Monday, October 25, 2010

Why not let docs have their own order sets?

Last week, I was asked a question I'd been asked many times before, by someone who was helping another hospital set up their EMR :

"Why shouldn't we let our docs make their own order sets?"

The reason I was asked this is because many EMR packages have this feature, where docs can make their own order sets for their own convenience. 

  1. Every doc struggles with efficiency, and making your own order sets certainly is tempting. Why not make order sets that accomplish exactly what you want? After all, if I'm a practicing physician, and I know what orders I 'always put in' in certain scenarios, why shouldn't I be able to make my own order sets?
  2. We could save so much committee time if the docs could just make their own order sets!
  3. If the docs could make their own order sets, they would probably feel "more comfortable" with order sets and CPOE, in general - Wouldn't this help us with our EMR implementation? Wouldn't we get a higher CPOE rate faster?
  4. It would save the time and labor of converting their old paper order sets - (Which, as I've discussed in past postings, are often loaded with embedded protocols which are expensive and time-consuming to engineer out!) - Just let the doctors make their own order sets!
  5. If docs could make their own order sets, then they probably wouldn't blame some poor informaticist for making a bad order set for them.
  1. If every doc can make their own order sets, you have no centralized mechanism for clinical decision support. For example, if your pharmacy previously paid a lot for omeprazole, and it suddenly gets a good deal on pantoprazole, you will probably want all of your doctors to take advantage of the cost savings by steering them towards pantoprazole (when backed by good evidence) - If they all have their own order sets, you won't be able to help guide physician behavior and take advantage of this cost savings. 
  2. If every doc can make their own order sets, you also have no centralized mechanism for standardizing care. E.g. an appendectomy could get very different care, depending on which physician was using which appendectomy order set. (Most hospital administrators are trying to standardize care to improve quality and reduce costs.)
  3. Order sets need to be maintained regularly, to be kept safe, evidence-based, and efficient. If every doc can make their own order sets, you may quickly end up with many, many different order sets which can be a challenge to maintain, from a technical standpoint. What are you going to do when new guidelines suggest you should be using different drugs to treat pneumonia? How will you find which order sets you need to update? Do you have the resources to keep ALL of your order sets updated? 
  4. If every doc can make their own order sets, you will miss out on the opportunity to teach your physicians what informatics is, and how they can improve their own care through evidence-based practice and standardization of processes.
I will admit, as a practicing physician, myself, there are times where I wish I could just make my own order sets. But I will also admit that being challenged on my own order sets is a great learning experience, and ultimately, sharing the discussion with my colleagues, and reviewing the literature is the best learning experience of them all. 

(Apparently I'm not the only one who frowns on personal order sets - A final web page, worth reading even though the author is unclear and this looks more like a comment than a legitimate argument : 

Ultimately, every hospital will need to make this decision for themselves, but remember, as I said - With order sets, there are no free lunches. The rule still applies. :)

Friday, October 1, 2010

Top things to do with your new CMIO

Dear CMIO-owner,

Congratulations on your new CMIO! With a few simple care instructions, your CMIO will serve you well and last a long time.

Here are some of the things you can do with your new CMIO :

1. Ask him/her to help design and develop an informatics platform for your healthcare organization.
2. Ask him/her for advice on how to budget for your next clinical IT project.
3. Instruct him/her to do clinical workflow analysis before you implement your next EMR rule.
4. Ask him/her for expert advice on clinical decision support - What it is, and why it could help your hospital.
5. Ask him/her to help fix and update your order set process to include evidence-based order sets.
6. Ask him/her to help dissect and improve your paper order sets.
7. Ask him/her to help design training curriculum for your physicians, and develop a training plan.
8. Ask him/her about "EMR Governance" and why people seem to write so much about it.
9. Instruct him/her to attend your Medical Executive Committee meetings and give expert input about clinical workflow issues.
10. Ask him/her to develop ARRA/HITECH educational summaries for your senior leadership.
11. Ask him/her to develop EMR implementation strategy.
12. Ask him/her for policy help in developing policies needed to support your EMR.
13. Ask him/her "What is informatics?" and "Do we need it?" and "Is this something other people should know about?"
14. Ask him/her to help develop physician buy-in for CPOE, Order Reconciliation, and other enterprise-wide EMR projects.
15. Ask him/her to build approval policies for your clinical tools.
16. Ask him/her to manage software upgrade projects.
17. Ask him/her to design informatics education materials for your department directors.
18. Ask him/her to network with other CMIOs to look for workflow solutions that meet the tough compliance questions.
19. Ask him/her to develop datamining solutions, so you can get quality data OUT of your EMR.
20. Ask him/her to work with your Chief Medical Officer (CMO), Chief Nursing Officer (CNO), and other leaders to fully implement your EMR and the order sets, protocols, and policies needed to support it.

We recommend keeping your CMIO out of direct sunlight, make sure he/she has a warm place to sleep, and most of all, never feed him/her after midnight.


The Manufacturer