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.

THE BASIC RECIPE :

Ingredients - What you'll need :

• A standard EMR, chock full of well-built electronic orders.
• A 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).

INSTRUCTIONS FOR BAKING :

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!

Order Set Development and Preparing for the Downtimes

So as if order set development wasn't challenging enough, some people will ask :

"Dirk... So once you go electronic, you don't need paper anymore, right...?"

Well, here's the bad news. You will probably still need paper order sets.

"Huh...?"

Yep. It's true.

You will probably still need paper versions of all of your order sets, just in case your EMR / CPOE goes down.

I know it seems like a lot of work, but think about this :

1. After you develop electronic order sets, your doctors will come to rely on them.
2. The time they save using good order sets will increase their efficiency.
3. The good order sets you've built will help them standardize care.
4. This improved efficiency and improved standardization will, over time, allow you to make staffing changes.

The problem, however, will be : What happens when your EMR goes down?

1. Will your docs have order sets that accomplish the same goals as your electronic order sets?
2. Will your docs suddenly lose efficiency that they accomplished with those electronic order sets?
3. Will your docs be able to handle as many patients as they did with the electronic order sets?
4. If your docs rely on those order sets, and your computer is down... What paper order sets will they use?

So here's the message : It's good practice if you simultaneously develop matching paper and electronic order sets.

"But Dirk... it takes so much time to make an electronic order set... how do I make a matching paper order set?"

Some people, when confronted with this demand, will try this approach :

1. Have one team make the electronic order sets
2. Have some person, after the electronic order set is built, type out a matching paper order set.

This approach works, but I think a smoother approach is to develop an order set process that allows your informaticists to develop both paper and electronic order sets as part of the same process.

This gets us into a discussion about order set development.

After a hospital goes electronic, they generally try to use the same process they used before to make paper order sets. Unfortunately, because of the new demands an EMR brings :

1. Now - Will need both paper and electronic order sets developed at the same time
2. Now - Will need better engineering (e.g. order sets separated from protocols, etc.)
3. So... Will need informaticists to help engineer those changes
4. And... Will need Clinical IT Analysts to help build the work that the informaticists do

... Eventually, you start to realize : The old process doesn't meet the demands of an EMR.

So I generally recommend developing an order set change process.

The Order Set Change Process

Order sets are like any other clinical tool your hospital uses : You will need to define :

1. Who is the owner?
2. Who are the builders / project managers? (Generally, an Informaticist + Clinical IT Analyst)
3. What importance/priority does the order set/change have?
4. Who will assign this importance / triage changes?
5. Who will build the first draft? 
6. Who will test the new order set / changes?
7. Who will review the testing results?
8. What education plan (if any) will you need?
9. What companion documentation (if any) will you need?
10. What implementation plan (if any) will you need?
11. What accompanying clinical policy (if any) will you need?
12. What committee will "approve" your order set, after testing?
13. Who will implement the order set and the implementation plan?

So if you need to build both a paper and electronic order set, at the end of this process, here are my recommendations :

A. Develop an order set "Change Request Form". You will need this to help understand the expectations and understanding of your owner. Typical questions you might ask include :

1. Date of order set request?
2. Owner of order set? (I generally recommend this be a department director)
3. Builder/Informaticist assigned to order set?
4. Request :  (   ) new order set    (   ) delete order set     (   ) change order set
5. If requesting a change, what is the previous order set you wish to change? __________
6. What change are you requesting? (Please be specific) : ________________________
7. What companion documentation will you need? : _________________________
8. Will you need an education plan/curriculum for this change? : ____________________
9. Will you need an accompanying clinical policy to support this? : ___________________
10. Will you need a protocol to help support this order set? : __________________________
11. Will you need an implementation plan for this change? : _________________________
12. Priority of change : (1-5, 1=low, 5=high) : ___________
13. Expected date of completion : __________________

(Generally, at the bottom of this form, it's helpful to have signature lines that match the key, important parts of the process below, so you can help keep track of the process...)

B. Develop a process. You will then need a process where that change request form helps lead your process. A typical process might look like this : (I've highlighted the various characters, so you see how many people might be involved and the roles they play...)

1. Change Request Form is published throughout hospital (explain to docs/directors that all order set building/changes/deletions will be done according to this form)
2. Change Request Form is completed by owner, and brought to CMIO for triage.
3. CMIO and Clinical Analyst Project Manager review form and assign a priority and assign an informaticist and clinical analyst to work on the project.
4. Informaticist works with owner to define workflows.
5. Informaticist creates first paper draft of order set, using orders found in your electronic order library/EMR. (This helps make sure your paper version matches with your electronic order sets.)
6. Informaticist defines testing plan : What front-line clinical staff will be needed for testing?
7. Informaticist gives first paper draft to clinical analyst to build first electronic draft.
8. Informaticist helps prepare companion documentation (if needed)
9. Informaticist helps prepare clinical policy (if needed)
10. Informaticist helps prepare protocol (if needed)
11. Informaticist helps prepare education plan/curriculum (if needed)
12. Informaticist helps prepare monitoring plan (if needed)
13. Informaticist helps prepare implementation plan (if needed)
14. Informaticist and Owner execute testing plan - Using front-line staffmembers the owner makes sure show up for testing
15. CMIO and Informaticist review results of testing together, and review current versions of paper/electronic order sets, protocols, policies, companion documentation, education plan
16. If CMIO and Informaticist approve - Then proceed
17. CMIO puts paper/electronic order sets on agenda for Order Set Committee - Sends notification/drafts/links to committee members
18. Informaticist and Owner - Pass clinical policy through committee for approval
19. Informaticist and Owner - Pass documentation through committee for approval
20. Informaticist and Owner - Pass protocol through committee for approval
21. Order Set Committee meets to review both paper and electronic order sets
22. If Order Set Committee approves - Then proceed
23. CMIO sends notification of approval of final paper draft to printshop : Paper order set is coded and published (usually to a "red file cabinet" where you keep "order sets needed for electronic downtimes)
24. CMIO sends notification of approval of electronic version to clinical analyst  : Electronic order set is coded and published (by your analyst moving from test-->live, usually via your EMR)
25. Informaticist and Owner conduct implementation plan
26. Informaticist and Owner conduct monitoring plan (if needed)
27. Owner : Continuously monitors order set after use
28. (Restart at step 1 if needed) 

Yes, it's a lot of work. Seems monotonous and boring, but you will need to define a process for order set change management, or else you will end up with order sets that lack support, order sets nobody uses, order sets with no monitoring/involvement, and poor project management.

You'll notice that the Informaticist title up above appears in many steps in the process. This is why you'll want an informatics platform after you "go EMR". Clinical IT Analysts (sometimes mistakenly referred to as "programmers") actually play a much smaller role in implementation than most people think - They're mainly there during development, to make the technical changes and advise the informaticist on technical limitations. You'll also notice that order set owners, once you define this process, will become much more involved in the development, testing, implementation, and monitoring of their order sets.

Finally, you'll want a CMIO to help manage your informaticists, and help corral your doctors/directors into this new process.

And, if you engage in this sort of process, your informaticists will be building/approving simultaneous paper and electronic order sets :

1. ... so you can have an electronic order set that helps expedite the electronic ordering process (CPOE) for a common clinical scenario...
2. ... and at the same time, you'll have a matching paper order set that can be filed in an emergency file cabinet to be used during electronic downtimes.

Phew! As I said : With order sets, there are no shortcuts. 

This is part of the culture that EMRs bring. My advice : Prepare for change. :)

Would love to hear other people's stories - of how you developed a streamlined change management process for your order sets - I look forward to feedback! :)

Converting paper order sets to electronic

If you're reading this, I hope you're the person in your institution trying to "convert the paper order sets to electronic ones".

Don't worry - you're perfectly normal. The job is usually a lot harder than it looks. And no, you're not the only one who hears, "Why can't you just take the paper order sets and put them on the screen?"

(Most people think it's simple, until they actually start to dissect the order sets.)

First, let's start with some of the challenges of paper order sets :

1. Paper order sets generally keep multiplying - Let's say you decide to fix the paper order sets, and so you need to take the old versions "off the shelves". Beware - People tend to make copies of paper order sets. So the old ones can turn up weeks and months later.
2. Paper order sets are often engineered differently - In the electronic (CPOE) world, orders are very concrete. You may have specific safety features put into your electronic PCA (Patient-Controlled Anesthesia) order. How will you put those safety features into your paper order set? You may also have hidden "protocols" in your paper order sets. What will you do with those protocol (conditional) orders? 
3. Paper order sets are sometimes ignored, after a hospital "goes electronic" - If you ignore your paper order sets, what will your hospital use during electronic downtimes? Can you afford not to have paper backup order sets, if your OR/ED are busy?

Believe it or not, how you address these paper-order-set problems will be vitally important in your long-term electronic success. Ignore the paper order sets, and you will miss an opportunity to really set up a robust electronic platform.

Let's look at each of these issues in a little more detail :

1. The "Multiplying paper order sets" -

This is a phenomenon many organizations struggle with. The solution : Centralize all of your order sets on one common electronic web site, and publish them as non-editable .PDF files. Create a clinical policy where "If it's not on this site, it's not an acceptable order set".  It will take you a while to get the site together, and organize all of your paper order sets there, but in the end, you will have a way of controlling the paper order sets in use. 

2. The "Engineering differences" between paper and electronic order sets

Some organizations, on going electronic, focus on developing electronic order sets, while the paper order sets continue to be produced in the way they "always have been built". If you have two separate processes (an electronic and a paper process), the problem is that you will start to have significant engineering differences between the two. 

If you have different paper and electronic order sets, you will then encounter :

• Paper order sets that don't meet the engineering standards needed for order entry in your EMR, so they will be very hard to "send-to-pharmacy-so-someone-else-can-do-the-order-entry"...
• Paper order sets that don't match the electronic order sets
• Two cultures : Docs who use electronic order sets, and docs who use paper order sets. (If your organization does a "flip-the-switch" approach to EMR/CPOE, then this won't apply to you. If you do a "gradual conversion", then this will apply to you.)

The way you fix this, of course, is to develop simultaneous paper and electronic order sets. Set up your informatics platform, update your policy on order set development (to include paper and electronic order sets), and ask your informaticists to develop the paper and electronic order sets simultaneously. Have them tested by the same people, and approved by the same committee. This will ensure that they match, and even if you are a "100% CPOE" organization, you will still appreciate having matching paper order sets during electronic downtimes.

Remember, the solution isn't to make electronic orders that mirror your bad paper processes. Make good, solid, and safe electronic orders, and then use those in your updated paper order sets.

A final tip : Embedded "protocol" (conditional) orders generally need to get pulled out of the paper order sets, before you can "make them electronic" - and you will need to decide what to do with those : A. publish them as new protocols, or B. throw them out. This will take work and can be politically challenging. 

3. The "Ignored Paper Order Sets"

Some organizations, on going electronic, ignore the paper order sets, thinking, "We don't need them anymore, right?". My advice : Don't ignore them. Not only will you need to figure out what your pharmacy will do if they end up getting faxed paper orders, but you will still need them for computer downtimes.

If all of this sounds complicated, and it sounds like a lot of work, you're right - It is. This is why order sets are the political and organizational challenge that they are. A good informaticist can help sort out the issues and put a plan and process into place for your organization, where it doesn't have to be too painful. Unfortunately, because healthcare doesn't have standards in clinical processes, every organization handles this conversion differently, and as a result, order sets are notoriously hard to standardize. (Think of them as a "custom-fitted suit".)

One last tip : Beware the "quick fix" - There are consultants who will "easily and quickly convert your paper order sets to electronic ones". The way they usually do this is by taking the paper orders, no matter how they are engineered, and simply build new electronic orders that match them. In the short term, this may appear to work, but in the long term, it may leave the nurses with orders which are unclear (and may create extra pages to doctors to clarify), since some paper orders are not as well-defined as their electronic counterparts. You may also miss out on the opportunity to streamline your clinical processes, and miss out on the time and cost savings that an EMR can really bring. My recommendation : Build the new paper order sets to match the engineering standards of your electronic order sets - Not the other way around. 

As always, my advice with order sets : There are no quick fixes. Hire a good informaticist to help you with this. :)

Hey, by the way, I'm open for questions - If anyone has any EMR conversion or informatics questions that you'd like to chat about, feel free to leave a comment here or email me. I'll try to devote my next posts to reader questions! So send me stories, questions, or whatever else you'd like to discuss in upcoming posts - I look forward to hearing from folks! :)