accurate decisions about patient care • Assist the organization to improve LGBTQ patient satisfaction and engagement • Assist the organization to Improve health outcomes for LGBTQ patients, especially transgender patients • Meet requirements for MU, TJC, UDS and OCR 1557 non-discrimination standards. • Rollout build to 3 Epic instances

43. Current SOGI Epic Build • We already capture nuances in a patients sex and gender identity beyond their legal sex today in Epic • The SOGI Smartform allows collection of sexuality, gender identity, transition status and organ inventory data. • The form allows users to collect complete and accurate medical histories on sexual and gender minorities. • We provide decision support that help clinicians make accurate decisions around when there is a documented incongruence between legal sex, sex assigned at birth and gender identity • A full list of current tools are in appendix

44. SOGI Phase 3 Project Overview • SOGI phase 3 focuses on improving the patient experience and on better supporting patient-centered care. • The upgrade brings additional features throughout the system to use and show patient’s gender identity or sex assigned at birth instead of legal sex when appropriate. • There are also updates throughout the system that make it easier for users to see a patient's preferred name. • Preferred name is especially important for transgender patients, but also helps improve the patient experience for any patient with a preferred name that differs from their legal name. • User can now collect additional sex information when capturing demographics. • Patient facing tools now show preferred name and respect gender identity

45. SOGI Workgroup Decisions SOGI Workgroup Task • Reconvened SOGI experts to review new features coming with 2018 Epic Upgrade Identified Risk • The new gender identity and preferred name features focused on patient experience but didn’t consider patient identification • Taking these automatic updates would have negative impacts on patient safety • It would not have been clear to clinicians that they were seeing the patient’s gender identity displaying in the Sex field • It would not be clear to clinicians that they were seeing the patient’s preferred name displaying in the Legal Name field • Gender identify would be assessed (in addition to legal sex) by Epic Beaker when applying lab result reference ranges Decisions to Restrict Automatic Updates • Better Support for Patient Preferred Names that allows the patients preferred name to auto replace legal first name where its displayed in Epic • Better Support for Transgender, Intersex, and Nonbinary Patients that allows patients legal sex to be auto replaced with their gender identity where its displayed in Epic • Better Support for Transgender, Intersex, and Nonbinary Patients that allows Beaker to assess gender identity when applying lab result reference ranges Solutions • Fields displaying legal sex, gender identity and sex assigned at birth are labeled as such Legal Sex: Male Gender Identity: Female Sex Assigned at Birth: Male • Preferred name will display in quotes after legal name Patient Name :Thompson, Joanne “Jojo” • Lab governance will lead future work that addresses sex, gender identity and range references for all Lab Information Systems

46. Preferred Name in Header and Chart Tab • Preferred name now displays in quotes next to legal name on the patient header and chart tab • Preferred name no longer appears with orange highlight below legal name in patient header

47. Displaying Preferred Name on Labels • Preferred Name now displays on patient labels and Beaker lab labels • Truncating criteria already exists for patient names that go beyond the maximum amount of characters • SOGI lab team worked to mitigate identification issues for lab and blood workflows • Clinical Lab FG & HCLL Workgroup reviewed – REMINDER: patient identifier policy changes may be needed • Preferred name is a discrete field and will not be passed through interfaces or to third party systems • Wristbands display preferred name today Beaker Lab Label Patient Label Wristband

48. Using Mother’s Preferred Name in Baby Naming • Thenewborn naming convention standardin Epic includes the mother’s first name (Last Name,) (Sex) (Mom) (First Name) Smith, Boy Mom Elizabeth • The baby naming convention standardwill now include mother’s preferred name (Last Name,) (Sex) (Mom) (First Name) (Moms Preferred Name) Smith, Boy Mom Elizabeth Lizzy

49. Demographics • Dow displays areas to capture gender identity, sex assigned at birth, and sexual orientation

50. MyChart has Expanded Personal Information • MyChart now allows patients to self report Gender Identity, Sex Assigned at Birth and Sexual Orientation