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Order Sets and Monoliths

June 26, 2009
by Joe Bormel
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The appearance of the Monolith marked a quantum leap forward in human evolution in the fantasy world of motion pictures.




In the real world, but in much the same way, the appearance of Order Sets on a meeting agenda represent a quantum leap forward in HCIT impact on clinical medicine. This is happening daily across the country, especially with the looming issue of CPOE and its accompaniments as part of meaningful use in HITECH.




When people bring up the topic of Order Sets, it's time to listen very carefully. This topic can be shorthand for a lot of things at various levels of organizational evolution. What people mean and want represent a spectrum. At any point in an organization’s growth where Order Sets become a focus, that organization is about to undergo a significant transformation.




Here's the basic progression I'm seeing:





1.

Birth

- Realization that creating OS creates value, paper, circa 1970s – 1980s:



- faster and less work than remembering and writing from memory



- the "goodness" of appropriate standardization



- personal or organizational, depending largely on demand





2.

Infancy

- Creation of sanctioned OS for 10 to 20 conditions – circa late 1980s – mid 1990s:



- drivers are quality, reduce variation, improve reimbursement
(e.g. induce sputum, increase authentic DRG 79 over 89, improve case mix)



- regulators and payers mandating their existence



- early governance models - which committees/departments own the Order Sets?





3.

Adolescence

- Early age of automation - CPOE systems support for "static" order sets - circa 1980s – 1990s:



- beginnings of electronic order sets



- issues and best practices begin to be understood



- utilization and/or standardization (is it an "or"?)



- duplicate orders issues from resulting from use of order sets



- pure order management perspective



- co-morbidity perspective



- team care/collaboration



- impact on teaching in AMCs





4.

Puberty

- Rapid growth and new hormones - CPOE Consensus - 9 Considerations for Success (

Joan Ash et al, JAMIA 2003;10:229-234

) – circa 2003



- Consideration 5: Value to Users/Decision Support Systems



- sub-context of Order Sets - need to develop, review, maintain



- HCIT pioneers (Partners, Kaiser, others) begin
formalizing knowledge management as a discipline where Order Sets are part of the knowledge



- implications became more clear and commonly discussed



- Evidence Based Medicine demands classifying patients consistently and following with proven diagnostic and therapeutic care (packaged as Order Sets)



- Unintended consequences becoming more apparent (alert fatigue with mindless overrides)



- Concurrent care coordination processes emerging with CPOE



- medication reconciliation



- BCMA



- e-Prescribing on hospital discharge



- etc.





5.

Early Adult

- early majority recognize that several hundred Order Sets are needed at a minimum. Development and maintenance requires sophistication; ad hoc approaches don't scale – circa 2008



- Order Set management is a multi-layer issue



- tools needed (loading at minimum), life-cycle management required



- skills (rarely exist locally, even at large AMCs and IDNs)



- knowledge (both discrete and global content issues)



- processes for review, ownership, dialogue, etc.



- people: adoption precedes meaningful use.



- structure: how do you do this with multiple facilities, practice models, etc.



- Order Set discussions that tend to be at the leading edge in practical organizations that are looking at the 3-5 year horizon



- real work and real costs are becoming discussion points; cost estimates and implications vary widely





6.

Future Maturity

, where what's wanted, needed and possible have not yet congealed – circa ? TBD (hopefully before 2015 but unlikely)



- Order Sets tightly integrated (closed-loop) with three other concurrent clinical processes: (rather than discrete tasks)


1) Adequately focused electronic (AFE)

results review

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Comments

The success rate is much, much higher in care provider organizations who are disciplined enough to develop, socialize, and maintain project charters.

The counter argument usually amounts to 1) we dont have time to clarify our goals, or 2) we are very clear about our goals and dont want to risk others scrutinizing them.

An important, distinct component is that, over time, things change, and without adequate relationships, renegotiating project charters is impossible. So, let's not even start with them; they're too restrictive!  (Bad move.)

Those are the biggest aspects of project charters I've seen. I'd love to have a PMP PMI certified project manager comment on all of this.

Thanks Charlie. To paraphrase Sun Tzu, Tactics without strategy is the noise before defeat.

In the absence of a project charter, excuses for not having one are the noise before defeat.

Of course, having project charter doesn't assure victory, but that's no excuse to skip them.

Hi Joe — as usual your thoughts and observations are 'spot on'.

Your description from infancy to young adult truly mirrors what I observed in my own practice setting as a director of pharmacies for a multi-hospital system (which was not unlike others across the country).

It truly is amazingly mind-boggling the number of order sets needed and the resources needed for the care and feeding for their management. The concept of a needed lifecycle support system is also accurate, but there is much to be determined on how to best and accurately (and cost effectively) do that in today's environment.

I think hospitals consistently underestimate the internal ownership and real costs, in particluar, the resources. Where are we going to get all these people?
BTW great photo, Joe.

Hello Joe,

You have encapsulated the emergence and progression of standardized order sets well. I would like to expand on your closing thoughts: to overcome the challenges you've identified at the Early Adult stage that are keeping us from moving into Future Maturity, I believe facilities should take a closer look at automation. Not only does this allow for a more streamlined authoring and maintenance process — which is imperative if we are to develop (and maintain) the volume of order sets necessary to realize their full potential — but it also provides the means by which reviewers and end-users alike can access the supporting literature that validates the order set, and more easily involves a wider group of physicians in the order set process. Automation and the audit functionality that it provides can also make the order set process transparent to clinicians and others involved with the process.

Unless physicians can participate in and trust the creation of the organization's order sets, and conveniently access current and accurate medical evidence from trusted sources, they will remain reluctant to fully embrace standardized order sets. In fact, I suggest that the quality and 'buy-in' of the clinical content is the single most important driver of order set adoption. The most expansive order set library in the world is worthless if physicians do not trust the process by which the order set was created, or do not trust the evidence upon which individual order sets are based. In addition, clinicians should be much more willing to use order sets if they can also access this evidence when they most need it when determining the appropriate course of care for their individual patients.

Linda, Thanks for your perspective. I'd like to reinforce:

1) Trust is critical. Trust must be built through experience and involvement and must be maintained. This is important work.

2) Local content management (eg of Order Sets) of this magnitude is a new thing for most hospitals. Locally, it takes time and skill.

3) I learned at AMDIS last year just how unique and valuable the reference tool Up-To-Date is for CMIOs (across all HIS vendor platforms.) I blogged about that a year ago. It's noteworthy that Wolters Kluwer purchased Up-To-Date several months later. Physicians at AMDIS found Up-To-Date far more practical than other resources in that it made suggestions when there was no evidence base to reference, which is pretty often. Having Order Sets that are editorially consistent with reference content is obviously important and something that CIOs should pay attention to.

Joe,

We met a few weeks ago on the phone. I am a PMI PMP certified project manager and wanted to comment on the importance of a Project Charter. This document formally authorizes the work of the project to begin (or continue) and gives the project manager authority to do their job. The project charter document may have different names in different organizations, which sometimes results in confusion over what the project charter is and how it should be used.

Per PMI, a project cannot start without a project charter and at a minimum should contain the following elements: a description of the business need the project will meet, the product resulting from the project, and ideally should be issued by a manager external to the project. This is typically a senior manager with the authority to marshal the necessary resources, influence key stakeholders, and enforce accountability on all project team members. The project charter should also include the objectives and goals, key assumptions, constraints, and/or target performance metrics for the initiative. In particular, any assumption or constraint affecting the project's schedule, budget, or quality should be identified.

The three primary reasons a project charter is important are that it legitimizes the project manager's role and grants them the authority to execute the project, legitimizes the project by authorizing it to exist and/or be extended and most importantly sets the targets for the project. The document is crucial to the planning phases of the project, and while the existence of a project charter does not guarantee the success of the project, numerous studies have shown that the lack of a project charter has resulted in high-profile project failures.

I hope that is helpful.

Thanks for the kind words, IA. As a network pharmacy director, I would suspect that you have a special appreciation for perhaps the biggest current issue for institutions around Order Sets, dealing with the internal ownership and real costs (content, related services, internal FTEs for training, maintenance, QA, utilization review, etc.) Order Sets are definitely driving a lot of new conversations in provider organizations!

Thanks again for your comment.

Thanks for the comment, Daphne.

It was great seeing you and comparing notes at x3summit09. Great conference!

Your comments bring us back to the issue of creating written artifacts like project charters, that explicitly commit to the goals of projects that are enabled by HCIT.

When Order Sets become primarily a content component of an EMR project, the ownership, institutional goals and commitments, and their resulting costs are always an after thought. With predictable results.

You're raising some great points:


Planning - There's work at step four that, if omitted, has predictable results.

Structure - who reports to whom, their defined responsibilities and reporting relationships (e.g. does the CMIO have true subordinates) have profound impact on execution of an Order Set strategy. You can change Order Set to Care Management or Health Management, etc in that last sentence!


Thanks again for your observation.  (Since you liked the graphic, here are the ones that were runners up.)


It was great seeing you too, swell conference. Joe, in your experience, in real life, do many people commit to project charters? We know they should, but do they?
And first pic best choice, well done.

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Joe Bormel

Healthcare IT Consutant

Joe Bormel

@jbormel

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