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Order Sets
Link to Current Order Set Page
Link to New Order sets brainstorming page
HIMSS Order Sets in CPOE, Luis Saldana, MD
Order sets in CPOE -Tools to provide disease or condition or procedure specific groups of orders to facilitate efficient order entry in CPOE for physicians
Order Sets are key success factor in CPOE implementation
Order sets are workflow sensitive CDS tools that can improve utilization, efficiency of order entry and help to overcome potential errors of omission.
Order sets provide straightforward clinical decision support within computerized provider order entry systems. They make "the right thing" easier to do because they are much faster than writing single orders; they can deliver real-time, evidence-based prompts; they are updateable
Consistency – Standard look, feel and function very important; "conversion" of Paper Order sets does not necessarily work in CPOE; Reinforce Best Practices and eliminate outdated or poor practices
·Standardized Order Sets. CPOE must be viewed as the tool to drive transformation, clinical quality and drive out costs.
Standardized protocols, such as DVT prophylaxis, glucose management, ICU sedation, and stress ulcer prophylaxis may be linked to appropriate admission order sets.
Upon initial implementation of CPOE, process change and interruptive decision support can be overwhelming to the clinician. Order sets may improve clinician efficiency and provide decision-making guidance, thereby increasing user acceptance of the system. Order sets can be viewed as basic building blocks of a decision support program, and should be developed and maintained with strong clinician and institutional support.
Use clinical content to drive engagement with CPOE
Use order sets to Improve Orders and Order Management Processes that promote patient safety and high
quality of care
Maximize CDS Capabilities of Order Sets and Orders Build to avoid overreliance on alerts
Evidence-based order sets, clinical pathways serve as a starting point for disease-specific orders. Allows providers to select all relevant orders for a specific diagnosis. Use order sets to Promote consistent standards of care based on identified best practices.
Upon initial implementation of CPOE, process change and interruptive decision support can be overwhelming to the clinician. Order sets may improve clinician efficiency and provide decision-making guidance, thereby increasing user acceptance of the system. Order sets can be viewed as basic building blocks of a decision support program, and should be developed and maintained with strong clinician and institutional support.
Challenges in development of CPOE ordersets -Physician engagement, Lack of top level support, lack of standardization, political, “just build my order sets"
The lack of a thoughtful well-defined content strategy at the outset of CIS implementation is responsible for more failures, setbacks and wasted resources than any other single factor.
Deloitte Report on Clinical Content, 2007
“Scouring existing literature for evidence and generating consensus on order sets are among the greatest challenges to creating evidence-based order sets; secondary challenge is commitment to maintaining current order sets, inspecting current literature for new research findings and recommendations.” Advisory Board
Many organizations do not formalize an approach to clinical content development and maintenance at the
beginning of CIS implementation, and simply begin with a “starter set” that the vendor supplies. This strategy, by itself, fails far more often then it succeeds. To ensure success, organizations must first establish a formal clinical content governance structure with
appropriate representation of constituencies, as well as establish a comprehensive clinical content strategy.
While evidence-based order sets can make it easier for CPOE clinician-users to "do the right thing," clinical knowledge advances rapidly. When order sets are implemented without organization standards and clinical review or inadequately maintained, they become templates for efficiently practicing outdated medicine on a widespread basis
-Bobb, JAMIA
To ensure success, organizations must first establish a formal governance structure for the approval, review and maintenance of clinical content with broad and multidisciplinary representation. A comprehensive clinical content strategy. Will need to develop methods and metrics to evaluate and redesign the clinical governance structure itself over time.
Goal is to maximize stakeholder buy-in and satisfaction with the process.
Clinical Content life Cycle: 1) Understand content Needs, 2) Identify and select content sources 3) Adaptation of content including vetting of clinical evidence and value, 4) Content review, maintenance and Update 5) ensure the right tools are available 6) Creation of a physician engagement and adoption strategy 7) define metrics and processes to measure success
A key element of successfully implemented CPOE systems throughout the United States has been the creation of an adequate volume of common order sets to facilitate the order entry process for clinicians while providing a platform for effective clinical decision support..
Evaluation & Prioritization of Order Sets
•Analyze Admission/Discharge diagnosis data to determine top 80% of diagnoses
•Identify diagnoses/conditions/procedures needing Order Sets
•Review content of existing Order Sets and consolidate whenever practical
•Create list of Order Sets by specialty
One challenge is how to get the clinicians involved in the process who add value to the process without taking away value from their practices (one variable here is in terms of compensation or incentives).
By reengineering the governance structure and processes of an organization to be owner-accountable and values driven, and carefully expressed through a concise set of written policies, the governance body is positioning that organization for sustainable greatness through the positive impact it has in the world and the way that impact is achieved.
Evidence-based content guides the clinician to do the right thing and EMR functionality can guide
the clinician to do it at the right time and with the right patient. Standardizing practice requires an
evidence base for changing current practice,strong clinical leadership, clinician-focused work
flows, clear accountability, and a culture that supports the change.
The emphasis is appropriately placed on improved patient safety and quality through the use of effective practices. Clinicians can embrace change when it leads to documented effective practice and has a favorable impact on patient safety.
Purchasing evidence-based content from a third party vendor can reduce the timeframe for
content development, help to reduce some of thepolitical issues, and may reduce the effort to manage
content updates.
During pre-implementation planning, organizations will debate the extent to which
process and quality improvement will drive their EMR implementation. There are multiple choices
that include clinical transformation, select process improvements based on their internal quality
agenda and implementation of the applications with a focus on quality post-implementation. The
organizations that have been most effective with EMR implementation led with quality and a critical
part of the strategy for clinician adoption is to focus on the quality improvements.
Plan with the end in mind
What a good CPOE Clinical content strategy can facilitate:
- The rapid incorporation and dissemination of current medical evidence into order sets.
- The rapid incorporation and dissemination of changes to current guidelines into order sets.
- The rapid incorporation and dissemination of changes to care delivery standards into order sets.
- The ability to continually update order sets and eliminate outdated order sets in an effective time fashion.
- The ability to comprehensively review order sets.
- Improved regulatory compliance.
- Decreased variation in nursing workflow.
- Decreased variation in pharmacy workflow.
- Improved patient safety.
- Improved patient care quality.
- Improved financial integrity.
Ideally the bulk of organizational standardization is done before implementation of CPOE so as to avoid "linking" CPOE and standardization, both fairly unpalatable change projects for physicians. This might act to diminish the potential success of both change intiatives.
Order set teams are where the bulk of the content work is done. Get clinicians to identify with the clinical content and understand best practices. Engage.
Clinicians’ membership in the governance process should be carefully assessed, and individual members should be
recruited to achieve a mix of skills, experience, medical specialty and practice geography. However, wanting to
help may not be enough if physicians or other clinicians do not possess the right skill sets to fully contribute.
The members of this group must include physicians, with support from nurses and pharmacists, as well as
other clinicians who are respected by their peers. Care should be taken to balance between technophiles and
technophobes, and all should have the ability to communicate a shared vision along with broad goals and
quantifiable objectives throughout the organization
THR uses a content source strategy which leverages content from a 3rd party vendor (Zynx) customized to suit the organization's clinical needs.
From Deloitte's report: the organizations executives should lead a change management program focused specifically on the importance of clinical content development, customization and maintenance as primary determinants of overall success in clinical transformation. In addition, to a clearly stated communication strategy, this change management program must include clearly stated, anticipated benefits, a rationale for process standardization and the acknowledgement that adoption and use of clinical content is never a substitue for sound clinical judgement.
Create a process for content update and maintenance
While most clinicians endeavor to keep up with the continuously changing bodies of evidence behind best practices as a routine part of their ongoing professional education, many find it difficult, if not impossible to keep abreast of all the potentially relevant updates. Therefore, it should not be surprising that among all the steps associated with sustained clinical transformation, none is more underestimated in terms of importance
compared to allocated time and resources than the content update and maintenance processes. This is particularly true whenever clinical content is highly customized as it necessarily requires significantly more
time and effort to maintain the customized content. Furthermore, there may be legal liabilities for
organizations that develop, but do not update clinical content and underlying evidence, so it might be advisable to conduct a risk assessment of existing clinical content and practices to assess their potential for legal liabilities and exposures. Like the content development process itself, content updating and management strategies are highly dependent on the specific organization. There are, however, some proven strategies that stratify content into different categories in an effort to guide the development of maintenance processes. For example, there should be a process to identify and rapidly replace content that adversely impacts patient safety or quality of care. Another process established to identify and
replace outdated content, as well as special processes to review multi-disciplinary content. Knowledge vendors update their content and evidence regularly ranging from weekly to yearly. And when an emergent need arises, such as the 2005 Vioxx recall, these vendors are able to assist their clients to immediately remove the medication from all existing order sets.
Prior to taking a technology live, ensure that all standardized order sets and guidelines are developed, tested on paper, and approved by the Pharmacy and Therapeutics Committee (or institutional equivalent) TJC Sentinel alert on HIT
•Take Complete Inventory of Existing Paper Order Sets and perform gap analysis for additional order set needs
•Standardize Order Set Development Process
•Standardize Order Set Format and Nomenclature
•Design, build and Validate CPOE order sets
•Develop Maintenance Schedule
With the advent of a comprehensive electronic medical record (EMR), new and innovative ways are being developed to improve the quality and safety of patient care that we provide at THR. A key portion of these efforts will be the implementation of a computerized physician (provider) order entry (CPOE) system. This has been advocated by many organizations including the Leapfrog group as a core benchmark for the improvement of patient safety1. The reason for this is that CPOE can provide support for clinical decisions being made at the point of care. This provision of clinical knowledge and patient-related information in a filtered and timely fashion gives physicians and other providers the information they need to practice safer medicine.
Existing paper order sets within THR have largely been personalized or individual with no consistent oversight or maintenance to assure some minimal level of content validity. This has resulted in a large number of paper order sets at each entity with a wide variation in quality and utility. To move forward in CareConnect by replicating these paper order sets would only serve to reinforce a broken process.
The THR Order Sets we create will be for conditions, interventions and processes that occur at multiple facilities as well as at only one facility. In all cases, there will be only one order set created for each condition, intervention or process. There will be no facility specific or physician specific order sets supported in this process other than as defined below.
The creation and maintenance of order sets for the purpose of care delivery is a dynamic ever-changing process. Maintaining paper copies of any given order set in any clinical environment can lead to the utilization of outdated and potentially inaccurate information. Physicians and ordering providers will be encouraged to be primarily responsible for accessing, completing and utilizing the appropriate order sets on an as needed, just in time basis. This approach provides physicians and ordering providers with direct access to the evidence, drug information and regulatory standards that support the orders.
What It Takes to Succeed with Order Sets: Lessons Learned
Governance
Presuming that executive-level leadership for clinical systems implementation/ transformation is already in
place, a governance structure is needed to direct the development and ongoing management of clinical
content. Given the need for objectivity, it is also advisable to develop methods and metrics to assess and
redesign the clinical governance structure itself over time. This will ensure objectives and timelines are met
while maximizing the likelihood of stakeholder buy-in.
The size and structure of the governance body that controls clinical content will vary with the size and complexity of the organization. Typically, there is a Physician Steering Committee (PST), Physician Order Set Design Teams and a similar structure to support nursing and other content design. The PST oversees all physician-related aspects of the design and implementation of advanced clinical information systems including workflow, content and adoption. They define the scope of content (what will or will not be developed), determine the amount of enterprise standardization that will be required in content development, and prioritize
the work of the development teams. The issue of content standardization is critical because clinicians are unlikely to use standardized practices (even if they tacitly acknowledge that reductions in practice variations between clinicians ultimately benefit both the patient and the organization as a whole) unless there is an
organizational imperative to encourage and support the use of standardized practices and tools to facilitate such use. The PST also charters the Order Set Design Teams and reviews and validates their work.
The PST should include about 10-12 physicians representing primary care, hospitalists, medical
subspecialties, surgery (general and/or subspecialty), OB/GYN, pediatrics, emergency medicine, and psychiatry with tailoring for the unique needs of specific health systems. In addition, representatives from nursing, pharmacy, and other key clinical departments should be given advisory positions to the PST. It is also worth considering the inclusion of an administrative/operations executive, since the PST will
make recommendations for resource requirements related to content development and maintenance. If the organization is geographically distributed, consideration should be given to either establishing a single PST for the entire organization where members adequately represent the different geographic areas, or establishing
multiple PSTs for each region. If multiple PSTs are established, a formal process should be developed to
ensure that leaders from each group freely share information among each other to encourage
organizational learning and leverage synergies. Delineating characteristics of endorsable variation (local antibiograms, local formularies, state requirements) will
provide guidance to the design process. Based on Deloitte’s experience, most organizations that have implemented CIS report that they regret not having pushed for more standardization. They report that, in retrospect, they could have achieved much more. Typically, the Order Set Design Teams are where the bulk of the content work is done. These teams are responsible for setting the overall content delivery design standards.
Standardize Order Set Development
Process
•Establish a clear process for new order set development and existing order set revision
•Establish “Order Set Coordinator”position to police the process
•Leverage existing department and service line committees for order set content
•Identify key MDs for early order set review
•Use email and online review tools (ViewSpace) to cut down review turnaround time
Can Embed evidence-based care into order sets (example, VTE prophylaxis sections) – THR Use Zynx as reference for evidence www.zynxhealth.com Orders Set Types: Optimized, Standardize only where there is Evidence and/or consensus. Identify opportunities for standardization
Use Order sets to Facilitate sharing and leverage of best practices across hospital/system- Mandatory for successful integrated Health Care Delivery Orgs
Convenience order sets
•Based on current practice
•NOT evidence-based (Community Standard)
•May be Required to support workflow
Assess current culture and practice to identify the level of clinical documentation
completeness and standardization, the importance of care planning in the current
environment, and the extent to which care plans and clinical pathways are developed
and evidence-based. The assessment needs to determine the extent to which
interdisciplinary practice is present and scopes of practice are defined and
understood.
• Develop an interdisciplinary governance structure where the content
and practice strategies can be developed by clinical leaders from across the
organization. This system-wide oversight group can lead nursing and discipline
participation in the design, implementation and proficient use of the
new documentation tools and contribute to work flow redesign.
• Develop objectives and guiding principles that define what the
organization wants to achieve through EMR implementation and the principles
that establish the boundaries around how the new EMR will be designed and used.
• Define the care delivery model and identify quality improvement targets
to include the patient/family role in the care delivery process, interdisciplinary
approach, level of clinician integration and the three to five areas the organization
will focus on for quality improvement, i.e., hand-off communications, results followup,
execution of IHI bundles, etc.
• Define content strategy to include the scope, source, resource requirements, process to develop, test and validate the
tools, and methods to monitor adoption and data quality. A vendor selection process needs to be undertaken if a third
party content vendor is desired.
• Define content prioritization based on quality & safety improvement targets
and high volume care. This includes the patient populations and nursing diagnoses
that will be covered, the timeframe for development and validation, and the
resource requirements to support.
• Define the methodology that will be used to customize content for the
organization. This includes precustomizing care plans so that teams can
expedite their work; assembling teams based on specialty experience, knowledge
and skills, prioritizing team activity based on volume & nature of care plans,orienting teams to “virtual” meeting processes (webinars), defining ground
rules for team conduct and preparing care plans to review by the larger clinical
organization.
• Develop a Clinical Content Team that can support the governance structure and
the content development teams. Clinical experience, knowledge and skills and
organizational familiarity are most useful among the team members. Members
need to be computer savvy and thoroughly oriented to the 3rd party
vendor content and functionality. Clinical Documentation certification on the
organization’s software can be a benefit. This team orients each content team, precustomizes
the care plans for each team, sends out meeting notices and web links
and prepares drafts as care plans evolve.
• Communication throughout all stages of the process cannot be overemphasized.
The process is complex and keeping people informed at each step can help
reduce resistance to change and enable clinicians to engage with design and
implementation activities.