Getting to Know Your Order Sets
While it's difficult to accurately define "computerized physician order entry" (CPOE), CMIOs know CPOE when they see it. And yet, managing CPOE and reining in the proliferation of order sets poses a battle royale between administration and providing safe clinical care.
Saying that a facility has computerized physician order entry (CPOE) is like saying "I got a coffee." The coffee could've come from Dunkin Donuts, Starbucks or poured from the steaming mouth of a French press. There are different implications and expectations on how the coffee might taste to the average coffee enthusiast. CPOE is similar with respect to its definite ambiguity.
While CPOE is more of a generic term, regardless of its ambiguous definition, its adoption is on the rise. According to an August report from market researcher KLAS, after reviewing eight consecutive years of CPOE, researchers found that before the American Recovery and Reinvestment Act of 2009 (ARRA), an average of 87 hospitals went live with CPOE. Since ARRA, that number has skyrocketed to 233 per year.
"No one wants to really define CPOE," says Robert D. Stanley, MD, MPH, CMIO at Cooley Dickinson Hospital. While the CPOE adoption rate at the 140-bed Northampton, Mass., hospital is currently at 70 percent CPOE use, Stanley says that the facility is gearing up to switch from a mixture of paper and electronic order set environment to a fully functioning electronic order set. Stanley is currently chairing an order set and protocol committee that meets weekly to iron out wrinkles in the workflow for the integration.
While switching to evidence-based order sets will aid with quality care, the empirical basis also helps enforce a certain rigor to the development process and formality to help design the possible best order sets, says Stanley.
One of the challenges, he says, is that hospitals need to confront the cost of maintenance attached to order sets. To stay on top of the latest medical literature and update order sets, a facility needs to assess their order sets every two to three years.
According to Stanley, this includes whenever the FDA approves a drug or takes a drug off the market, as well as evaluating order sets when the provider wishes to adopt new technologies, such as ECG, which could change a physician's workflow.
"Knowing what order sets to approve or change can be difficult," says Stanley. Noting order sets need to be maintained and updated, he says that a liaison is needed between the clinical workflow and order set development, ideally a quality director. While the hospital is currently working on converting 150 order sets from paper, Stanley notes that once that batch of integration is finished, the work is far from over. "Managing order sets is like tending to a garden. You're never done weeding," he says.
While order set maintenance is a never-ending process, providers can't discount a very important aspect of order set management: ramping up an order set go-live date. Since order sets don't automatically set themselves up, providers should invest time into preparing their go-live date. This includes discussing sets across groups within an organization and thorough testing.
Across the three hospital system of Alameda County Medical Center (ACMC) in Oakland, Calif., a web-based system in the inpatient setting is currently being used in preparation and prior to implementing a true CPOE system in late 2012, according to Howard M. Landa, MD, CMIO at ACMC.
In the current inpatient hospital environment, the system leverages existing order sets and merges a combination of those order sets based on patients' symptoms and procedures to create a single order set and conclusion. The order set is then printed on paper once the unique patient's order set is created. Because there is no order transmittal, the creation of new content is relatively easy with a small number of simple order combinations blasting out to a larger, complete set. According to Landa, the system uses 50 original order sets that ACMC internally created, which are processed into the system when a patient is admitted and as his or her clinical needs are identified. "Physicians vet the orders. Each line in an order is an independent data element that is tracked and potentially modify at the end of the day," he says.
A reporting feature in the system allows Landa's team to drill down by user, problem, procedure or specific order. The ability to answer questions such as "How many times has this order been used?" or "How many times has this order been used by attending or a group of residents?" has helped ACMC manage their order sets by being able to add information accordingly. While 50 individual order sets were internally created, Landa believes that these powered about 150 combined order sets for patients.
Streamlining the approval process through the collaboration of the pharmaceutical, safety, health information management back to an approval committee shaves a month or two off of order set development, says Landa who adds that changes in the sets can be made in minutes.
Theal stresses the importance of preparing the clinical team for changes related to CPOE. Three years before its go-live date, North York began discussing what CPOE might mean for the clinical workflow. "We knew it was not going to be easy and there would be challenges to adopting a new way of working," says Theal. While new technology might initially slow down the physician ordering process, he believes the advantage of CPOE is in the ability to have evidence for the best patient care practices built into the physician ordering workflow. The literature demonstrates that standardization of care in addition to clinical decision support can help save lives and reduce adverse events, and Theal uses this evidence to appeal to physicians. "Referring to the literature is helpful in reassuring physicians that undergoing the effort to adapt to CPOE will result in better outcomes for their patients," says Theal.
Physicians were initially slower as they learned to use CPOE, but Theal notes that over time, they got better and faster. The organization has had not only a 100 percent adoption rate amongst physicians, but user surveys also confirm that the majority of the physicians feel the CPOE the system has been a positive change. "After go-live, the lines of communication should remain open," advises Theal who notes that physicians can get frustrated on the frontline of care and need colleagues to share that frustration, ensure that support is provided, and that feedback is acknowledged.
He also emphasizes the need to have a post-implementation operating budget to continually maintain and improve order sets and recoup costs. At North York, they measure use and feed outcomes data back to a development team. Depending on the length of the order set and the set itself, it can take anywhere from one hour to 10 hours on a yearly basis to update an order set.
While North York is just beyond the post-live bubble and there is less than nine months of live system data to analyze, evidence already is emerging that there are improvements to patient care with CPOE. For instance, there has been a 36 percent improvement in compliance with recommended prophylaxis for venous thromboembolism in patients with hip fracture, a 35 percent improvement in medication reconciliation use on patient discharge from hospital and a trend toward reduced inpatient mortality in the [Canadian] Medicine program.
While CPOE and order sets are not the end-all, be-all of clinical care, they are sure to become a part of everyday operations as more hospitals begin adopting and implementing the systems. CMIOs will want to get physicians in on the ground floor of initiatives to make sure workflows and the technology match up.
With clinical collaboration efforts, organizations can best drive the maximum efficiency resulting in the best possible care for patients.
Saying that a facility has computerized physician order entry (CPOE) is like saying "I got a coffee." The coffee could've come from Dunkin Donuts, Starbucks or poured from the steaming mouth of a French press. There are different implications and expectations on how the coffee might taste to the average coffee enthusiast. CPOE is similar with respect to its definite ambiguity.
While CPOE is more of a generic term, regardless of its ambiguous definition, its adoption is on the rise. According to an August report from market researcher KLAS, after reviewing eight consecutive years of CPOE, researchers found that before the American Recovery and Reinvestment Act of 2009 (ARRA), an average of 87 hospitals went live with CPOE. Since ARRA, that number has skyrocketed to 233 per year.
"No one wants to really define CPOE," says Robert D. Stanley, MD, MPH, CMIO at Cooley Dickinson Hospital. While the CPOE adoption rate at the 140-bed Northampton, Mass., hospital is currently at 70 percent CPOE use, Stanley says that the facility is gearing up to switch from a mixture of paper and electronic order set environment to a fully functioning electronic order set. Stanley is currently chairing an order set and protocol committee that meets weekly to iron out wrinkles in the workflow for the integration.
While switching to evidence-based order sets will aid with quality care, the empirical basis also helps enforce a certain rigor to the development process and formality to help design the possible best order sets, says Stanley.
One of the challenges, he says, is that hospitals need to confront the cost of maintenance attached to order sets. To stay on top of the latest medical literature and update order sets, a facility needs to assess their order sets every two to three years.
According to Stanley, this includes whenever the FDA approves a drug or takes a drug off the market, as well as evaluating order sets when the provider wishes to adopt new technologies, such as ECG, which could change a physician's workflow.
"Knowing what order sets to approve or change can be difficult," says Stanley. Noting order sets need to be maintained and updated, he says that a liaison is needed between the clinical workflow and order set development, ideally a quality director. While the hospital is currently working on converting 150 order sets from paper, Stanley notes that once that batch of integration is finished, the work is far from over. "Managing order sets is like tending to a garden. You're never done weeding," he says.
A soft order set opening
| A Successful CPOE Initiative | |||
1. Physician adoption attention; 2. Building evidence into the workflow; 3. A user feedback system; and 4. Post go-live commitment to addressing user feedback, updating system content (such as order sets) and measuring patient outcomes to ensure constant system improvement. |
Across the three hospital system of Alameda County Medical Center (ACMC) in Oakland, Calif., a web-based system in the inpatient setting is currently being used in preparation and prior to implementing a true CPOE system in late 2012, according to Howard M. Landa, MD, CMIO at ACMC.
In the current inpatient hospital environment, the system leverages existing order sets and merges a combination of those order sets based on patients' symptoms and procedures to create a single order set and conclusion. The order set is then printed on paper once the unique patient's order set is created. Because there is no order transmittal, the creation of new content is relatively easy with a small number of simple order combinations blasting out to a larger, complete set. According to Landa, the system uses 50 original order sets that ACMC internally created, which are processed into the system when a patient is admitted and as his or her clinical needs are identified. "Physicians vet the orders. Each line in an order is an independent data element that is tracked and potentially modify at the end of the day," he says.
A reporting feature in the system allows Landa's team to drill down by user, problem, procedure or specific order. The ability to answer questions such as "How many times has this order been used?" or "How many times has this order been used by attending or a group of residents?" has helped ACMC manage their order sets by being able to add information accordingly. While 50 individual order sets were internally created, Landa believes that these powered about 150 combined order sets for patients.
Streamlining the approval process through the collaboration of the pharmaceutical, safety, health information management back to an approval committee shaves a month or two off of order set development, says Landa who adds that changes in the sets can be made in minutes.
Hard line, hard order setting
At North York General Hospital in Toronto, Canada, 100 percent of physicians have adopted the new CPOE system, with 94 percent of physician orders directly entered by physicians electronically. According to Jeremy Theal, MD, director of medical informatics at North York, the provider went live with CPOE in their medical/surgical units in October 2010. At the time of go-live, 350 evidence-based order sets were available for the clinicians to use. As of eight months after implementation, 45,000 evidence-based order sets had been activated by physicians in the system, an average of three to four order sets per patient.Theal stresses the importance of preparing the clinical team for changes related to CPOE. Three years before its go-live date, North York began discussing what CPOE might mean for the clinical workflow. "We knew it was not going to be easy and there would be challenges to adopting a new way of working," says Theal. While new technology might initially slow down the physician ordering process, he believes the advantage of CPOE is in the ability to have evidence for the best patient care practices built into the physician ordering workflow. The literature demonstrates that standardization of care in addition to clinical decision support can help save lives and reduce adverse events, and Theal uses this evidence to appeal to physicians. "Referring to the literature is helpful in reassuring physicians that undergoing the effort to adapt to CPOE will result in better outcomes for their patients," says Theal.
Physicians were initially slower as they learned to use CPOE, but Theal notes that over time, they got better and faster. The organization has had not only a 100 percent adoption rate amongst physicians, but user surveys also confirm that the majority of the physicians feel the CPOE the system has been a positive change. "After go-live, the lines of communication should remain open," advises Theal who notes that physicians can get frustrated on the frontline of care and need colleagues to share that frustration, ensure that support is provided, and that feedback is acknowledged.
He also emphasizes the need to have a post-implementation operating budget to continually maintain and improve order sets and recoup costs. At North York, they measure use and feed outcomes data back to a development team. Depending on the length of the order set and the set itself, it can take anywhere from one hour to 10 hours on a yearly basis to update an order set.
While North York is just beyond the post-live bubble and there is less than nine months of live system data to analyze, evidence already is emerging that there are improvements to patient care with CPOE. For instance, there has been a 36 percent improvement in compliance with recommended prophylaxis for venous thromboembolism in patients with hip fracture, a 35 percent improvement in medication reconciliation use on patient discharge from hospital and a trend toward reduced inpatient mortality in the [Canadian] Medicine program.
While CPOE and order sets are not the end-all, be-all of clinical care, they are sure to become a part of everyday operations as more hospitals begin adopting and implementing the systems. CMIOs will want to get physicians in on the ground floor of initiatives to make sure workflows and the technology match up.
With clinical collaboration efforts, organizations can best drive the maximum efficiency resulting in the best possible care for patients.