FrontPage => Stages of Implementation => The Executing Stage or => Building Blocks

Introduction

Some 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 or to gather the paper forms that already exist in the organization.

This strategy can be risky.

Gathering the Paper

Most CPOE implementation will have a stage where the team will physically walk the floors and gather as many paper order set forms as can be found.  There is value to this step.  It gives a sense of what tools clinicians may be using for order sets.  It can give a sense of the ammount of variation on a particular diagnosis.  For example, if there are 6 different order forms for "Total Hip", it wll indicate that standardization on that order set may be challenging. 

However, gathering the paper and then returning to the IT department to build those order sets directly into the CPOE application is rarely a good idea.  Unless the paper order sets have been regularly reviewed and the clinical evidence vetted, something that is rarely the case, building these order sets into the computer application will not result in any advances in quality of patient care.

On the other hand, at some point during the implementation, order sets that are built into the system should be converted to paper since they will be required for downtime.

Steps  

1.  Understand Content needs including metrics to be tracked

• This may require a vendor selection for the content vendor, dependant on the integration capabilities of the core CPOE vendor. 
• Use the CPOE initiative to engage clinicians.  They can get excited about clinical evidence and bring it to the bedside.  
• Consider the needs of multiple sites as they may have very different needs. 

2.  Identify and select Content sources

• Agreement at this step on the value of particular resources can reduce the political arguments later.  If all agree about the value of particular resources, it will diminish later arguments
• "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.  

3.  Vet clinical evidence, determine value and scope of use

• Third party vendor content cannot be accepted without at least some review by the organization. 
• Considerations such as patient mix, geographic location should be considered.

4.  Implement Content including customization

• Define the methology to customize content for the organization, including careplans by a broad group of clinicians.

5.  Check metrics around usage and outcomes

• If the metrics have been carefully considered in step 1, then this is a more simple reporting function.  More commonly, sites realize that as much as theytry to “plan with the end in mind”, it is difficult to determine all the key performance indicators up front.  Some adjustment during this step is common.

6.  Maintain and update Content

•  The effort to maintain content is significant.  Medical knowledge is increasing exponentially every year and working clinicians do not have the time to keep up to date.
• Create a process for dealing with urgent or emergent changes, like drug recalls.

Potential Outcomes for measurement

• Incorporation and dissemination of current medical evidence into order sets.
• Incorporation and dissemination of changes to current guidelines into order sets.
• Incorporation and dissemination of changes to care delivery standards into order sets.
• Ability to continually update order sets and eliminate outdated order sets in an effective time fashion.
• Ability to comprehensively review order sets.
• Regulatory compliance
• Variation in nursing workflow.
• Variation in pharmacy workflow.
• Patient safety.
• Patient satisfaction
• Financial integrity.