Design of a Cardiovascular Discharge Tool: An Optimization Project

Background: National public reporting by hospitals and healthcare systems provides transparency and accountability to the public regarding cardiovascular surgical outcomes. The Society of Thoracic Surgeons (STS) and the American College of Cardiology (ACC) have data registries in which hospitals can participate in this reporting. These registries generate performance scores for participating institutions. Intermountain Health's Cardiovascular program has fallen short of meeting its goals for exceeding "better than expected" ratings, or 100% achievement. Methods: This optimization project looked at four Intermountain Health System hospitals in Utah that report outcomes to the STS and ACC after a cardiovascular (CV) intervention. Using Intermountain Health's systems development lifecycle (SDLC) as a guide, the project's primary focus was evaluating the discharge workflow and recommended discharge medications. The evaluation was done by identifying patient encounters where recommended medication prescribing was missed, looking at current discharge order sets, meeting with CV providers who excelled at meeting discharge medication requirements, and forming a team to determine what type of alert or tool providers wanted. Results: After considering the information gathered from chart checks, provider meetings, and the need for an alert, it was decided that a SmartZone alert would be designed and built. A SmartZone alert and an associated mPage would include a checklist to guide the providers to order the correct medications (and other follow-up). The results reflected in this paper stem from the analysis phase of the project; no implementation results are available as this project is currently awaiting governance approval to continue. Conclusions: The lack of a standard workflow or guide for medication prescribing after a cardiac procedure or hospitalization highlights the need for a CV alert and tool to ensure all patients receive appropriate guideline-based medications and follow-up care. If the CV alert and tool prove beneficial, utilization in other specialties that must meet national reporting standards could be considered for further endorsement of the interventions in this project.

1 Design of a Cardiovascular Discharge Tool: An Optimization Project Jessica A. Gomez College of Nursing: The University of Utah NURS 6881: Master’s Practicum and Project Capstone II April 30, 2023 2 Abstract Background: National public reporting by hospitals and healthcare systems provides transparency and accountability to the public regarding cardiovascular surgical outcomes. The Society of Thoracic Surgeons (STS) and the American College of Cardiology (ACC) have data registries in which hospitals can participate in this reporting. These registries generate performance scores for participating institutions. Intermountain Health’s Cardiovascular program has fallen short of meeting its goals for exceeding “better than expected” ratings, or 100% achievement. Methods: This optimization project looked at four Intermountain Health System hospitals in Utah that report outcomes to the STS and ACC after a cardiovascular (CV) intervention. Using Intermountain Health’s systems development lifecycle (SDLC) as a guide, the project’s primary focus was evaluating the discharge workflow and recommended discharge medications. The evaluation was done by identifying patient encounters where recommended medication prescribing was missed, looking at current discharge order sets, meeting with CV providers who excelled at meeting discharge medication requirements, and forming a team to determine what type of alert or tool providers wanted. Results: After considering the information gathered from chart checks, provider meetings, and the need for an alert, it was decided that a SmartZone alert would be designed and built. A SmartZone alert and an associated mPage would include a checklist to guide the providers to order the correct medications (and other follow-up). The results reflected in this paper stem from the analysis phase of the project; no implementation results are available as this project is currently awaiting governance approval to continue. 3 Conclusions: The lack of a standard workflow or guide for medication prescribing after a cardiac procedure or hospitalization highlights the need for a CV alert and tool to ensure all patients receive appropriate guideline-based medications and follow-up care. If the CV alert and tool prove beneficial, utilization in other specialties that must meet national reporting standards could be considered for further endorsement of the interventions in this project. 4 Design of a Cardiovascular Discharge Tool: An Optimization Project Problem Description National public reporting by hospitals and healthcare systems provides transparency and accountability to the public regarding cardiovascular surgical outcomes. (Society of Thoracic Surgeons, 2023b). Reporting also helps identify disparities in care and demonstrates a commitment to quality improvement (American College of Cardiology, 2023) and quality patient care. The Society of Thoracic Surgeons (STS) and the American College of Cardiology (ACC) each have specific data registries to which hospitals can participate. These national public databases collect information on select cardiac conditions and hospital procedures (American College of Cardiology, 2023). All information provided is voluntary and shared, allowing patients to search by procedure, hospital/health system, or location. Both the STS and ACC reporting systems generate performance scores for organizations based on the data reported to them. Despite having a high success rate for prescribing appropriate discharge medication, Intermountain Health’s Cardiovascular (IHCV) program falls short in meeting quality targets for the measures established by these professional societies. IHCV is currently in the 50th percentile nationally in reporting criteria measures (Cardiovascular Clinical Program, 2022). Specifically, cardiovascular patients are not all prescribed the recommended medications upon discharge. Missing quality targets for these measures may result in readmissions, complications, and on occasion, mortality. Furthermore, no standard guide is available to help Intermountain providers prescribe the appropriate medications after a cardiac procedure or hospitalization. 5 Available Knowledge The key aims of IHCV’s program are to reduce complications and readmissions for cardiac patients. A 97% success rate for prescribing appropriate medications to patients discharged from the cardiovascular clinical service places the program in the 50th percentile nationally. A high medication success rate would seem adequate for most programs; however, the IHCV program’s leadership sees an opportunity to provide even greater quality of care, by further improving this percentile. The STS and the ACC scores are rated using a star rating system based on metrics established by each organization. The STS (2023a) uses a three-star rating system, rating one star for “worse than expected,” two for “as expected,” or three for “better than expected.” This measure consists of four categories (Table 1), with ratings of each category and an overall score. The STS Coronary Artery Bypass Graft (CABG) categories include: 1) Absence of Operative Mortality, 2) Absence of Major Morbidity, 3) Use of Internal Mammary Artery and, 4) Receipt of Required Perioperative Medications (preoperative beta blocker and upon discharge an antiplatelet medication, beta blocker, and anti-lipid medication). IHCV programs (Figure 1) have at least one 3-star rating in one or more categories, and one hospital program has an overall 3star rating for a CAGB (Intermountain Heart Institute, 2022). The ACC (2023), on the other hand, uses a four-star rating system. A one-star rating for 65%-74.9% criteria compliance, two for 75%-84.9% compliance, three for 85%-94.99% compliance, or four for 95%-100% compliance. The ACC Percutaneous Coronary Intervention (PCI) measure includes the following five categories (Table 2): 1) Number of PCI procedures performed during a calendar year, 2) Use of aspirin after PCI, 3) Use of P2Y12 inhibitor after PCI, 4) Use of a statin after PCI and, 5) Use 6 of all recommended medications after PCI. IHCV programs (Figure 2) average 4 stars in each PCI category (Intermountain Heart Institute, 2022). In 2016, Intermountain Health underwent an Electronic Health Record (EHR) overhaul, transitioning to an entirely new Oracle Cerner-based system branded by Intermountain Health called iCentra. Before iCentra, the IHCV program had created a functional decision support tool in the EHR to help CV providers make the best decisions for patients on discharge. This tool was widely used and associated with improvements and optimal prescribing of medications per guidelines and reporting criteria. Various attempts to integrate a similar tool in iCentra have begun but subsequently paused due to employee turnover and other factors. However, a strong desire exists to develop an iCentra tool to aid providers in discharging CV patients with the appropriate medications and care. A cardiovascular discharge discovery project is underway to identify possible tools or solutions. The discovery phase has been described as “the planning” stage (Pluszczewska, 2021). During this stage, team members gather information to make data-driven decisions, reduce risk, and help lead to a successful tool or product from the start. Discovery project team members pull data, audit charts, and query providers on workflow and needs. After gathering data, the team explores possible solutions. These solutions vary from alerts, new order sets, workflow changes, checklists, and other options presented by team members to meet the key goal of increasing discharge medication success rate. Based on focus groups, Trinkley et al. (2019) reported that clinical decision support (CDS) alerts and tools are beneficial today in helping providers stay up to date with new health information. They emphasize, however, the importance of providers viewing these tools as valuable. It is also critical to consider different alert types (passive vs. 7 interruptive), the severity of the alert to reduce alert fatigue (Khalifa & Zabani, 2016), and other factors that may interfere with a tool benefiting providers with discharge orders. Rationale Meeting discharge measures for medication prescribing has been shown to decrease complications, readmissions, and mortality (Levine et al., 2015; O’Gara et al., 2013). Providing quality patient care is the goal of all health systems, and success in the reporting criteria percentage demonstrates to the public that Intermountain Health is committed to providing the best care possible. The conceptual model used to guide this project is Intermountain Health’s systems development lifecycle (SDLC) (Appendix A). Numerous SDLC models are available (Kyeremeh, 2021); however, Intermountain has taken its own approach to this model. A 10phase cycle with a specific breakdown of standards and requirements to be addressed before moving on to the next phase. This model provides a visual of the entire project and infers who may need to be involved in the project. Specific Aims This project aims to help Intermountain Health’s CV program meet established standards for discharge measures regarding medication prescribing in order to reduce complications, readmissions, and mortality in CV patients. To meet this goal, the objectives of this project are as follows: 1. Assessing the current workflow and discharge orders, finding gaps or issues in the current order sets, or assessing reasons why medications were not prescribed on discharge. 8 2. Identifying documentation requirements and the providers’ wants or wishes in developing a tool or alert. 3. Identifying the pros and cons of different alert types and tools that may help increase the medication prescribing success rate. 4. Developing (build or third party) a tool or alert to help guide providers when discharging CV patients should lead to improved clinical outcomes after discharge. Methods Context The Intermountain Health (2023) system has hospitals (33) and clinics (385) across eight states, with its home base in Utah. Intermountain Health provides modern heart care to all communities throughout these states. With a CV group of close to 400 physicians and Advanced Practice Providers (APPs), these teams have experience in multiple CV specialties (Intermountain Health, 2023). This project looks specifically at four Utah hospitals that report outcomes to the STS and the ACC after a CV intervention. The primary focus of the project is to observe and analyze discharge workflow and how to ensure patients are being discharged with the appropriate medications (and other follow-up). The inpatient nursing departments included in the project are cardiac intensive care units, cardiac step-down units, and outpatient cardiac surgery/intervention units. These units have a variety of caregivers ranging from physicians, APPs, nurses, pharmacists, patient care techs, and physical and occupational therapists. The project also includes clinical informatics (CI), digital technology services (DTS), and clinical operations. 9 Interventions Objective 1 The first phase of this project was to assess patient encounters where recommended medication prescribing was missed. Cardiovascular clinical program leadership provided the CI and DTS teams with the Financial Identification Number (FIN) numbers of known CV patients where reporting criteria were not met. Chart reviews (i.e., review of provider documentation, progress notes, medications given etc.) and standard order sets specific to the CV service line were looked at to determine if there were any identifiable issues. Objective 2 Next, the documentation requirements to meet reporting criteria were identified. Once identified, DTS teams abstracted a larger set of CV patient data from the EHR to explore. This data was sorted by patient FIN number, hospital, surgeon, procedure ID, and the subsequent requirements depending on the procedure ID. The requirements either needed to be addressed by a “yes” or “contraindicated” (Table 3), or the requirement was missed and went against reporting metrics. Once the missed patient encounters were identified, the provider-specific and generic CV discharge order sets were combed through again, searching for any anomalies or missing components that may interfere with providers missing the mark with discharge order medications or contraindications. Along with the EHR data, information was collected through meetings with CV providers (surgeons and APPs) who excelled at meeting discharge medication requirements and reviewing their workflow and what they were doing to ensure patients were discharged with the appropriate medications. These meetings also included discussions on what type of alert or tool providers wanted, i.e., what might work best within their current workflows, alerts or tools 10 already available in the current EHR system, or if a completely new tool would have to be built, or outsourced to a third-party vendor based on wants. Objective 3 Lastly, during the meetings, the CI and DTS leaders shared their insights on the different EHR alert types and tools suggested by the providers, drawing from their extensive experience and knowledge with iCentra and different project implementations. The discussions continued through subsequent meetings and email correspondence until a final decision was made on the alert type or tool to be used. Objective 4 Of note: the intended development and implementation of an alert or tool to help guide providers did not occur when this paper was written. This project is currently awaiting governance for approval to continue. Study of the Intervention The content of this section centers on the fourth objective outlined in the specific aims. It assumes that an alert or tool has been identified, undergone the necessary governance procedures for approval, and is currently undergoing the design and build phase of the project. The first approach that will be used to assess the tool will be to evaluate it in a testing environment. While in the test domain, the tool will undergo Quality Assurance (QA) testing by those with no ties or bias for the tool (A. Tovar, personal communication, February 7, 2023). Testing will also allow CV providers, leaders, CI, and DTS to look at the design and usability in a “live” environment similar to the iCentra system. Specifically, the live environment will allow authentication so that the tool operates as expected and can reveal any issues early (Sophocleous & Kapitsaki, 2020). 11 The plan is to pilot this tool at one Intermountain facility and focus on only the PCI measures. This will allow the project team to identify needs and problems early, recognize successes and make changes based on feedback obtained by the CV informatics team, providers, and other caregivers who participated in the pilot. After the pilot, a formal decision will be made to implement the tool system-wide or discontinue the solution. System-wide implementation would then include using the tool with more extensive cardiovascular procedure measures like CABG. Once the tool is implemented, to assess the short-term impact of the intervention, a comparison will be made with the previously abstracted patient data (i.e., missing medication prescribing) to the new EHR data collected after the launch of the tool. Next, providers will be re-interviewed, measuring satisfaction by obtaining feedback from CV providers. Obtaining direct feedback will give insight into what the providers like about the tool and what they would change. Finally, usability will be measured by the tool’s success rate after implementation. This will be done by seeing if providers (number of providers) use the tool as part of their workflow along with the alert data. Data will be pulled on the implemented alert. This data will include how often the alert fires and whether providers acknowledge the alert, dismiss, override, or ignore an alert altogether. This data will help identify potential barriers to the tool’s usage and what works well. The long-term impact of the alert or tool would be assessed by comparing the annual national public reporting scores to previous years to determine if there is an increase after the tool’s implementation. 12 Measures After implementation, data will be pulled by the CV abstractors and compared to the previously collected data. Abstractors will look specifically at the number of encounters that a measure was missed and what medications were missed; this will reflect if the alert or tool is helping reduce the number of missed medication prescriptions at discharge. Also, surveying the number of readmissions, complications, and mortality pre and post-implementation will be a good measure of effectiveness. Analysis This project will be analyzed using quantitative and qualitative approaches. These approaches include EHR audits, chart reviews, caregiver feedback, and national reporting scores. EHR audits and frequency statistics will be used to compare the number of alert fires, acknowledgments, dismissals, and overrides. The number of providers utilizing the tool for discharge will weigh feasibility and usability. In addition, chart reviews will ensure that patients are prescribed the correct medications. To evaluate satisfaction, interviews and feedback will be obtained from providers and end-users. Ethical Considerations The Department of Health and Human Services (HHS) offers guidance to identify whether a project qualifies as research and requires an Institutional Review Board (IRB) oversight (Office for Human Research Protections, n.d.). This optimization initiative was assessed using the HHS criteria and was found not to meet the definition of research and, therefore, not subject to IRB approval. However, the optimization activities followed ethical standards widely accepted in healthcare and research. This project has gone through and will continue to seek approval through Intermountain Health’s governance structure. All chart 13 reviews, patient records, and other internal documents have been accessed from secure Intermountain computers. No conflicts of interest have been identified. Results Objective 1 Patient encounters where recommended medication prescribing was missed, along with chart reviews, revealed that there were standard cardiovascular discharge order sets, but no standard guide (i.e., what medications should be ordered, labs, and follow-up appointments) for all providers to follow. Objective 2 These generic orders contained no guidance on what medications and follow-up should be reviewed and ordered based on the guidelines and reporting metrics. These reviews also revealed an inconsistency in discharge orders, which may have led to missed medication prescribing measures. The inconsistency was mainly that the option for contraindication was missing from certain medication orders. To meet the standards and guidelines set by societies, a medication must be ordered, or a reason that it is contraindicated is entered. The example in Figure 3 shows that there is no option for contraindication for anticoagulant/antiplatelet agents on a commonly used discharge order set by IHCV providers. After meeting with those CV providers consistently meeting the required standards and metrics, it was found that had created their own standardized list of important items to track during a patient’s stay. This list was at the end of their progress note. The list included the relevant discharge medications (if they were held or not prescribed) to track in their progress note. The provider would review this list and complete a progress note at each patient visit. 14 These same providers were included in meetings with the CI, DTS, and clinical operations teams on what types of alerts or tools they would like, and what may or may not work with the current EHR system. An alert for the provider at discharge was mutually agreed upon, but the type of alert required discussion. Objective 3 A pros and cons chart of two common alert types was drafted by members of the DTS team and presented to the group of CV providers and other project team members for discussion and decision (Table 4). Objective 4 After considering the information gathered from chart checks, provider meetings, and the need for an alert, it was decided that a SmartZone alert would be designed and built. A SmartZone alert along with an associated mPage would include a checklist to guide the providers to order the correct medications (and other follow-up) based on the clinical diagnosis code. SmartZone alerts are non-disruptive alerts. They do not stop a provider’s workflow but rather provide a gentle reminder off to the side (Figure 4) that a concern or matter needs to be addressed. A mPage is a custom workflow page with data groups comprised of components (e.g., patient demographics, advanced directive, home medication, etc.) A mPage provides a standard library of components but allows the provider to configure and customize clinical information views and actions all on one page (Munson Healthcare, 2018). SmartZone alerts and mPage are already elements of Oracle Cerner; therefore, the expectation is that this build will not take long. The project is back in governance, awaiting approval for the design and build phase of the decided alert and tool. Discussion 15 Summary There was an identified need by the IHCV clinical program team to improve their performance on national measures. An area for improvement for the two measures identified (CABG and PCI), was the need for consistent ordering of discharge medications unique to each standard. The findings indicated the need and desire for a CV alert and tool. The findings of chart reviews and provider meetings indicate that there was no standard guide for providers to follow. Previously, many providers developed their own system, or relied upon memory. Alternatives to memory and non-standardized workflows in the form of an alert and workflow mPage are valuable tools for CV providers to ensure all patients have been prescribed the appropriate guideline-based medications and follow-up to ensure safe, quality care and to reduce readmissions and complications. Using data directly from CV patient charts and audits and involving CV providers (end-users) in the project, the decision on an alert and tool came without difficulty. These findings show that engaging end users in future phases of the project will be beneficial for this project and in future optimization projects that directly involve providers and patient care. Interpretation The association between the interventions and outcomes for this project was positive. The project team developed a solution (an alert and workflow tool) to aid in the ultimate goal of decreasing complications and readmissions. This effort was supported by Intermountain’s commitment to quality improvement, providing quality patient care, and increasing national reporting scores as a health system. Using a SmartZone alert and mPage, aligns with the literature that recommends reducing the number of hard stop or interruptive alerts (Khalifa & Zabani, 2016). Along with mPages already being used by Intermountain providers, this will not 16 be a steep learning curve and will be integrated into a workflow they are familiar with. These factors have been found to lead to the beneficial implementation of the interventions (Trinkley et al., 2019). This project could optimize workflow and tools in multiple areas and specialties where specific guidelines must be met. Improving the provider’s workflow and providing reminders can relieve the burden of recall needed to remember and implement the various discharge standards and allowing them to focus on patient care. Efforts like this project can increase positive patient outcomes and decrease morbidity and mortality. Improving positive outcomes and reducing complications can also lower healthcare costs, as patients are not being readmitted for complications. The results of this project also show the importance of involving specific endusers in projects, as their knowledge and expertise can help determine the right alert or tool to use in specific circumstances. Limitations Several limitations were identified in this project. First, this project is limited to CV providers (surgeons and APPs) who write discharge orders. It has not been considered when a nurse may have to enter discharge orders per a provider’s verbal or telephone request. Gathering data on how often nurses place orders on CV units may help minimize this limitation. Second, the proposal is only to pilot this project with PCI patients as it is the least ambiguous of all the cardiac conditions and procedures. This leaves uncertainty regarding how it will work with the more complex procedures. Last, this project has been limited to an analysis project so far, as it is still awaiting approval and resources assigned to continue into the next design and development phases. 17 Conclusions National public reporting by hospitals and healthcare systems provides a platform for accountability, transparency, and quality improvement in patient care. Intermountain Health's Cardiovascular program falls short of meeting the highest quality targets for medication prescribing upon discharge established by professional societies, which may lead to readmissions, complications, and mortality. The lack of a standard guide for medication prescribing after a cardiac procedure or hospitalization highlights the need for a CV alert and tool to ensure all patients receive appropriate guideline-based medications and follow-up care. After going through the proper governance structure and validating the projected effectiveness of the CV alert and tool identified in this project phase, it will be necessary to implement the interventions and measures identified above and conduct a thorough analysis and evaluation. If the CV alert and tool prove beneficial, utilization in other specialties that must meet national reporting standards could be considered for further endorsement of the interventions in this project. 18 Acknowledgments I want to acknowledge Aurie Tovar, MSN-I, RN, my preceptor, for her guidance and mentorship throughout this project. Also, Dr. Christopher Macintosh, Ph.D., RN, for all the support and feedback during this project and my entire master’s program. In addition, a big thank you to Suzanne Lareau, MS, RN, for her invaluable feedback and editing of my project paper. I could not have completed this project without your help and support. 19 References American College of Cardiology. (2021, April 1). American College of Cardiology National Cardiovascular Data Registry. American College of Cardiology National Cardiovascular Data Registry – Public Reporting Metric Data Download User’s Guide. Retrieved January 23, 2023, from https://www.cardiosmart.org/docs/librariesprovider3/documents/metric-data-userguide.pdf?sfvrsn=534db996_4 American College of Cardiology. (2023). Find your heart a home: For hospitals. CardioSmart. Retrieved October 17, 2022, from https://www.cardiosmart.org/find-your-heart-ahome/Hospitals Cardiovascular Clinical Program. (2022). Cardiovascular Discharge Tool Business Case [Unpublished report]. Intermountain Health. Cerner Corporation. (2022, May 2). Overview of SmartZone. Centrally-Deployed Components Help Pages. Retrieved February 15, 2023. Intermountain Health. (2023). Learn about Intermountain Heart & Vascular. Intermountain Heart Institute. Retrieved January 28, 2023, from https://intermountainhealthcare.org/services/heart-care/heart-institute/about-us/ Intermountain Heart Institute. (2022). Learn more about our volumes and outcomes. Learn about Intermountain Heart &Vascular. Retrieved January 18, 2023, from https://intermountainhealthcare.org/-/media/files/services/heart-care/0722-cvcp2160203_2021ar_sprd_a10.pdf?la=en 20 Khalifa, M. & Zabani, I. (2016). Improving utilization of clinical decision support systems by reducing alert fatigue: Strategies and recommendations. Studies in Health Technology and Informatics, 226, 51–54. https://doi.org/10.3233/978-1-61499-664-4-51 Kyeremeh, K. (2021). Overview Of System Development Life Cycle Models. Journal of Management and Science, 11(1), 12-22. https://doi.org/10.26524/jms.11.3 Levine, G.N., O’Gara, P. T., Bates, E. R., Blankenship, J. C., Kushner, F. G., Bailey, S. R., Bittl, J. A., Brindis, R. G., Casey, D. E., Cercek, B., Chambers, C. E., Chung, M. K., de Lemos, J. A., Diercks, D. B., Ellis, S. G., Fang, J. C., Franklin, B. A., Granger, C. B., Guyton, R. A., . . . Zhao, D. X. (2015). 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of STElevation Myocardial Infarction. Journal of the American College of Cardiology, 67(10), 1235-1250. https://doi.org/10.1016/j.jacc.2015.10.005 Munson Healthcare. (2018, May 2). MPages overview guide. Retrieved January 13, 2023, from https://www.munsonhealthcare.org/media/file/MPage%20Overview%20Guide(2).pdf Office for Human Research Protections. (n.d.). How does HHS view quality improvement activities in relation to the regulations for human research subject protections? [Question on Quality Improvement Activities FAQs page]. HHS.gov. Retrieved February 16, 2023 from https://www.hhs.gov/ohrp/regulations-and-policy/guidance/faq/qualityimprovement-activities/index.html O'Gara, P. T., Kushner, F. G., Ascheim, D. D., Casey, J. D. E., Chung, M. K., de Lemos, J. A., Ettinger, S. M., Fang, J. C., Fesmire, F. M., Franklin, B. A., Granger, C. B., Krumholz, 21 H. M., Linderbaum, J. A., Morrow, D. A., Newby, L. K., Ornato, J. P., Ou, N., Radford, M. J., Tamis-Holland, J. E., . . . Zhao, D. X. (2013). 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 61(4), 485-510. https://doi.org/10.1016/j.jacc.2012.11.018 Pluszczewska, B. (Ed.). (2021, April 20). Project discovery phase – what is it? why do you need it? Brainhub. Retrieved January 16, 2023, from https://brainhub.eu/library/projectdiscovery-why-you-need-it Sophocleous, R., & Kapitsaki, G. M. (2020). Examining the Current State of System Testing Methodologies in Quality Assurance. Agile Processes in Software Engineering and Extreme Programming: 21st International Conference on Agile Software Development, XP 2020, Copenhagen, Denmark, June 8–12, 2020, Proceedings, 383, 240–249. https://doi.org/10.1007/978-3-030-49392-9_16 The Society of Thoracic Surgeons. (2023a). Performance measure descriptions. Retrieved January 27, 2023, from https://www.sts.org/quality-safety/performancemeasures/descriptions#CABGCompositeScore The Society of Thoracic Surgeons. (2023b). STS public reporting. Retrieved October 17, 2022, from https://www.sts.org/registries/sts-public-reporting Trinkley, K. E., Blakeslee, W. W., Matlock, D. D., Kao, D. P., Van Matre, A. G., Harrison, R., Larson, C. L., Kostman, N., Nelson, J. A., Lin, C.-T., & Malone, D. C. (2019). Clinician preferences for computerised clinical decision support for medications in primary care: A 22 focus group study. BMJ Health & Care Informatics, 26(1), 0–0. https://doi.org/10.1136/bmjhci-2019-000015 23 Table 1 Coronary Artery Bypass Graft (CABG) Measure Domains Descriptions From The Society of Thoracic Surgeons, 2023 Domain Domain Description Perioperative Medication, Scored all-or-non Based on 4 National Quality Forum (NFQ) process measures: • Preoperative beta blockade • Beta blockade at discharge • Anti-platelet medication at discharge • Anti-lipid treatment at discharge Operative Care Process Percentage of first time CABG patients who receive at least one internal mammary artery graft. Risk-Adjusted Operative Mortality Percentage of patients who did not experience operative mortality. Operative mortality is defined as death during the same hospitalization as surgery or after discharge but within 30 days of the procedure. Risk-Adjusted Morbidity, Scored any-or-non Percentage of patients who did not experience any major morbidity. These are: • Stroke/cerebrovascular accident • Surgical re-exploration • Deep sternal wound infection rate • Postoperative renal failure • Prolonged intubation (ventilation) Note: A score is received for each of the four domains, plus an overall composite score. 24 Table 2 Public Reporting Metric for Cath Percutaneous Coronary Intervention (PCI) From American College of Cardiology, 2021 Metric Title Metric Description Number of PCI/angioplasty procedures performed during the calendar year. The number of PCI/angioplasty procedures a site performs does not necessarily indicate higher quality, but it may be an indication of how experienced this site is with the procedure. Use of Aspirin to reduce the chance of blood clots after PCI/angioplasty. Patients should be prescribed Aspirin to reduce the risk of heart attacks caused by blood clots in new stents after having a PCI/angioplasty- unless there is a reason not to use the medicine (such as an allergy). This score shows how well this facility is following this guideline - higher is better. Use of a P2Y12 inhibitor medication to reduce the chance of blood clots after PCI/angioplasty. Patients should be prescribed a P2Y12 inhibitor medication to reduce the risk of heart attacks caused by blood clots in new stents after having a PCI/angioplastyunless there is a reason not to use the medicine (such as an allergy). This score shows how well this facility is following this guideline - higher is better. Use of a Statin to decrease cholesterol after PCI/angioplasty. Patients should be prescribed a Statin to decrease cholesterol and reduce the risk of heart attacks after having a PCI/angioplasty- unless there is a reason not to use the medicine (such as an allergy). This score shows how well this facility is following this guideline - higher is better. Use of all recommended medications (Aspirin, P2Y12 inhibitor medication, and Statin) to reduce the chance of blood clots and decrease cholesterol after PCI/angioplasty Patients should be prescribed Aspirin, a P2Y12 inhibitor medication, and a Statin medication after having a PCI/angioplasty to reduce the chance of blood clots in new stents, decrease cholesterol and reduce the risk of heart attacks- unless there is a reason not to use these medicines (such as an allergy). This score shows how well this facility is following this guideline - higher is better. 25 Table 3 Example of Abstracted Data from EHR (iCentra) FIN_NBR HOSPITAL SURGEON STS PROCEDUREID 1 Facility 1 MD 1 DCMED BETA BLOCKERS Contraindicated 2 Facility 1 MD 1 Contraindicated Yes No Yes Yes 3 Facility 1 MD 1 Contraindicated Contraindicated Yes Yes Yes 4 Facility 2 MD 1 Yes Yes No No Yes 5 Facility 3 MD 1 Contraindicated Contraindicated No Yes Yes 6 Facility 2 MD 1 Contraindicated Yes No No Yes 7 Facility 1 MD 1 No* No Yes Yes Contraindicated 8 Facility 1 MD 1 Contraindicated Yes No Yes Yes 9 Facility 3 MD 1 Yes Yes No Yes Yes 10 Facility 3 MD 1 Yes Yes No Yes Yes 11 Facility 4 MD 1 Contraindicated Yes No No Contraindicated 12 Facility 1 MD 1 Contraindicated Yes No Yes Yes 13 Facility 4 MD 1 Yes Yes No No Yes Note: STS procedure ID 1 is a Coronary Artery Bypass Graft (CABG) *Missed requirement for Beta Blocker at discharge. DCMED ASPIRIN DCMED COUMADIN No DCMED ADP INHIBITORS Yes DCMED LIPID LOWERING STATIN Yes Yes 26 Table 4 Pros and Cons of different EHR alerts SmartZone Pros Maintain clinical decision support without adding alert fatigue Integrates across platform data Available throughout patient chart (right-hand side of the page) Passive alerting for some roles, as defined Alert present upon entry into chart/refresh Cloud-enabled SmartZone Cons Not for critical alerts (labs, vitals, etc.) Not for time-sensitive alerts Not for immediate action Discern Alert Pros Immediate time-sensitive action(s) Disruptive - tells caregiver of needed immediate action Automated processes run in the background without interrupting caregiver Pops up in the middle of the screen Discern Alert Cons Disruptive Increased frustration Missed contextual Information Pop-ups on screen Alert fatigue 27 Figure 1 Intermountain Health Coronary Artery Bypass Graft (CABG) Star Rating From Intermountain Heart Institute: Annual Report, 2022 28 Figure 2 Intermountain Health Percutaneous Coronary Intervention (PCI) star rating From Intermountain Heart Institute: Annual Report, 2022 29 Figure 3 Example of inconsistent order set from iCentra From Intermountain Health, 2022 NO CONTRAINDICATION 30 Figure 4 Visual Representation of a SmartZone Alert From Cerner Corporation Components Help Page, 2022 Note: SmartZone is a feature of Oracle Cerner that displays passive alerts rather than the more disruptive pop-up alerts. When a patient has a SmartZone alert, an extra vertical bar will be on the right side of the screen in iCentra. There are three notification types: blue, an informational notification; red, a high alert notification; and yellow, a warning notification. Icons will display the number of notifications present for that category. This information was accessed through secure Intermountain Health pages; PDF is available for reference. 31 Appendix A A graphic rendering of Intermountain Health’s version of the systems development lifecycle (SDLC), used as a framework to guide projects throughout the system. Scope Post Implementation Review Analysis Deployment/ Implmentation Design Pilot Development Testing Documentation Education Note: A list of project steps was provided (A. Tovar, personal communication, November 11, 2022) by Intermountain Health; the visual representation above was created from those provided steps.