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Order Set Development
 

Order Set Development

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My take based on experience at two IDNs on how to move from the paper-based order world into CPOE

My take based on experience at two IDNs on how to move from the paper-based order world into CPOE

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  • Introduce evidence based content in paper world so you are introducing less change with CPOE roll out Process we used to convert from paper to CPOE Handwritten Paper orders- Paper Order sets- EB paper order sets- CPOE
  • Purposefully engaged key physicians at each step along the way Buy-in leads to Ownership leads to Advocacy leads to OS usage paper CPOE Same process then used in electronic world
  • Unit clerks, Service line admins, OR staff etc. As you collect OS find out key MD users or champions of the OS I would not suggest trying to introduce EB/OS into your OSs without licensing content from a content provider Development and maintenance of EBOSs would be a logistical nightmare without a continual feed of updates and content from a trusted third party
  • Keep team small One team for all order sets: MD, RN, Pharmacist Or one team for each OS group (IM, Surg, Peds, CV, Ortho etc.) Depending on size of your organization and your resources This team will get Oss “90%” complete OS Coord. moves order sets through various stakeholders for comments, revisions etc… (Key MDs, RNs, Pharmacist, ancillary, committees etc.)
  • Once you have nailed down what process you will use to develop your OS; your core team needs to agree on a standardized OS format and nomenclature
  • A standard look and feel helps users navigate when they are using a new OS
  • Now that you have agreed on a process and format- work of core team begins
  • Come armed with the evidence from your content provider
  • Now you have your “completed” OS you must do UAT before releasing to live
  • UAT (user acceptance testing) Get a naive set of eyes looking at OS Engenders more buy-in -> sense of ownership -> advocacy
  • Leverage MDs who “own” the OSs as advocates for their use
  • Keeps feedback coming (avoids sense of Black Hole) Engenders “ownership” -> advocacy: “I made this change”
  • Very hard to do without a content provider feeding you regular updates based on the latest literature
  • Urgent: Email or online tool Routine: Follow standard development process steps With Key MDs, committees etc.
  • Buy-in leads to Ownership leads to Advocacy leads to OS usage Same process then used in electronic world

Order Set Development Order Set Development Presentation Transcript

  • Order Set Development
    • Managing the Transition from Paper
    • to Electronic Order Sets
    • Brian D. Patty, MD CMIO
    • HealthEast Care System
    • St. Paul, MN
  • Key Steps
    • Take Complete Inventory of Existing Paper Order Sets
    • Standardize Order Set Development Process
    • Standardize Order Set Format and Nomenclature
    • Develop Suggested OS’s for MD Review
    • User Acceptance Testing
    • Move Paper Order Sets On-Line
    • Promote Order Sets
    • Develop Feedback Mechanism, Maintenance Schedule and Tracking Log
  • Take Complete Inventory of Existing Paper Order Sets
    • Locate “pockets” or collections of order sets
    • Identify “owner” of each order set collection
    • Move all order sets into a secure master database
    • Create a master list of order sets
    • Begin the process of identifying duplicate and unused order sets
    • Match existing order sets with their counterpart from your content provider
  • Key Steps
    • Take Complete Inventory of Existing Paper Order Sets
    • Standardize Order Set Development Process
    • Standardize Order Set Format and Nomenclature
    • Develop Suggested OS’s for MD Review
    • User Acceptance Testing
    • Move Paper Order Sets On-Line
    • Promote Order Sets
    • Develop Feedback Mechanism, Maintenance Schedule and Tracking Log
  • Standardize Order Set Development Process
    • Establish a clear process for new order set development and existing order set revision
    • Identify core team (MD, nurse and pharmacist) for review and initial build
    • Establish/identify “Order Set Coordinator” to police the process
    • Leverage existing department and service line committees for order set content development and review
    • Identify key MDs for early order set review
    • Use email and online review tools (ViewSpace) to cut down review turnaround time
  • Standardize Order Set Development Process
    • More on the “Core Team”
      • Keep team small
        • One team for all order sets: MD, RN, Pharmacist
        • Or one team for each OS group (IM, Surg, Peds, CV, Ortho etc.) Depending on size of your organization and your resources
      • This team will get OSs “90%” complete
  • Key Steps
    • Take Complete Inventory of Existing Paper Order Sets
    • Standardize Order Set Development Process
    • Standardize Order Set Format and Nomenclature
    • Develop Suggested OS’s for MD Review
    • User Acceptance Testing
    • Move Paper Order Sets On-Line
    • Promote Order Sets
    • Develop Feedback Mechanism, Maintenance Schedule and Tracking Log
  • Standardize Order Set Format and Nomenclature
    • Identify format used by CPOE vendor (if known) and mimic this as much as possible
    • ADC VAAN DIMSLE is format familiar to most MDs:
      • Admit Diet
      • Dx IVs
      • Condition Meds
      • Vitals Studies (Radiology, etc.)
      • Activity Labs
      • Allergies Extra
      • Nursing
  • Key Steps
    • Take Complete Inventory of Existing Paper Order Sets
    • Standardize Order Set Development Process
    • Standardize Order Set Format and Nomenclature
    • Develop Suggested OS’s for MD Review
    • User Acceptance Testing
    • Move Paper Order Sets On-Line
    • Promote order sets
    • Develop Feedback Mechanism, Maintenance Schedule and Tracking Log
  • Develop Suggested OS’s for MD/Committee Review
    • Use core team(s) to:
      • Merge duplicates
      • Merge internal OS’s with content provider OS’s
      • Get content feedback from quality leaders
      • Develop suggested Evidence-Based Orders Sets (EBOS’s) to present to MDs
    • Get EBOSs 90% done and then apply your review process with Key MDs, RNs, pharmacists, ancillaries, committees etc.
  • Key Steps
    • Take Complete Inventory of Existing Paper Order Sets
    • Standardize Order Set Development Process
    • Standardize Order Set Format and Nomenclature
    • Develop Suggested OS’s for MD Review
    • User Acceptance Testing
    • Move Paper Order Sets On-Line
    • Promote Order Sets
    • Develop Feedback Mechanism, Maintenance Schedule and Tracking Log
  • User Acceptance Testing
    • Test usability of final EBOS’s in mock live or live environment
    • Script: “You are admitting a patient with a diagnosis of X, using this admission OS for X, what works, what doesn't work”
    • Process works best if you use MDs who were NOT involved in the development of the OS
      • Get a naive set of eyes looking at OS
      • Engenders more buy-in -> sense of ownership -> advocacy -> OS use
  • Key Steps
    • Take Complete Inventory of Existing Paper Order Sets
    • Standardize Order Set Development Process
    • Standardize Order Set Format and Nomenclature
    • Develop Suggested OS’s for MD Review
    • User Acceptance Testing
    • Move Paper Order Sets On-Line
    • Promote Order Sets
    • Develop Feedback Mechanism, Maintenance Schedule and Tracking Log
  • Move Paper Order Sets On-Line
    • Advantages
      • Version Control
      • MD “Buy-In”
      • Access
    • Disadvantages
      • Training
      • Process change
  • Order Set Retrieval Sight
  • Key Steps
    • Take Complete Inventory of Existing Paper Order Sets
    • Standardize Order Set Development Process
    • Standardize Order Set Format and Nomenclature
    • Develop Suggested OS’s for MD Review
    • User Acceptance Testing
    • Move Paper Order Sets On-Line
    • Promote Order Sets
    • Develop Feedback Mechanism, Maintenance Schedule and Tracking Log
  • Promote Order Sets
    • Don’t assume that if you build it they will come
      • Use MD newsletters and bulletins to promote quality outcomes from EBOS
      • Announce release of OSs at key committee meetings
      • Get them on the chart
        • If clear admit dx, unit clerk places appropriate OS in orders section of the chart
      • MD to MD follow-up for high target EBOS’s if OS not used for a given admit dx
      • Leverage MDs who “own” the OSs as advocates for their use
  • Key Steps
    • Take Complete Inventory of Existing Paper Order Sets
    • Standardize Order Set Development Process
    • Standardize Order Set Format and Nomenclature
    • Develop Suggested OS’s for MD Review
    • User Acceptance Testing
    • Move Paper Order Sets On-Line
    • Promote Order Sets
    • Develop Feedback Mechanism, Maintenance Schedule and Tracking Log
  • Develop Feedback Mechanism
    • Ensure end-user feedback on order sets is acknowledged as soon after it is received as possible
      • Script: “We received your feedback on order set X, thank you. Once we review your recommended change with other stakeholders we will get back to you on the status of this request.”
    • Ensure final decision on that feedback is communicated back to the end-user as soon after the decision is made as possible, including the reasoning behind the decision – especially if the recommended change is rejected
  • Develop Maintenance Schedule
    • “ When order sets are…inadequately maintained, they become templates for efficiently practicing outdated medicine on a widespread basis”
      • — A. Bobb et.al., JAMIA v14 Jan/Feb ’07 pp 41 – 47
  • Develop Maintenance Schedule (continued)
    • Develop a triage protocol for change requests
      • Emergent: “core team” identifies change as patient safety issue and initiates change immediately—change is communicated to stakeholders
      • Urgent: request for change is broadcast to stakeholders (via email or online tool) with expectation that final decision is made in 2–4 weeks
      • Routine: request for change is put into queue for routine review schedule for order set
  • Develop Maintenance Schedule (continued)
    • Determine frequency of routine review for your EBOS’s
    • Tie maintenance schedule to your existing committee meetings
    • Start order set review process 6-8 weeks prior to associated committee meetings
    • Track progress using milestones
  • Develop Tracking Log
    • Tracking log for your order sets should include:
      • Date order set first put into live environment
      • Dates changes to live order set were put into live environment
      • Routine Review dates: most recent and next
      • Associated order sets
      • Key stakeholders for order set: MD’s, committees etc.
      • Key contacts
      • Evidence sources for order set
  • Key Steps
    • Take Complete Inventory of Existing Paper Order Sets
    • Standardize Order Set Development Process
    • Standardize Order Set Format and Nomenclature
    • Develop Suggested OS’s for MD Review
    • User Acceptance Testing
    • Move Paper Order Sets On-Line
    • Promote Order Sets
    • Develop Feedback Mechanism, Maintenance Schedule and Tracking Log
  • Final Points
    • By establishing and mastering the order set development and maintenance process while on PAPER, you will not only be introducing less change to your organization at the time of CPOE go-live, you will also have more stable order sets to build into your CPOE system.
    • Online retrieval of paper order sets ensures that most recent versions of your order sets are being used at all times throughout the organization.
    • Engage MDs often in all stages of OS development to ensure Buy-in which leads to Ownership which leads to Advocacy which leads to OS usage
    • Changing order sets on paper is infinitely easier than changing coded and mapped order sets in your CPOE system