How much of an improvement can evidence-based order sets make in patient outcomes? The answer, according to Jeremy Theal, M.D., CMIO of North York General Hospital, a 428-bed provider organization in Toronto, is a very significant difference. The hospital has documented statistically significant declines in mortality for two conditions: COPD and pneumonia, after implementing computerized physician order entry (CPOE) with evidence-based order sets, which were developed in partnership with Los Angeles-based Zynx Health Inc. Just as significant, those results reflect cultural changes that resulted in broad uptake by the hospital’s physicians, 90 percent of whom are independent practitioners, and successful integration into the clinical workflows.
Theal presented the key findings of its analysis at the Healthcare Information and Management Systems Society (HIMSS) conference last week in Orlando, Fla. North York, which went live with the evidence-based admission order sets in 2010, has built up a library of 500 such order sets today, as well as a considerable track record in their use. With that data, it decided to measure the impact they have had on patient outcomes. What if the provider was able to use the correct order set specific to the disease versus a general order set or one that didn’t match the diagnosis, Theal asked during an interview.
To find out, the hospital took a snapshot of two specific diagnoses—COPD exacerbation and pneumonia, before and after using CPOE with correctly matched evidence-based order sets. It had a fairly large sample size of 500 patients in each group, which showed a strong reduction in mortality, Theal said. North York reported a 56-percent mortality reduction for COPD and pneumonia using CPOE with correctly matched evidence-based order sets. He noted that order sets that correctly matched the discharge diagnosis had an independent effect on mortality, while order sets that did not match the diagnosis had no effect.
That sample was from a period nine-months before and nine months after using evidence-based orders sets, saving roughly 75 lives, he said. “This is just a tiny corner of that hospital, and we are not a huge hospital.” He estimated that within a year, 100 lives could have been saved with just those two conditions; order sets that did not match the diagnosis had no effect on mortality, he said. Embedded in the order set are additional granular evidence around various decision points to aid physicians in their decisions, Theal said. He added that there is good evidence that building evidence into the clinical decision workflow makes a difference in whether or not something will be used in clinical care.
Theal said that the CPOE system with a library of evidence-based order sets has resulted in cultural change at the hospital. Prior to the CPOE system being implemented, standardized order sets were used with only 37 percent of patients, compared to 97 percent today. He acknowledged that the hospital had no way of mandating that is independent practitioners use evidence-based order sets, but said conversations with colleagues, including many that had training with evidence-based medicine, contributed to the uptake by North York’s physicians.
One concern of physician when the hospital initially embarked on the project was that use of evidence-based order sets was going to slow them down, affecting how many patients they could treat in a given period of time. “It’s often what physicians push back on, when you talk about CPOE,” Theal said. “We tried to refocus them not on the what, that they are going to use a computer, but on the why, which is, we are going to change the outcomes for your patients. We are going to help you be a better decision-maker.”
Theal said that North York initially focused on COPD and pneumonia because they are common diagnoses in the hospital, which can reasonable be diagnosed in the ED, with good evidence for treatment. It has since expanded the project to pediatrics and critical care, Theal said, adding that congestive heart failure is another area that could potentially see a big reduction in mortality, as well as readmission rates.