Order Sets, Done Well

This article appears in the December 2012 issue of HealthLeaders magazine.

As adoption of EMRs and CPOE continues, an old debate heats up: How do providers strike a balance between standardizing order sets and customizing care for each patient?

The payoff for more standardized order sets is more reliable care, better outcomes, and greater physician satisfaction.

"Order sets are one of the first lines of clinical decision support within an electronic health record," says Howard Landa, MD, chief medical information officer of the Alameda County Medical Center, an Oakland, Calif.–based system with 475 licensed beds on three hospital campuses, and several ambulatory care centers.

"Order sets basically are groupings of orders used to standardize andexpedite the ordering process for a common clinical scenario," says R. Dirk Stanley, MD, MPH,  chief medical informatics officer at Cooley Dickinson Hospital, a 140-bed acute care facility based in Northampton, Mass. He has formed an ad hoc group of New England providers to try to share and standardize order set technology (see related story, page 45).

Landa says order sets represent the distillation of the science in evidence-based medicine into instructions that can be aligned with a given patient's conditions and history. But because electronic health records are also the new focus of doctor-patient interactions, the order set can be seen as a threatto the traditional supremacy of the doctor's opinion during the treatment of care.

"Clinical decision support is not alerts and reminders," Landa says. "Clinical decision support is the building of a system that facilitates the care of an individual patient based on their conditions and history."

Putting a list of questions together formed around evidence-based medicine isn't that difficult to do, Landa says. "Everyone knows you give antibiotics to people who have infections, and for this infection here are the best antibiotics."

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."

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.

"We came to our clinical leaders, whether it was a division leader, department leader, or the residents in the trenches, and we asked them what they wanted in the order sets," Lockerman says. "Not having lived with this system, they couldn't answer the question. They thought they could, but not knowing how the system functions and really having a sense of how they were going to live and breathe within this system, they were not in a position to really answer the question."

Lockerman's advice is to respect the learning curve and gradually grow order sets and their adoption.

Another strategy, if the provider hasn't implemented an EMR yet, is to start with existing paper-based order sets, which can provide a gentler transition into EMRs than implementing new order sets at the same time as the EMR, says Alameda County Medical Center's Landa.

"We took a system that essentially took our paper order sets and 'electronified' them so the physicians would use an electronic system to create the orders, but at the end of the ordering session, it just drops them to paper," Landa says. "We handed that paper to the nurses the same way we did with paper order sets before, so it didn't really impact their processes dramatically, but it still allowed for us to use the electronic tools without necessitating all of the overhead."

Well-implemented order sets can also smooth the way for other meaningful use of electronic medical records by physicians. "Doctors are not really good at conforming," says Landa. "We like doing what we want to do. So by giving them real benefit—the tools actually speeded their process—they were willing to do the little bit of extra work that they knew they needed to do but didn't always get to. By having an order set that addressed everything they needed in one place, [physicians] went along and didn't buck against the decision support as physicians often do."

Reprint HLR1212-6

This article appears in the December 2012 issue of HealthLeaders magazine.