Order Sets, Done Well
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Landa says the aggregation of order sets also adds other vital information: "What are the patient's allergies? What's the patient's kidney function? What has the patient responded to before? What do we have in our formulary? What is specific about our patients versus someone in another state? And then eventually we're going to get down to genomic data and say, 'Okay, this person has this particular genetic makeup, therefore they will respond much better to drug A than drug B.' And that's when we're going to be completely lost, because no one's going to be able to keep track of that stuff."
For some providers, achieving shared order sets requires a journey that gets doctors talking to each other about topics rarely broached.
"Docs don't talk to one another," says Marc Chasin, MD, MMM, CPE, system vice president and chief medical information officer at St. Luke's Health System in Boise, Idaho. "You could be in an office for 20 years with a partner and not really talk for those 20 years. You're just doing your thing."
Chasin arrived at St. Luke's, a nonprofit system that serves Idaho and eastern Oregon with six hospitals and other facilities, in 2010. "I looked at all the docs in the ambulatory environment and divided them up by specialty and by geography," Chasin says. "I started getting them together, with the sole topic of trying to come up with an order set for certain disorders. My intention was, it was a bit nice if I had an order set. But my greater intention was to get them talking, so they could figure out that they're more alike than they're different."
Most critically, Chasin says, "you have to get critical mass in engaging your clinicians. If it's done by the hospital, it's not going to work."
One hospital that tried that top-down approach was Maimonides Medical Center in Brooklyn, N.Y. In June 2010, the hospital changed EMRs from an older system to Allscripts Sunrise Clinical Manager and at that time built a host of admission order sets, says Zachary S. Lockerman, MD, MBA, FACG, director of clinical information technology and physician practice integration at Maimonides, a 711-bed nonprofit that had FY2010 total operating revenue of just under $1 billion.
"These order sets were very large, very cumbersome, and didn't really promote efficiency," Lockerman says. "Many are not used. There are a few generic admission order sets that are used, but the bulk of orders are probably placed outside of those order sets."
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