Cutting Healthcare Costs by Making A Better Brick

1. THE BRICK

An interesting question I get asked is, "Why don't all order sets look the same at every hospital, even for the same disease?"

This question can be posed in several other ways, including :

1. "Why can't we just use order sets from someone else?"
2. "Why can't we just use canned order sets without editing them?"
3. "What do your policies look like?"
4. "Why can't we just use canned policies?"
5. etc...

But all of these basically ask the question, "Why isn't this standard?" and, of course, the follow-up question is, "Why is every hospital re-inventing the wheel?".

For inspiration to answer this question, I'd like to first explain a little bit about a wonderful thing : The brick.

According to the Wikipedia article, bricks have been in use since about 7500 BC to help construct things. (It's actually a really interesting article - If you appreciate human civilization, the brick has played a big role in building our streets, aqueducts, houses, walls, etc...)

The reason the brick is such a useful thing, from a design standpoint, is because it has two features :

1. A brick has a fairly predictable shape that allows you to easily arrange them to connect two or more places in space.
2. A brick is designed to withstand a particular load.

You'll notice these two features are helpful when designing any system - Having basic units engineered in a predictable manner, which can be assembled to make a bigger, more complex system that achieves a certain goal.

Hospitals contain systems that are also made of smaller units - Order sets are made of orders, clinical pathways are made of order sets, charts are made of notes, policy manuals are made of policies, etc. 

Unlike a physical brick, however, all of these basic units are conceptual - They are mostly complex documents - not physical objects - so it's a little harder to tell how predictable they are - e.g. to know if they're not engineered exactly the same.

For example, with physical bricks, it's much easier to tell if one hasn't been engineered exactly the same as the others :

You can immediately and obviously see the entire system is off, and locate the offending brick quickly.

But real bricks are not 100% predictable - They all have some degree of imperfections between them -As a kid, I occasionally ran into bricks behind our grade school, or around landscaping projects - I think I could only stack about 10 of them on top of each other before they start to fall over. (Legos are about the only bricks I can think of that are engineered to such a high standard that you can stack virtually hundreds of them on top of each other and still have practically a straight wall.)

But because regular bricks in the real world have subtle imperfections, humans have developed a tool we can use to compensate for these imperfections : Mortar, or cement.

Mortar/cement only works, however, to help straighten out the system when our brains get involved - We see the system leaning, so we set up guidelines/markers to help determine what is straight, and we put down the mortar/cement to compensate and correct the system. Again, the compensation depends on our human brain.

Because documents are not physical objects, we may not see the system leaning - But it can lean the same way in a conceptual manner. Fortunately, our brains can still compensate for a lot of conceptual leaning. 

So in my job in clinical informatics, I look at the standards by which the "document" bricks are built - To determine just how standard they are, and how much people's brains are compensating.

And this is why hospitals all have order sets that look and behave slightly differently - Because there aren't national standards by which their bricks are engineered. Fortunately, human brains are filling in the mortar.

What would it take to get all hospitals to engineer exactly the same bricks? The same engineering standards at all hospitals. 

And what would it take to get all hospitals to engineer bricks as well as Legos? An engineering process that was detailed enough to ensure that every brick looked virtually identical.

So why don't all hospitals have the same engineering standards and engineering process? Because documents, unlike bricks and Legos, are not as easily understood/studied/observed as physical objects. And because, for better or for worse, human brains can compensate extremely well - So there is little pressure to engineer them exactly the same. 

So as a result : Every hospital is re-inventing the wheel when it comes to their processes and their documents. In almost every hospital, they are looking to achieve exactly the same goal (in brick terms, "bear the same load") - Delivering standardized but customizable, evidence-based, high-quality care. But because the engineering standards and processes are not defined nationally, their tools are all ever-so-slightly different, and so virtually every hospital has to engineer them slightly differently.

2. A NEW IDEA ON CUTTING HEALTHCARE COSTS

The number of people employed to re-engineer all of these tools is remarkable. And it doesn't just include order sets - It includes every document in a hospital, virtually everything I mentioned in the CMIO's Checklist - Order sets, policies, protocols, documentation/forms, templates, etc. And all of these tools have to be continuously updated to reflect best practices, new technology, new evidence, etc.

These operations have become part of the price of healthcare - Continuously re-engineering all of these tools, so that the front-line doctors and nurses have the best and most up-to-date :

• Policies and Procedures to learn from and operate by
• Orders to take care of patients and deliver care
• Order sets to standardize and expedite the ordering process for a common clinical scenario
• Clinical Pathways to standardize care for a common clinical diagnosis
• Protocols to standardize and automate care for a common clinical scenario
• Guidelines to help standardize outcomes for a common clinical scenario
• Documentation tools to record and transmit data about care, and guide their thinking
• Templates to help them standardize and expedite the documentation process
• etc...

Unfortunately, keeping up with all of this information, and managing it, is very challenging for most hospitals. The professional industry term for this is "document management", and hospitals that do this well will probably have an easier time in the next five years than hospitals that do this poorly.

So to help hospitals struggling with this, I have often wondered why nobody publishes national, standard definitions of these tools, so that we could at least have the same engineering standards, and maybe then the same engineering processes - So that the order sets would all look the same - And you could truly use the same order set at any hospital...?

I suspect the reason that no regulatory body currently wants to offer these standard definitions is this : Anyone who tries to introduce these definitions and engineering standards nationally will have a big operational and financial challenge : 99% of hospitals would suddenly have to re-tool all of their documents to meet these national standards. Imagine the cost to healthcare nationally.

But so then I wondered - could we do something like this on a much smaller basis, in a much slower, more controlled manner?

Again I'll mention our Interstate 91 Informatics project - Where a bunch of volunteer Informaticists along the Interstate 91 Corridor here in New England are starting to meet regularly to talk about our common informatics issues. As I mentioned in a previous post ("Can we do better than SOAP?"), we are going to start talking about ways to standardize our documentation on a regional level. I'm interested to hear people's responses because it could be very interesting if, in the next step, we looked at standardizing our definitions, engineering processes, and engineering standards. Would it allow us to share resources that ultimately saved all of our hospitals money, and reduced the cost of operations and care in the entire region?

Stay tuned!

My belief is that we are all both teachers and students our entire lives - So I love to hear people's feedback and thoughts. Feel free to leave comments or questions - Always glad to entertain any new or interesting ideas!

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?

I. BACKGROUND

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.

II. DESIGN / CATEGORIZATION

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.

III. OWNERSHIP

Order sets are typically owned by a defined clinical director.

IV.  CONSTRUCTION

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.

V. TESTING

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.

VI. APPROVAL

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.

VII. PUBLICATION

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.

VIII. EDUCATION

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.

IX. MONITORING

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

X. CITATIONS

ISMP's Guidelines for Standard Order Sets : http://www.ismp.org/tools/guidelines/StandardOrderSets.pdf