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Empowering Physicians at the Point of Care

September 25, 2012
by Lucio Martinez, M.D.
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Electronic order sets provide the foundation for clinical decision support, but a solid workflow assessment is necessary for successful deployment

Point-of-care decision support technologies such as electronic order sets are central to standardizing care practices and paving the way for the practice of evidence-based medicine. By providing physicians with a checklist to guide care decisions as well as direct access to supporting medical evidence, electronic order sets also help reduce errors and improve quality and core measures performance.

A recent KLAS Enterprises report specifically found that when compared to other clinical decision support (CDS) tools, healthcare providers cited electronic order sets most often when identifying the technology that has greatest impact on their organization. The report covered the use of order sets, multi-parameter alerting, nursing care plans, reference content and drug information databases.

Industry studies also reveal that electronic order sets have a proven track record of reducing errors and improving clinical practice. A recently-published study in the Journal of Hospital Medicine Early View found that hospitals using the UpToDate clinical knowledge system improved mortality rates and experienced shortened length of stays, equating to better quality performance than hospitals not using the tool.

The challenge for many hospitals is dedicating the resources necessary to build and maintain a suitable library of evidence-based order sets to integrate with computerized physician order entry (CPOE). It can also be a struggle to encourage physicians to embrace the use of order sets so that the efficiencies of standardized care can be realized.

Thus, when FHN Memorial Hospital, Freeport, Ill.,  decided to deploy electronic order sets as part of its CDS strategies, it was determined that a workflow assessment would be an important starting point. Previously, order sets were completed on paper via a time-consuming, manual process—a distinctly different method than what was required for electronic development. While the move to a more efficient, digital mode of order set development held great promise, success required a carefully crafted strategy for gaining clinician acceptance of the resulting process changes and for minimizing workflow disruptions.

What we ultimately instituted was a completely revamped governance strategy that dictates the process by which order sets are developed, reviewed, approved, deployed and utilized. By establishing clear policies, resistance was minimized as clinicians made the transition from paper to electronic order sets.

The successful process that delivered these outcomes is illustrated here.

Uncovering the Impact on Workflow  
FHN Memorial is part of a large regional healthcare system covering northwest Illinois and southern Wisconsin. The 172-bed hospital was looking for a solid CDS tool to guide clinical decision making, empower physicians at the point of care and help evaluate patients, especially those with less common conditions.

After evaluating its needs against CDS tools available on the market, the organization chose ProVation Order Sets (supplied by Wolters Kluwer Health, Philadelphia), powered by UpToDate Decision Support to supplement its CPOE efforts.  The software’s evidence-based knowledge accessible at the point of care was an important differentiator for FHN and would form the foundation of the hospital’s clinician adoption strategy.

With the order set solution identified, the next step was to establish an order set committee and identify physician champions. The order set committee works as one of five subcommittees under the physician electronic health record committee. Other committees include training, workflow, communication and metrics, and each one is led by a physician champion.

The identification of physician champions to openly participate and lead the process was a crucial element, as some clinician resistance was expected. For example, some physicians feared that moving to standardized practices was simply a move to “cookbook medicine,” where experience and expertise were not taken into consideration. It was equally important to have champions validate the evidence-based aspect of a product as trustworthy.

The order set committee then set out to develop policies that would minimize workflow disruptions and help foster a sense of clinician ownership. To accomplish this goal, a workflow assessment was initiated to determine the impact the development of a single order set would have on back-end processes.

What was found was that one single order would, on average, impact 12 separate back-end processes. Failure at any step would impact how quickly a physician’s orders were enacted and their satisfaction with the technology.

The Quest for a Solid Governance Plan
To begin building the governance plan that would drive order set development at FHN, a workflow diagram was completed. Having a visual road map to back up the process has proved very beneficial when questions or issues arise.

A “no-tolerance” policy was also established early in the process to eliminate deviation from the workflow road map. This rule was important for establishing ownership. If the governance process was followed, then physicians owned the order set.

To determine which order sets would be developed first, the committee looked at FHN’s top 10 DRGs in terms of frequency and importance. The first four placed in the queue for development included congestive heart failure, chest pain, pneumonia and a general medicine admission.

The order set committee then decided to cut its teeth on the general medicine admission order set, working through every department to get feedback on the process. While the first electronic order set took roughly a month to develop, the overall evaluation provided powerful insight into what physicians saw and how the chain of events impacted the back-end.

Once developed, that first order set was then forwarded to the physician EHR committee and then to the medical executive committee. Full medical staff participation was accomplished by sending the order set to all the hospital’s physicians for comment across multiple communication channels and in multiple formats. Upon reconciliation of all issues, the order set was sent back to the medical executive committee for final approval and then mapped from the ProVation software to the MEDITECH ((westwood, Mass.) CPOE system.

Increasing Momentum Towards Evidence-Based Medicine
Order set development time is down to just two weeks. Within an eight-month period, 132 order sets were developed and built, and there is currently 100% utilization by the physicians at FHN.

Acceptance of the technology has gone remarkably well and has impacted compliance with regulatory standards, appropriate core measures and other reporting initiatives. Having standardized practices in place and the availability of CDS at the point of care is also beginning to change physician attitudes regarding choices in care at FHN.

For example, requests would be made to add Cipro to an order by some physicians because it was what they had always used. However, evidence-based best practices do not support that conclusion in every case. Thus, decision support technology helps physicians make the choice for the most appropriate antibiotics and practice patterns according to the latest accepted evidence.

In critical care areas, the use of electronic order sets has helped provide guidance for such things as running ventilators and management of septic patients.  Especially for primary care physicians, having a check-list of appropriate care measures provides a higher level of confidence when working with critical conditions.

Electronic order set technology is proving to be a smart choice for advancing evidence-based practices, but success could not have been achieved with technology alone. A solid workflow assessment coupled with a solid governance plan provided the foundation for timely uptake by curtailing the likelihood of physician resistance. FHN is continuing to take its order set strategy to the next level, moving towards more progressive evidence-based practices that will improve quality and cost efficiency.

Lucio J. Martinez, M.D., order set champion, FHN Memorial Hospital, 172-bed hospital in northwest Illinois. 


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