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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
  • Transcript

    • 1. Order Set Development
      • Managing the Transition from Paper
      • to Electronic Order Sets
      • Brian D. Patty, MD CMIO
      • HealthEast Care System
      • St. Paul, MN
    • 2. 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
    • 3. 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
    • 4. 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
    • 5. 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
    • 6. 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
    • 7. 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
    • 8. 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
    • 9. 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
    • 10. 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.
    • 11. 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
    • 12. 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
    • 13. 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
    • 14. Move Paper Order Sets On-Line
      • Advantages
        • Version Control
        • MD “Buy-In”
        • Access
      • Disadvantages
        • Training
        • Process change
    • 15. Order Set Retrieval Sight
    • 16. 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
    • 17. 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
    • 18. 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
    • 19. 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
    • 20. 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
    • 21. 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
    • 22. 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
    • 23. 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
    • 24. 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
    • 25. 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