Tuesday, August 31, 2010

The Cost of Hidden (Embedded) Protocols in your Order Sets

I've recently been paying a lot of attention to the cost of hidden and embedded protocols in healthcare. When physicians argue about the efficiency of EMRs, I think this is really what they're talking about.

Let me explain.

Know that tool we commonly use in healthcare, known as the "clinical protocol"? Common examples of this tool found in most hospitals include the "heparin protocol", the "insulin protocol", and the "STEMI protocol". You've probably heard of them.

So what exactly is a protocol?

A protocol is a set of well-defined care instructions and conditional statements which allow nurses, pharmacists, respiratory therapists, and other licensed medical professionals to initiate, modify, or discontinue an order, on behalf of the ordering physician, as instructed by the protocol. Any conditional statements (IF/THEN arguments) in a protocol should refer to a discrete, well-defined data element. Protocols are primarily activated/deactivated by a physician order, but may in rare instances be activated by a clinical policy in situations where regulatory laws permit (e.g. "pharmacy substitutions" are a common protocol/policy combination). Protocols are typically published through a printshop or an electronic site.

Where did that definition come from? CMS? Joint Commission? Neither. I actually penned it. It probably could use work, but it's a start, and since neither AMIA, HIMSS, Joint Commission, or CMS endorses a particular definition of this tool, I had to write it myself. (Feel free to use the definition for your own uses, and comments are definitely welcome!)

Protocols are generally loved by physicians - They generally allow other healthcare professionals to automate a process on behalf of the physician. The Heparin protocol allows nurses to titrate heparin on their own. Respiratory protocols generally allow a respiratory therapist to manage a vent automatically. And so on.

And here's the surprise : Protocols are sometimes found in many more places than just those sheets.

I think the easiest way to spot a protocol hiding somewhere else is the reference to a conditional statement - An IF/THEN - That allows someone to initiate, modify, or discontinue an order on behalf of the physician who ordered the protocol, as defined by the protocol.

So if you use the "IF/THEN" as your guide, try taking a look at your old paper order sets - you may be surprised when you start to notice a bunch of conditional statements (hidden protocols) in them, such as :

1. "Advance diet as tolerated"
2. "Out of bed as tolerated"
3. "These orders are only supposed to be active in the _______ department."
4. "Titrate sedation for comfort".
5. "Use this drug, unless patient is allergic, then use this other drug" (or some variation of that theme...)

From an engineering standpoint - Having all of these little pieces of embedded protocols hidden in your order sets makes it very difficult to convert a paper order set to the electronic form. Why?

Because computers are unforgiving.
  1. Electronic Order sets generally go in one specific section of your EMR.
  2. Protocols (If/then statements) generally go in another section of your EMR (or your hospital intranet, depending on how you publish them.)
So how did they live, so long, hidden in your paper world?

Because paper is forgiving.
  1. Paper Order sets can have "IF/THEN" and other conditional statements in them.
Q : "So Dirk, what exactly is the cost issue then?"

Here's the challenge : In converting paper order sets to electronic order sets, often, depending on the design, you have to decide what to do with these hidden embedded protocols.
You basically have two choices :
  1. Develop the protocol, but this often takes a significant amount of time and committee and policy work, OR....
  2. You simply leave the protocol out of the new electronic order set.
What ends up happening, often? Order set designers are forced to simply leave out most of these conditional orders (embedded protocols) in the new electronic world.

As a result, this is why, often, the electronic order sets :
  1. Don't LOOK like the paper order sets.
  2. Don't FUNCTION like the paper order sets.
Q: "So Dirk, again, where's the cost issue?"

Well, here it is : If your electronic order sets have been stripped of all of the hidden, embedded protocols found in your paper order sets -

Then your physicians, on "going electronic", may notice many more phone calls from nurses looking to clarify orders that were previously initiated, modified, or discontinued by these embedded protocols.

And you may notice efficiency changes after you "go electronic".

Q : "Wow. And is there any way to help avoid this?"

It takes a lot of work, but fixing this "hidden protocol cost of EMR implementation" will depend on various factors :
  1. How many "hidden protocols" you had in your paper order sets, to begin with. (They generally appear more often in specialties that are not in-house 24/7.)
  2. How reliable your protocol framework is.
  3. How efficient your committees are at examining protocols for safety and approving them.
  4. Your informatics resources, to analyze the workflows, and re-engineering those protocols absolutely necessary for safe workflow to continue.
The cost of not fixing it? Your physicians may sense a significant slowdown after your EMR go-live.

This is where the lack of a Joint Commission-endorsed, or CMS-endorsed definition, causes a problem. By not having a standard definition for hospitals to work with, many protocols go hidden in policies and order sets. (When there isn't a good definition for a protocol, it's easy to engineer them into the wrong tools.)

Avoid the problem by :
  1. Trying to avoid these hidden, embedded protocols in your paper order sets, as much as possible.
  2. Having a robust informatics platform before your EMR and CPOE and documentation go-live dates, to help analyze the paper order sets and begin re-engineering those protocols that are absolutely essential for proper functioning of your hospital.
  3. Making sure your committee structure can analyze these necessary protocols for safety, and approve them in a timely manner.
Again, enjoy! I hope this helps! :)

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