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Order sets

FrontPage => Stages of Implementation => The Executing Stage =>

or => Building Blocks

 

Order Sets


 

General

 

In post CPOE lessons learned, many organization will determine that the success or failure of the initiative was largely tied to the order set creation process.  Success in motivating the organization around the creation of clean, clear evidence based order sets often means CPOE success.  Difficult or non-existant order sets can lead to clinician frustruation and sometimes refusal.

 

It is important to spend some time thinking about the process to create and approve order sets. 

 

Generate a list of the order sets that are needed.

  • Admission diagnosis
  • Common in-hospital status changes, ie: Sepsis evaluation

 

Consider how existing hospital committees will be involved including a Medical Executive Committee, Pharmacy and Therapeutics, department or divisional committees.

  • Some organization will convene a separate physician-clinician structure for the creation and review of order sets and others will use existing departmental structures.
  • Nurses, pharmacists and others will need to be involved from the beginning.

 

Build in as much time as possible for review.

  • Order set review is not typically the physician’s first priority.
  • Receiving departments will need to review the order sets.

 

Create a style sheet.

  • There should be a consistent nomenclature for individual orders
  • There should be a consistent naming mechanism to find each order set
  • Order sets should have a consistent format and order.
  • Consider the use of the “ADCVANDISMAL” order.  It is a certainly a hold-over from paper based ordering so it may or may not be appropriate.  In some organizations, especially those that have older or computer resistant physicians it will encourage physician adoption.  In other organizations, especially academic medical centers, it may not be needed

 

Screen design and button placement is an important aspect of creating a consistent experience when navigating the screens.

  • When possible, screens should have the same framework and layout. 
  • Users will learn where buttons and tabs are on the screens, and expect the same placement of buttons/tabs on every screen. Once facile with the system, users will barely look at screens and click through very quickly.
  • Pay special attention to the buttons that advance to the next screen, cancel the current action; and the buttons that result in orders being processed or completed. Variability in the placement of these buttons can result in user dissatisfaction; and result in patient safety issues.  

 

Default doses for individual orders or order sets.

CPOE systems often allow the organization to specify a default dose for a medication order.  More sophisticated systems will specify a default dose based on the patient's condition or a unique "default dose" for an order set for a condition.  This can be helpful to guide the clinician.  On the other hand, a default dose can also lead to under or overdosing the patient if the clinicians "guesses" the dose.  In general, specifying default doses should be avoided where the dose of medication is highly variable (such as insulin) and default doses should probably be set to minimize the risk of overdoses if the clinician happens to pick the default dose of a hospital medication because the home dose has not been specified.

  

Standardized content from a vendor vs. internal expertise

 

Order sets may be built using current paper orders, developed using vendor supplied "starter sets" or developed from "evidenced based orders" from third parties.  Using current paper orders creates the least disruption but the organization may miss the opportunity to "clean up the orders" or miss out on the opportunity to take advantage of new electronic capabilities if they are used as a starting point.   Also, competing physicians may each wish their order set to be the standard.  Using orders from the vendor or a third party allows the organization to use a neutral party as the starting point and create more standardized orders. 

 

  

Types of Order Sets

 

Standard or Institutional Order Sets 

Standard (Institutional) Order Sets are those that are hospital developed and approved by the appropriate governing body.

 

Convenience Order Sets or Order Bundle 

Convenience Order Sets or Order Bundles may be defined as those that are a group of orders put together at the request of end users in order to speed ordering.

 

Favorite or Personal Order Sets 

Favorite or Personal Order Sets are created specifically by an individual physician if the system has this capability.  Typically, these order sets are only available to the physician for whom they are created.

 

A governance procedure needs to be decided by the organization including the degree of personalization allowed.   The two extremes are each clinician gets any order set requested with any content they request and all order sets are standardized by medical staff or hospital committees with no individual order sets.  Most organizations will want to be somewhere between these extremes.

 

Maintenance & Approval

Order sets will need to be periodically reviewed and maintained.  Also new order sets will need to be created if there are new procedures or specialties using the CPOE system.  Avoid creating a new, and possibly unnecessary, process by evaluating the current approval processes for your clinical system and include the review and updating of orders and order sets in that process if appropriate.  If a current venue does not exist, it is important to create one early in your implementation. 

 

References

Baston, J. M. (2004).  A utilization study of order sets at Providence Portland Medical Center.  Presented to the Department of Medical Informatics and the Oregon Health and Science University School of Medicine in partial fulfillment of the requirements for the degree of Master of Biomedical Informatics.

Morgenstern, Dan. CPOE University, A CPOE Primer for Nursing.  Retrieved February 10, 2010 from:  http://www.masstech.org/ehealth/CPOE%20University/courses_2009_2010/WhatisCPOERN.pdf 

Morgenstern, Dan. CPOE University, A CPOE Primer for Physicians.  Retrieved February 10, 2010 from: http://www.masstech.org/ehealth/CPOE%20University/WhatCPOE.pdf

 

Resources 

 CPOE: Getting Order Management Right  Authors: Donna Schmidt, Mamie Stalvey, Beverly Bell, Jane Metzger 

 Improve Core Processes for Ordering Medications From IHI.....FANTASTIC Resource  

 

Landmines and Pitfalls of Computerized Prescriber Order Entry from American Society of Health-System Pharmacists Center on Patient Safety

 

 

"Guidelines for Standard Order Sets" Institute for Safe Medication Practices, http://www.ismp.org/Tools/guidelines/StandardOrderSets.pdf 


The following reference was added by Jeffrey Tingle, MSc

 

The Boston area community has been actively working on CPOE implementations for a number of years now.  The following is an excerpt from John Halamka, MD regarding the implementation experience and the Beth Isreal Deaconess Medical Center in Boston in reference to providing rules for the system.

 

7. Many CPOE systems are a toolkit without rules -Many commercial CPOE systems are 'some assembly required'. They provide a container for rules, but do not come with an initial set. You can establish internal committees to build best practice rulesets, purchase rules from vendors such as Zynx or First Data Bank, or use rules others have created, such as ours.

 

8. CPOE decision support is only as good as the data available - Decision support depends upon accurate medical history. Safe drug dosing requires a current medication list, updated allergies, creatinine and other current labs, a problem list, and even genomic testing results. This means that all aspects of the hospital information system must be fully integrated into CPOE to achieve the best result. There is no such thing as a standalone CPOE system and it's best that CPOE be purchased as part of an integrated hospital information system. "

 

John has stated publicly that new implementors should feel free to use BIDMC's drug-drug interaction list as a starting point.  That document can be found here.

 

The full blog entry can be found here

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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