Wednesday, January 12, 2011

Order Set Development and Preparing for the Downtimes

So as if order set development wasn't challenging enough, some people will ask :

"Dirk... So once you go electronic, you don't need paper anymore, right...?"

Well, here's the bad news. You will probably still need paper order sets.


Yep. It's true.

You will probably still need paper versions of all of your order sets, just in case your EMR / CPOE goes down.

I know it seems like a lot of work, but think about this :
  1. After you develop electronic order sets, your doctors will come to rely on them.
  2. The time they save using good order sets will increase their efficiency.
  3. The good order sets you've built will help them standardize care.
  4. This improved efficiency and improved standardization will, over time, allow you to make staffing changes.
The problem, however, will be : What happens when your EMR goes down?
  1. Will your docs have order sets that accomplish the same goals as your electronic order sets?
  2. Will your docs suddenly lose efficiency that they accomplished with those electronic order sets?
  3. Will your docs be able to handle as many patients as they did with the electronic order sets?
  4. If your docs rely on those order sets, and your computer is down... What paper order sets will they use?
So here's the message : It's good practice if you simultaneously develop matching paper and electronic order sets.

"But Dirk... it takes so much time to make an electronic order set... how do I make a matching paper order set?"

Some people, when confronted with this demand, will try this approach :
  1. Have one team make the electronic order sets
  2. Have some person, after the electronic order set is built, type out a matching paper order set.
This approach works, but I think a smoother approach is to develop an order set process that allows your informaticists to develop both paper and electronic order sets as part of the same process.

This gets us into a discussion about order set development.

After a hospital goes electronic, they generally try to use the same process they used before to make paper order sets. Unfortunately, because of the new demands an EMR brings :
  1. Now - Will need both paper and electronic order sets developed at the same time
  2. Now - Will need better engineering (e.g. order sets separated from protocols, etc.)
  3. So... Will need informaticists to help engineer those changes
  4. And... Will need Clinical IT Analysts to help build the work that the informaticists do
... Eventually, you start to realize : The old process doesn't meet the demands of an EMR.

So I generally recommend developing an order set change process.

The Order Set Change Process

Order sets are like any other clinical tool your hospital uses : You will need to define :
  1. Who is the owner?
  2. Who are the builders / project managers? (Generally, an Informaticist + Clinical IT Analyst)
  3. What importance/priority does the order set/change have?
  4. Who will assign this importance / triage changes?
  5. Who will build the first draft? 
  6. Who will test the new order set / changes?
  7. Who will review the testing results?
  8. What education plan (if any) will you need?
  9. What companion documentation (if any) will you need?
  10. What implementation plan (if any) will you need?
  11. What accompanying clinical policy (if any) will you need?
  12. What committee will "approve" your order set, after testing?
  13. Who will implement the order set and the implementation plan?
So if you need to build both a paper and electronic order set, at the end of this process, here are my recommendations :

A. Develop an order set "Change Request Form". You will need this to help understand the expectations and understanding of your owner. Typical questions you might ask include :
  1. Date of order set request?
  2. Owner of order set? (I generally recommend this be a department director)
  3. Builder/Informaticist assigned to order set?
  4. Request :  (   ) new order set    (   ) delete order set     (   ) change order set
  5. If requesting a change, what is the previous order set you wish to change? __________
  6. What change are you requesting? (Please be specific) : ________________________
  7. What companion documentation will you need? : _________________________
  8. Will you need an education plan/curriculum for this change? : ____________________
  9. Will you need an accompanying clinical policy to support this? : ___________________
  10. Will you need a protocol to help support this order set? : __________________________
  11. Will you need an implementation plan for this change? : _________________________
  12. Priority of change : (1-5, 1=low, 5=high) : ___________
  13. Expected date of completion : __________________
(Generally, at the bottom of this form, it's helpful to have signature lines that match the key, important parts of the process below, so you can help keep track of the process...)

B. Develop a process. You will then need a process where that change request form helps lead your process. A typical process might look like this : (I've highlighted the various characters, so you see how many people might be involved and the roles they play...)
  1. Change Request Form is published throughout hospital (explain to docs/directors that all order set building/changes/deletions will be done according to this form)
  2. Change Request Form is completed by owner, and brought to CMIO for triage.
  3. CMIO and Clinical Analyst Project Manager review form and assign a priority and assign an informaticist and clinical analyst to work on the project.
  4. Informaticist works with owner to define workflows.
  5. Informaticist creates first paper draft of order set, using orders found in your electronic order library/EMR. (This helps make sure your paper version matches with your electronic order sets.)
  6. Informaticist defines testing plan : What front-line clinical staff will be needed for testing?
  7. Informaticist gives first paper draft to clinical analyst to build first electronic draft.
  8. Informaticist helps prepare companion documentation (if needed)
  9. Informaticist helps prepare clinical policy (if needed)
  10. Informaticist helps prepare protocol (if needed)
  11. Informaticist helps prepare education plan/curriculum (if needed)
  12. Informaticist helps prepare monitoring plan (if needed)
  13. Informaticist helps prepare implementation plan (if needed)
  14. Informaticist and Owner execute testing plan - Using front-line staffmembers the owner makes sure show up for testing
  15. CMIO and Informaticist review results of testing together, and review current versions of paper/electronic order sets, protocols, policies, companion documentation, education plan
  16. If CMIO and Informaticist approve - Then proceed
  17. CMIO puts paper/electronic order sets on agenda for Order Set Committee - Sends notification/drafts/links to committee members
  18. Informaticist and Owner - Pass clinical policy through committee for approval
  19. Informaticist and Owner - Pass documentation through committee for approval
  20. Informaticist and Owner - Pass protocol through committee for approval
  21. Order Set Committee meets to review both paper and electronic order sets
  22. If Order Set Committee approves - Then proceed
  23. CMIO sends notification of approval of final paper draft to printshop : Paper order set is coded and published (usually to a "red file cabinet" where you keep "order sets needed for electronic downtimes)
  24. CMIO sends notification of approval of electronic version to clinical analyst  : Electronic order set is coded and published (by your analyst moving from test-->live, usually via your EMR)
  25. Informaticist and Owner conduct implementation plan
  26. Informaticist and Owner conduct monitoring plan (if needed)
  27. Owner : Continuously monitors order set after use
  28. (Restart at step 1 if needed) 
Yes, it's a lot of work. Seems monotonous and boring, but you will need to define a process for order set change management, or else you will end up with order sets that lack support, order sets nobody uses, order sets with no monitoring/involvement, and poor project management.

You'll notice that the Informaticist title up above appears in many steps in the process. This is why you'll want an informatics platform after you "go EMR". Clinical IT Analysts (sometimes mistakenly referred to as "programmers") actually play a much smaller role in implementation than most people think - They're mainly there during development, to make the technical changes and advise the informaticist on technical limitations. You'll also notice that order set owners, once you define this process, will become much more involved in the development, testing, implementation, and monitoring of their order sets.

Finally, you'll want a CMIO to help manage your informaticists, and help corral your doctors/directors into this new process.

And, if you engage in this sort of process, your informaticists will be building/approving simultaneous paper and electronic order sets :
  1. ... so you can have an electronic order set that helps expedite the electronic ordering process (CPOE) for a common clinical scenario...
  2. ... and at the same time, you'll have a matching paper order set that can be filed in an emergency file cabinet to be used during electronic downtimes.
Phew! As I said : With order sets, there are no shortcuts

This is part of the culture that EMRs bring. My advice : Prepare for change. :)

Would love to hear other people's stories - of how you developed a streamlined change management process for your order sets - I look forward to feedback! :)

1 comment:

katmd said...

Great (and timely) post. We are just beginning our order set project in preparation for go-live this fall for a multi-facility system. I am interested in hearing how others deal with the order set review process across multiple facilities that are standardizing? We are using Zynx which will make it easier, but how is the final approval done when you have 3 different medical staffs?