demystifying cascading epic xgm 2016
TRANSCRIPT
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Better Health for All
DEMYSTIFYING CASCADING
Dr. Pramanik Sharmila
Poorva DesaiApril 2016
Efficiency in Preference and
Cascading Rules for Microbiology
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Better Health for All © 2013 Santa Clara Valley Health & Hospital System | 2
Efficiency in Preference and Cascading Rules for
MicrobiologyPramanik Sharmila, M.D.Laboratory PathologistSanta Clara Valley Medical [email protected]
Elisabeth Mailhot, M.D.Medical Director of LaboratorySanta Clara Valley Medical [email protected]
Desai Poorva, CLS.Beaker Application CoordinatorSanta Clara Valley Medical [email protected]
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Better Health for All © 2013 Santa Clara Valley Health & Hospital System | 3
Overview of Santa Clara Valley Medical Center
Review rule types affecting susceptibility results
Advantages of consolidated cascading structure
Deep dive into technical build with examples
Agenda
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SANTA CLARA VALLEY MEDICAL CENTER
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Santa Clara Valley Medical CenterServices: General acute care, Obstetrical service,High Risk obstetrics, Pediatric service, Psychiatric inpatient service
Intensive Care Services:Burn, Medical, Level I Trauma Center, Surgical, Cardiac, Pediatric, Maternal, Neonatal
Facility Data:77% acute care & 23% non-acute care574 Hospital Beds16 Outlying Clinics
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Santa Clara Valley Medical CenterLaboratory Statistics:•Total billable tests > 2,000,000/year•Microbiology lab tests > 344,962/year•One main laboratory, 95% testing done onsite•59% tests performed on outpatients
EPIC- Healhlink:• Inpatient, Ambulatory and Beaker version 2014• Live with Inpatient and Ambulatory - May 2013• Live with Beaker since - July 2015
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MICROBIOLOGY DATA FLOW
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General Data Flow for Microbiology
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Physicians
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General Data Flow for Microbiology
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Physicians Beaker
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General Data Flow for Microbiology
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Maldi/Vitek, Microscan
Physicians Beaker Instrument
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General Data Flow for Microbiology
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Maldi/Vitek, Microscan
Physicians Beaker Instrument
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General Data Flow for Microbiology
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Maldi/Vitek, Microscan
Physicians Beaker Instrument
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Microbiology Susceptibility Workflow
• Some rules evaluate in instrument
• Susceptibility result files into LIS• Preference rules are evaluated• Cascading rules are evaluated
• Culture order is placed• Culture is setup• Organism is isolated• Technologist orders
susceptibilities
Orders
Results
Microscan
Results
Orders
Orders
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Various Rules Involved In CascadingCascadi
ng rules
Intrinsic rulesInstrum
ent limitati
on rules
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Distributed Rules Structure
Limitation with
antibiotics defined in Instrument
Intrinsic rules
defined in instrument
Preference and
Cascading rules
defined in LIS
Pre-Beaker workflow
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Pain Points With BuildDistributed rule structure hurdles
• Inefficient for maintenance and support •Major changes if susceptibility instrument replaced
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Pain Points With BuildBeaker specific hurdles for cascading rules
•Limited guidance on defining cascading rules•No model build available for cascading rules•Large amounts of manual build
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Consolidated Rules Structure
Few instrument specific rules may
be defined at instrument level
Beaker houses : Instrument limitation rules
Intrinsic rules Preference
rules Cascading rules Override rules
Post-Beaker workflow
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Advantages of Consolidated Structure
• Easier maintenance, troubleshooting and support in Beaker
• CLSI standard updates only need to be applied in Beaker
• Minimal impact when lab replaces susceptibility instruments
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DEEP DIVE INTO TECHNICAL BUILD
(WITH EXAMPLES)
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Build Overview
Organism
(LLO)
Interface(MAC)
Preference rules(TRE)
Cascading rules(TRE)
Rules(CER)
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Susceptibility Interface Build
Organism
(LLO) Interface
(MAC)
Preference rules(TRE)
Cascading rules(TRE)
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Susceptibility InterfaceInterface (MAC) item Interface (MAC)
Item 605 – Type 1 - Micro Isolation Item 757 – Result Checking
0 - Deselect Result Checking
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Susceptibility InterfaceInterface (MAC) item Interface (MAC) value
Item 605 – Type 1 - Micro Isolation Item 757 – Result Checking
0 - Deselect Result Checking
Interface (MAC) item Interface (MAC) value
Item 605 – Type 1 - Micro Isolation Item 757 – Result Checking
0 - Deselect Result Checking
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PreferenceRulesPrioritization
Organism
(LLO) Interface
(MAC)
Preference rules(TRE)
Cascading rules(TRE)
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Preference Rules – Prioritization
Ln #1 Description: 21R-For Organism Do not report AMP and AMP/SulbactamOrganism Specimen
Rule Condition ResultsGroup Type SourceAll All All 198324 Amp/Sulbactam is
(S or I or R)Don’t report [0] for Amp/Sulbactam
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Preference Rules – Prioritization
1. Rules specific for specimen types, but general to all organisms
2. Intrinsic rules and instrument limitation rules 3. Primary antibiotics appropriate for the organism
or group of organisms
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Example #1: Preference rules specific to a specimen type but generic to all organisms
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Description: 0-Sterile body site not CSF Don’t report ClindamycinLn# Organism Type Source Rule Condition Results1 All All All 195978 Clindamycin
is(S or I or R)
Don’t Report Clindamycin
Description: 0-Specimen site is CSF Don’t report Ciprofloxacin2 All All All 197549 Ciprofloxacin
is(S or I or R)
Don’t Report Ciprofloxacin
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Example #2:Ln # Description: E coli-Kleb-Proteus Mirabilis Group Urine67 Group Rule Report Do not report
EKPM Group
195978 AmpicillinCeftriaxoneGentamicinTrim/SulfaPip/TazobactamNitrofurantoin Cefazoline
Piperacillin AmikacinAmp/sulbactam CefoxitinCefepime Cefuroxime Cefuroxime OralCeftazidime AztreonamLevofloxacin Tetracycline Ertapenem Imipenem
Preference rules for specimen type urine
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Example #2:Ln # Description: E coli-Kleb-Proteus Mirabilis Group Non-urine68 Group Rule Report Do not report
EKPM Group
AmpicillinCeftriaxoneGentamicinTrim/SulfaPip/Tazobactam
Piperacillin AmikacinAmp/sulbactam CefoxitinCefepime Cefuroxime Cefuroxime Oral AztreonamNitrofurantoin CefazolineCeftazidime Levofloxacin Tetracycline Ertapenem Imipenem Tobramycin
Preference rules for specimen types non-urine
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CascadingRulesPrioritization
Organism
(LLO) Interface
(MAC)
Preference rules(TRE)
Cascading rules(TRE)
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Cascading Rule - Prioritization1. Rules specific to specimen types, but general
to all organisms2. Intrinsic rules and instrument limitation rules 3. Override rules4. Cascading rules appropriate for:• An Organism• A Genus• A Group of organism
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Cascading Rules – Override Preference Rule
Override preference rules - Item TRE 51590
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Example #1:Ln # 21 Intrinsic Resistance Proteus vulgaris193 Species Rule Condition: If “S” or “I” or “R” Do Not Report
Proteus vulgaris
Ampicillin Cefazolin Cefuroxime Cephalexin Tetracycline Doxycycline Cefadroxil Cefprozil Nitrofurantoin Minocycline Tigecycline Meropenem
Ampicillin Cefazolin Cefuroxime Cephalexin Tetracycline Doxycycline Cefadroxil Cefprozil Nitrofurantoin Minocycline Tigecycline Meropenem
Intrinsic rules specific to an organism
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Example #2:Ln # 21A Urine not reported Ampicillin/ Sulbactam for organisms IR198 Group Rule Condition Report
EBAN Group
198324 AmpicillinAmpicillin /Sulbactam is (S or I or R)
Don't report Ampicillin and Ampicillin/Sulbactam
Intrinsic rules similar for multiple organisms
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Example #3:Ln # 21E-Override Cascading and report 2nd drugs when 1st drugs are I/R201 Group Rule Condition Report
Enterobacteriaceaegroup
196133 Cefepime is S and Ciprofloxacin is I or R
Report Cefepime And Ciprofloxacin
Prioritizing the override rules
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1. Cascading for specific specimen types2. Intrinsic rules specific to subset of organism
within a group3. Cascading rules for rest of the organisms within
a group
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Example #4: Prioritization for more complex scenarios
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Ln # 221Q-Group EBACT Urine isolate, Do not report AMP/SULB if AMP is S or I or R216 Group Rule Condition Report
Enterobacteriaceaegroup
195978 Amp/Sulbactam (S or I or R)
Don’t report Ampicillin/Sulbactam
Ln #
Ln # 21R-For Organisms Do not report AMP and AMP/SULB217 Group Rule Condition Report
Enterobacteriaceaegroup
198324 Ampicillin (S or I or R)
Don’t report Ampicillin and Ampicillin/Sulbactam
Ln # 21S-IR Organisms Do not report AMP but report AMP/SULB218 Group Rule Condition Report
Enterobacteriaceaegroup
198326 Ampicillin(I or R)
Don’t report Ampicillin,Report Ampicillin/Sulbactam
21S-IR Organisms Do not report AMP but report AMP/SULB219 Group Rule Condition Report
Enterobacteriaceaegroup
195962 Ampicillin(I or R)
Report Ampicillin and Ampicillin/Sulbactam
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Example #4:Ln # 221Q-Group EBACT Urine,
Do not report AMP/SULB if AMP is S or I Or R216 Group Rule Condition Report
Enterobacteriaceaegroup
195978 Amp/Sulbactam isS or I or R
Don’t report for Ampicillin/Sulbactam
Suppression of antibiotics based on specimen types
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Example #4:Ln # 21R-For Organisms Do not report AMP and AMP/SULB
217 Group Rule Condition ReportEnterobacteriaceaegroup
198324 Ampicillin is(S or I or R)
Don’t report Ampicillin and Ampicillin/Sulbactam
Intrinsic rules specific to a subset of organisms within a group
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Example #4:Ln # 21S-IR Organisms Do not report AMP but report AMP/SULB
218 Group Rule Condition ReportEnterobacteriaceaegroup
198326 Ampicillin is( I or R)
Don’t report AmpicillinReportAmpicillin/Sulbactam
Intrinsic rules specific to a subset of organisms within a group
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Example #4:Ln # 21S-IR Organisms Do not report AMP but report AMP/SULB
219 Group Rule Condition ReportEnterobacteriaceaegroup
195962 Ampicillin is( I or R)
Report AmpicillinReportAmpicillin/Sulbactam
Cascading rules for remaining organisms within a group
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Ln # 221Q-Group EBACT Urine isolate, Do not report AMP/SULB if AMP is S or I or R216 Group Rule Condition Report
Enterobacteriaceaegroup
195978 Amp/Sulbactam (S or I or R)
Don’t report Ampicillin/Sulbactam
Ln #
Ln # 21R-For Organisms Do not report AMP and AMP/SULB217 Group Rule Condition Report
Enterobacteriaceaegroup
198324 Ampicillin (S or I or R)
Don’t report Ampicillin and Ampicillin/Sulbactam
Ln # 21S-IR Organisms Do not report AMP but report AMP/SULB218 Group Rule Condition Report
Enterobacteriaceaegroup
198326 Ampicillin(I or R)
Don’t report Ampicillin,Report Ampicillin/Sulbactam
21S-IR Organisms Do not report AMP but report AMP/SULB219 Group Rule Condition Report
Enterobacteriaceaegroup
195962 Ampicillin(I or R)
Report Ampicillin and Ampicillin/Sulbactam
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Rules (CER)
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Organism
(LLO)
Interface(MAC)
Preference rules(TRE)
Cascading rules(TRE)
Rules(CER)
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Rules Used in Preference & Cascading
•CER rules usage dependent on:
• Antibiotic interpretations• Specimen types• Specimen sources• Patient age• Specific organism, genus or organism group
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Example #1: Rule evaluating antibiotic interpretation and specimen types
+ 23 additional Sources
+ 24 additional Types
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Example #2: Rule evaluating patient age & specimen types
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Example #3: Rule used with susceptibility test
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Rule grouping organisms Example #4:
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Applying Comments with Cascading
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Organism
(LLO)
Interface(MAC)
Preference rules(TRE)
Cascading rules(TRE)
Comments
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Comments used in preference & cascading
• Comments applied via preference and cascading rules:• Antibiotics• Organisms
• Using a rule (CER)and mnemonic (OVD) to reflex comments:
• Culture test (OVT)• Susceptibility test (OVT)
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Appending Comments
Organism commentAntibiotic comment
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Example #1: Applying comments in culture test(s)
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Example #2: Applying comments in susceptibility test(s)
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Lessons Learned
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• Decide early if a consolidated rule structure is right for you
• Strategize early on prioritization of rules and comments
• Allow time for multiple rounds of testing with cascading rules
• Monitor cascading rules for some time after go-live
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Summary
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• Easier maintenance, troubleshooting and support in Beaker
• CLSI standard updates only need to be applied in Beaker
• Minimal impact when lab replaces susceptibility instruments
Advantages of a Consolidated Rule Structure
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Questions?
Simplicity is the soul of efficiency
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―Austin Freeman
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Contacts• Contact information:• Sharmila Pramanik, MD
• Poorva Desai, CLS/Beaker [email protected]
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