Strong Recommendations for new Applied Clinical Informaticists, Part 2 of 2

 Hi fellow CMIOs, CNIOs, and other Applied Clinical #Informatics and #HealthIT friends,

Today, I thought I'd share the second half (next ten suggestions) of my general advice to new Applied Clinical Informaticists, and other people interested in smooth clinical #workflow design. 

Strong recommendation #11 (of 20) below involves understanding the inseparable, symbiotic relationship between Information Technology (IT) and Information Science (IS), the discipline that drives Applied Clinical Informatics. While it's tempting to think only one is more necessary or relevant than the other, they are both equally necessary and relevant - You cannot have one without the other. 

Coming in at #12 is the strong recommendation (below) to understand the difference between the 'seeds' of good ideas, and the 'soil' (operational infrastructure) necessary to grow those seeds. While operational infrastructure is not always a high priority, neglected infrastructure can lead to frequent project delays, project failures, and inability to move forward. Take some time every year to look carefully at operational infrastructure, and make sure you devote the time and resources necessary to be able to grow the seeds of good ideas. 

Strong recommendation #13 (of 20) below sometimes becomes more visible after a few years in Applied Clinical Informatics, but it addresses the relationship between inconsistent or incomplete workflows, and burnout (moral injury). Especially in routinely high-risk, high-stress operations, your clinical teams will always appreciate having a smooth, predictable, well-understood pathway (workflow) from problem (point A) to solution (point B). Tangled, confusing, or incomplete workflows only create stress and confusion. Having well-designed, well-developed templates will help you make sure you're covering all of your bases, and that every step of your workflow is well-planned, clear, and complete.

My next strong recommendation (#14 of 20) below is just to be prepared to answer common questions about "Why do we need an interdisciplinary Applied Clinical Informatics team?" While there are many reasons, six of the most common include :

1. Project Intake / Procurements that require additional support or workflow analysis / evaluation to help ensure the technology doesn't already exist (in your organization), and to help ensure proper scoping, budgeting, stakeholder identification, resource allocation, alignment with safety or compliance needs, and expected outcomes. 
2. Special Event Workflow Planning (e.g. Planned maintenance or unplanned downtimes, planned upgrades, or project go-lives)
3. Complex IT Tickets that require workflow updates / modifications (often span areas with multiple stakeholders)
4. Complex Projects that require clinical translation, terminology work, stakeholder identification and alignment, or workflow updates/modifications.
5. Ongoing maintenance of existing configuration / workflows to meet CMS/TJC regulations (and other payer and user requirements), that requires continuous staff engagement with multiple stakeholders across different areas/specialties. 
6. Helping to ensure clinical workflows are aligned with the clinical, HIM, coding/billing, and revenue capture needs of the organization.

To have the skills and expertise necessary for these common functions, you will need an Applied Clinical Informatics team. Knowing some good reasons to have such a team will help support the discussions about how to build one. 

Strong recommendation #15 (of 20) for new Applied Clinical Informaticists (below) is to really care about design. Cooking food is not enough, you need to care about cooking great food. While discussing details is sometimes seen in healthcare as 'getting too into the weeds', our clinical teams need you to care about the details, so that you can develop the complete blueprints that will help technical teams to build great workflows. Also : Try to resist the urge to use short-term solutions for long-term problems - While they might temporarily help, they usually create workarounds that then need even more work to fix.

At #16 is my strong recommendation (below) to know the sixteen (16) most common (CPOE) order types. These are the basic building blocks that work together to build all of your clinical worfklows. It's very helpful to know what they are, what they do, how they work together, and when to use them. Many incomplete workflows come from not including one or more of these order types in an order set, order panel, or other ordering tool, so you can help improve workflow design by including all sixteen order types in an order set template, and then using that to guide the development of all of your order sets. *Note : Not every order set will use all sixteen order types, and you will only use the ones you need to address your desired clinical scenario. Having all sixteen types in a template (for developing your order set blueprints) will help create consistency and completeness for your clinical teams. 

My strong recommendation #17 (of 20) below is simply not to minimize the complexity of ordering tool ('order set') requests. I'm often fascinated by the small requests that have the largest operational impact, and thus require more time and effort to plan and execute than most people have budgeted for. Setting realistic expectations is the first step to good planning, so do your worfklow (gap, current-state-future-state) analysis early, and be prepared to inform your requestor when a project is larger than originally anticipated. 

Strong recommendation #18 (of 20) below is simply to consider how you will manage the intake of maintenance tickets and new project requests, from a variety of stakeholders. Navigating HealthIT (and Applied Clinical Informatics) often means managing the competing interests of : 

• Software vendors
• Patient/Caregiver input/feedback
• User input (from multiple stakeholders)
• Contracting and Payer Updates
• Formulary Updates
• Practice Onboarding
• Institutional Decisions
• Federal, State, and Department of Public Health regulations
• Evidence-based best practices
• Institutional policies and bylaws
• Privacy and Security Needs
• Quality Reporting
• External advisory organizations (e.g. The Joint Commission, Leapfrog, etc.)
• Vendor choices

... so you will want to consider all of these potential sources of change in your intake and prioritization processes.

Nearing the end, my strong recommendation #19 (of 20) below is to learn the most common types of Computerized Provider Order Entry (CPOE) order modes. Ideally, providers would always enter their own orders, but there are some very important, very legitimate reasons (clinical scenarios) why they sometimes cannot (without delaying necessary patient care). Understanding these reasons (and scenarios) will help you create and support compliant and safe order entry workflows all across your organization.

Finally, my strong recommendation #20 (of 20) below is simply to empower a clinical leader. Whether they are a nursing leader, physician leader, APP leader, radiology leader, laboratory leader, pharmacy leader, or other ancillary staff leader - they are all important and deserve your support. Usually, they are already great clinicians - Help them learn leadership skills, and they will be better leaders, and help you solve more problems. Skills like : 

• Reading a bylaw / policy
• Writing a bylaw / policy
• Reading a budget
• Planning a budget
• Writing a charter
• Chairing a committee
• Planning an agenda
• Project and change management basics
• Documentation and coding basics
• Hiring a staff member
• Managing a staff member

... can go a long way to long-term success for any leader. If you see a new clinical leader, make sure you reach out to them and support them as they grow - This will help empower leaders to retain staff and solve problems.

Okay, along with my first ten recommendations, I think these additional ten above cover my top twenty (20) strong recommendations for new Applied Clinical Informaticists seeking to design smooth workflows. If you have other suggestions, please leave them in the comments section below!

Remember - This blog is for educational and discussion purposes only, and is not formal advice - your mileage may vary. Have any other helpful ideas, suggestions, or experiences you'd like to share? Feel free to leave them in the comments section below!

Intro to CPOE and Order Sets

Hi to my fellow CMIOs, CNIOs, Clinical Informaticists and other HealthIT and clinical friends,

Order sets can be a real gift to modern medicine, but only when they are designed by experienced, capable Clinical Informaticists and Analysts, in conjunction with the clinical end-users. Usually, this requires more work and planning than most people are aware of - until they dive into the waters themselves.

So for anyone who's ever had to explain the work it takes to produce good, evidence-based order sets that support smooth workflows with minimal clicks - I thought I'd share this cute little video I produced recently. Think of it as an easy way of teaching some of the basics to newcomers : 

This is the strategy I've used professionally to create great, evidence-based, easy-to-use order sets that give my fellow physicians the right guidance and confidence they need to navigate even the most complicated workflows. Feel free to share with anyone who's new, or looking to learn more about how good workflows and decision support strategies are designed. 

Have any secrets of your own? Feel free to share them in the comments field below!

Remember, this blog is for educational purposes only - Your mileage may vary. Have any other comments or feedback? Please leave them in the comments section below!

Using CPOE Order Modes to Streamline Workflows

Hi fellow CMIOs, CNIOs, and other Clinical #Informatics enthusiasts,

This month, I thought I'd help demystify a common Computerized Provider Order Entry (CPOE) issue, that actually has a big impact on clinical workflows - Order modes.

Having a good understanding of order modes is essential to resolving many clinical workflow issues. If you've ever asked yourself : 

• When is it appropriate to use telephone orders?
• When is it appropriate to use verbal orders?
• When is it appropriate to use written orders?
• When is it appropriate to use protocol orders?

... then you've shared in the very common struggle with CPOE order modes. 

Order modes don't need to be confusing. One of the most common sources of confusion stems from the use of the term 'Computerized Provider Order Entry', or 'CPOE'. 

On selecting an EMR, some organizations assume that having a 'CPOE system' implies that all orders will be entered directly by a provider (The POE in 'CPOE') - And that once it is up-and-running, that there will no longer be any reasons for anyone else to enter orders. Some of those organizations may recognize the need to maintain telephone and verbal orders, for emergency purposes, but don't appreciate the same need for written or protocol orders. 

The truth is that while providers entering their own orders is a best practice, ideal and applicable in almost all ordering scenarios - It is not useful, or even possible, in all scenarios. For this reason, out of necessity, most EMRs recognize a few different ways that orders get entered into the EMR. 

I'm hoping this post will help generate more clarity around their use, and how they can help you streamline, and even improve, your clinical workflows. 

A. Order Mode Basics
To better understand order modes and how they help streamline and support workflows, it's first helpful to understand the difference between an order mode, and order status. 

(Click image to enlarge)

Basically :

• Order Status - Tells you whether or not you should be executing ('following') the order
• Order Modes - Tells you how the order got into the computer

The following slide gives a basic summary of the common order statuses and order modes, found in most electronic medical records : 

(Click to enlarge image)

It's again important to note that direct provider order entry ('CPOE') may be a best practice in almost all clinical scenarios - But the other order modes exist to support order entry in scenarios where it is impossible or even undesirable for the provider to enter the order directly. So to make sure you're only using those other order modes for the right scenarios, you'll want organizational policies in place to make sure they are being used appropriately and safely. The following policy discussion sheds more light on these scenarios, and at the end I've provided a nice summary table. 

B. Sample Policy Definitions
Since order statuses represent the different states that an order can have inside most EMRs, some [ DRAFTED ] policy-grade definitions for these four common order statuses ('states') might look like this : 

• ACTIVE orders - Orders which HAVE been submitted and signed by a licensed prescriber, or by a well-trained, delegated clinical team member on behalf of a licensed prescriber as part of a standardized, clear, well-developed protocol approved by legal, nursing, provider, and pharmacy leadership. These orders are ACTIVE and should be executed in a timely manner, according to the details contained inside the order. Outcomes from all active orders are attributed to the licensed prescriber.
• PENDED orders - Future orders which HAVE been submitted and signed by a licensed prescriber, in anticipation of planned future release ('activation') at a future date/time by the licensed prescriber, or by a well-trained, delegated clinical team member on behalf of the licensed prescriber as part of a clear, standardized, well-developed protocol approved by nursing, provider, and pharmacy leadership. These PENDED orders are NOT ACTIVE and  SHOULD NOT be executed until they are released ('activated') into ACTIVE order status by a licensed prescriber, or by a well-trained, delegated clinical team member on behalf of a licensed prescriber as part of a standardized, clear, well-developed protocol approved by legal, nursing, provider, and pharmacy leadership. Outcomes from all pended orders are attributed to the licensed prescriber.
• HELD orders - Previously ACTIVE orders which have been placed on hold ('paused') by a licensed prescriber, or by a well-trained, delegated clinical team member on behalf of a licensed prescriber as part of a standardized, clear, well-developed protocol approved by legal nursing, provider, and pharmacy leadership. These HELD orders are NOT ACTIVE and SHOULD NOT be executed until they are again released back into ACTIVE order status by the licensed prescriber, or by a trained, delegated clinical team member on behalf of the licensed prescriber as part of a standardized, well-developed protocol approved by legal, nursing, provider, and pharmacy leadership. Outcomes from all held orders are attributed to the licensed prescriber.
• DISCONTINUED orders - Previously ACTIVE, PENDED, or HELD orders which have been discontinued ('deactivated') by a licensed prescriber, or on behalf of the licensed prescriber by a well-trained, delegated clinical team member as part of a clear standardized, well-developed protocol approved by legal, nursing, provider, and pharmacy leadership. These discontinued orders must be retained as part of the legal medical record but must NO LONGER be executed for patient care purposes. Outcomes from all discontinued orders are attributed to the licensed prescriber.

And if the order MODES include the different ways that those orders can get into the computer, then some [ DRAFTED ] policy-grade definitions for these different order modes might look like this : 

1. CPOE ('PROVIDER') order MODE - Routine orders originated, entered directly, reviewed, and immediately signed (authenticated) by a licensed prescriber, allowing the prescriber to follow decision support rules and order designs that guide best practices and identify errors before they occur. 
2. TELEPHONE order MODE - Orders originated by a licensed prescriber via direct telephone ('voice-to-voice') communication, and transcribed by a Registered Nurse, Registered Pharmacist, or other registered, licensed, and trained, delegated team member on behalf of the originating licensed prescriber according to a well-developed plan approved by legal, nursing, pharmacy, and provider leadership. Telephone orders must be signed by the originating licensed prescriber within _?12_?24_ hours.
3. VERBAL order MODE - Orders originated by a licensed prescriber via direct verbal ('face-to-face') communication, transcribed by a Registered Nurse, Registered Pharmacist, or other registered, licensed, and trained, delegated team member, on behalf of the licensed prescriber, according to a well-developed plan approved by legal, nursing, pharmacy, and provider leadership. Verbal orders must be signed by the originating licensed prescriber within _?1_?2_?6_ hours.
4. WRITTEN order MODE - Orders originated by a licensed prescriber via a pre-approved paper form (approved by legal, nursing, pharmacy, and provider leadership), and transcribed by a Registered Nurse, Registered Pharmacist, or other registered, licensed, and trained, delegated team member (according to a well-developed plan approved by legal, nursing, pharmacy, and provider leadership). Since these paper orders must be signed prior to transcription, they [ usually ] do not require re-authentication ('re-signing') after transcription. The original paper orders are part of the legal medical record and should be retained for quality-control purposes. 
5. PROTOCOL - WithOUT SIGNATURE order MODE - LOW-risk patient care orders which are activated, modified, or discontinued by a Registered Nurse, Registered Pharmacist, or other registered, licensed, and trained, delegated team member, on behalf of an attending prescriber, as part of a standardized, clear, well-developed protocol approved by legal, nursing, pharmacy, and provider leadership. By policy, all child orders from these low-risk patient care protocols are attributed to the attending provider, and do not require signature.
6. PROTOCOL - WITH SIGNATURE order MODE - HIGH-risk patient care orders which are activated, modified, or discontinued by a Registered Nurse, Registered Pharmacist, or other registered, licensed, and trained, delegated team member, on behalf of an ordering prescriber, as part of a standardized, clear, well-developed protocol approved by legal, nursing, pharmacy, and provider leadership. By policy, all child orders from these high-risk patient care protocols are attributed to the ordering provider, and require signature within __?12_?24__ hours.

You'll notice in the above [ DRAFT ] definitions : 

• These are all just [ DRAFT ] definitions - You'll want to check with your own legal team before you consider them and approve them for use in your own organization.
• There are several signature timeframes which are unidentified (E.g. "__?__ hours") - You will want to review them with your own risk, legal, nursing, provider, and pharmacy leadership to decide on an organizational standard for these. Since these orders all carry risks of miscommunication, you will want to set these timeframes to as short a time period as possible. 

COMMON QUESTION : 

Q: Will every provider sign these orders within the assigned timeframes? 

A: Probably not. But you will want to regularly monitor compliance with your organizational standard, and that probably includes provider report cards for CPOE compliance. Some organizations find that connecting these CPOE statistics to compensation helps improve compliance with organizational standards. 

C. The Summary Table
Confused by the above definitions? Don't like the policy mumbo-jumbo? To help make more sense out of these order modes, and how they impact workflow, I've put together a little summary table which should help clarify them. It includes a summary of the order modes, WHEN to use them, their risks/benefits, and helpful ways to minimize the risks : 

(click to enlarge image)

Remember, it's all about safety and great patient care. Using the right order modes is essential to designing and implementing workflows that deliver that safe, great patient care. Once you have that good understanding of these modes, and the organizational policies to back them up, it becomes much easier to design clinical workflows that meet the needs of your patients, providers, nurses, pharmacists, and other ancillary staff. 

Hope this was a helpful summary! If you have any questions or feedback, please leave them in the comments section below!

Remember, this post is for educational and discussion purposes only - Your mileage may vary. Do not use any of these standards or definitions without first consulting with your informatics team and legal counsel!

Have your own tips for educating CPOE order modes, or anecdotes about how they improved your workflows? Feel free to leave them in the comments section below!

CPOE and Building a Well-Indexed Order Set Catalog

Hi fellow Clinical Informaticists and other #HealthIT leaders,

Sorry, it's been a while since I've been able to blog much. Been very busy recently, engaging physicians, APRNs/PAs, residents, nurses, pharmacists, and other clinical leaders. Since I had a few free minutes this holiday season, I just wanted to take the time to offer some insights into the links between Computerized Provider Order Entry (CPOE) and order set design and strategy.

Developing a good order set strategy can sometimes take a while. Many organizations go through a gradual learning curve, which unfortunately, can sometimes take years. In general, some organizations will start their CPOE journey with a rudimentary strategy, often based only on the popular med-school mnemonic 'ADCVANDISMAL', that can sometimes leave providers unhappy with their early CPOE exposure. Some hints that an organization may be at the beginning of their order set design journey : 

1. The doctors are using 'ADCVANDISMAL' or pre-existing paper order sets as the only guidelines for building their new electronic order sets.
2. Order sets are quite long, sometimes several (2-3) pages.
3. Providers find themselves spending time searching through these long order sets, looking for the two or three orders they want to place at a particular moment, or using the same order set over-and-over for different clinical scenarios.
4. Providers might have somewhere between 2-4 order sets that they use for all of their ordering needs.
5. There is limited use of headers above sections of orders, to give providers guidance about when to check (or uncheck) an order.
6. There is limited use of pre-checked orders.
7. Providers might complain about 'long order sets', clunky order sets' or 'too many alerts'.
8. Order set names are non-standard format (e.g. one catalog has order sets named "Pneumonia Admission Order Set" and "Hospitalist General Admit order set" and "ED Pneumonia", all in the same catalog.)

Gradually, through trial-and-error, some organizations learn that good order set design takes real work and very detailed planning. So I'd like to offer you a way for you to develop what I call a "well-indexed order set catalog strategy", before you begin your CPOE journey. 

(Remember, providers will want a good experience when they start CPOE - Giving them bad order set design will color their first experiences with CPOE!)

Before we begin, let me warn you that there may be other strategies that may work better for your organization. The strategy described below may work, but it may not be ideal for your organization - especially if you already have a starkly different strategy, in which case there may be a serious learning curve for your providers. Read on, and judge for yourself - But always make sure you check with your local informatics professionals before designing an order set strategy for your organization.

ONE WAY TO DEVELOP YOUR NEW ORDER SET STRATEGY :
To develop a stronger order set strategy, it's helpful to start with a good working definition of the term "order set". Although published definitions can vary (see the ISMP Guidelines for Standard Order Sets), there is a simpler one I can offer up, that still works very well from a functional standpoint : 

"Order set (n.) - a collection of orders used to standardize and expedite the ordering process for a common clinical scenario."

Take a good look at the above definition. Does it work for you? Simple and effective, but before we move on, make sure it looks good for you.

If you think that's fairly reasonable, then let's build an index on this definition. If the concept of "order set" is linked, by this definition, to the concept of "common clinical scenario", then what exactly are common clinical scenarios? 

In addition to good listening, and displaying compassion and empathy, physicians/providers generally have two things they do to actively help patients - Either do a procedure, or write an order. Since we're talking about the orders that physicians/providers write, what are the common clinical scenarios that these orders are used for? The common ones seen in most organizations : 

1. Admitting a patient
2. Transferring a patient 
3. Discharging a patient
4. Working up a complaint or condition
5. Treating a diagnosis
6. Pre-operative or pre-procedure care
7. Post-procedure or post-operative care
8. Protocols - (Allowing registered nurses, pharmacists, or other licensed medical professionals to act on an order or orders on behalf of the ordering provider or attending physician)
9. Other (for those things not in 1-8 above)

So now take a look at the above 9 scenarios. Do they work for you? If they still seem reasonable, then you can then use them to build out your new order set index : 

1. ADMIT - To admit an adult patient to an inpatient level-of-care
2. TRANSFER - To transfer an adult patient to another inpatient level-of-care
3. DISCHARGE - To discharge an adult patient from an inpatient level-of-care to home
4. WORKUP - To work up a common chief complaint (e.g. SOB, abd pain, fever, etc)
5. TREATMENT - To treat a common diagnosis (often the top 50 DRGs)
6. PRE-OP - To treat a patient about to undergo a procedure
7. POST-OP - To treat an adult patient after a procedure
8. PROTOCOLS - To allow a registered nurse, pharmacist, or other licensed medical professional to start/modify/stop an order (or orders) on behalf of a Licensed Independent Practitioner (LIP), Physician Assistant (PA), or resident. (E.g. Med titration protocols, dietary interchange protocols, vent liberation protocols)
9. OTHER ('Convenience Panels') - For other common clinical scenarios not outlined in 1-8 above (e.g. Routine pain control, Anti-Emetics, Sleep Agents, Blood Transfusion, etc.)

You'll notice that for the above nine chapters, these all typically refer only to ADULT patients. Pediatric patients, generally, have different diseases, different complaints, different workups, and different drug dosages (usually with weight-based dosing) - So if you have both adult and pediatric patients, you could potentially have an index that looks like this :

A. ADULT LIBRARY

1. ADMISSION ORDER SETS
2. TRANSFER ORDER SETS
3. DISCHARGE ORDER SETS
4. WORKUP ORDER SETS
5. TREATMENT ORDER SETS
6. PRE-PROCEDURE ORDER SETS
7. POST-PROCEDURE ORDER SETS
8. PROTOCOLS
9. OTHER (CONVENIENCE PANELS) ORDER SETS

B. PEDIATRIC LIBRARY

1. ADMISSION ORDER SETS
2. TRANSFER ORDER SETS
3. DISCHARGE ORDER SETS
4. WORKUP ORDER SETS
5. TREATMENT ORDER SETS
6. PRE-PROCEDURE ORDER SETS
7. POST-PROCEDURE ORDER SETS
8. PROTOCOLS
9. OTHER (CONVENIENCE PANELS) ORDER SETS

Using this hierarchy, you can then start to build out the catalog - I'll use only the adult catalog as an example : 

A. ADULT LIBRARY

1. ADMISSION ORDER SETS

• ADMIT TO MED/SURG
• ADMIT TO TELEMETRY
• ADMIT TO ICU
• ADMIT TO LABOR AND DELIVERY
• ADMIT TO PSYCHIATRY
• ADMIT TO SURGICAL DAYCARE
• ADMIT TO MEDICAL DAYCARE 

2. TRANSFER ORDER SETS 

• TRANSFER TO MED/SURG
• TRANSFER TO TELEMETRY
• TRANSFER TO ICU
• TRANSFER TO LABOR AND DELIVERY
• TRANSFER TO PSYCHIATRY
• TRANSFER TO SURGICAL DAYCARE
• TRANSFER TO MEDICAL DAYCARE

3. DISCHARGE ORDER SETS

• DISCHARGE FROM MED/SURG
• DISCHARGE FROM TELEMETRY
• DISCHARGE FROM ICU
• DISCHARGE FROM LABOR AND DELIVERY
• DISCHARGE FROM PSYCHIATRY
• DISCHARGE FROM SURGICAL DAYCARE
• DISCHARGE FROM MEDICAL DAYCARE

4. WORKUP ORDER SETS (based on chief complaints)

• WORKUP - ABDOMINAL PAIN
• WORKUP - AMENHORRHEA
• WORKUP - BACK PAIN 
• WORKUP - CHEST PAIN
• WORKUP - CONFUSION
• WORKUP - COUGH
• WORKUP - FEVER
• WORKUP - GI BLEEDING
• WORKUP - HEADACHE
• WORKUP - SUSPECTED HYPERCOAGULABLE DISORDER
• ...
• WORKUP - OTHER 
• WORKUP - SHORTNESS OF BREATH 
• WORKUP - SWOLLEN EXTREMITY
• WORKUP - SYNCOPE 
• WORKUP - TICK BITE 
• WORKUP - VAGINAL BLEEDING

5. TREATMENT ORDER SETS (based on common diagnoses or DRG)

• TREATMENT - ACS - UNSTABLE ANGINA/NSTEMI
• TREATMENT - ACS - STEMI
• TREATMENT - AFIB WITH RVR
• TREATMENT - ANAPHYLAXIS
• TREATMENT - ASTHMA EXACERBATION
• TREATMENT - BACK PAIN 
• TREATMENT - CELLULITIS
• TREATMENT - CHF EXACERBATION
• TREATMENT - COPD EXACERBATION
• TREATMENT - FEVER
• TREATMENT - GI BLEEDING
• TREATMENT - HEADACHE
• ...
• TREATMENT - PNEUMONIA - HCAP
• TREATMENT - PNEUMONIA - ASPIRATION  
• TREATMENT - STROKE 
• TREATMENT - SWOLLEN EXTREMITY
• TREATMENT - SYNCOPE 
• TREATMENT - VAGINAL BLEEDING

6. PRE-OP AND PRE-PROCEDURE ORDER SETS (based on procedures)

• PREProcedure - CARDIOVERSION
• PREProcedure - CENTRAL LINE PLACEMENT
• PREProcedure - HEMODIALYSIS
• PREProcedure - INTUBATION
• PREProcedure - PARACENTESIS
• PREProcedure - THORACENTESIS
• PREop - APPENDECTOMY
• PREop - ARTHROPLASTY
• PREop - KYPHOPLASTY

7. POST-OP AND POST-PROCEDURE ORDER SETS (based on procedures)

• POSTProcedure - CARDIOVERSION
• POSTProcedure - CENTRAL LINE PLACEMENT
• POSTProcedure - HEMODIALYSIS
• POSTProcedure - INTUBATION
• POSTProcedure - PARACENTESIS
• POSTProcedure - THORACENTESIS
• POSTop - APPENDECTOMY
• POSTop - ARTHROPLASTY
• POSTop - KYPHOPLASTY

8. PROTOCOLS (allowing a registered nurse, pharmacist, or other licensed medical professional to START/MODIFY/STOP an order or orders on behalf of a Licensed Independent Practioner (LIP), Physician Assistant (PA), or resident.) 

• PROTOCOL - HEPARIN TITRATION PROTOCOL
• PROTOCOL - INSULIN TITRATION (DKA/HNK) PROTOCOL
• PROTOCOL - CARDIZEM TITRATION
• PROTOCOL - PROPOFOL TITRATION 
• PROTOCOL - ALCOHOL WITHDRAWAL
• PROTOCOL - MASSIVE TRANSFUSION PROTOCOL
• PROTOCOL - VENTILATOR LIBERATION

9. OTHER ('CONVENIENCE PANEL') ORDER SETS - For those common clinical scenarios not outlined in #1-8 above, also helpful for using as building blocks in other order sets (e.g. having a routine pain management panel in your admission order set)

• CONVENIENCE - Routine Pain Management
• CONVENIENCE - Routine Anti-Emetics
• CONVENIENCE - Routine Bowel Regimen
• CONVENIENCE - Routine Sleep Management
• CONVENIENCE - Routine Glycemic Control 
• CONVENIENCE - Routine VTE Prophylaxis 
• CONVENIENCE - Routine Blood Transfusion

Having this well-stratified an index will let you build small, short order sets, with only a few orders in each order set. The benefits of such a strategy :  

1. Shorter, faster order sets which can often be pre-clicked (in many scenarios, depending on your local policies), and pre-built with better decision support to better guide providers to better choices.
2. Fewer duplicate-order, duplicate-therapy, and drug-drug interaction alerts = Less alert fatigue.
3. Better ability to share order sets among specialties - Why should the workup for chest pain be different in the ED than on the floor? If one provider builds an order set, shouldn't everyone benefit? 
4. Faster build time and easier maintenance - Need to make sure all admissions to med/surg have a code status order? Only one order set needs fixing, not twenty.
5. Faster CPOE - Docs can breeze through an order set tailored to exactly the clinical scenario they are trying to address

And the disadvantages of this strategy? Your providers will use more order sets, and so having them go through the catalog to select their favorites and use them may take a few more clicks than if they just have 2-3 order sets that they use for everything. But you can always build synonyms that help speed up the alpha-search for these order sets, and I do believe that the many benefits outweigh this small disadvantage.

Of course, if this is a significant deviation from your current strategy, you will want to engage your local leadership to review this strategy, think about the cost of re-training your docs, and going forward with such a new strategy. And if you already have such a strategy - Congrats!

In closing - I hope this has been an interesting discussion on order set indexing, and how it impacts the naming convention, speed of ordering, ability to custom-design decision support, physician/provider experience with CPOE, and ultimately, the ability to continuously encourage physicians to deliver better, evidence-based, updated best practices. 

Thanks for taking the time to read this, and I hope everyone is looking forward to 2017 and what it will bring the #HealthIT and #Informatics communities!

This post is for discussion and educational purposes only - Always consult your local informatics professionals before deciding to adopt an order set strategy. Have any thoughts, comments or feedback? Or want to share your own order set indexing strategy? Feel free to leave them in the comments section below!

What exactly is "Alert Fatigue"?

Clinical Decision Support (CDS) - It's the mythical creature that every healthcare administrator and informaticist is hunting, to help reduce costs and improve care. Loosely, it can be broken into a few different areas :

1. Electronic decision support (e.g. CPOE Alerts to help prevent errors)
2. Order / order set design (e.g. to help prevent errors / guide docs to evidence-based care)
3. Workflow/documentation redesign (e.g. tools used to standardize high-risk decisions, e.g. procedure checklists)
4. Workflow/protocol design (e.g. tools used to automate high-risk procedures)

One of the hardest to tackle is #1 - CPOE Alerts. Are there too many, or too few? Everyone I know seems to be struggling with the same issue :

• Wanting to provide CPOE alerts to avoid errors, but
• Providing "too many alerts" could cause docs to ignore the "important alerts".

This phenomenon is loosely called alert fatigue, and has been fairly well-documented in literature as, paradoxically, a potential risk. 

When you hear Informatics professionals discuss alert fatigue, the challenging part is actually knowing when alert fatigue exists. Docs sometimes complain about it, but the response docs get to this is often skepticism - After all, how can an alert be bad? Maybe the doc just complains too much? And who is going to turn off the alert? Is it safe to turn off the alert? What if this opens up other problems? When is it too much? When is it too little?

So when you ask docs to define alert fatigue, they typically use general, loose definitions, like :

• "It's when the system gives me too much information and I miss the important stuff."
• "It's when the system tells me about the Tylenol interacting with Colace, but I miss out on the Coumadin/Bactrim interaction."
• "It's when I can't read all of the alerts."
• "It's when I just keep clicking 'Bypass' without actually reading the alert."
• "It's when I just keep clicking 'Acknowledge' without actually reading the alert."
• "It's when I click 'bypass' within 3 seconds, so I know I didn't read the alert."

And recently, when I asked some informatics colleagues for their definition of alert fatigue, I again got a myriad of responses, followed by the same sort of response Supreme Court Justice Potter Stewart gave in 1964, when defining "obscenity" in the Jacobellis v. Ohio case : "I know it when I see it."

Unfortunately, this doesn't help much for those of us who are really working to combat alert fatigue. 

The problem with all of these definitions is that they are fairly loose and subjective, and don't make a good litmus test to answer the question : Do you have alert fatigue?

So I'm going to use some reason and inference, to try to develop a better definition of alert fatigue that is quantifiable. (I used to be a mathematician/statistician, so please forgive the quasi-mathematical approach.)

Since it seems the "undesired scenario" nobody wants is made up of two steps :

• An EMR providing a confusing alert environment, and
• A doc displaying signs of poor response to that environment

So I'd like to submit two proofs, for two conditions which then go into a third proof. Here they are :

PROOF1 : "AlertOverload"

1. [AlertOverload] = [Bad] > [Good]

2. [AlertOverload] = [Noise] > [Signal] 

3. [AlertOverload] = [Low-value alerts] > [High-value alerts]

4. [AlertOverload] = [Low-risk alerts] > [High-risk alerts] 

5. [AlertOverload] = [# of low-risk alerts] > [# of high-risk alerts] 

6. [AlertOverload] = [Number of low-risk alerts in a time period] > [Number of high-risk alerts in a time period]

7. [AlertOverload] = When the number of low-risk alerts exceeds the number of high-risk alerts for a given physician in a given time period

PROOF2 : "AlertLoss"

1. [AlertLoss] = [Bad] > [Good]

2. [AlertLoss] = [BypassedAlert] > [AcknowledgedAlert] 

3. [AlertLoss] = [Number of bypassed alerts in a given time period] > [Number of acknowledged alerts in a given time period] 

4. [AlertLoss] = When the number of bypassed alerts exceeds the number of acknowledged alerts in a given time period

If one were to accept proof #1 and #2 as true, then I would propose this final proof/definition of AlertFatigue :

PROOF3 : "AlertFatigue"

1. [Bad] = [Bad] 

2. [AlertFatigue] = [Bad]

3. [AlertFatigue] = [AlertOverload] + [AlertLoss] 

4. [AlertFatigue] = Exists when a given physician experiences [AlertOverload] and displays [AlertLoss] in a given time period

So voila - My proposed definitions :

1. Alert Overload = When the number of low-risk alerts exceeds the number of high-risk alerts for a given physician in a given time period
2. Alert Loss = When the number of bypassed alerts exceeds the number of acknowledged alerts in a given time period
3. Alert Fatigue = "When a given physician experiences alert overload and displays evidence of alert loss in a given time period."

It's certainly not a universally-recognized definition, and I'm curious if other people are aware of any other professional, practical, policy-grade definitions that exist out there. Obviously, this definition now needs to be peer reviewed, tested, validated, and professionally accepted, so please don't use it in your own organization without consulting a legal professional, informatics professional, and your local regulatory agencies first.

Remember : As always, this discussion is for educational purposes only! Remember, your mileage may vary! Always enjoy thoughts, comments, and ideas!