Order Sets, Done Well

Compounding the problem, because they were designed as admission order sets, these order sets were not stackable, he says.

"If you have a patient who comes in with multiple diagnoses, you can only pick one order set," Lockerman says. "So our typical patient who comes in with pneumonia, CHF, a urinary infection from a nursing home, and a decubitus, you had to pick the one that covered most of the orders."

If instead the physician decided to use admission order sets for three conditions, there would be a lot of check boxes to uncheck, crippling efficiency, Lockerman says.

Lockerman would like to replace these order sets with a new tiered set, with admission-level order sets, floor-level order sets, and disease management order sets. "Those should be very small and very focused, and should only have best practices in them, not all the choices that we have now,"
he says.

The new tiered order sets will be easy to build and maintain, and will be stackable, Lockerman says. "If the patient has four diagnoses, you could pick each focused order set that will have just the things that they need or should always be done. A pneumonia order set would have community-acquired, hospital-acquired, penicillin-allergic, and nonpenicillin-allergic branches." The EMR "should actually pretty much pick them for you, and then what cultures and maybe one or two other things that are in there, that are required, but not have all the extraneous stuff in them."

Right now, planning for these new disease management order sets at Maimonides is "in the conceptual stage."

Part of the chicken-egg challenge of building these order sets is engaging physicians in the early use of some form of the order sets  to garner meaningful feedback on needed improvements.