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Lessons Learned In an Ongoing Journey

August 6, 2011
by Mark Hagland
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How the leaders at the University of Kansas Hospital are leveraging evidence-based ordering for process improvement

The use of evidence-based order sets within computerized physician order entry (CPOE) systems is expanding rapidly these days, spurred on by requirements under meaningful use, the development of accountable care organization (ACO) and medical home models under healthcare reform, and a general movement forward towards evidence-based medicine and advanced clinical decision support.

At the University of Kansas Hospital in Kansas City, Kan., Gregory Ator, M.D., the hospital’s CMIO, and Dawn Walters, R.N., its assistant director of nursing, have been helping to lead the transition to the use of evidence-based order sets within CPOE. Partnering with the Verona, Wis.-based Epic Systems as the organization’s core electronic health record (EHR) provider, the 606-bed University of Kansas team went live with CPOE in November 2010, having prepared an initial set of 250 evidence-based order sets, which were developed with the help of the Los Angeles-based Zynx Health, and custom-built for the hospital’s particular needs and its physicians’ preferences (the hospital has about 500 attendings and 400 residents).
Ator and Walters spoke recently with HCI Editor-in-Chief Mark Hagland regarding their organization’s evidence-based ordering journey. Below are excerpts from that interview.

What made you and your colleagues decide to make the leap to evidence-based order sets within CPOE?
Gregory Ator, M.D.:
I think that evidence-based, or evidence-informed, medicine, is where it’s at. I’m handling physician informatics, and am also senior medical director here, working with physicians who are being paid by the hospital to handle certain tasks, including developing evidence-based order sets.

How many order sets did you initially have?
Ator: Approximately 250.

Gregoy Ator, M.D.
Dawn Walters, R.N.: We used Zynx as a collaborative partner, but we didn’t build from their platform of order sets. That was an intentional decision on our part to gently go into CPOE.
Ator: This is the plight of many organizations; we had over 1,000 paper-based order sets, in an incredible disarray, at the beginning of this process. It was just tons of order sets without any standard orderables, no structure from one paper order set to another, and no standard way to name them or refer to them. And there was no process for bundles of care. So that was one of our first efforts, to try to get a process that corrected those problems, and create bundles around various critical care processes, such as ventilator-facilitated care.

So we decided to go live with CPOE, using Epic, and calling it O2 Order Management, for Optimal Outcomes—as in the element, oxygen. So order management is a framework for clinical content management. We really tried to do change management. And we redeployed clinical management in general, and used Zynx on an order-set-by-order-set basis. If we didn’t have an existing order set, we would use Zynx as a starter, but we would use Zynx to supplement an order set if one already existed. And part of this was that this was a collaborative space for discussion.
Walters: We also use it to archive, for versioning control. Prior to using the solution, we had been having multiple meetings that weren’t convenient to the physicians, nurses, and ancillary departments; but now you could be involved on your own time. So that brought an efficiency to our program.

How many electronic order sets are live now?
Walters: We’re still in that general area.

Dawn Walters, R.N.

You’re focusing on adoption first?
Walters: Yes, our focus is on our outcomes coming out of order set development, first. And then we’ll add more.
What is your overall strategy with regard to the ongoing rollout of evidence-based order sets?
Walters: We had had over 1,000 order sets in some form on paper; and we reduced that number to 250 by applying a matrix involving length of stay and efficiency improvement opportunity, as well as our specialty matrix—making sure every specialty had some involvement and interest.
Ator: It was a cost and quality opportunity, and mortality was a part of that. We are a UHC [University Health System Consortium] hospital, so we rely on some information from them. We benchmark with them. And we looked at the high-volume areas, but also the issue of ‘specialty equity’—we wanted all the specialties to have some order sets. And we looked at high-volume areas, like the operating room.

What has been the adoption trajectory so far, and what have been the outcomes?
Walters: We monitor our usage of the order sets, and we’re beginning to look at specific outcomes with regard to the order sets in place.
Ator: One example is around the time it takes to administer antibiotics and the appropriateness of those antibiotics—that’s one area where we’ve definitely improved. And more broadly, we’ve shortened the length of time from order to action.

What has been the reaction of the physicians?
Ator: We have 100 percent use; we have nobody entering orders on paper. We do have some areas of paper order sets, particularly for ambulatory care orders. But basically, where the physician has the option to order electronically, they’re using them.
Walters: From my point of view of the practical application of it, our success has been in getting the engagement of the stakeholder groups early on; that’s why we have a good adoption rate. We engaged the stakeholders in each area and involved them in the process. Also, you need to have a communication plan in place, especially in an organization as large as ours, making sure people feel apprised of the changes, and of the why of the changes, all of that is essential for a successful go-live and buy-in.
Ator: In our particular situation, we have had to work with a legacy system that is providing our revenue cycle system, and CPOE really requires a complete redesign of processes. And there are frequently business processes that need to be reworked. We’ve had to [get granular to rework processes], as physicians are creating clinical events in the EHR, and there continues to be a disconnect between the clinical side and the business side of operations. So you’ve got to be very aware of things, because people fall into the gaps. For example, the ADT [admissions-discharge-transfer] system knows where the patient is, but the Epic EMR doesn’t, because we have an interface there. So some interfaces, while they’re technically feasible, just introduce all kinds of workarounds, and then have an impact on business process issues. And you start having doctors getting involved in business processes.
Walters: It’s not just about putting paper into the system; but in fact, every aspect of every process around paper-based ordering has to be rethought.
Ator: We went from 5,000 to fewer than 1,000 orderables; so, we achieved an 80-percent trim of orderables in our catalog.

Do you have any advice for other CIOs, CMIOs and other informaticist and clinical informaticist leaders in other organizations?
Ator: I think physician engagement is key; and that’s what we’ve seen here, as we’ve created order sets. We had a very aggressive timetable. And it used to be, before meaningful use and all the current challenges in medicine, it was ‘OK’ to have evidence, but now you really need it for support as you take care of patients. And we’re grappling with how we monitor day to day that people are using the evidence; and this evidence is defined by the enterprise. And we’re engaged in that whole conversation about how much a particular physician is allowed to deviate from a particular approach to clinical care.

You’re obviously going to continue to analyze outcomes as you go forward?
Ator: Oh, yes. We think that’s the long-term challenge. And of course, we’ll continue to build on the information and knowledge from the Zynx system; but it’s always going to be a work in progress.

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