Thursday, June 3, 2010

Denial, Anger, Bargaining, Depression, and Order Sets

More answers to questions about order sets.

Another common question I get asked, actually usually comes to me in one of three flavors :

1. "You mean we spent all of this money on an EMR, and they don't even give you decent order sets?"
2. "Can't we just copy order sets from ______ hospital? I have a friend there!"
3. "Can't we just scan the paper order sets and make them electronic?"

These are all variations on the same theme - What you purchased doesn't seem to fit, and there MUST be an easier way to do this.

I get this fairly commonly.

Many EMR vendors will sell you some sort of package of "Pre-made order sets". Beware! What vendors think of as "pre-made order sets" and what most administrators/clinicians think of as "pre-made order sets" are very different.

Pre-made order sets from a vendor are typically built around common clinical scenarios that most hospitals share in common - The CHF exacerbation, the pneumonia, the chest pain, the pre- and post-op patients.

The problem : A vendor has no way of knowing the exact idiosyncracies of your hospital or office. So they design something in a "one-size-fits-all" kind of way. (Think of it as a "one-size-fits-all" suit - Yes, it'll be too big for most people, but at least everyone can fit into it.)

So typically, these order sets tend to be VERY long, including EVERY evidence-based test and study and medication you can possibly think of.

When most doctors look at these lengthy, one-size-fits-all order sets, however, their first reaction is often : "What?!?! This is WAY too big!! We don't need all this stuff!!"

So the only way you end up trimming this order set to your particular hospital's culture is to go through the entire order set, line-by-line, and checking to see what you need and what you don't.

In the end : You usually end up doing the same amount of work you would as if you started from scratch.

Yes, this leaves many doctors and administrators frustrated. Some will complain to the vendor about this.

A vendor *could* try to help, and take a "best-guess" approach, and try to trim their "standard CHF admission" order set down - But this would leave 1/2 of their customers more happy, and 1/2 of their customers less happy. (Now, think of it as the vendor trying to make a smaller suit - It'll fit 1/2 of their customers better, but 1/2 won't be able to fit in the suit at all.)

Again - This is why the pre-built order sets often leave doctors and administrators frustrated.

After experiencing this phenomenon, clinicians and administrators will often go into "bargaining mode" - You may hear things like "I have a friend who can give us their order sets!" or "I found a web site with order sets!" or "Can't we just scan our paper order sets?"

The problem is - These order sets generally suffer from the same problem as the "best-guess" approach I described above - The suit may fit, if you're lucky, but it also may not. Often, getting order sets from a friend, or from a web site, or from your old paper version is a lesson in frustration, and again you have to tailor it to your hospital with your culture and your clinical circumstances.

In short : Thinking there is a "quick fix" to your order set problem is like thinking there's a "quick fix" to having a custom-made suit. Order sets, like a well-fitting suit, need to be tailored and adjusted and updated regularly.

Remember - It's the custom-fitted suits that look good - In the same way, custom-fitted order sets are the ones that doctors will *want* to use, will help increase your efficiency the most, and ultimately help cut your hospital's operating costs.

So ask yourself before you buy an EMR - Do I need a tailor to help build and adjust these order sets? Or can I get copies from other people, and hope they'll fit?

My advice : Make sure you have a tailor when you go electronic! :)


Vince Kuraitis said...

... of course, another way to look at this is to ask "Why is there such high variability across hospitals in order sets for 'common' conditions."

rvaughnMD said...

Nice job Dirk! We experienced a lot of angst around order set names (almost no meaning at all in the electronic world) and arguments about creating complete admission order sets for a lot of diagnoses vs. using multiple order sets for an ordering session (pick the general admission order set and add in condition specific order sets as needed). Also I would add that the electronic conversion eliminates the human interpreter (ward clerk) and delays in routing the orders - hence the need for additional precision compared to paper.

Vince - 1. A lot of what Dirk is describing is related to appropriate local variation like hospital formulary (free market in action), order routing and idiosyncratic operational workflows (nurse draws blood vs. lab drawing blood). 2. We have proven EBM for a minority of clinical decisions. 3. A lot physician ordering behaviour is established by where the physician trained. They gain confidence in that subset of choices and tend to stick to it unless forced out of their comfort zone.

Dirk Stanley, MD, MPH said...

I think you both have valid points - Vince, you're right, it's odd that there is such variability between order sets. All I can tell you is that they behave a bit like chaos theory - All it takes is a small difference in physical layout, or nursing policy, or state regulations, and you suddenly have a completely different workflow and thus different order sets. It's very hard to "predict" what order sets will be needed - The better option is to look at what people are already doing, and start to tailor the suit to fit properly. :)