Evidence-Based Order Sets: One Hospital’s Nuanced Experience

And in addition, Zynx has expanded beyond just treatment each time, to long-term outcomes, such as looking at patient conditions over the long term, as well as adding in economic elements, such as, what is the most fiscally conservative way to order a work-up that is appropriate? And they’re adding in instructions for follow-up and assistance at home, for example, so those elements are now being built into the order set. And that’s a big part of what Zynx is analyzing for us; not only are they looking at which antibiotic a physician is ordering for a pneumonia case, but is also checking to see that we have a good process for follow-up on that same patient, post-discharge.

And so even if we chose the right antibiotic, and ordered the appropriate treatment, then it will also be important to check for social issues for the patient, and whether there was follow-up to make sure the patient had an appointment with their primary care physician. You’re sometimes dealing with elderly patients who might get confused. The fact is that making sure that you’re planning for follow-up and other elements represents a change in the way we’ve delivered care; and it will be a big element in accountable care going forward.

Are you thinking of participating in the federal program or in a private program?

UW Medicine is looking very seriously at what its role might be in accountable care, and is working with local payers, and will most likely begin doing it in a stepwise fashion, and we may do something like providing a packaged care for the major insurance products in the area—bundled payments for total joint replacement or cardiac surgery or certain other treatments that are relatively discrete—while we wait to see what happens on the national health scene to see what direction we’re going. In the meantime, we’re going to put the right infrastructure in place, making sure we have an adequate primary care base, and all the necessary specialty services, and making sure we have the right IT infrastructure, and developing urgent care centers to support our emergency department.

So we’re really focused right now on using Zynx to help us focus our inpatient care, but also to help us make sure we’re prepared for that broader set of care interventions.

Do you have a data warehouse? Are you using any business intelligence or analytics tools yet?

We’re doing a number of different projects around that; the University of Washington has partnered with Microsoft, and is using Amalga to do analysis, particularly in their research and education areas. We’ve done some work with The Advisory Board, and have looked at their Crimson Clinical Advantage and Market Advantage, trying to analyze our care delivery.

Are you using Amalga specifically at Northwest Hospital?

The University is, and we’re just about to go live with it in order to analyze our surgical services, particularly our supply use. Meanwhile, Harborview and UW Medical Center are also using Zynx for their evidence-based order sets; and UW Medical Center went live in July, and Harborview is set to go live later this fall. Harborview is on Cerner.

Are you going to participate in or create a health information exchange?

We plan on participating in health information exchanges. Right now, we’re working on a statewide initiative to do an exchange between all the EDs in the state—ED Information Exchange, or EDIE; it’s a proprietary information exchange to help manage emergency department visits. It is live at other institutions; we’ll be going live in mid-September. And our plan internally is to have all our outpatient practices within UW Medicine on Epic within the next several years.

Have you attested for stage 1 of meaningful use yet?

Yes, we have. That happened earlier this year. Our dates on the CPOE go-live were very carefully timed, in order to allow us to do that. And we’ve also received Medicaid payments, as well as Medicare payments.

Based on what we’ve just talked about, what would your advice be for CIOs and CMIOs in this area?

I think it would be for them to make certain that, before implementing computerized order entry, that they have a very good catalog of orderables for laboratory, diagnostic imaging, and medications, such that the physicians are not overwhelmed with choices of items to order that may or may not be appropriate, or even a part of the formulary. So it’s to simplify as much as possible, and to make things clear. And once you’ve done that, my advice would be to make sure that you have enough condition-specific order sets to allow physicians to feel that the CPOE is a time-saver and an expeditious way of caring for their patients. I think that if you can do those specific things, you’ll be successful. And then also, the nuisance factor, the low irritant factor, will be overcome. The system needs to be easy to use; and then whatever cultural or individual hesitations physicians have about ordering on the computer will become a secondary thing.