Friday, March 25, 2011

What is an Order Set?

It's funny. When I first got involved with electronic medical records at the Albany VA Hospital, as a resident, I remember one of their informatics people telling me, "You have no idea how political order sets are. The arguments I have seen over whether to check or uncheck a box... It's unbelievable."

She was right.

After you go electronic, prepare for the political discussions about order sets. Lots of people have opinions, but not many are actually are involved with building, testing, or development of order sets or using them.

So I thought I'd present this primer, to help people understand - "It's not just a bunch of orders with boxes." :

What is an Order Set?


An order set is a grouping of orders, used to standardize and expedite the ordering process for a common clinical scenario.

Before an order set can be created, the goal of the order set must be clear. Any necessary orders, contained in the order set, must be built first. (Order sets for new or innovative workflows should first be examined for any new orders that need to be engineered first.)

Order sets should only contain orders. They should not be confused with :
  1. PROTOCOLS - Conditional IF/THEN statements, allowing a nurse/pharmacist/other licensed medical professional to start/modify/stop orders on behalf of a licensed physician, to automate and standardize the care for a common clinical scenario.
  2. CLINICAL PATHWAYS - Tools used to standardize the discussion and goals of therapy, during rounds, for a common clinical diagnosis.
  3. CHECKLISTS - Documentation tools used to document, standardize, and expedite the screening process for a common clinical scenario.
  4. POLICIES - Agreed-upon standards for your organization
  5. PROCEDURES - Detailed steps about how to achieve a desired standard.
  6. PATIENT EDUCATION MODULES - Documents that help educate a patient about a particular subject (e.g. diet, disease, procedure, or aftercare)
  7. STAFF EDUCATION MODULES - Documents that help educate a staff member about a particular subject (e.g. diet, disease, procedure, or aftercare)
  8. DOCUMENTATION - Tools that help record and transmit patient history, condition, activities, responses, laboratory values, radiology images, and notes
  9. GUIDELINES - Educational tools to help educate a staffmember about a general clinical objective (more flexible and negotiable than a policy)
For maximum safety, order sets should be built :
  1. With clarity and a standard layout (Please see the ISMP Guidelines).
  2. With all necessary information required to safely complete the order set.
  3. With only those automating features which are absolutely necessary. (Risks/benefits of pre-checking orders must be closely examined on each order. As a general recommendation, pre-checking orders should be avoided on medication orders.)
  4. With evidence-based practices.
  5. To reduce variation and unintentional oversight.
  6. To prompt for all necessary information.
Order sets can range widely in complexity, from very simple convenience order sets, to very complex order sets used to trigger clinical pathways or protocols.


Order sets typically fall into one of two primary categories :
  1. Charge Order Sets - Those used by nurses and other clinical staff to create charges for common clinical materials (e.g. gauze, dressings, etc.)
  2. Physician Order Sets - Those used by physicians to standardize and expedite the ordering process for a common clinical scenario.
Physician Order Sets may vary widely in complexity, but typically come in one of several types :
  1. Admission Order Sets - (Sometimes called "Venue-specific order sets") - Used to admit a patient to a particular attending, level-of-care, and service.
  2. Transfer Order Sets - Used to transfer a patient to a particular attending, level-of-care, and service (rarely used in clinical practice, but hypothetically these could be used to standardize care on transfer of a patient)
  3. Discharge Order Sets - Used to discharge a patient from a particular level-of-care
  4. Workup Order Sets - Used to workup a particular condition of complaint
  5. Treatment/Diagnosis Order Sets - Used to standardize and expedite care orders for a common clinical diagnosis.
  6. Prep (aka Pre-procedure or pre-operative) - Used to prepare a patient for a procedure or operation.
  7. Recovery (aka Post-procedure or post-operative) - Used to recover a patient from a procedure or operation.
  8. Convenience Order Sets - Used for another common clinical scenario, other than those in 1-7 above (e.g. nursing protocols, heparin titration protocol, alcohol withdrawal protocol, insulin titration protocol, vent liberation protocol, etc.)
More complex physician order sets may fall outside one of these categories.


Order sets are typically owned by a defined clinical director.


Order sets should generally be constructed by a person trained/experienced in building order sets (e.g. clinical informaticist) in conjunction with a Subject Matter Expert (SME) and a Clinical IT Analyst.


Order sets should be tested by all parties involved in the use and function of the order set. Generally, at a minimum :
  1. One end-user physician should be able to understand and complete the order set
  2. One end-user nurse should be able to understand and complete the orders from the order set
Additional users (e.g. Pharmacists, respiratory therapists, etc.) may be necessary for testing, depending on the type, complexity and goal of the order set. 

Testing needs shall be determined by the clinical Informaticist in conjunction with the chairperson of the Order Set Committee.


After testing is completed, the order set may be brought to a committee for approval. The chairperson of the Order Set Committee will put the order set on the agenda, and allow a period of comments from voting members before the order set is brought to a vote.

Voting will be conducted by the Order Set Committee Chairperson.

If the order set is approved by committee, the chairperson will forward the order set to the Clinical Analysts for publication.

In the event of a tie vote, the order set will be brought to the Medical Executive President for further discussion or placement on the Medical Executive Committee.


After approval by committee, the order set will be published for use :
  1. An electronic version will be published in the EMR Order Set Catalog.
  2. A paper version will be published into the Emergency Downtime Order Set Folder
  3. An electronic version will be published in the Printshop Order Set Catalog, for creation of any paper order sets needed for remaining paper functions.

After publication, staff education on the existence, goal, and use of the order set is the responsibility of the owner.

It is helpful if users are made aware of order sets, how to use them, changes, and reasons for change.


After publication, all order sets will be monitored by their owner.


ISMP's Guidelines for Standard Order Sets :

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