A Road Runs Through These Order Sets

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

Can a wiki share and standardize order sets? R. Dirk Stanley, MD, MPH, aims to find out.

"The fact that they're not standardized across the country leads to enormous costs and inefficiencies in healthcare," says Stanley, chief medical informatics officer at Cooley Dickinson Hospital in Northampton, Mass. "For example, if you have a doctor who's moonlighting, you know if you have a doctor from hospital A that you need to fill a shift in hospital B, if the doctor doesn't know what order set, kind of how the clinical functions operate, then it means you basically have to retrain the doctor on your clinical functions, but that's a lot of time and a lot of money."

Informally, order sets are finding their way from provider to provider through several routes today. Incoming residents are a source. Another is occasional informal exchange of order sets on the online forum run by the Association of Medical Directors of Information Systems.

Stanley recently began meeting with colleagues all along the Interstate 91 corridor in New England to help build a structure for sharing information.

"If you invent safety belts, is it really fair that you keep the patent for safety belts all to yourself?" Stanley says. "If you know you have something that can help improve care and improve safety and reduce costs, why wouldn't you share it with other people? I figure if I can share things with other people, then maybe they'll help share their lessons with me, and together we can actually reduce each others' operations costs and improve each others' safety."

Like the highway itself, Stanley's wiki-powered I-91 Informatics Group is a shared project that benefits everyone, Stanley says. Order sets are only one area of interest. Stanley sees it as a way to share protocols, documentation, policies, and procedures. "When a carpenter builds a house, there are standard tools that every carpenter knows how to use and maintain," he says. "I'm hoping that together we'll be able to write the book on how to manage the tools and make them better and make them more affordable and safer."

The consortium's barn-raising attitude is partly born in the high cost of purchasing order sets from companies such as Zynx and Provation, Stanley says. "Even when you get those canned products, you have to review; for example, do we have this drug in our formulary?" Stanley says. "In hospital A, they might use levofloxacin, and in hospital B they might use ciprofloxacin. If the standardized order set has levofloxacin, but you don't have that on your hospital formulary, then you have to fix the order set. Usually somebody still has to go through line by line to ensure the proper functioning and safety of every single order in the order set, and what you start to learn is, even when you get one of those canned solutions, it's still a lot of work."

Because EMR vendors are also offering their own order set suites, contractual restrictions and competitive considerations make efforts such as Stanley's an uphill battle. "Do you know how hard it is for me to call another health system and request their clinical content?" says Marc Chasin, MD, MMM, CPE, system vice president and chief medical information officer for St. Luke's Health System in Boise, Idaho. "When they've spent so much time and money developing their content, why would they give it away?" Thus, the sharing Stanley envisions may be a crowdsourcing and barn-raising strategy used by smaller providers to compete more effectively with their bigger rivals.

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