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Clinical Content

Building Blocks

 

Clinical Content

 

Screen design and button placement

Consistancy of screen flow

  • 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.  

 

 

Order sets

Clinical Decision support

Clinical decision support may be divided into two main categories:

  1. Checking built into the software such as drug/allergy checking
  2. Guidance built into the orders such as a line of text with the suggested lock-out interval for patient controlled anesthesia (PCA

Some software can also be used to create and display complex custom rules.

 

A large numbers of "false positive" rules can cause "alert fatigue" in which the user focuses so much on "clicking through" the large number of clinically relevant alerts they pay no attention to some of the clinically relevant alerts.    Much current software does not have the ability to create highly specific alerts.   Common problems include displaying lactation alerts for all women between the ages of 12 and 60 because the "might be breast feeding" instead of only displaying these alerts if there is a current history of lactation.    

 

The organization will need to strike a balance between displaying so many alerts that clinical care is slowed and turning off alerts that could improve patient safety.

 

Formularies

During the CPOE build the the hospital formulary is entered.  The CPOE team needs to review what happens when non-formulary items are entered.  In some systems the drugs will be "invisible" to the clinician if have not been entered during the build.  The workflow for non-formulary items also needs to be determined.   Some options that will vary by institution and medication requested include: an automatic substitution, an expectation the patient will bring the medication from home to administer or the pharmacy orders the requested drug?  

 

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. 

 

Maintenance & approval - governance vs personalization

Orders 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.   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.

 

Evidence based links / references

"Evidence based orders" are a current buzzword.  Many specialty societies distribute free order sets for specific conditions.   There are also vendors that provide sets of "evidenced based orders" for a fee.  When the "charge per order set used" is calculated, the cost may be hard to justify. The evidenced based order set vendors also provide software for the maintenance and review of orders that helps justify the expense. 

 

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.