Zynx Health's mission is to provide evidence-based products and services that empower our clients to measurably improve the quality, safety, and efficiency of patient care. ZynxOrder is an Internet-based product that facilitates the integration of “best practices” into hospital-based clinician workflow. It empowers quality improvement teams in their continuing efforts to manage evidence-based clinical content.
ZynxOrder content is divided into modules that represent either clinical conditions (eg, Heart Failure – Systolic) or procedures (eg, Total Hip Replacement). Modules may consist of one or more of the following components: evidence, order sets, and rules. The methodology for development of each component is described below.
EVIDENCE
"Zynx Health’s research experience and clinical expertise makes us confident that we’ll produce evidence-based order sets for years to come."
Leigh Miller, Director of Clinical Outcomes, AnMed Health |
Content Organization
Evidence pages are divided into the following 3 sections:
1. Reminder
- The reminder is a concise and prescriptive statement summarizing the action to be taken based on the evidence.
- There are 5 levels of reminders pertaining to diagnostic or therapeutic interventions:
- Always use
- Consider using
- No recommendation (evidence is insufficient, inconsistent, conflicting)
- Avoid routine use of
- Never use
- Each reminder level is selected based on the relative weighting of evidence concerning clinical benefit, harm, cost, and expert consensus.
2. Rationale
- The rationale section provides a summary of key messages from all cited references.
3. References
- All references are assigned a class of evidence based on the Zynx Health Evidence Classification System.
- The authors, title, and source are stated when applicable.
- For selected articles, a Synopsis or Synopsis+ (a quantitative summary of the study’s key metrics) may be written by Zynx and provided via a hyperlink.
- Hyperlinks to the following external sources are provided when they are available in the public domain: PubMed citations, relevant Web sites, and/or Adobe® Acrobat® Portable Document Format (PDF) files.
PubMed is provided by the National Center for Biotechnology Information (NCBI), a division of the National Library of Medicine (NLM) at the National Institutes of Health (NIH). For information on NCBI disclaimers and copyright information, see www.ncbi.nlm.nih.gov/About/disclaimer.html.
Article Identification
The primary supporting evidence for each topic is identified through searches of English-language references pertaining to human subjects, using the following sources:
- Bibliographic Databases and Systematic Reviews
- National Performance Measures
- National Organizations
Article Selection
The eligibility for inclusion of each reference in a topic is determined based on module specificity and the degree to which each reference contributes to the overall utility of evidence for a given topic.
Module specificity for evidence is defined as either (1) a majority (ie, > 50%) of the patient population having the clinical condition or undergoing the procedure of interest or (2) the condition or procedure is stated in the title of a reference.
Articles are preferentially included in each topic page using the following citation hierarchy:
- Meta-analyses, systematic reviews, and randomized controlled trials
- Nonrandomized prospective studies
- Retrospective studies
This hierarchy is similar to the scheme used by Rhew et al (Evaluating quality indicators for patients with community-acquired pneumonia. Jt Comm J Qual Improv 2001; 27:575-590) and the BMJ Publishing Group (How clinical evidence is put together: searching and appraising the literature. Clinical Evidence 2001; 6:xviii). The following criteria are also applied:
- More recent publications are preferentially cited over older publications.
- For a given topic, the rationale section may be divided into sections in which the evidence pertaining to each section follows the same citation hierarchy.
- When there are different studies of the same class of evidence for a given topic, studies that describe clinical outcomes (eg, mortality rates, quality of life) are preferentially cited over studies that describe nonclinical outcomes (eg, laboratory values, radiographic findings, statistical techniques).
- When there is conflicting evidence, articles of varying levels of evidence may be included to address the topic more comprehensively.
- Guidelines and consensus statements from national organizations are cited for each topic when available.
Topic Selection: Adult Medical Modules
Topic pages are created for processes of care based on available evidence. Topics for each module are chosen based on any of the following criterion groups:
- Class P Criteria (National Performance Measures)
- The topic is addressed as a national performance measure.
- Class E Criteria (Guidelines)
- A reference with recommendations from a national organization (but not an individual author) is published in the form of a guideline, consensus statement, position statement, or technology assessment.
- References with recommendations from national organizations are eligible for inclusion if they are published in journals that are indexed in PubMed. References that are not indexed in PubMed may be cited if an older version of the guideline from the same organization was previously indexed in PubMed.
- Class M and S Criteria (Meta-Analyses and Systematic Reviews)
- A meta-analysis demonstrates a statistically significant outcome for a clinical endpoint between an intervention group and a comparison group.
- A meta-analysis demonstrates equivalency for a clinical endpoint when an intervention is compared to an alternative intervention that has been shown to be superior to a control group.
- A systematic review addresses a clinical endpoint.
- Meta-analyses and systematic reviews may be used to define new topics irrespective of whether their results demonstrate benefit, harm, or no effect.
- Class A Criteria (Randomized Controlled Trials)
- At least 2 randomized controlled trials demonstrate a statistically significant outcome for a clinical endpoint between an intervention group and a comparison group.
- At least 2 randomized controlled trials demonstrate equivalency for a clinical outcome when an intervention is compared to an alternative intervention that has been shown to be superior to a control group.
- A single randomized controlled trial involving > 1,000 patients demonstrates a statistically significant outcome for a clinical endpoint between an intervention group and a comparison group.
- Class B and C Criteria (Nonrandomized Prospective and Retrospective Studies)
- A single nonrandomized study involving > 10,000 patients demonstrates a statistically significant outcome for a clinical endpoint.
- Class Q Criteria (Economic Analyses)
- At least 2 studies demonstrate an economic advantage or disadvantage for a process of care.
- Diagnostic Article Criteria
- An article about a diagnostic test defines a reference standard for comparison, is available for use in a clinical setting, and reports any of the following test characteristics: area under the receiver operator characteristics curve, positive or negative likelihood ratio, sensitivity, or specificity.
- Prognostic Article Criteria
- Scoring systems, prediction rules, and other studies assessing multi-factorial clinical prognostic tools may be included if they are prospectively validated.
Processes of care are excluded when they are not available for use in clinical practice (eg, medications, laboratory studies, and diagnostic tests that are not commercially available).
Topic Selection: Pediatric, Surgical, and Obstetric Modules
For pediatric, surgical, and obstetric modules, a topic page may be created if any of the following criterion groups are satisfied:
- Class P Criteria (National Performance Measures): same criteria as for adult medical modules
- Class E Criteria (Guidelines): same criteria as for adult medical modules
- Class M and S Criteria (Meta-Analyses and Systematic Reviews): same criteria as for adult medical modules
- Class A or B Criteria (Randomized or Nonrandomized Prospective Studies)
- A prospective clinical trial addresses a process of care (eg, an intervention, test, or prognostic factor) that can be applied in current clinical practice (ie, it is not limited to experimental or research applications).
- Class C Criteria (Retrospective Studies)
- A single retrospective study involving > 1,000 patients demonstrates a statistically significant outcome for a clinical endpoint.
- Class Q Criteria (Economic Analyses)
- Any study that demonstrates an economic advantage or disadvantage for a process of care.
- Diagnostic Article Criteria
- An article about a diagnostic test defines a reference standard for comparison, is available for use in a clinical setting, and reports any of the following test characteristics: area under the receiver operator characteristics curve, positive or negative likelihood ratio, sensitivity, or specificity.
- Prognostic Article Criteria
- Scoring systems, prediction rules, and other studies assessing multi-factorial clinical prognostic tools may be included if they are prospectively validated.
Processes of care are excluded when they are not available for use in clinical practice (eg, medications, laboratory studies, and diagnostic tests that are not commercially available).
ORDER SETS
ZynxOrder default order sets are composed of order items and reminder items that are grouped into sections.
Order Items
Order items in Zynx default order sets may be evidence-based, in which case an “Evidence” hyperlink is provided. Additional common practice order items may also be added for completeness. In some cases, entire order sets may be created based upon common practice. National performance measures are denoted by blue ribbon icons with pop-up text descriptions indicating each performance measure's source.
Medication order items consist of a drug name as well as 1 or more permutations of dose, route, frequency, and other attributes. Medication order items may be evidence-based or common practice and are not necessarily approved by the U.S. Food and Drug Administration for use in the respective clinical module. Recommendations by the Institute for Safe Medication Practices for abbreviations and dose designations are reviewed and applied to the order sets in a timely manner (http://www.ismp.org/Tools/errorproneabbreviations.pdf). When applicable, look-alike and sound-alike medication names are displayed using “tall man” lettering in compliance with the U.S. Food and Drug Administration Name Differentiation Project (www.fda.gov/cder/drug/MedErrors/nameDiff.htm).
Reminder Items
In some cases, clinical evidence may satisfy topic inclusion criteria but cannot be directly translated into order items, so a reminder item is embedded in the order set, and a hyperlink to the evidence page is provided. For example, a topic regarding the use of a prediction rule to guide triage decisions for patients with community-acquired pneumonia cannot be translated into an order item, but an order set reminder item can serve as a timely evidence-based reminder to the physician at the point of care. Reminder items are created only for topics that are presented in the evidence. National performance measures are denoted by blue ribbon icons with pop-up text descriptions indicating each performance measure's source.
Sections
Order set section names are internally standardized healthcare concepts that are used to group order items into the following top-level sections: Condition, Vital Signs, Activity, Nursing Orders, Respiratory, Diet, IV Fluids, Medications, Blood Bank, Laboratory, Diagnostic Tests, Specialty, Consults, and Noncategorized. Sections are often divided into subsections for the purpose of subgrouping similar concepts. The ontology of sections, order items, and reminder items within Zynx default order sets can be rearranged and renamed during customization in the AuthorSpace environment.
RULES
Sample rules are provided to exemplify how evidence can be translated into alerts and reminders within electronic medical record systems. Alerts refer to notifications of potentially critical situations and adverse events. Reminders refer to prompts to perform a specific clinical action.
Rule Organization
ZynxOrder sample rules are written for various clinical scenarios that may apply to a single venue of care (eg, an admission or discharge reminder) or multiple venues of care (eg, an alert to avoid a medication). Rules are written in plain English with Boolean operators (eg, “AND”, “OR”, “NOT”). Each rule contains 3 main sections: Evoke, Logic, and Action.
The Evoke section describes criteria that could potentially trigger the rule.
The Logic section provides clinical criteria that should be satisfied for 1 or more actions to be performed. Not all evoking events or logic criteria may be available for all electronic medical record systems, although surrogate markers may be substituted at the discretion of each organization.
The Action section provides sample alerts and reminders with possible actions that could be performed as a result. In clinical scenarios where multiple logic criteria may be satisfied in more than 1 permutation, subsets of logic statements are conceptually related to each other using action groups. In these instances, the logic criteria are listed as L1, L2, L3, etc. and the action groups are listed as A1, A2, A3, etc. Items in the Action section may be hyperlinked to corresponding Zynx evidence.
Additionally, the purpose of the rule is displayed.
Rule Selection
Clinical rules for general adult and pediatric modules are derived from at least 1 of the following criteria:
- Topics that include at least 1 Class P article
- Topics that include at least 1 Class M or Class S article
- Topics that include at least 2 Class A articles
- Topics that include at least 2 Class E articles
Clinical rules are developed and reviewed by Zynx clinicians if the clinical evidence topic can be translated into the appropriate syntax.
PRODUCTION ISSUES
Editorial Process/Quality Control
All components of ZynxOrder are written and maintained by Zynx clinicians. Additionally, a Zynx librarian assists with literature searches and reference cataloging. Zynx pharmacists review medication-related order sentences and their corresponding evidence. Zynx editors review all content for technical accuracy and style consistency. External clinician review is also performed for selected modules.
Physician Editorial Advisory Board
The Zynx Health Physician Editorial Advisory Board is comprised of accomplished and respected physicians who represent a wide spectrum of medical disciplines and specialty areas.
Update Process
ZynxOrder content is updated every 6 months; additional interim updates may be performed on selected modules and submodules based upon the emergence of new evidence. Hyperlinks to external Web sites and documents are reviewed on a regular basis to verify functionality.