Setting The Stage

for

MEDITECH POM/CPOE & Zynx

The IN Group, Inc Bruce Matthias Penny Hilton July 2010

Goals

• Prepare MEDITECH dictionaries to be POM/CPOE and Zynx ready • Provide knowledge-based content to Physicians at the point of CPOE • Support performance improvement • Decrease practice variation • Automate evidence link updates

Background

• MEDITECH established a strategy with Zynx to import Order Sets, and maintain updated evidence links in content.

– custom links can be added in MEDITECH • Previously Zynx order sets had to be manually recreated in MEDITECH – evidence links were not available during CPOE.

Things To Consider When Converting from OE to POM

• Search in POM does not use Category • Prefix Procedure descriptions with Category – MRI Ankle Left Complete • Convert Proc descriptions to sentence case • Procedures should be as “flat” as possible – Oxygen via nasal cannula vs. Oxygen w/CDS • Minimize use of CDSs, except when regulated – Reason for Exam

Dictionary Modifications

• Change Control Process established • PHA Meds need to be enabled for POM • PHA Meds need Dosing Sets built for weight based medications • PHA IV “Fluid” & “Carrier” Y/N fields • OE Category “Orderable From” set to POM or BOTH or OE • PCS Intervention desc 30 character max

How Physicians Communicate

Add communication orders as needed: – PHA Faux Meds (drips, protocols) • Heparin Drip per Pharmacy • Warfarin Dosing per Protocol – PCS/OE communication orders • Do not wedge PA catheter • If patient temp > 104 degrees, get blood culture – Standard of Care orders • Organizational decision point

Zynx

Integration

•

MEDITECH

feeder application “defaults” trump details sent from

Zynx

: – Pharmacy Dose Units (1 gm vs 1,000 mg) – PCS Intervention defaulted frequencies • Field length limitations: – Order Set Name (max 30 characters) – Reminders (100 characters) – External ID (10 characters) – PHA Comments (Label formats)

Order Set Build Philosophy

• Start with

Zynx

content • Use linkable or modular sets • Build convenience sets in

MEDITECH

only • Establish consistent “look and feel” • Streamlined content design approach – Remove content that is “Standard of Care” – Reduce number of medication choices (beta blockers, antibiotics)

Ready to Begin

Zynx

Build

• Develop a content folder structure • Develop user access profiles • Prioritize Order Set build (80/20 rule) • Establish a Versioning Strategy • Develop a Tracking Mechanism

Dictionary Export Prep

• OE Category Orderable From – POM, OE, or BOTH, *not BLANK* • Field size limitations – PCS Intervention • Formulary – IV Fluid & Carrier (Y/N) – POM enabled – C/S don’t load Strings file

Mapping

•

Zynx

does the initial mapping of your

MEDITECH

dictionaries to their terms.

• You need to understand mapping because you will be responsible to maintain the

Zynx

vocabulary mappings.

• One

MEDITECH

term to many

Zynx

terms, but not the other way around!

Content Folder Structure

• Should be structured the same as

MEDITECH

Order Set Groups (OE Toolbox parameter)

Versioning Strategy

•

Zynx

External ID becomes

MEDITECH

OE Order Set mnemonic – 10 characters, last 2 represent version number (AMISTEMI03) – Importing & Tracking new versions (history)

Finalizing Content

• Make final edits based on Subject Matter Expert feedback • “Scrub” order sets for integration – Medication Details (order type required) – Weight/Rate/BSA-based order detail – Override removals –

Zynx

Vocabulary mapping adjustments

After

Zynx

Importation

• Medication Edits – POM Display Name for all IVs – Carrier or Additive added for all IVs – Dosing Sets for Weight based orders • POM Rules for Order Sets –

MEDITECH

development • Fully test orders and evidence links in POM for all sites!

• New Routine – Move OS from TEST to LIVE – Available in 5.65

Change Control

• Ongoing changes to

MEDITECH

effect

Zynx

integration • Modifications to mapping dictionaries, • Inactive terms in

Zynx

and/or • TEST/LIVE synchronization

MEDITECH

• Modifications to

Zynx

order sets • Versioning • Tracking • Maintenance Reviews

Lessons Learned

• Changes in PHA formulary do not update order sets unless the set is re-filed • Limit of 10 custom queries display detail on main OS View Screen in POM • Orders restricted by site will display in OS dict, but may not show in POM • Do NOT use a linkable set within another linkable set in

Zynx

(creates circular logic) • C/S sites tell

Zynx

not to load the PHA Strings file (they load a blank file instead)

Non-Integrated Fields

• Some fields in the

Zynx

Workspace do not integrate to

MEDITECH

5.64 C/S: – Medication Workspace: • Duration • Duration Units • PRN Reason Override – Non-Medication Workspace: • Overrides • End Date • PRN Reasons and PRN Reason Override • Detail & Free Text Detail Sentence (PCS only, not POM)

Favorites…

UNDERSTANDING MEDITECH FAVORITES PARAMETERS

(a cautionary tale of two parameters)

PARAMETER SELECTION ACTION OUTCOME

Individual Orders (Medications or Procedure) “ADD FAVORITE” (Orderable) Pick List of Orderables Physician has access to in or (Details can be saved) (Orderables NOT preselected) --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Multiple Orders (Medications or Procedures)

YES

“SAVE AS SET” Pick List of Orderables Phys has access in or (Details can be saved by Physician) (ALL Orderables preselected) (ALL Headers/Reminders/Evidence Links are gone) (Does NOT update if original set is updated) Evidence Based (Zynx) and/or Convenience Order Sets “VIEW”

NO

“ADD FAVORITE” (Set) Link to Original Set Phys has access in or (Can be renamed) (If in Favorites, may be easier to find) (ALL Headers/Reminders/Evidence Links are intact) (Details can be added via Dictionary routine) (Re-File of the original set will overwrite the Favorite set) (If not in Order Group, cannot see all sets other than Favorites)

Contact information

  Bruce Matthias [email protected]

Penny Hilton [email protected]  website www.theingroup.com