1. Chad Hodge Mark Rimbergas Amy Rubin

2.  Identify High Risk Area  Make It Easy to do Right Thing at Right Time  Standardized, Structured, and Reliable Approach Venous Thromboembolism (VTE) Prevention

3.  Two conditions  Life-threatening  Very Preventable

4.  200,000 people per year develop venous thrombi with 50,000 going on to develop a pulmonary embolism (PE)  1 in 10 of the 2 million patients per year that develop PE will die  Incidence is 80 cases/100,000 patients

6.  Stratification levels  High, Moderate and Low  Treatment  Early and frequent ambulation  Pharmacologic  Mechanical

7.  Pharmacologic  Absolute Active hemorrhage, severe trauma to head or spinal cord with hemorrhage in last 4 weeks  Relative Intracranial hemorrhage within last year, craniotomy or intraocular surgery within 2 weeks, gastrointestinal, genitourinary hemorrhage within last month, thrombocytopenia or coagulopathy, end stage liver disease, active intracranial lesions/neoplasm, hypertensive urgency/emergency and post-operative bleeding concerns  Mechanical  Known DVT, previous immobility, severe arterial insufficiency

8.  Cost  Regulatory  National Quality Forum (NQF)  Centers for Medicare and Medicaid Services (CMS) Clinical Measures Never Events EHR Incentive Program Meaningful Use Clinical Quality Measures

9.  Showed Impact/Improvement however…  Not comprehensive enough  Not proactive  Not fully incorporated into workflow

10.  Automation of risk stratification  Streamlined and automated process for:  Recommendation of prophylaxis based on stratification  Mechanical prophylaxis order for placement and/or  Pharmacologic prophylaxis order Associated safety processes  Incorporated into workflow

11. To Prevent Venous Thromboembolism and associated complications!

12.  Cost Reduction  Meet regulatory and quality assurance requirements  National Quality Forum (NQF)  Centers for Medicare and Medicaid Services (CMS) Clinical Measures Never Events EHR Incentive Program Meaningful Use Clinical Quality Measures

13. Rule CategoryVTE Intervention protocol Rule Title Stratify the patient’s level of VTE risk and prompt clinicians to intervene. Risk Group Definition Age >= 70 (demographic data); Obese ((the weight in kilograms divided by the square of the height in meters) >= 30) OR ICD9 code of 278.0; Bed Rest or Immobility (found through NLP of nursing documentation); Female Hormone Replacement Therapy or oral contraceptives (found on active medication list); Major Surgery (any surgery lasting over 1 hour); Active Cancer (ICD9 149.0 to 172.99, 174.0 to 209.9); Prior VTE (ICD9 415.1, 415.19, 453.8, 453.9, and 671.31 to 671.50); Hypercoagulability (presence of factor V Leiden, lupus anticoagulant, and anticardiolipin antibodies); Trigger Condition Admission of Hospitalized patient; During normal activities of patients stay (time and data driven); During discharge; Displayed Message This patient has been identified as having a risk for venous thromboembolism (VTE). Based on his recent medical/surgical history, his risk level is (LOW|MED|HIGH). His contra-indications for potential interventions are: (list indications). Based on both his risk status and his contra-indications, the following interventions are appropriate for this patient: (list any pharmacological and any mechanical interventions that are still appropriate) Coded ResponsesA.Order early and frequent ambulation B.Order suggested pharmacological intervention; C.Order suggested mechanical intervention; D.Acknowledge alert, but take no action; (Reason Required )

15.  Active hemorrhage (Boolean)  Severe trauma to head or spinal cord with hemorrhage in the last 4 weeks (Boolean)  Intracranial hemorrhage within last year (Boolean)  Craniotomy within 2 weeks (Boolean)  Intraocular surgery within 2 weeks (Boolean)  End stage liver disease (Boolean)  Thrombocytopenia ( 18 seconds) (Boolean)  Hypertensive emergency (Boolean)  Allergic to warfarin (Boolean, and severity)  Allergic to un-fractionated heparin (UFH) (Boolean, severity)  Allergic to low molecular weight heparin (LMWH) (Boolean, severity)  Has skin lesions on left leg (Boolean)  Has skin lesions on right leg (Boolean)

16.  Alert trigger time (date/time)  Alert ignored / cancelled (Boolean)  Risk group pre-selected on alert by CDSS (enumeration: Low, Med, High)  Pharmacological intervention selected (enumeration: UFH, LMWH, warfarin)  Pharmacological intervention dosage (unsigned integer)  Early and frequent Ambulation  Pharmacological intervention rate in hours (unsigned integer)  Mechanical intervention selected (enumeration: (sequential compression device, leg hose)  Mechanical intervention area: (enumeration: left leg, right leg, both)

17.  CDS rule to be coded using standard terminology and stored in KR.  Semantic shift  Better criteria for rule  New / different coding schemes.  Layering  Department specific contraindications (OB/GYN)  Analytics / Reports

18.  End User Interface  EMR  Analysis and Data Mining Module  Knowledge Base Interface  Knowledge Base Module  Active Integrated NLP-CDS inference engine

21.  HL7: Will be used for the exchange, integration, sharing, and retrieval of electronic health data.  XML: Will be used document storage and data integration.  CDA: For specifying encoding, structure, and semantics of clinical documents for exchange.  LOINC: For identifying medical laboratory observations.  SNOMED: To help index, store, retrieve, and aggregate the data.  CCOW: To enable the disparate applications in our organization to synchronize in real-time.  HIPPA: To ensure patient confidentiality when patients are transferred to other healthcare providers and hospitals.  ICD-9: To classify diseases, injuries, and cause of death.

22.  Interface Engine  Interfacing with internal systems  Interfacing with external systems

23.  Implementation  Settings and Test Environment  Utilizing Plan, Do, Study and Act (PDSA)  Challenges

24.  Questions?