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

September 26, 2012
by Mark Hagland
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At Northwest Hospital in Seattle, a chief medical officer shares his perspectives on what has worked in implementing evidence-based physician order sets

Clinical transformation is moving ahead at Northwest Hospital, a 250-bed facility in Seattle. Northwest Hospital, a community hospital, has for the past three years been a part of the University of Washington, under the umbrella of UW Medicine, along with University Medical Center, Harborview Medical Center, and Valley Medical Center (in nearby Renton).

Like its fellow affiliated hospitals within UW Medicine, Northwest Hospital continues to make progress with regard to the adoption of evidence-based medicine tools. The organization has been partnering with the Los Angeles-based Zynx Health to implement evidence-based order sets, and the progress of that work has been accelerated through its implementation of computerized physician order entry (CPOE) earlier this year. Chief medical officer Gregory Schroedl, M.D. spoke recently with HCI Editor-in-Chief Mark Hagland regarding his organization’s work in this area. Below are excerpts from that interview.

I had interviewed you for the HCI January 2011 cover story on evidence-based care. At that time, you hadn’t yet gone live on CPOE. Have you gone live on CPOE since then?

Yes, we went live on CPOE in April 2012, and that was with the Siemens Soarian EMR, and we did use Zynx as the underpinnings for building evidence-based order sets. We went live several units at a time, first in our childbirth and geriatric psychiatric units, and eventually across the enterprise. And it was very smooth and very successful.

Gregory Schroedl, M.D.

Were there any challenges in the CPOE go-live or in the go-live with the Zynx order sets?

One of the challenges that occurred between the time you and I spoke in 2011 and going live was, we were planning to build our order sets in the Zynx author space… They have a software program where you can go into a Zynx site and build your order sets and do your drafts, and it references the evidence, and then when you’ve completed all your order sets, they’re then transferred to your hospital EMR. And we found that we were having difficulty accomplishing that, and that we were going to have to duplicate work to use that methodology. And Zynx was realizing that, depending on the hospital EMR vendor, the ease of that method varied significantly. So that was part of the reason that Zynx developed their new value-based program, because what we were able to do, then, is to build our order sets in the Siemens EMR, and link it to the Zynx evidence; and we’re now arranging for Zynx to come back and do a gap analysis.

So you more or less had to rework that implementation process?

Well, we had used Zynx in the past to build paper-based order sets; our next step was to get those online so that physicians could print them out as PDFs. And if we had done it the way Zynx had originally planned it for us, we would have built the order sets in Zynx and then launched them in the EMR. But we were one of the institutions that turned to them and said, this is too cumbersome, based on the interaction between the Zynx order sets, and our EMR. So we built them in the EMR. And then the Zynx people adjusted their methodology to meet our needs by reviewing our order sets after we had built them.

And right now, we’re in the process of taking 35 of the most common order sets built based on Zynx order sets, and having Zynx do an analysis for gaps in key evidence. And we’ve actually sent them those order sets for analysis. Our next step is to allow them VPN [virtual private network] access to our system, so they can just actively go in, say on a quarterly basis, to help us make modifications. That will allow us to not only allow us to make sure we don’t have any gaps in our initially published order sets, but then if there are any needed changes, such as an FDA black-box warning, we would probably ask them to tell us about the modification, and then we would make it. But they would be able to look at the order sets and make recommendations for changes, on a regular basis.

When implementing evidence-based order sets for CPOE, how does a patient care organization get the best results along with the greatest buy-in from the physicians?

Well, the first phase is to have the physicians acknowledge that there are bodies of knowledge and sets of evidence that will help them with the care of the patients; in some cultures, that’s a little harder to do. You know, medicine has oftentimes been experience-based and authority-based, as opposed to evidence-based. It’s the notion that “I’ve always done it this way, I think it’s right,” as opposed to using careful analysis. We’ve been fortunate that we really began this whole process 14 years ago. But once you have that acknowledgement, which is the first step, the key is to make the process simple and make it easy for physicians to do the right thing.

So if I’m presented with an order set for a patient with pneumonia that already has all the CMS components in it, and the simple elements are pre-checked on the order set, and I’m given choices of appropriate antibiotics that are acceptable, including alternatives to penicillin, for example, and there’s some simple explanation for me as to when I should choose one item over another, then it’ll be faster and easier for me, and I’m more likely to do the right thing each time.

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.

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