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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:



- 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



- 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?



- 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



- 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


- e-Prescribing on hospital discharge

- etc.


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


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

2) AFE

clinical documentation

3) AFE

clinical order entry

- integration requires a problem list foundation, cognizant of classification criteria, as well as quality and cost-effectiveness dimensions factored in – a great place for government to invest in open source content

- an adequately mobile user interface that uses AFE to eliminate redundant entry requirements and offer truly appropriate workflows (someday!)

- a clinical decision support competency that can deal, dynamically, with orders within order sets that conflict with patient conditions, other concurrently necessary order sets, and best available knowledge (aka 'the co-morbidity problem')

- what to do with, a classic example here, a patient with a new-onset of an abnormal heart rhythm (atrial fibrillation), a new resulting stroke, with a history of an uncommon clotting disorder, and a history of falls

- few systems in broad use allow order sets to carry extra rules with them that go beyond drug interaction checking and reflexive criteria; this kind of decision support goes beyond the production rules methodology that is in common use today. It requires the ability to help physicians by facilitating knowledge-based arguments with them. See

The Butler Model for more on that concept. There are vendors who have proven this kind of decision support in other countries. An example of this comes from

InferMed, here.

Closing Thought

Returning to Joan Ash's article (

ASH ET AL., A Consensus Statement on Considerations for a Successful CPOE Implementation, 2003), there have been many CPOE studies since, but few as clear as this review article. Here's an excerpt:

Consideration 3: Costs

Financial considerations are of critical importance. Often, costs are underestimated because purchase of the software is only the beginning of financial outlays; other expenditures such as person-hours for training and support are harder to predict. Decision makers need to consider the following issues: ...

I would strongly encourage any organization developing their own Order Set strategy to review all nine considerations in this classic 2003 article. Failure to address any one bullet point will make any Order Set strategy moot.

As with Monoliths, an organization commitment to an updated strategy for Order Sets represents a huge step forward, with the tremendous promise that represents.

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