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. :)


rvaughnMD said...

Standardization is very important to creating highly reliable outcomes. Unfortunately good evidence is only available for about 20-30% of health care. This does not mean that we should encourage a 'free for all approach' because we can't currently prove one way is better than another. We need to use the EHR as a tool to organize continuous investigations to discover best care. Unfortunately most organizations are so focused on impementing an EHR and 'getting the dollars' for Meaningful Use that they are not properly focusing on creating the clinical infrastructure for achieving consensus and love of change. Intermountain Health Care remains the best example of how to use informatics and EHR to discover new best practices, rapidly implement them across the organization and achieve improved outcomes measured in lives saved. Dr. James feels they have the potential to publish 1000 articles a year based on their continuous improvement process. Buying and installing an EHR will not transform your organization alone; investment in physician informatics leaders, and unparalleled medical staff engagement is an absolute requirement to achieve better outcomes.

Dirk Stanley, MD, MPH said...

Agreed - And most people don't appreciate the cost of maintaining an order set. IMHO they should, like policies, only be built when there is a clear need to standardize a particular process. Letting docs "make their own" is a quick fix for not investing in informatics, but you will lose out on the ability to make changes, cut costs, and improve care quickly.