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!

Why not let docs have their own order sets?

Last week, I was asked a question I'd been asked many times before, by someone who was helping another hospital set up their EMR :

"Why shouldn't we let our docs make their own order sets?"

The reason I was asked this is because many EMR packages have this feature, where docs can make their own order sets for their own convenience. 

REASONS TO LET DOCS MAKE THEIR OWN ORDER SETS :

1. Every doc struggles with efficiency, and making your own order sets certainly is tempting. Why not make order sets that accomplish exactly what you want? After all, if I'm a practicing physician, and I know what orders I 'always put in' in certain scenarios, why shouldn't I be able to make my own order sets?
2. We could save so much committee time if the docs could just make their own order sets!
3. If the docs could make their own order sets, they would probably feel "more comfortable" with order sets and CPOE, in general - Wouldn't this help us with our EMR implementation? Wouldn't we get a higher CPOE rate faster?
4. It would save the time and labor of converting their old paper order sets - (Which, as I've discussed in past postings, are often loaded with embedded protocols which are expensive and time-consuming to engineer out!) - Just let the doctors make their own order sets!
5. If docs could make their own order sets, then they probably wouldn't blame some poor informaticist for making a bad order set for them.

REASONS NOT TO LET DOCS MAKE THEIR OWN ORDER SETS :

1. If every doc can make their own order sets, you have no centralized mechanism for clinical decision support. For example, if your pharmacy previously paid a lot for omeprazole, and it suddenly gets a good deal on pantoprazole, you will probably want all of your doctors to take advantage of the cost savings by steering them towards pantoprazole (when backed by good evidence) - If they all have their own order sets, you won't be able to help guide physician behavior and take advantage of this cost savings. 
2. If every doc can make their own order sets, you also have no centralized mechanism for standardizing care. E.g. an appendectomy could get very different care, depending on which physician was using which appendectomy order set. (Most hospital administrators are trying to standardize care to improve quality and reduce costs.)
3. Order sets need to be maintained regularly, to be kept safe, evidence-based, and efficient. If every doc can make their own order sets, you may quickly end up with many, many different order sets which can be a challenge to maintain, from a technical standpoint. What are you going to do when new guidelines suggest you should be using different drugs to treat pneumonia? How will you find which order sets you need to update? Do you have the resources to keep ALL of your order sets updated? 
4. If every doc can make their own order sets, you will miss out on the opportunity to teach your physicians what informatics is, and how they can improve their own care through evidence-based practice and standardization of processes.

I will admit, as a practicing physician, myself, there are times where I wish I could just make my own order sets. But I will also admit that being challenged on my own order sets is a great learning experience, and ultimately, sharing the discussion with my colleagues, and reviewing the literature is the best learning experience of them all. 

(Apparently I'm not the only one who frowns on personal order sets - A final web page, worth reading even though the author is unclear and this looks more like a comment than a legitimate argument : 

http://www.informatics-review.com/wiki/index.php/Personal_Order_Sets) 

Ultimately, every hospital will need to make this decision for themselves, but remember, as I said - With order sets, there are no free lunches. The rule still applies. :)

Hollywood and CPOE : Why you don't want to take the humans out of the silos

As a CMIO doing front-line informatics, I sometimes get asked, "Can't we make the computer automatically delete that order?"

This is a hard question to answer. The short answer is always "Well, yes....", but the longer answer is usually, "...but you probably don't want to do that."

The explanation why "you probably don't want to do that" takes some time, but interestingly, Hollywood can sometimes provide some good teaching examples. (Even if they are fictional, they are still useful to demonstrate the real answer.)

One of the most influential movies for me, growing up in the early 80s, was the movie Wargames, directed by John Badham and starring Matthew Broderick and Ally Sheedy. Interestingly, it provides some useful teaching examples for healthcare informatics. Allow me to demonstrate :

Pay close attention to this opening clip which parallels what nurses experience every day. Two men, in a nuclear missile silo, show up for work and get an electronic order to launch a missile. The codes authenticate, they have clear procedures and protocols to follow. And yet, before launching missiles that could kill millions of people, one of the men smartly asks the question, "Does this seem right?".

(Note, because he doesn't trust the electronic order he's received, he smartly picks up the phone and tries to get a human being to clarify for him - AKA he tries to page the doctor to make sure the order is real.)

I think most nurses watching this clip can relate to these two men.

I suppose some of it is human nature, to trust a human being more than a machine. We are tribal, and so it seems intuitive to want to speak to a human being, before carrying out an order received from a machine. A written order, despite all of its flaws, carries a certain amount of intuitive trust - The physician's pen hit the paper, the ink is dried in place, this is the handwriting of the doctor I usually work with - It provides much more confidence for a nurse.

An electronic order does not deliver the same trust. We worry that the machine may have interpreted the instruction wrong. Or perhaps the programmer didn't think of this particular scenario. We're trained from childhood on how to figure out machines that don't work. We know they sometimes make mistakes.

So getting back to the question about "automatically canceling orders", and "why you probably don't want to do that".

After this opening scene of the movie, the very next scene shows technicians ripping the chairs out of the missile silo, while a team of strategists deep inside the NORAD missile command say, "We had to take the men out because we learned we couldn't trust them to push the button... So now we've wired the WOPR computer directly to the button."

This then sets up the plot for the rest of the movie - The WOPR computer is wired directly to the button, and when David Lightman (Matthew Broderick's character) hacks into the WOPR to make it malfunction, they are stuck - There is no human being between the computer and the missile launch.

What does this teach us about the importance of human beings carrying out your order protocols, rather than the computer "just doing it automatically?"

Because computers are unforgiving. If you ask them to do something, they will do it. 100% of the time. No questions asked.

The problem with a computer discontinuing an order, then, is this : What happens if you ever have a patient, who for some bizarre and unplanned reason, shouldn't have the order automatically discontinued? What if this one patient, in a million, actually needs the order to continue longer?

1. If you have a computer automatically discontinue the order - That one patient will suffer the problems of being "the one-in-a-million" exception.
2. If you have a nurse following a protocol to discontinue the order - Then you actually have a chance that the nurse will ignore the protocol, knowing "it's the right thing to do". (Yes, good nurses know when to ignore orders and protocols if they could harm the patient.)

What does this clip help demonstrate?
1. Electronic Order Entry comes with an inherent fear, and rightfully so - This is why nurses page us to clarify orders, and when they do, we as doctors should be glad nurses are asking questions - I never want a nurse who is an automaton.
2. For patient safety and good care, communication between nurses and physicians should be ample, easy, and painless. Nurses should never feel forced to press a button without understanding the impact and reasons why they are being asked to do it. If the situation doesn't make sense to them - You want them to call!
3. Nurses are the last safety gap before the delivery of care / button gets pressed. (See the men in the movie clip above!) We should respect their professional judgement - It's there for very good reasons.
4. You generally don't want to take the nurses out of the silos. Imagine the risks of EMR software actually delivering the medications! :)
5. For safety reasons... you generally don't want the computer to automatically cancel the order. Why?
    a. Because a computer canceling it 100% of the time may not be safe for 100% of the patients.
    b. Because you can never create a protocol that is 100% safe for 100% of patients.
    c. Because for safety, in that unplanned circumstance - you want a nurse to know when to say "no".