Wednesday, August 29, 2012

Recipe for baking matching electronic and paper downtime order sets

EMR downtimes occur. Hopefully not often, but when they do, you'll want to make sure you have order sets for your docs to use. If you don't have downtime order sets, easily available for them to use, you'll probably notice a downgrade in their clinical efficiency, as they struggle to write out all orders by hand from scratch.

Much has been said about physician over-reliance on order sets, but the truth is that they become tools that physicians rely on, much like a carpenter might rely on an electric screwdriver to help put in screws. In a downtime, could the carpenter make do with a manual screwdriver, or a Swiss Army knife, for that matter? Sure. But you want to keep things running smoothly and predictably, so it's helpful if there are order sets available during downtimes.

The problem is, it's sometimes hard to maintain paper downtime order sets. Some reasons include :
  • After a hospital "goes electronic", the focus of order set development is often the electronic order sets.
  • Not all EMR software has functionality to "print out" an order set.
  • Sometimes, printing out an electronic order set makes a funny-looking order set that docs may not intuitively know how to use
  • The exact functions and formats of the paper and electronic order set, often, do not entirely match.
So it's easy to leave the paper order sets behind, as you work to optimize your order set strategy.

And this is why I've been asked, "How can I consistently make matching, high-quality paper and electronic order sets?"

Here's my recommended recipe. You may want to add some touches, depending on your needs.


Ingredients - What you'll need :
  • A standard EMR, chock full of well-built electronic orders.
  • standard word processor and hard drive.
  • A standard Order Set template, to help the Clinical Informaticist maintain consistency in order set headings and order types.
  • A standard indexing system for your order sets, so you'll know how staff will search, find, and track them (e.g. "Order Set #1" vs. "ABC-123" vs. "Pneumonia Order Set")
  • A standard Order Set Style Guide, to help the Clinical Informaticist make sure the format all looks the same.
  • A Clinical Informaticist, willing to help examine workflows and draft paper order sets.
  • A Clinical IT Analyst, willing to help build electronic order sets in your EMR.
  • A Clinical Director, willing to own (test, monitor, maintain, and educate) the order set and round up end-users for testing.
  • An electronic page on your Intranet where you'll publish your paper order sets for electronic downtimes.
  • Some end-users to help test your order sets (e.g. a willing physician, nurse, pharmacist, and/or other users).

STEP 1 : Clinical Director determines need for an order set and asks Clinical Informaticist for help.

STEP 2 : Clinical Informaticist examines workflow, and ensures resources (ingredients) are available for development.

STEP 3 : Clinical Informaticist decides on category for order set :
  • Admission Order Set (e.g. "Admit to ICU", "Admit to CCU", "Admit to Med/Surg")
  • Diagnosis Order Set (e.g. "Pneumonia Order Set", "Knee Replacement Order Set", "CHF Order Set")
  • Convenience Order Set (e.g. "Hypercoagulable Workup Order Set", "Blood Transfusion Order Set", or "Insulin Drip Order Set")
STEP 4 : Clinical Informaticist names the order set and uses a standard word processor and electronic orders to create a DRAFT paper order set :
  • Name the DRAFT paper order set according to proper category (from Step 3 above), index it properly, and label it "DRAFT".
  • Use your organization's standard order set template and style guide to start!
  • Look up each electronic order in the EMR, and review the function and necessary fields in the electronic order.
  • Create a matching paper order, with those necessary fields.
  • Gradually start to collect those matching paper orders to draft a paper order set that matches the standards in your electronic orders.
  • Any discharge instructions? Put them on a drafted discharge instruction sheet!
  • Any protocols? Put them on a drafted protocol sheet!
STEP 5 : Clinical Informaticist gives the drafted paper order set over to Clinical IT Analyst to build a matching DRAFTED electronic order set in TEST system. (Because the Clinical Informaticist used the standards of the electronic orders, when making the paper draft, this will be very easy to do!)

STEP 6 : Clinical Informaticist and Clinical Director now review the :
  • DRAFTED paper order set (labeled "DRAFT")
  • DRAFTED electronic order set (in TEST environment)
STEP 7 : Clinical Informaticist, Clinical Director, and end-users (usually a minimum of physician, nurse, and pharmacist) "test" both paper and electronic order sets using some realistic "mock scenarios"
  • Consider collecting any "testing" data, e.g. physician/nurse/pharmacist satisfaction, time-to-completion, etc.
  • If any changes arise during testing, Clinical Informaticist and Clinical IT Analyst can correct both paper and electronic order sets simultaneously, to make sure they match.
STEP 8 : Once testing is completed, Clinical Informaticist and Clinical Director develop education and go-live plan for order sets.

STEP 9 : Clinical Informaticist and Clinical Director present, to your organization's formally-chartered approval committee :
  • DRAFTED paper order set (labeled "DRAFT")
  • DRAFTED electronic order set (in TEST environment)
  • DRAFTED discharge instructions (if any exists from step 4 above)
  • DRAFTED protocols (if any exists from step 4 above)
  • Testing results/data
  • Educational Materials
  • Go-live plan
for their final review and approval.

STEP 10 : After approval, you remove the "DRAFT" label from the paper order set and publish :
  • Paper order set - Put up on your intranet "Downtime Order Set" page, or some other common location your staff agrees to look for during electronic downtimes.
  • Electronic order set - Move the draft from your TEST to your LIVE/PROD system.
STEP 11 : Clinical Director will deliver education, and continuously monitor the order set for safety, effectiveness, and new evidence/regulations.

STEP 12 : Clinical Director will return to step 1 as needed!

Bake at 350 degrees, or until golden brown!

I'm always interested in discussion! Feel free to leave comments about your process for developing matching order sets for your downtime! Questions are welcome!