Tuesday, March 15, 2011

How to Install an Informatics Policy Framework, and Why?

A common question I get asked is :

Q: "Dirk... We have over 600 different order sets... Now we can't save money on formulary costs, because the doctors still keep ordering the old antibiotics on the old order sets. What can I do?"

The answer is simply : You need to define your standards. By defining a standard way in which your order sets will be built, you can do a lot to "clean up the order set catalog".

STEP 1 : You will need to decide : Should we let doctors make their own order sets?
Pros : Less work to build order sets, and docs can build exactly what they want.
Cons : Less organizational control over standardizing care, less control over costs, higher maintenance costs.
If you decide 'we want to standardize our order sets', proceed to Step 2.

STEP 2 :  You will need to convince your medical staff of the need for such standards. Create the following policy, then bring it to your medical executive committee for approval as a "General Clinical Policy". This will allow you to have a chapter of informatics policies in your clinical policy manual, and then start building a number of informatics policies to fill that chapter.
POLICY NAME : Chapter of Informatics Policies
POLICY : "All patients at Acme Hospital will be cared for with clinical information tools developed according to policies outlined in the chapter of Clinical Informatics Policies."
Clinical Tools - Any documents or other tools used to guide the delivery of clinical care. These may include, but are not limited to : Policies, Procedures, Orders, Order Sets, Protocols, Documentation/Forms, Templates, Patient Education Modules, Staff Education Modules, Charters, Schedules,  and Minutes. 
A. Staff will consult the chapter of Clinical Informatics Policies prior to the construction of any clinical tool.
B. Staff may ask the Director of Clinical Informatics for guidance if any questions arise regarding the construction of these tools.
If you've designed this correctly, and your medical staff understands the issues, this should generate some discussion before it gets approved.

STEP 3 : You will then need a committee to help approve the policies that go in that chapter of Clinical Informatics Policies. Develop a committee charter, and bring it to your medical staff for approval.
Charter : Clinical Informatics Committee
Meeting Frequency : Monthly
Jurisdiction : Reports to Medical Executive Committee
Purpose/Task : To approve Clinical Informatics Policies on behalf of the Medical Executive Committee
Quorum : 50%
Voting Structure : By majority
Chairperson : The CMIO
Voting Members : ___________, ___________, ____________, _____________ 
If you can't get this committee approved by your Medical Executive Committee, then you will need to bring all Clinical Informatics Policies to the MEC for approval.

STEP 4 : Come up with a standard policy definition for an order set.
"An order set is a grouping of orders used to expedite and standardize the ordering process for a common clinical scenario."
"An order set is a document with a group of orders, used to expedite and standardize the ordering process for a common clinical scenario."
or even better yet...
"An order set is a document with a group of orders, with evidence-based links, that is used to expedite and standardize the ordering process for a common clinical scenario. All orders on an order set are started, modified, and stopped by a licensed physician."
Any of the above definitions should suffice, depending on your need for clarity.

STEP 5 : Use that definition to write your first good informatics policy, in your chapter of informatics policies, to standardize your order set development.
POLICY NAME : Order Set Development Policy 
POLICY : "All order sets will be built according to the procedure outlined below."
Order Set - A document with a group of orders, with evidence-based links, that is used to expedite and standardize the ordering process for a common clinical scenario. 
A. Order sets will be owned by a Clinical Director.
B. Order sets will be designed by an Informaticist and a Clinical IT Analyst.
C. Order sets will be tested by the Clinical Director and Informaticist and subject matter expert, using  at least (1) doctor and (1) nurse, in a testing environment.
D. Order sets will be presented by the Informaticist to the Chairperson of the Order Set Committee for placement on the Order Set Committee Agenda.
E. Order set creation, change, and deletion will be approved by the Order Set Committee at the next available meeting.
F. Order sets will be published in the Order Set Catalog in the Electronic Medical Record.
G. Order sets will be monitored by the Owner (Clinical Director). 
STEP 6 :  Bring the policy you wrote in Step 5 to your Clinical Informatics Committee (so they can approve it on behalf of your Medical Executive Committee), OR if you can't get your Med Exec to approve the committee charter, bring the policy to the Med Exec for approval.

Voila! If you were successful, you should now have :
  1. A chapter of Clinical Informatics Policies, in your clinical policy manual, that has been approved by your Medical Executive Staff.
  2. A charter giving authority to a Clinical Informatics Committee to approve Informatics Policies on behalf of the MEC.
  3. Your first Clinical Informatics Policy outlining the steps required to build, test, approve, and publish a standardized, evidence-based order set
  4. Your first meaningful change management mechanism for implementing electronic decision support and clinical workflows.
Once you have this rudimentary framework in place, you can then start working on updating the old 600 or more order sets. And if your order set committee is multidisciplinary and well-balanced, you can get balanced input before the order set goes live.

And your Informatics Committee can nimbly continue to develop informatics standards/policies that govern all of your clinical tool development.

This then brings you to Step 7 :
- Bring any old order sets to your order set committee for consideration of speedy deletion from your catalog.
- Build any new order sets according to the standard procedures outlined in the Order Set Development Policy (outlined above).
(You will probably need to tweak/format these policies to meet your organization's needs.)

I hope this was educational! Would love to hear how other folks handled their Informatics Policy framework! Remember, my advice is free, and as always, you get what you pay for. :)

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