If you feel your patient should not be on the protocol, other options for activity restrictions are available within this order.

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1 ORDERS AND POWERPLANS Mobility Protocol New Activity Order Recently, a mobility protocol was approved to facilitate increased patient activity/mobility as early as possible during the hospital stay. In order to facilitate execution of this protocol, we have created a new activity order in HERO. This order will include initiation of the mobility protocol as the default option. This order will be included in admission powerplans. If you feel your patient should not be on the protocol, other options for activity restrictions are available within this order. All other orders for activity (i.e. bedrest, out of bed with assistance, etc.) will ultimately be removed from the system with this change. Users will need to order or modify the activity order to specify activity/restrictions when indicated. Urinary Catheter Removal Protocol To reflect the recently approved protocol for urinary catheter removal, we are modifying orders for urinary catheter insertion, continuation, and removal. The default selection in the insertion and continuation orders will be to initiate the removal protocol. Providers will need to opt out of the protocol option within the order if they have a patient who they feel should not be part of the removal protocol. For cases where removal is never indicated (i.e urology cases, chronic indwelling catheters), providers will have access to an order for DO NOT REMOVE urinary catheter. Use of this order will prompt providers to document a reason for keeping the catheter in for an extended period of time. Providers will no longer receive reminder messages for catheter continuation via message center. All of the related orders for catheter management will be included in a powerplan, but will also be available outside of the powerplan. We will be updating admission powerplans to include the updated orders where needed.

2 ADMISSION ORDERS Code/Resuscitation Status Order Changes By revised policy, there are now only 2 acceptable options for code/resuscitation status: -Full Resuscitation -Do Not Resuscitate The code/resuscitation status order is intended to inform staff who would assist in a cardiopulmonary arrest. We realize that many patients have more specific requests regarding care in their advanced directives and/or POLST forms. These preferences should be documented in the physician progress notes and should be honored by the care teams when the patient is NOT in cardiopulmonary arrest. The code status order will be updated in all admission powerplans to reflect changes to the policy. The comments and special instructions fields will be blocked to avoid any confusion regarding the code status. If you have questions regarding the policy, please contact myself or Dr. Carol Fox. New Bed Placement Orders for Telemetry and/or Increased Care Needs In order guide appropriate bed selection/utilization, we will be adding orders for bed placement to admission powerplans. These orders will replace the current selection for unit location in the Admission order. When increased care is needed outside of the critical care setting, providers will need to use the Bed Placement: Increased Care Needs order and document the rationale within the order. When telemetry is needed, the provider will need to use the Bed Placement: Telemetry order and document the rationale within the order. When a critical care bed is needed, the provider will need to select the Critical Care options. Patients who do not have specific orders for bed placement will be placed on an age appropriate Med/Surg unit consistent with the admission status (inpatient or observation). ICU and CCU admission powerplans will have the Bed Placement: Critical Care option pre-selected. OB and pediatric cases will go to the appropriate unit by default. As part of these changes, the order for Cardiac Monitor will ultimately be removed from the system as patients will no longer be able to have cardiac monitoring on a non-telemetry or non-critical care unit.

3 MRI Order Changes to Guide Appropriate Utilization When an MRI study is ordered for an inpatient and the study is not directly related to the admitting diagnosis or a related comorbidity, the cost of the exam is not included in the DRG reimbursement. While we appreciate the importance of patient centered care and the convenience of having issues addressed during the hospitalization, these cost and reimbursement issues ultimately increase our difficulty in maintaining an operating margin large enough to accommodate new equipment, staff, or services that we as a medical staff believe we need to deliver care of the highest quality. To guide appropriate utilization, we will be adding 2 questions to all MRI orders to clarify the need for the study in the inpatient setting. If there is a possibility that the study can be performed as an outpatient, radiology staff will work with the patient care team to coordinate the scheduling of that study. GI Prophylaxis Powerplan/Subphase In order to guide best practice use of medications for stress ulcer prevention in the inpatient, we have developed a powerplan for GI prophylaxis. This powerplan will be included in relevant admission powerplans. Within the plan, options are limited to a 5 day duration. This limit is intentional as it is important to reassess the need for these medications after the patient s condition stabilizes. Proton pump inhibitors are intentionally left out of the plan as they are not considered first line agents for GI prophylaxis. These items are available for order entry outside of the plan if indicated.

4 DISCHARGE DME and Face to Face Documentation Requirements CMS now requires that orders for select DME items must be accompanied by documentation to substantiate a face to face encounter with the provider and patient prior to dispensation of the equipment. We have created specific orders for these items in HERO. These orders will be included in a DME powerplan. The DME powerplan can be found within the Discharge powerplan or on its own. After selecting the appropriate item in the powerplan, when modifying the details, the ordering provider will be directed to a form to capture additional information required by CMS.

5 After signing the form by clicking on the green check mark to complete any required details in the order., the provider will be directed back to the powerplan The provider will then need to sign the powerplan. The prescription for the DME item will print at the local printer. Case management and MedCare staff will obtain the necessary documentation from the record as needed. While only CMS is requiring this information currently, we anticipate that other payors will soon ask for the same and are keeping the process the same for all. Items that are not covered in the CMS policy may be ordered using the standard DME order which is available on its own and within the DME powerplan.

6 Diabetes Management Powerplan/Subphase We have developed a powerplan for diabetes management that will be included in the Discharge Orders powerplan. This plan contains orders for correction scale parameters, insulin, oral agents, and supplies. Orders captured in this plan will be included on the discharge medication list.

7 Outpatient Prescriptions Powerplan/Subphase Please remember that the discharge powerplan has a subphase to include common prescriptions for medications that are often started at discharge. We have recently added common steroid tapers to the list. Items added through this subphase will be included on the discharge medication list.

8 BMI in Patient Banner Bar By request of a number of providers, we will be adding the calculated Body Mass Index to the patient header. Due to space issues, this value will replace the previously displayed value for height. Users can click on the BMI value to see which height and weight values were used for the calculation. We hope that this change will raise awareness regarding elevated BMI.