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!

Building a Business Case for Clinical Informatics

Hi fellow Informatics leaders,

After my last post on The Offerings of Clinical Informatics, I'm planning a follow-up post on the business case for Clinical Informatics.

After all, we all know the clinical case - More predictable workflows, better clinical decision-support strategies, better data management, better engagement of clinical staff, and better prioritization of clinical improvement projects - But what exactly is the business case? Does having certified, well-trained, and well-supported clinical informatics professionals actually save money? Improve charge capture? Improve efficiency? If so, how much?

Sure, there are plenty of industry anecdotes - but I'm searching for published data too.

If you have any good anecdotes, and would be willing to share them for my next post, please leave a comment below, so I can compile them and share your story. And if you are aware of any good published data, please feel free to leave that too. 

More to come soon, and thank you all for your help.

- Dirk :)


Have any good anecdotes about the business case for clinical informatics? Or know of any published data? Feel free to leave information in the comments below!

#Informatics : Why can't I just pre-check this order?

Hi all - Sorry it's been a few months since my last post. No excuse other than lazy blogging. Oh, and developing an Informatics platform in the middle of Meaningful Use, ICD-10, and new regulatory focus on interoperability and configuration - It's can keep you very busy!

For this post, I wanted to try to address a few common questions, that many lonely Informatics people of the world sometimes hear, and sometimes struggle to answer : "Why can't I just ____________?", as in :

1. "Why can't I just pre-check this order?"
2. "Why can't I just make this order set?"
3. "Why can't I just approve this policy?"
4. "Why can't I just do what I used to do BEFORE?"

There is an answer to these vexing questions. It's called workflow. And if you're not clear about workflow is, you won't know how it quietly impacts us all.

WHAT EXACTLY IS WORKFLOW?

Searching the web, I found a few competing definitions of the term "workflow" : 

1. From Wikipedia's entry on Workflow : "an orchestrated and repeatable pattern of business activity enabled by the systematic organization of resources into processes that transform materials, provide services, or process information"
2. From Whatis.com : "Workflow is the series of activities that are necessary to complete a task.
3. From the very talented #workflow expert, Charles Webster, MD : "Workflow is a series of tasks, consuming resources, achieving goals." 
4. Or from Google : "the sequence of industrial, administrative, or other processes through which a piece of work passes from initiation to completion."

Interestingly, Google also reports that the term "workflow" has suddenly become quite popular in writing :

From my perspective, workflow is what you do, how you do it, and when you do it. It's the [ WHO ] will [ WHAT ], in order, that drives the basic processes of your organization. Workflow is your recipe for success. If you're a chef, workflow is your winning recipe, perfectly executed. If you're a hospital, it's your clinical policies, perfectly executed. Workflow does not answer every detail about diagnosing pneumonia, but it outlines the mission-critical steps you need to identify/register your patient, listen to your patient, diagnose their disease, treat their disease, document their treatment, and finally bill effectively.

However you define it, organizations with good workflows generally succeed by delivering a high-quality product, predictably, at a good price. Organizations with bad or confusing workflows will struggle to do that. So it's vitally important to have good workflows to support your goals.

WHAT DOES A WORKFLOW LOOK LIKE? 

When discussing/documenting workflows, it's very common for people to use Visio or other software to create swim-lane diagrams or other algorithms or flowcharts. In experienced hands, they can be vital in documenting current and future-state workflows, but they can require some degree of training and time to create and interpret them correctly.

So I'm proud to share that I recently had the opportunity to collaborate with my outstanding informatics colleague Jessica Gould! Together we did some archetypal analysis and redesign, and developed this handy workflow documentation template that's fairly easy to teach and learn quickly :

[ WHO ] will [ WHAT ] [ how ] [ when ] [ where ] [ why ]

… where :

• [ WHO ] will [ WHAT ] are the mandatory pieces of every workflow line.
• [ how ] [ when ] [ where ] [ why ] are the optional descriptors of every workflow line.

So just as a teaching example, you can use this template to convert your favorite food recipe into a workflow/procedure - e.g. from the Food.com web page, this recipe for Quick Macaroni and Cheese :

1. Cook two cups of macaroni until al-dente
2. Make a roux by melting butter in pan and adding flour
3. Stir constantly and cook until it is the color of caramel candy
4. Slowly and carefully add milk while stirring
5. Add cheese and seasonings when milk starts to steam, until melted and well-combined
6. Pour over cooked macaroni and noodles

If we feed this recipe into our template, we get something that looks like this : 

1. [ WHO ] will cook two cups of macaroni [ until al-dente ] 
2. [ WHO ] will make a roux [ by melting butter in pan and adding flour ] 
3. [ WHO ] will stir constantly and cook [ until it is the color of caramel candy ]
4. [ WHO ] will slowly and carefully add milk while stirring
5. [ WHO ] will add cheese and seasonings [ when milk starts to steam, until melted and well-combined ]
6. [ WHO ] will pour [ over cooked macaroni and noodles ]

Now this incomplete workflow leaves us with a lot of questions, about who exactly should be doing these steps? 

HOW TO BUILD A NICE, LEAN, COST-EFFECTIVE WORKFLOW : 

To help fill out this workflow, we can expand the template just slightly : 

From : 

[WHO] will [WHAT] [how] [when] [where] [why] 

To : 

[WHO] will [WHAT] [how] [when] [where] [why] [time] [materialcost] [laborcost] [TOTALCOST] 

… and this now lets you play several "What-if?" scenarios, to help work out the most cost-effective way to execute your workflow. For example, if we ask a doctor to make this macaroni and cheese, if we assume a salary of $80/hr, then executing this workflow will take 23 minutes and cost you $33.17. (That's an expensive plate of macaroni and cheese!) (Click on the picture below to expand.)

By looking at the workflow designed with this template, you can quickly rearrange steps, reassign roles, and develop lean, cost-effective workflows that ultimately support your organizational goals. I believe that teaching this template to your staff can help them to easily write, analyze, and better develop your common workflows and procedures.

SO WHY CAN'T I JUST ADD THE BOX LIKE I USED TO DO BEFORE OUR EMR?

The reason is because your workflows support your organizational goals. And what supports the workflows? The people and tools in your organization. By that I mean all of your talent, and all of the tools they use to do their jobs : Your policies, procedures, guidelines, orders, order sets, clinical pathways, protocols, Alerts/MLMs (Medical Logic Modules), Documentation, Reports/Dashboards, Patient Education, Staff Education, Budgets, Job Descriptions/Contracts, Glossaries, Wikis, and Org Charts.


So often when a well-trained, seasoned Informaticist is assigned to a project, they might first ask :

1. What is the goal of the project?
2. What workflow(s) is/are needed to achieve the goal?
3. What tools will we need to effectively support the needed workflow(s)?

Visually, this looks something like this :

… where the documents support the workflows that support the goals. And so depending on the workflow change, or desired new workflow, you have to mentally go through each one of those tools and ask : Do we need to create/modify/delete this tool to effectively support the desired workflow?

• Some smaller change projects might be accomplished through developing only one of those tools.
• Other larger change projects might require the development of many tools.

So when someone asks me, "Why can't I just pre-check the order in this this order set?", I will typically ask myself : 

1. What is the organizational goal?
2. What desired workflow does this order set support?
3. What other tools are working together to support this desired workflow?

And if pre-checking the box will mean changes to other tools, then I might tell them something that sounds like this : "I know that pre-checking the order seems like a simple issue, but to make sure it continues to harmoniously support the workflow and organizational goals, we may have to update the staff education, patient education, and pharmacy budget too. Let's look at these and how they work together before we make the change."

Workflows also teach us that we are all, in fact, interconnected - both clinical and administrative staff. Each side depends on the other for success. 

WE DIDN'T DO THIS BEFORE - WHY IS THIS DIFFERENT NOW?

This workflow issue existed in the paper world, but there was one crucial difference - There was more wiggle room. EMRs generally increase workflow accountability through two means : 

• They make large amounts of data easily available for analysis - Reports that used to take months of chart review now takes seconds. It's easier to find poorly-supported workflows.
• They enforce stricter documentation standards that were harder to enforce on paper - The legal-grade authentication of most EMRs prevents scenarios where one-person-filled-out-the-form-and-another-signed-it, just to satisfy a confusing workflow.

So I generally tell people that after their enterprise EMR goes live, they may experience a demand for workflow analysis and redesign to a degree and standard they were unused to in the paper world. I suspect it's this demand for high-grade, well-supported workflows that is driving the demand for trained, qualified, and experienced clinical Informaticists - And I'm proud to be one of them!

As always, this blog is for educational purposes only. I welcome discussion and feedback! How do you explain to end-users why it's sometimes-not-that-simple? All comments below are welcome!

Could Healthcare use a SimHospital?

It's July, 2014. Meaningful Use Stage 2 is underway, ICD-10 has been delayed again, the Affordable Care Act is happening, and healthcare is reforming at a pace it's never been subjected to. Change is afoot. So this has been keeping me quite busy.

So I thought I'd write a bit about the potential value of gaming and simulation in healthcare reform.

As a CMIO in a community hospital, you sometimes fill a lot of roles - Physician informaticist, project manager, trainer, workflow analyst, policy writer, regulatory guru, strategist, and practicing physician all in one. I think this is one of the reasons the CMIO role continues to expand and evolve nationally - It's helpful to have someone who sees so many facets of your care delivery system.

And as an Informaticist, to help the REAL world, you end up spending a lot of time in a VIRTUAL world, with dummy patients, dummy lab tests, and dummy tools, trying to test things in a virtual TEST environment, to make them work properly before they go into the LIVE environment. Sometimes I'm very surprised at what this virtual world teaches us about the real world. (For some Hollywood context, see Gary Sinise playing astronaut Ken Mattingly in the movie Apollo 13, where they work out problems in the virtual training environment that help save the real-life astronauts.)

Anyway, with all of the change going on in healthcare, we need to identify and train future healthcare leaders who will help see healthcare through these changes. Here is where gaming comes in.

Gaming could help healthcare, by allowing our future healthcare leaders to learn strategy in a safe, dummy, TESTING environment - No real workers, no real patients, no real budgets. If pilots can practice flying and landing planes in a simulator, why can't healthcare leaders? What if they could really experiment with revolutionary efficiency and cost-cutting strategies in a safe, TEST environment, where they wouldn't have to worry about departments or hospitals shutting down?

One thing I've learned from studying workflows is that most people behave in fairly predictable ways. Most people want to do the right thing - They want to practice their trade, make a living doing it, and be proud of their work - so if you give them enough structure and reinforcements, they will do it fairly predictably. In other words, predictable things happen predictably.

So if you were designing a healthcare simulator, it probably wouldn't be too hard to develop some common clinical and administrative avatars :

1. [ CLINICAL ] Nurse avatars
2. [ CLINICAL ] Physician avatars
3. [ CLINICAL ] Pharmacist avatars
4. [ CLINICAL ] Ancillary staff avatars (e.g. Respiratory, Dietary, Rehab, Case Management, etc.)
5. [ ADMIN ] Manager-type avatars (e.g. Nursing, Providers, etc.)
6. [ ADMIN ] Director/Chief avatars
7. [ ADMIN ] Executive avatars
8. [ ADMIN ] Board Member avatar

And in this game, with simulated budgets, each of these avatars would generally conduct themselves with a predictable degree of certainty, based on what I think are a few key environmental variables, which are all related to each other : 

1. Amount of Education/Training (includes everything from formal, professional education to organizational orientation to continuing ed)
2. Strength of Operational Infrastructure (includes everything from policies to governance to committee structure to supervision to technology to organized change management)
3. Quality of Documentation (includes everything from contracts to job descriptions to committee charters to bylaws)
4. Efficiency and Flexibility in Finance/Budgeting (includes everything from salaries to budgets to facilities and equipment)
5. Effectiveness of Communication (includes everything from emails to committee meetings to reporting structure to internal/external posters and publicity)

So in a virtual, gaming scenario, you could potentially build a virtual SimHospital, from the ground up, full of these avatars. And if you wanted it to be successful - Or really successful -  you would probably want your virtual avatars to have the highest amount of education, strongest operational infrastructure, highest quality documentation, most efficient and flexible finance/budgeting, and most effective communication.

But the real world doesn't work like that - you can't have the highest degree of all of them. You have to make compromises. Usually limitations come in the form of time, resources, or both. So to be successful, most organizations constantly work to maximize all five of those factors.

But the virtual avatars in this virtual hospital would all be continuously responding to these environmental variables, and in this way, one could build this SimHospital - A virtual environment in which the goal is to make a working, functional, and financially viable hospital. You make the decisions, you juggle the variables, and the avatars and budgets will respond to your decisions. You could be your own virtual board member.

Why would someone want to play this game? To learn safely. To experiment. To try new ideas without people getting hurt. Heck, you could even make it fun and award points for things like delivering a quality procedure without complications, or saving money. What if healthcare administrators played this game at home, competitively, trying to see who could get the highest score?

Let's face it, running a healthcare corporation isn't easy, with these many complex internal and external environmental variables that are constantly changing. But helping leaders to understand the these changing variables in a safe, TEST environment, would have enormous educational value to future healthcare leaders.

After all, if pilots have virtual simulators for flying a plane, why not a virtual simulator for running a healthcare organization?

The challenge with this whole gaming idea, of course, would be deciding : What would you award points for, exactly? Would it be :

1. Financial Profitability?
2. Quality of Care?
3. Quantity of Care?
4. All of the above?

Whatever the scoring schema is, a place for healthcare leaders to learn managerial and leadership skills safely, and try out new ideas without risk, would be a tremendous help in training the leadership we will need to see our industry through the next ten years.

What would you award points for? Leave your thoughts in the comments below! Remember, this post is for educational purposes only, and to stimulate discussion about new and innovative ways to help improve the delivery of healthcare.