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Embedding Evidence Into Physician Ordering

January 5, 2012
by Mark Hagland
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How one Canadian hospital has moved ahead rapidly in its clinical IT development, incorporating evidence-based order sets

North York General Hospital (NYGH) is a 423-bed community teaching hospital affiliated with the University of Toronto, in Toronto, Ontario. Under its clinician and IT leadership, North York last year became the first “stage 6” community teaching hospital in Canada, according to the electronic health record (EHR) schematic developed by HIMSS Analytics, a division of the Chicago-based Health Information and Management Systems Society (one small rural hospital in Canada had previously achieved stage 6; and another Canadian hospital, an academic medical center, achieved stage 6 at the same time as NYGH).

North York is also the first Canadian hospital to implement computerized physician order entry (CPOE) that includes regularly updated evidence from the medical literature embedded into physician workflow. The clinicians at North York are using the evidence-based order set solution from the Los Angeles-based Zynx Health, embedded into their Cerner Millennium core EHR. As of late last autumn, medicine, surgery, and critical care, which represent the bulk of the hospital’s inpatient care volume, were live on the Zynx solution, with the remaining units in the hospital set to go live in the coming months.

Jeremy Theal, M.D., North York’s director of medical informatics, and effectively the hospital’s CMIO, spoke recently with HCI Editor-in-Chief Mark Hagland regarding his organization’s journey to date around evidence-based clinical decision support. Below are excerpts from that interview.

What was your organization’s preparation like for the rollout of the Zynx solution?

We didn’t use interim paper-based order sets with Zynx; we went directly into electronic. We had a core order set build team, comprised of four physicians and four pharmacists, as well as clinical informatics experts, which customized order sets to 80-percent completion, and we then had clinical subject matter experts review those order sets. Front-line clinicians from all scopes of practice were a part of the process the whole way through.






Jeremy Theal, M.D.


Were there any nurses on that team?

Not on the core team, but our clinical informatics analysts have past nursing backgrounds. And the first step with the prototype order sets was to have nursing, allied health, OT/PT [occupational therapy/physical therapy], radiology, etc., review the order sets. As a next step, we had our specialist physicians review the order sets. For example, for our pneumonia order sets, we had our respirologists review it, and so on.

What were the biggest challenges, if any, in preparing for the implementation of the new order sets?

For us, the biggest challenges were that we had a hospital whose culture, prior to this implementation, had not particularly been of the type where people were used to using standardized orders. We had a few standardized order sets, but for the most part, doctors wrote their own orders. So the standardization of care was a new thing for most people. We wanted to treat that situation carefully; we didn’t want people blaming the system. Because of all that, we were very careful to have the docs review the order sets, so that they could have direct input into how it was designed.

Were there any specific challenges for you personally in all this?

Our core vendor was Cerner; all the large core clinical vendors are based in the United States. There are some differences in terms of medical practice in Canada; so we had to create some custom workflows, as well as ask Cerner for Canadian-specific code changes. Those changes had nothing to do with the Zynx element; in fact, we found the Zynx content to be applicable to Canadian practice, with no significant modification required.

Can you mention one example of where differing practices in medicine have affected workflow, and thus, the EHR?

The way that our emergency department admissions are designed is that, when a patient comes into the emergency department, a new encounter is created for them, which is like an episode of care. Normally, in the States, all the care of that patient, even after being admitted as an inpatient, is part of that episode of care. But in many hospitals in Canada, the process is different due to government reporting requirements. In those hospitals, when the patient is admitted to hospital, the emergency department encounter is closed, and a new one is created. And that posed a problem in Cerner, because the orders would have been entered on the emergency encounter, and would not carry forward to the inpatient encounter. To solve this problem, we had to create special software patches in collaboration with Cerner, as well as to train our doctors on a new patient admission workflow.

Did the acceptance of Zynx and of evidence-based ordering come easily among physicians at your hospital?


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