Thursday, May 6, 2010

Why don't the order sets work anymore?

One of the most frequent questions I get asked is :

Q : Why is it so hard to make the paper order sets work in our electronic EMR?

Sometimes, this is accompanied by stares of disbelief, or better yet, a suspicious glance, wondering if I'm 'just making this up'.

Here's the sad truth : No, you can't just put the paper orders on the computer screen and make them work.

Why that is, is a complex answer. I'm going to share two simple ways of looking at it.

Some people have tried to equate the electronic world and the paper world as "two different languages" - Anyone who has ever tried to translate between two languages will show you how difficult it is to translate idioms. E.g. "Hit the Road!", "Drop Dead!", "Happy as a clam!" are all idioms that don't translate too well into other languages.

This is where you see the cultural differences between electronic medicine and paper medicine - It just doesn't translate well.

The problem with this example is that people who aren't bilingual won't really appreciate this difference. (Many people seem puzzled to find out that the best interpreters are only about 95% accurate... Usually, 90% is good enough for most communication, so it generally works.)

THE INFORMATICS ANSWER : (Easier to understand, trust me!)
The Informatics answer to this question requires one to understand some basic premises of information science.
1. An order set is a group of lab and medication orders which can either be ordered, or not, depending on a physician's or nurses's decision when they execute the order set.
2. Clinical Documentation is something your clinicians will write on a piece of paper, or a form, to document what's going on with the patient.
3. Clinical Protocols are essentially "if-then" instructions that tell your staff how to react in a particular patient situation, to achieve a certain goal.

So here's the problem most people face when trying to translate from the electronic world to the paper world : Most "paper-based" hospitals have paper order sets with pieces of documentation and clinical protocols built into them.

Q : Huh? How is that possible? My order sets have policies and documentation built into them?!?

The truth is often : Yes.

Q : How did that happen?

Basically - Paper is flexible. You can write anything you want on it.
Computers are much more fussy about :
  1. Where protocols go (read-only)
  2. Where documentation goes (read/write, for your clinicians to use)
  3. Where order sets go
Q : I'm still not sure I get it.

Let's look at this another way.
  • On paper : [Protocol + Order set + Documentation] = All on one sheet of paper, often labelled "Order Set"
  • Electronic : [Protocol] + [Order set] + [Documentation] = All go in different places in your EMR.
Q : So what do I have to do, then, to make my paper order sets electronic?

It takes work - To fix this, then, means someone has to separate your paper order sets into :
  1. Clinical Protocols
  2. Order sets
  3. Documentation (Notes, forms, etc.)
Q : Can you give me some examples?

Sure. Let's make up a hypothetical order set - Not based in reality, I assure you, but not uncommonly seen before a hospital "goes live with CPOE"...

Sometimes on a paper order set you will see things like this :
[Line 1] ( ) Tylenol 650mg PO q6 hours PRN mild (1-3) pain
[Line 2] ( ) Percocet 5/325 (1) tab PO q6h PRN moderate (4-6) pain
[Line 3] ( ) Morphine 2mg IV q30 minutes PRN severe (7-10) Pain
[Line 4] These orders are only to be used in Emergency Department!
[Line 5] ( ) If O2sat is less than 85% check ABG STAT and call MD.
[Line 6] Please assess vitals and assess respiratory rate : ________ breaths/minute
[Line 7] If patient respirations less than 10 then give Narcan 0.4mg IV x1 dose STAT and call MD.

Let's examine this hypothetical order set above...
  • Line 1 = Fine order. No problem putting this into an electronic order set.
  • Line 2 = Fine order. Again, no problem.
  • Line 3 = Fine order. Glad to see pain levels specified for patient safety! Again, no problem.
  • Line 4 = Problem. By saying "These orders are only to be used in the ED", this is technically a clinical protocol. Essentially, it tells a nurse : "If the patient is discharged from the ED, these orders must be discontinued by a nurse."
  • Line 5 = Similar problem. This is actually a clinical protocol. Needs to be written into a separate document, instructing a nurse what to do if the O2sat drops below 85%.
  • Line 6 = This is also a problem, because it's clinical documentation. Needs to go on a separate form to work with this order set.
  • Line 7 = Another clinical protocol. It also suffers from the problem : How do you execute an order for Narcan at some point in the future, when you're running this order set now? Again - This needs to be a clinical protocol.
So to fix this paper order set would require designing new documentation and new clinical protocols to function with this order set. You typically end up making a whole lot of new clinical policies and documents and need the committee structure that can handle this in a nimble way. Phew!

Q : This seems like a lot of work, isn't there some simpler way to do this?

It is a lot of work! And there isn't a really simple way to do this. If there were, hospitals wouldn't often look for specialist help to convert to the electronic world.

Next article, we'll talk about "Why didn't the vendor give us order sets that work?!?!". Stay tuned. :)

1 comment:

Unknown said...

You explained well, how an idiom cannot be translated exactly in any other language. The linguistic system, is vast chapter, one has to experience it to understand it.
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