Clinical Quality Framework cqframework.info All Hands Meeting February 25, am-12:30pm ET

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Agenda TopicPresenter WelcomeSwapna Bhatia, Project Administrative Support HL7 May WGM FHIR Connectathon: CQF Track and Request for Participation Bryn Rhodes, CQF Subject Matter Expert Next StepsKen Kawamoto, CQF Co-Coordinator Questions and DiscussionKen Kawamoto, CQF Co-Coordinator CQF Wiki: cqframework.info 3

Welcome Announcements, Meeting Schedules, Agendas, Minutes, Reference Materials, Use Cases, Project Charter, and General Information are posted on cqframework.info cqframework.info Clinical Quality Framework (CQF) All Hands meetings are held bi-weekly on Thursdays from 11am to 12:30pm ET Dial In: Access code: CQF Data Model meetings are held weekly on Wednesdays from 1 to 2pm ET NQM-8ENJ&rnd= NQM-8ENJ&rnd= Dial In: Participant passcode: CDS-on-FHIR/CQF Office Hours meetings are held weekly on Wednesdays from 11am to 12pm ET Dial In: Participant passcode: CQF Wiki: cqframework.info 4

Exclusive Breastfeeding Scenario

EHR Delivery/Xfer Note or ADT Event EPSCDS Topic Subscription Notification UCS Notification Message Physician Portal Notification Message The Physician Portal(s) would allow the various providers to receive and respond to the recommendations from the CDS system. Optional: Invoke order service and place an order for an education intervention and/or breastfeeding assessment FHIR subscription listener is publisher to EPS? Events: Registration of baby after birth or mother’s transfer to post-partum ward. Alternative may be persistence of nurses notes indicating successful delivery and/or mother transfer. a) If the mother’s intention to breast feed has not been documented in the admission note, notify provider that an order is recommended and/or alert nurse that education is required per protocol. b) If the mother’s intention has not been documented by the time infant is admitted to recovery, alert charge nurse and bedside nurse. Note: Should consider exclusion criteria such as active herpetic lesions, mastectomies, chemo therapy, etc. Provider: The mother’s primary care provider. Charge Nurse: The primary nurse involved with the mother’s care Bedside Nurse: The nurse currently assigned to bedside care for the mother The UCS system would use these roles and the communication requests from the CDS system to determine the most appropriate channel for notification of the participants.

Some Updates Trigger notification if admission note of mother or delivery note of baby does not document mother’s feeding intention – Create rules combing the mothers for exclusion criteria Transfer to post-partum ward is too late as baby may already have been provided formula.

Proposed rule If no documentation after delivery of baby Generate alert requesting a breast feeding assessment/education intervention (must take into account exclusion criteria). If mother qualifies for breast feeding and mother’s decision has been documented and she declines to breast feed Place an order for a lactation consult Goal: To promote exclusive breast feeding post-partum and to ensure that mother receives proper information about the benefits of breast feeding prior to making her formal decision.

Key events Admission of mother Delivery of child Transfer post-recovery Note that window of opportunity is short. Transfer to recovery ward may occur four hours post delivery. During that time, formula may be administered to the baby. Hence, the goal of the CDS alert is to increase the chance that the baby is exclusively breastfed after birth.

Workflow Diagram Admissi on Birth Infant Transfer to Recovery Transfer to Post- Partum Planned Cancelle d Approve d Complete d Conditi on Procedu re Request Procedu re Comm. Request Comm. Decision Support Logic Events Workflow Status Patient Information As the mother and infant move through the care process, the EPS system will surface these events. The CDS system will receive the appropriate information, resulting in the underlying patient information being created as part of moving the recommended orders through the fulfillment workflow. The UCS and Order Service will be used to coordinate that process with the participants and the underlying EHR.

Rule Logic (exclusions omitted for brevity) a: if the mother's intention regarding breast feeding has not been documented if there is a pending and uncancelled procedure request for education of the mother create a communication request to the bedside nurse to perform the procedure elseif there is an unsigned procedure request for education of the mother create a communication request to the ordering provider to sign the order elseif there is no procedure request for education of the mother create a procedure request for an education for the mother regarding exclusive breastfeeding create a procedure request to document the mother's intention regarding breastfeeding create a communication request to the provider to sign the order endif

Rule Logic (cont.) b: elseif the mother's intention regarding breast feeding has been documented if the mother has refused to breastfeed but no education of the mother has been documented if there is a pending and uncancelled procedure request for education of the mother create a communication request to the bedside nurse to perform the procedure elseif there is an unsigned procedure request for education of the mother create a communication request to the ordering provider to sign the order elseif there is no procedure request for education of the mother create a procedure request for an education for the mother regarding exclusive breastfeeding create a procedure request to document the mother's intention regarding breastfeeding create a communication request to the provider to sign the order elseif the mother has refused to breastfeed and education of the mother has been documented create a procedure request for a lactation consult for the mother endif

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Next Steps Engage in workgroups ( Pilots – Co-Coordinator, Ken Kawamoto Co-Coordinator, Ken Kawamoto Standards Development – Subject Matter Expert, Bryn Rhodes Subject Matter Expert, Bryn Rhodes Join us for the upcoming Clinical Quality Framework All Hands meeting: 3/10 CQF Wiki: cqframework.info 14

Questions and Discussion Name Ken Kawamoto, Floyd Eisenberg, Swapna Bhatia, Initiative cqframework.info CQF Wiki: cqframework.info 15

EHR Delivery/Xfer Note or ADT Event EPSCDS Topic Subscription Notification UCS Notification Message Physician Portal Notification Message The Physician Portal(s) would allow the various providers to receive and respond to the recommendations from the CDS system. Optional: Invoke order service and place an order for an education intervention and/or breastfeeding assessment FHIR subscription listener is publisher to EPS? Events: Registration of baby after birth or mother’s transfer to post-partum ward. Alternative may be persistence of nurses notes indicating successful delivery and/or mother transfer. a) If the mother’s intention to breast feed has not been documented in the admission note, notify provider that an order is recommended and/or alert nurse that education is required per protocol. b) If the mother’s intention has not been documented by the time infant is admitted to recovery, alert charge nurse and bedside nurse. Note: Should consider exclusion criteria such as active herpetic lesions, mastectomies, chemo therapy, etc. Provider: The mother’s primary care provider. Charge Nurse: The primary nurse involved with the mother’s care Bedside Nurse: The nurse currently assigned to bedside care for the mother The UCS system would use these roles and the communication requests from the CDS system to determine the most appropriate channel for notification of the participants.

EHR Delivery/Xfer Note or ADT Event EPSCDS Topic Subscription Notification UCS Notification Message Physician Portal Notification Message The Physician Portal(s) would allow the various providers to receive and respond to the recommendations from the CDS system. Optional: Invoke order service and place an order for an education intervention and/or breastfeeding assessment FHIR subscription listener is publisher to EPS? Events: Registration of baby after birth or mother’s transfer to post-partum ward. Alternative may be persistence of nurses notes indicating successful delivery and/or mother transfer. a) If the mother’s intention to breast feed has not been documented in the admission note, notify provider that an order is recommended and/or alert nurse that education is required per protocol. b) If the mother’s intention has not been documented by the time infant is admitted to recovery, alert charge nurse and bedside nurse. Note: Should consider exclusion criteria such as active herpetic lesions, mastectomies, chemo therapy, etc. Provider: The mother’s primary care provider. Charge Nurse: The primary nurse involved with the mother’s care Bedside Nurse: The nurse currently assigned to bedside care for the mother The UCS system would use these roles and the communication requests from the CDS system to determine the most appropriate channel for notification of the participants.