Demystifying cascading EPIC XGM 2016

Better Health for All

DEMYSTIFYING CASCADING

Dr. Pramanik Sharmila

Poorva DesaiApril 2016

Efficiency in Preference and

Cascading Rules for Microbiology

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]

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

SANTA CLARA VALLEY MEDICAL CENTER

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

© 2013 Santa Clara Valley Health & Hospital System | 9

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


MICROBIOLOGY DATA FLOW

General Data Flow for Microbiology


Physicians



Physicians Beaker



Maldi/Vitek, Microscan

Physicians Beaker Instrument

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


Various Rules Involved In CascadingCascadi

ng rules

Intrinsic rulesInstrum

ent limitati

on rules


Distributed Rules Structure

Limitation with

antibiotics defined in Instrument

Intrinsic rules

defined in instrument

Preference and

Cascading rules

defined in LIS

Pre-Beaker workflow


Pain Points With BuildDistributed rule structure hurdles

• Inefficient for maintenance and support •Major changes if susceptibility instrument replaced


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


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


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


DEEP DIVE INTO TECHNICAL BUILD

(WITH EXAMPLES)

Build Overview

Organism

(LLO)

Interface(MAC)

Preference rules(TRE)

Cascading rules(TRE)

Rules(CER)


Susceptibility Interface Build

Organism

(LLO) Interface

(MAC)




Susceptibility InterfaceInterface (MAC) item Interface (MAC)

Item 605 – Type 1 - Micro Isolation Item 757 – Result Checking

0 - Deselect Result Checking


Susceptibility InterfaceInterface (MAC) item Interface (MAC) value



Interface (MAC) item Interface (MAC) value




PreferenceRulesPrioritization

Organism

(LLO) Interface

(MAC)




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


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


Example #1: Preference rules specific to a specimen type but generic to all organisms


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

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


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


CascadingRulesPrioritization

Organism

(LLO) Interface

(MAC)




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


Cascading Rules – Override Preference Rule

Override preference rules - Item TRE 51590


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


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


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


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


Example #4: Prioritization for more complex scenarios

Ln # 221Q-Group EBACT Urine isolate, Do not report AMP/SULB if AMP is S or I or R216 Group Rule Condition Report


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


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


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



Report Ampicillin and Ampicillin/Sulbactam


Example #4:Ln # 221Q-Group EBACT Urine,

Do not report AMP/SULB if AMP is S or I Or R216 Group Rule Condition Report


195978 Amp/Sulbactam isS or I or R

Don’t report for Ampicillin/Sulbactam

Suppression of antibiotics based on specimen types


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)


Intrinsic rules specific to a subset of organisms within a group


Example #4:Ln # 21S-IR Organisms Do not report AMP but report AMP/SULB


198326 Ampicillin is( I or R)

Don’t report AmpicillinReportAmpicillin/Sulbactam

Intrinsic rules specific to a subset of organisms within a group


Example #4:Ln # 21S-IR Organisms Do not report AMP but report AMP/SULB


195962 Ampicillin is( I or R)

Report AmpicillinReportAmpicillin/Sulbactam

Cascading rules for remaining organisms within a group


Ln # 221Q-Group EBACT Urine isolate, Do not report AMP/SULB if AMP is S or I or R216 Group Rule Condition Report


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


198324 Ampicillin (S or I or R)


Ln # 21S-IR Organisms Do not report AMP but report AMP/SULB218 Group Rule Condition Report



Don’t report Ampicillin,Report Ampicillin/Sulbactam

21S-IR Organisms Do not report AMP but report AMP/SULB219 Group Rule Condition Report



Report Ampicillin and Ampicillin/Sulbactam


Rules (CER)


Organism

(LLO)

Interface(MAC)



Rules(CER)

Rules Used in Preference & Cascading

•CER rules usage dependent on:

• Antibiotic interpretations• Specimen types• Specimen sources• Patient age• Specific organism, genus or organism group


Example #1: Rule evaluating antibiotic interpretation and specimen types

+ 23 additional Sources

+ 24 additional Types


Example #2: Rule evaluating patient age & specimen types


Example #3: Rule used with susceptibility test


Rule grouping organisms Example #4:


Applying Comments with Cascading


Organism

(LLO)

Interface(MAC)



Comments

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)


Appending Comments

Organism commentAntibiotic comment


Example #1: Applying comments in culture test(s)


Example #2: Applying comments in susceptibility test(s)


Lessons Learned


• 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

Summary


• 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

Questions?

Simplicity is the soul of efficiency


―Austin Freeman

Contacts• Contact information:• Sharmila Pramanik, MD

[email protected]

• Poorva Desai, CLS/Beaker [email protected]


Demystifying cascading EPIC XGM 2016

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Transcript of Demystifying cascading EPIC XGM 2016