Tuesday, July 9, 2019

Why You Should Always Map the Current State

Hi fellow CMIOs, CNIOs, #Informatics, and other #HealthIT leaders,

Today I'm writing to discuss a fairly common question in clinical change management, related to the practice of 'mapping the current state': Is it really necessary?

When planning a clinical improvement project, it may be one of the most common newbie mistakes: Thinking you can't, or don't need to analyze the current state : 

It has been said that Clinical #Informatics and #workflow engineering is a bit like 'rebuilding the plane while it is still in the air' - Healthcare is in business 24x7, and can't really shut down, even for a few minutes, without a potential impact on patient care. (This is one of the things that separates #HealthIT from #BusinessIT, #AcademicIT, and #ResearchIT.)

So in today's fast-paced healthcare environment, it's more important than ever to make sure that projects are executed well, on-time, on-budget, and according to plan. And this is where our discussion starts : How to make sure you're really planning well

First - Without mapping the current state, it looks something like this : 

... and then it becomes impossible to tell if your project is going to look like this : 

... or this...

... and so without a current-state assessment, it's easier to either under- or over-estimate the work it will require to get to Point B. 

Remember, smooth workflow change is not just about the configuration you need to do inside the EMR - It's the work you need to do outside of the EMR too, including development of staff education needed to get your clinical teams from Point A to Point B - See #7 in the grey box on the left-handed side below : 
Taken from my 11-18-2015 blog post, 

Again, in today's healthcare environment, having smooth, well-executed workflows and projects is more important than ever. As an example, Dr. Danielle Ofri recently wrote this very relevant opinion piece in the New York Times which really introduces the importance of well-designed, well-planned workflows :

(June 8th, 2019)

... in which she writes, "With mergers and streamlining, [corporate medicine] has pushed the productivity numbers about as far as they can go." After she describes some real problems with the efficiency of some EMR documentation, she shares this insight, "But in health care there is a wondrous elasticity - you can keep adding work and magically it all somehow gets done."

While Dr. Ofri is quite right that this is a commonly-held belief, there's still a basic problem: Math is math. Healthcare should not plan to do 25 minutes of work in a 15 minute timeframe. So in the national discussion about physician burnout (#physicianburnout, or as ZDoggMD describes it, 'moral injury'), it's more important than ever to make sure workflows serve the needs of the patients, providers, nurses, pharmacists, and other clinical and administrative people working in #healthcare. To make sure we're not overloading our clinical teams, every data element needs to be well-analyzed, well-studied, well-planned, and serve a legitimate patient care or business function.

And this is why the current state is important. Without studying the current state, it becomes very challenging to answer questions like: 
  • Which stakeholders need to be involved in this project?
  • How much time will this project take?
  • What training and support will we need to go-live with the planned future state?
Still, some people express concern about the work it takes to map the current state, or question the real benefits. Allow me to share some common arguments, along with my counter-arguments
ARGUMENT : "We don't have time or resources to map the current state." 
COUNTER-ARGUMENT : "Will we have time or resources to fix things that we didn't account for? How will we know the scope of the effort, who to invite to meetings, or how much educational effort we will need to plan for?" 
ARGUMENT : "It's not worth mapping the current state, last time it took us hours and we still couldn't figure it out." 
COUNTER-ARGUMENT : "Not being able to map the current state, despite best efforts, is still a really important factor to consider when scoping and planning a project." 
ARGUMENT : "We don't want to map the current state because we don't want to bring old habits into our new workflow." 
COUNTER-ARGUMENT : "Even though there may be parts of your current-state workflow worth keeping, it's not to bring old habits into your new workflow - It's to make sure we're covering all of our bases, and doing the best job planning, designing, and executing that we can."
ARGUMENT : "It takes too much work to map the current state." 
COUNTER-ARGUMENT : "It doesn't need to take a lot of work, and you don't always need Visio swimlane diagrams. For many workflows, a simple well-written procedure with each line written as [WHO] will/may [WHAT] will do the trick. Even if it's not documented - it's still important that whoever plans the project has ample access to someone with a good understanding of the current-state workflow(s)."
Fortunately, most experienced Clinical #Informatics and #HealthIT professionals know the importance of mapping the current state in planning clinical improvement projects, and how to map it quickly. So if you ever need help mapping the current state, ask your local Clinical #Informatics or #HealthIT experts for assistance!

Remember, this blog is for academic discussions only - Your mileage may vary. Seek expert advice from your leadership, legal counsel, clinical informatics, or project management teams before changing strategies. Do you have any questions, comments, or feedback? Leave them in the comments section below!

Thursday, June 6, 2019

Working in Healthcare, are you "Clinical"?

Hi fellow #Informatics friends and other #healthcare leaders,

So for this post, I thought I'd tackle an interesting question - What does the word "clinical" mean, exactly?

This is an interesting challenge - When people hear the word "clinical", they usually think someone taking care of a patient, usually in scrubs, often with a stethoscope around their neck - E.g. : 
While that may be true, it's also an incomplete definition. There is more to the story. What about people who don't wear scrubs, like social workers and case managers and registration, who all have a great deal to do with clinical care and patient safety? Or people without stethoscopes, like pharmacists

If we ask Google for a definition of "clinical", on 06-01-2019 it gives us this result : 
... which, interestingly, includes the description of "efficient and unemotional; coldly detached". (How exactly did that happen?)

Anyway, what I find more interesting is the part of the definition above, "...relating to the observation and treatment of actual patients..." - To me, this is more relevant, because it brings into focus the connection with "actual patients", who are what clinical care is all about.

Unfortunately, in some healthcare settings, the word "clinical" is sometimes used to distinguish, incorrectly, between two 'types' of workers in healthcare :
  • Those people who directly or indirectly take care of patients. (?"clinical"?)
  • Those people who don't directly (or indirectly?) take care of patients. (?"administrative"?)
When compared to the term "administrative", the word "clinical" becomes meaningless and confusing. This confusion is sometimes perpetuated by policy manuals which generally describe two sets of policy standards commonly found in healthcare operations : 


It may not be that big a deal, but in my opinion, this older terminology division sets up an unnecessary and incorrect misunderstanding in healthcare, leading some to wrongly believe that a healthcare organization is essentially made of two tribes : 
  • The "Administrative" Tribe - Finance, HR, IT, and legal/compliance workers who are necessary to help the organization run but don't really understand or get involved in patient care.
  • The "Clinical" Tribe - Doctors, nurses, pharmacists, and others who are taking care of the patient, but don't need to understand administrative functions.
  • And maybe a few people who fall somewhere in between these two tribes, to help each tribe understand the other (e.g. Clinical leaders)??
Conceptually, this old-fashioned thinking might be thought of as a Venn diagram, with a few key "clinical leaders" who might fall in the middle :


In this context, the word "clinical" only helps reinforce an outdated notion that creates unnecessary antagonism. It incorrectly implies :
  • That there are "clinical staff" who know intimately well what patient care needs are, but no need to understand administrative functions.
  • That there are "administrative staff" who know intimately well what the organization needs, but don't need to understand patient care, or have any responsibility for patient safety. 
Both of these are misleading and incorrect. We in healthcare can do better

For this reason, I'd propose a new way of thinking about healthcare operations, using a different way of categorizing operational standards :


In this way, we avoid the unnecessary "Clinical" versus "Administrative" distinctions, and encourage teamwork, collaboration, and understanding. Organizationally, I believe this would help both sides to better understand each other : 
  • As the Google definition of "Clinical" implies,  almost everyone in a healthcare organization has a relationship (direct or indirect) with patient care.
  • The traditionally "Clinical" workers (those with a direct relationship with patient care) can benefit by learning more about the needs of the traditionally "Administrative" workers (those with an indirect relationship with patient care).
  • The traditionally "Administrative" workers (those with an indirect relationship with patient care) can benefit by learning more about direct patient care, and their own indirect but real relationship with good, safe, efficient patient care.
So perhaps a newer way of thinking about this could be presented in a new Venn diagram:


While changing this thinking may not be a high-priority issue, I do hope it stimulates discussion and helps encourage understanding, collaboration, and teamwork. Whether you are direct or indirect - In Healthcare, we are all clinical. :)

Remember, this blog is for discussion and education purposes only - Your mileage may vary. Have any feedback or thoughts? Leave them in the comments section below.

Sunday, April 28, 2019

The Tribes of Healthcare

Hi fellow Informatics friends,

#whyinformatics... This weekend I worked on a video little video, for a team building meeting, to try to explain the different 'Tribes of Healthcare', the clinical and administrative teams that work together to make patient care happen. 

As we've explored in prior posts, healthcare has a uniquely complex set of stakeholders, each with its own skill set, culture, and terminology. Together, they can make amazing things happen - Real advances in patient care and treatment of disease. Separately, they can struggle. 

It's intended to be a little tongue-in-cheek, but clinical informaticists may find this especially amusing, since informatics sits at the intersection of all of these stakeholders - working to translate their needs and concerns into actionable items, projects, and EMR configurations. If you're struggling to assemble these teams for an operational discussion, make sure to ask your local clinical informatics professional for help. :)

The video has a little introduction from one of my educational side projects, with the sound of a cardiac monitor during a code, so make sure your volume is low if you're using headphones. (Believe it or not, it was all created with some very common phone and laptop tools.)

The result is only about three minutes long, so enjoy!


(Click to open)

Remember - This blog is for educational discussions only - Your mileage may vary. Have any anecdotes you'd care to share? Feel free to leave them in the comments below!

Thursday, April 18, 2019

Culture, Terminology, and EMR Usability

Hi fellow Informatics friends and colleagues,

When sharing the secrets of electronic medical record (EMR) usability, some people are surprised at how much culture and terminology impacts user satisfaction. Allow me to explain.

EMRs are essentially tools used to store and retrieve patient care information. When configuring an EMR, the most common mistake is thinking it's 'like paper', simply a bunch of words, lines, and boxes on a page. EMRs are different - Buttons open menus that lead to other tools and actions, so it's more helpful to think of it more like you are organizing a closet
  • Socks go in the sock drawer.
  • T-shirts go in the t-shirt drawer.
  • ... and so on.
Only an electronic patient record literally contains hundreds of drawers, each containing as few as a handful, or as many as hundreds of documents, images, vitals, or other data elements. E.g. : 

... and when you click on the button "RADIOLOGY ORDERS", one would expect to find the orders related to diagnostic and therapeutic/procedural radiology modalities.

So a key design element to consider : 
  • How many items do you need to store in a chart, for patient care purposes?
  • In which 'drawers' will you store them?
And so when organizing a closet at home, most people realize they don't have room for a separate drawer for every piece of clothing, so they will use some categorization scheme (that makes sense to them) to combine related items in the same drawer, E.g. : 
  • Top Drawer = Undergarments (Socks, Underwear, and T-shirts)
  • Bottom Drawer = Outer garments (Shirts / Pants)
We don't consciously think about categorization schemes very much, but our brains do this naturally, to try to make sense of the world, and establish a pattern that will ultimately help us get dressed in the morning

Anyone who's ever had to share a closet, however, knows there can be disagreements about categorization schemes, resulting in some interesting household debates. If you have children, you also know it's helpful to label drawers, or explain the categorization scheme, so your kids can find their clothes in the right drawers. Food pantries and refrigerators are common sources of domestic debates, because different family members might have different ideas about ideal organizational schemes.

So it's no surprise that people who are responsible for configuring and organizing an EMR often stumble upon the many cultural differences in thinking and terminology between "healthcare tribes" - E.g. between physicians, nurses, pharmacists, radiologists, laboratorians, ancillary services, medical records, finance, etc.

Here's a good teaching example to better understand what I'm talking about, and how these terminology issues have real-world impact in user EMR satisfaction

Imagine it's the year 2050
You run a hospital with an EMR. It is suddenly discovered that tomatoes save lives, so you prepare to have tomatoes in your hospital, keeping them in your Pyxis machine, and create tomato orders in your EMR, to order and release the tomatoes for patient care (when needed). 

After meeting with your available subject matter experts (SMEs), many of whom, for scheduling reasons, just happen to be from clinical Tribe A - your analysts build the "Tomatoorderand make it available under the "Vegetable" menu choice below :

Shortly after building this, you suddenly get complaints from Tribe B users, who couldn't show up to the earlier meeting but say, "Hey wait, tomatoes are technically berries, which are technically fruit - Here is the evidence : https://en.wikipedia.org/wiki/Tomato - So they should be listed under the "Fruit" menu choice instead! Those of us who know this can never find the Tomato order!"

You also get complaints from Tribe C users, who say, "What's a Tomato? We've never heard of that. Oh, wait, you mean that red thing we put in our salads/sauces/sandwiches? We've been doing this for 20 years, and in our experience, we've always called it a Golden Cherry."

Do you :

  • OPTION 1. Listen to Tribe A, and file the tomato order under the "vegetable" menu, and educate Tribes B and C that tomatoes are red fruit that grow on a vine, are commonly used to make sauces/salads/sandwich toppings, and most commonly thought of as vegetables?

  • OPTION 2. Listen to Tribe B, file the tomato order under the "fruit" menu, and educate Tribes A and C that tomatoes are red fruit that grow on a vine, are commonly used to make sauces/salads/sandwich toppings, and correctly categorized as fruit

  • OPTION 3. Listen to Tribes A and C, rename the tomato order to a golden cherry order, file it under "vegetable", and educate Tribe A that tomatoes will now be referred to as a golden cherry and will be filed under the vegetable menu? 
  • OPTION 4. Listen to Tribes B and C, rename the tomato order to a golden cherry order, file it under "fruit", and educate Tribe B that tomatoes will now be referred to as a golden cherry, and will be filed under the fruit menu? 
  • OPTION 5. Bring Tribes A, B, and C together for a meeting, review the concepts, terminology, and taxonomy of tomatoes together, and agree to a functional definition (for your glossary!) that meets the needs of all three tribes

Tomato ('golden cherry') - A common red fruit/vegetable that grows on a vine in temperate climates, that is commonly used to make salads, sauces, and sandwich toppings. 
... and then build the tomato order, attach a synonym of 'golden cherry', and then file it under :
  • the "vegetable" menu choice? 
  • the "fruit" menu choice? 
  • BOTH the "vegetable" and "fruit" menus? (making Tribe A complain that it shouldn't be making the fruit menu look messy, and Tribe B complain it shouldn't be making the vegetable menu look messy
  • Or build a hybrid "vegetable/fruit" menu choice? 
... or more options we haven't considered yet?

How these terminology, taxonomy, and conceptual issue get managed will ultimately impact the satisfaction of users who are trying to find a tomato ('golden cherry') in the EMR for patient care.

Hope you enjoyed chewing on this interesting EMR terminology challenge! If you think terminology issues might be impacting your workflow, feel free to ask your local clinical informaticist for help! (#whyinformatics!)

Remember this blog is for education and sharing purposes only. Have other examples of terminology and classification systems impacting EMR usability and satisfaction? Or have you struggled with this yourself? Feel free to share in the comments section below!

Monday, April 1, 2019

Highlights From The Last 250 Years of Healthcare

Hi fellow #Informatics enthusiasts, physician leaders, CMIOs, CNIOs, and other #healthcare junkies,

So I'm working on a blog post about physician leadership and healthcare traditions, but before I can write that blog post, I had to research some about our history in healthcare - When major things happened, how we got here, and how those discoveries years ago helped to shape our modern healthcare landscape today.

Initially, I thought I'd go back 100 years, to see what the major achievements were - and how they impact us in today. And then I found out - there were several achievements way before that, that I needed to include, because they are still shaping modern healthcare. 

The healthcare environment we think of today is largely the result of many decisions, discoveries, and role developments, some serendipitous, that occurred slowly over the last 250 years.

So I thought I'd document some of the major highlights here, for review and discussion, before I plan my next blog post. Feel free to review and enjoy - And if you see items that need to be added, please leave them in the comments section below!

Some Highlights From The First 250+ Years of Healthcare :
1700s
  • 1765 - First US Medical School opens, the College of Philadelphia (now the University of Pennsylvania). Ben Franklin recommends documenting care, and creates first medical record.
1800s - 1850s
  • 1800s -1900s - While German and British healthcare models grow in Europe, most American ‘healthcare’ exists largely as a mix of voluntary, religious, and charitable alms houses, along with some battlefield doctors and nurses tending to the wounded.
  • 1846 - Hungarian doctor Ignaz Semmelweis recommends hand washing to help prevent the spread of disease. 
  • 1846 - Dentist William T. Morton and Surgeon John Collins Warren do first surgical procedure with anesthesia at Mass General Hospital.
  • 1854 - Florence Nightingale documents first Quality Improvement project during Crimean war, reducing mortality rate in Crimean War from 42% to 2% - Registered Nursing soon becomes a profession, with formal hospital-based training programs.
  • 1854 - Cholera outbreak occurs in London, and John Snow investigates and practically invents Public Health
1860s 
  • 1860 – 1960 – Deliberate Quality Improvement efforts take a foothold in other industries (eg. automobile manufacturing, etc.)
  • 1861 – 1865 – American Civil War
  • 1862Louis Pasteur develops pasteurization.
1870s - 1890s 
  • 1879 – French physician Charles Chamberland develops sterilization technology.
  • 1881Louis Pasteur develops anthrax vaccine.
  • 1883 - German Chancellor Otto Von Bismark develops first state-run medical insurance program.
  • 1885Louis Pasteur develops rabies vaccine.
  • 1895 - William Conrad Roentgen accidentally discovers X-rays, wins Nobel in 1901.
1900s - 1920s 
  • 1910 - Flexner Report formalizes and standardizes medical education to 4-years plus residency.
  • 1914 – 1918World War I
  • 1916 - After isolating it from canine liver cells, heparin discovered by surgeon Jay McLean and physiologist William Henry Howell, but not available for clinical trials until 1935.
  • 1918 - Influenza Pandemic kills millions worldwide. Surgeon General Dr. Rupert Blue uses public health tools and documentation to save lives.
  • 1920s – 1980s - A predominantly employer-based fee-for-service health insurance system develops in the US, in a very fragmented, decentralized manner - with private insurers and the government eventually filling some, but not all of the gaps.
  • 1928 - Sir Alexander Fleming accidentally finds an empty circle around some mold on a staphylococcus culture plate, and discovers the "wonder drug" penicillin.
  • 1928 - First MCAT Test.
1930s - 1950s 
  • 1930President Hoover creates Veterans Administration and first VA Hospitals.
  • 1935 - Heparin first available for clinical trials.
  • 19411945World War II
  • 1942 - William Beveridge publishes "Beveridge Report" which advocates for England to build a "National Health System"
  • 1942 - After noting that WWI mustard gas was a potent suppressor of hematopoeisis, nitrogen mustards were further developed during WWII at Yale University and were given by vein (instead of inhaling irritant gas) to several patients with advanced lymphomas who had temporary but notable improvements, in what was the first chemotherapy regimen
  • 1945 - Industrialist Henry Kaiser builds first pre-paid health program for his employees which becomes "Kaiser Permanente"
  • 1945 – 1950Penicillin becomes more widely available. Narcotic analgesia also becomes available.
  • 1950sJonas Salk develops polio vaccine. Nursing training programs begin to move from hospitals to colleges and universities.
  • 1950s - Physicist Gordon Brownell and neurosurgeon William Sweet from Mass General use first PET scanner to detect brain tumors using sodium iodide.
  • 1951Joint Commission establishes itself as “The Joint Commission of Accreditation of Hospitals”, but accreditation has no significant impact until 1965 (see below).
  • 1951 - American College of Obstetricians and Gynecologists (ACOG) formed, formalizing specialty training for obstetric care and Women's Health.
  • 1952 - American Psychiatric Association publishes first Diagnostic and Statistical Manual (DSM) of Mental Disorders, standardizing and formalizing diagnostic criteria for patients with mental health needs.
  • 1953 - Although they did not 'discover DNA', James D. Watson and Francis Crick build upon X-ray crystallography work by Rosalind Franklin and Maurice Wilkins to publish description of double-helix structure of DNA.
  • 1955 - Chemist Leo Sternbach invents benzodiazepines when he accidentally discovers chlordiazepoxide (Librium), first available for clinical use in 1960.
  • 1956 – 1958 - Dr. Peter Safar develops A-B-C technique for CPR, convinces Baltimore Fire Department to have first ambulance staffed with Emergency Medical Technicians, and creates first 24-hour ICU.
1960s - 1980s 
  • 1960 - First oral contraceptive pill, Enovid, is approved by FDA.
  • 1964 - First loop diuretics ethacrynic acid and furosemide approved for use. 
  • 1965Centers for Medicare and Medicaid Services (CMS) established, and establishes Joint Commission accreditation as a Condition of Participation (CoP).
  • 1967 - South African surgeon Christiaan Barnard does first heart transplant.
  • 1968 - First 911 call made in Haleyville, Alabama to the Fire Chief, starts first US 911 service.
  • 1968 - NEJM publishes 'Medical Records that Guide and Teach' by Larry Weed, MD, creating the first SOAP note allowing easier transfer of patients between providers.
  • 1971 - First CT scan used to image a living brain.
  • 1970s - 1980s – Most US patients continue to receive care in Fee-for-Service. 911 service continues to expand.
  • 1973 – Rising healthcare costs spur President Nixon to sign Health Maintenance Organization (HMO) Act, opening way for development of for-profit hospitals and private HMOs.
  • 1975 - First whole-body CT scanner was built.
  • 1977 - American physician Dr. Raymond Damadian does first MRI to diagnose cancer.
  • 1979American Board of Medical Specialties votes to create American College of Emergency Physicians, formalizing the training and role of Emergency Medicine physicians. Many hospitals go from having daytime ‘Accident Rooms’ to formal, 24/7 ‘Emergency Departments’.
  • 1980s - AIDS epidemic discovered to be caused by HIV virus, nationally changing infection control procedures and safety standards for blood supply.
  • 1980s - 1990s – HMOs and Payment Reform start to significantly change the billing landscape and increase demands on physician documentation.
1990s 
  • 1996Health Insurance Portability and Accountability Act (HIPAA) first signed into law (with updates in 2004, 2005, 2009, and 2013). NEJM Publishes first article describing new specialty of Hospitalist Medicine.
  • 1999Institute Of Medicine (IOM) releases report To Err Is Human : Building a Safer Healthcare System.
2000s - 2010s
  • 2000 - 93% of the US Population has access to 911 service, and WHO ranks Britain 18th, Germany 25th, and America 37th best in the world.
  • 2008 – Global financial crisis leads to US American Reinvestment and Recovery Act (ARRA), including HITECH Act with $19.3 Billion for Meaningful Use. EMRs become ubiquitous across healthcare landscape.
  • 2017More female candidates than male candidates enroll in American medical schools.
[ End of List ]

Remember : This list is not comprehensive - Have anything you'd like to add to this list? Leave comments in the comments section below! Remember, this blog is for only for educational/discussion purposes only!

Sunday, February 17, 2019

Using CPOE Order Modes to Streamline Workflows

Hi fellow CMIOs, CNIOs, and other Clinical #Informatics enthusiasts,

This month, I thought I'd help demystify a common Computerized Provider Order Entry (CPOE) issue, that actually has a big impact on clinical workflows - Order modes.


Having a good understanding of order modes is essential to resolving many clinical workflow issues. If you've ever asked yourself : 

  • When is it appropriate to use telephone orders?
  • When is it appropriate to use verbal orders?
  • When is it appropriate to use written orders?
  • When is it appropriate to use protocol orders?
... then you've shared in the very common struggle with CPOE order modes

Order modes don't need to be confusing. One of the most common sources of confusion stems from the use of the term 'Computerized Provider Order Entry', or 'CPOE'. 
On selecting an EMR, some organizations assume that having a 'CPOE system' implies that all orders will be entered directly by a provider (The POE in 'CPOE') - And that once it is up-and-running, that there will no longer be any reasons for anyone else to enter orders. Some of those organizations may recognize the need to maintain telephone and verbal orders, for emergency purposes, but don't appreciate the same need for written or protocol orders. 
The truth is that while providers entering their own orders is a best practice, ideal and applicable in almost all ordering scenarios - It is not useful, or even possible, in all scenarios. For this reason, out of necessity, most EMRs recognize a few different ways that orders get entered into the EMR. 

I'm hoping this post will help generate more clarity around their use, and how they can help you streamline, and even improve, your clinical workflows. 

A. Order Mode Basics
To better understand order modes and how they help streamline and support workflows, it's first helpful to understand the difference between an order mode, and order status


(Click image to enlarge)

Basically :
  • Order Status - Tells you whether or not you should be executing ('following') the order
  • Order Modes - Tells you how the order got into the computer
The following slide gives a basic summary of the common order statuses and order modes, found in most electronic medical records : 

(Click to enlarge image)

It's again important to note that direct provider order entry ('CPOE') may be a best practice in almost all clinical scenarios - But the other order modes exist to support order entry in scenarios where it is impossible or even undesirable for the provider to enter the order directly. So to make sure you're only using those other order modes for the right scenarios, you'll want organizational policies in place to make sure they are being used appropriately and safely. The following policy discussion sheds more light on these scenarios, and at the end I've provided a nice summary table. 

B. Sample Policy Definitions
Since order statuses represent the different states that an order can have inside most EMRs, some [ DRAFTED ] policy-grade definitions for these four common order statuses ('states') might look like this : 
  • ACTIVE orders - Orders which HAVE been submitted and signed by a licensed prescriber, or by a well-trained, delegated clinical team member on behalf of a licensed prescriber as part of a standardized, clear, well-developed protocol approved by legal, nursing, provider, and pharmacy leadership. These orders are ACTIVE and should be executed in a timely manner, according to the details contained inside the order. Outcomes from all active orders are attributed to the licensed prescriber.
  • PENDED orders - Future orders which HAVE been submitted and signed by a licensed prescriber, in anticipation of planned future release ('activation') at a future date/time by the licensed prescriber, or by a well-trained, delegated clinical team member on behalf of the licensed prescriber as part of a clear, standardized, well-developed protocol approved by nursing, provider, and pharmacy leadership. These PENDED orders are NOT ACTIVE and  SHOULD NOT be executed until they are released ('activated') into ACTIVE order status by a licensed prescriber, or by a well-trained, delegated clinical team member on behalf of a licensed prescriber as part of a standardized, clear, well-developed protocol approved by legal, nursing, provider, and pharmacy leadership. Outcomes from all pended orders are attributed to the licensed prescriber.
  • HELD ordersPreviously ACTIVE orders which have been placed on hold ('paused') by a licensed prescriber, or by a well-trained, delegated clinical team member on behalf of a licensed prescriber as part of a standardized, clear, well-developed protocol approved by legal nursing, provider, and pharmacy leadership. These HELD orders are NOT ACTIVE and SHOULD NOT be executed until they are again released back into ACTIVE order status by the licensed prescriber, or by a trained, delegated clinical team member on behalf of the licensed prescriber as part of a standardized, well-developed protocol approved by legal, nursing, provider, and pharmacy leadership. Outcomes from all held orders are attributed to the licensed prescriber.
  • DISCONTINUED ordersPreviously ACTIVE, PENDED, or HELD orders which have been discontinued ('deactivated') by a licensed prescriber, or on behalf of the licensed prescriber by a well-trained, delegated clinical team member as part of a clear standardized, well-developed protocol approved by legal, nursing, provider, and pharmacy leadership. These discontinued orders must be retained as part of the legal medical record but must NO LONGER be executed for patient care purposes. Outcomes from all discontinued orders are attributed to the licensed prescriber.
And if the order MODES include the different ways that those orders can get into the computer, then some [ DRAFTED ] policy-grade definitions for these different order modes might look like this : 
  1. CPOE ('PROVIDER') order MODE - Routine orders originated, entered directly, reviewed, and immediately signed (authenticated) by a licensed prescriber, allowing the prescriber to follow decision support rules and order designs that guide best practices and identify errors before they occur. 
  2. TELEPHONE order MODE - Orders originated by a licensed prescriber via direct telephone ('voice-to-voice') communication, and transcribed by a Registered Nurse, Registered Pharmacist, or other registered, licensed, and trained, delegated team member on behalf of the originating licensed prescriber according to a well-developed plan approved by legal, nursing, pharmacy, and provider leadership. Telephone orders must be signed by the originating licensed prescriber within _?12_?24_ hours.
  3. VERBAL order MODE - Orders originated by a licensed prescriber via direct verbal ('face-to-face') communication, transcribed by a Registered Nurse, Registered Pharmacist, or other registered, licensed, and trained, delegated team member, on behalf of the licensed prescriber, according to a well-developed plan approved by legal, nursing, pharmacy, and provider leadership. Verbal orders must be signed by the originating licensed prescriber within _?1_?2_?6_ hours.
  4. WRITTEN order MODE - Orders originated by a licensed prescriber via a pre-approved paper form (approved by legal, nursing, pharmacy, and provider leadership), and transcribed by a Registered Nurse, Registered Pharmacist, or other registered, licensed, and trained, delegated team member (according to a well-developed plan approved by legal, nursing, pharmacy, and provider leadership). Since these paper orders must be signed prior to transcription, they [ usually ] do not require re-authentication ('re-signing') after transcription. The original paper orders are part of the legal medical record and should be retained for quality-control purposes. 
  5. PROTOCOL - WithOUT SIGNATURE order MODE - LOW-risk patient care orders which are activated, modified, or discontinued by a Registered Nurse, Registered Pharmacist, or other registered, licensed, and trained, delegated team member, on behalf of an attending prescriber, as part of a standardized, clear, well-developed protocol approved by legal, nursing, pharmacy, and provider leadership. By policy, all child orders from these low-risk patient care protocols are attributed to the attending provider, and do not require signature.
  6. PROTOCOL - WITH SIGNATURE order MODE - HIGH-risk patient care orders which are activated, modified, or discontinued by a Registered Nurse, Registered Pharmacist, or other registered, licensed, and trained, delegated team member, on behalf of an ordering prescriber, as part of a standardized, clear, well-developed protocol approved by legal, nursing, pharmacy, and provider leadership. By policy, all child orders from these high-risk patient care protocols are attributed to the ordering provider, and require signature within __?12_?24__ hours.
You'll notice in the above [ DRAFT ] definitions : 
  • These are all just [ DRAFT ] definitions - You'll want to check with your own legal team before you consider them and approve them for use in your own organization.
  • There are several signature timeframes which are unidentified (E.g. "__?__ hours") - You will want to review them with your own risk, legal, nursing, provider, and pharmacy leadership to decide on an organizational standard for these. Since these orders all carry risks of miscommunication, you will want to set these timeframes to as short a time period as possible. 

COMMON QUESTION : 
Q: Will every provider sign these orders within the assigned timeframes? 
A: Probably not. But you will want to regularly monitor compliance with your organizational standard, and that probably includes provider report cards for CPOE compliance. Some organizations find that connecting these CPOE statistics to compensation helps improve compliance with organizational standards. 

C. The Summary Table
Confused by the above definitions? Don't like the policy mumbo-jumbo? To help make more sense out of these order modes, and how they impact workflow, I've put together a little summary table which should help clarify them. It includes a summary of the order modes, WHEN to use them, their risks/benefits, and helpful ways to minimize the risks : 

(click to enlarge image)

Remember, it's all about safety and great patient care. Using the right order modes is essential to designing and implementing workflows that deliver that safe, great patient care. Once you have that good understanding of these modes, and the organizational policies to back them up, it becomes much easier to design clinical workflows that meet the needs of your patients, providers, nurses, pharmacists, and other ancillary staff. 

Hope this was a helpful summary! If you have any questions or feedback, please leave them in the comments section below!

Remember, this post is for educational and discussion purposes only - Your mileage may vary. Do not use any of these standards or definitions without first consulting with your informatics team and legal counsel!

Have your own tips for educating CPOE order modes, or anecdotes about how they improved your workflows? Feel free to leave them in the comments section below!