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!

Saturday, January 12, 2019

Building your #Workflow Glossary

Hi fellow Clinical #Informatics and other #workflow enthusiasts, 

Happy 2019! While I continue to work on compiling the business case for Clinical Informatics, I thought I'd take a minute to talk about #workflow terminology

A. THE BACKGROUND :
Simply put - words matter. Any bilingual person who has ever tried to translate the phrase 'scram' or 'hit the road' into another language knows that a word-for-word translation does not always work. (Really? Hit the road..?) One might try to translate it as 'it's time to leave', but even that fails to convey the certain informal, vernacular quality that the phrase 'hit the road' conveys so well. So my advice to anyone working in a translational role - Do your best, but always translate at your own risk

In healthcare, we have a number of terms that people generally understand, but their exact definitions may vary from organization to organization. They include such common terms as : 
  • Order
  • Order Set
  • Protocol
  • Policy
  • Procedure
  • Guideline
  • Standing Order
  • Clinical Pathway
  • Documentation
  • Templates
  • ... and more!
While almost all clinical staff have a general sense of these terms, their true understanding may not be exactly the same - And so, with regard to the term ‘protocol’, for instance, they may quietly have overlapping circles of a common understanding :

The problem is that these differences in understanding may result in dramatically different expectations about how exactly a 'protocol' works, and what it can do to help their workflow : 
  • Can a protocol be used to allow a Registered Nurse to titrate an IV heparin drip?
  • Can a protocol be used to allow a Registered Nurse to give a pneumonia vaccination?
  • Can a protocol be used to allow a Respiratory Therapist to titrate the settings on a ventilator in the ICU?
  • Can a protocol be used to allow a Registered Dietitian to modify a diet for an inpatient?
  • What is the difference between a protocol and a standing order?
To increase the amount of common understanding, it's helpful to look at your federal and state regulations, along with your own safety and operational needs, to see if they offer any definitions that help clarify the answers to these questions :

After all, once there is a clear definition - then you can create a standardized template, development procedure, and staff education to give everyone on your team a greater, more standardized understanding of the tool and what it can do. Remember - It all starts with the definition.

B. THE PROBLEM :
Healthcare faces some challenges in harmonizing this terminology - What a protocol can do in some organizations is different than what a protocol can do in others. And despite CMS regulations which refer to the use of protocols, many federal and state regulations use these terms interchangeably - See this 2013 letter from the Centers for Medicaid Services (www.cms.gov), page 4 : 
Standing orders: Drugs and biologicals may be prepared and administered on the orders contained in pre-printed and electronic standing orders, order sets and protocols (collectively referred to as “standing orders” in our guidance) only if the standing orders meet the requirements of the medical records CoP.
And this, from the Interpretive Guidelines §482.24(c)(3) on page 78 : 
There is no standard definition of a “standing order” in the hospital community at large (77 FR 29055, May 16, 2012), but the terms “pre-printed standing orders,” “electronic standing orders,” “order sets,” and “protocols for patient orders” are various ways in which the term “standing orders” has been applied. For purposes of brevity, in our guidance we generally use the term “standing order(s)” to refer interchangeably to pre-printed and electronic standing orders, order sets, and protocols. However, we note that the lack of a standard definition for these terms and their interchangeable and indistinct use by hospitals and health care professionals may result in confusion regarding what is or is not subject to the requirements of §482.24(c)(3), particularly with respect to “order sets.” 
Making it even worse is when Informatics professionals then have to compare this with their state regulations :


... which may have slightly different understandings and definitions of these terms.

Fortunately, there are some very talented medicolegal and compliance experts out there, who can help an organization to develop a strategy for navigating these regulations, while planning their workflows, both before and after an EMR implementation. One of the best I've seen is Sue Dill Calloway, BSN MSN JD, who has a fantastic series of lectures on the importance of this terminology, for regulatory, financial, and patient safety reasons.

But in the absence of a simple, standardized national glossary, with good functional definitions of these tools - It can be very hard to develop the templates, development procedure, and education you need for your team. 

C. THE SOLUTION :
Given the lack of clarity about these terms, what's the average CMIO, CNIO, or clinical informaticist to do? Fortunately, there is a strategy you can employ, and that is expanding upon a fairly simple template for functional definitions : 
[ TermWhat It's Called ] - [ Functional Definition: What It Does
This simple template is helpful in separating terminology for tools that have slightly different functions, e.g. : 
Term1 - FunctionalDefinition1
Term2 - FunctionalDefinition2
 ...and so on...
So if we can accept this simple template for separating terminology and function, we can then start to draft a 'conceptual map' for these common terms in healthcare (click the image below to enlarge) : 
(REMEMBER - THIS GRID IS JUST A DRAFT AND IS NOT COMPLETE!)

As you start to do this exercise, you'll see that there are some terms which have very similar functions, and other terms which don't
  • Guidelines and Policies initially look like they might have similar functions - until you consider that policies might result in root cause analysis and disciplinary action, and guidelines don't. (Policies=rulesguidelines=suggestions).
  • Protocols and Standing Orders seem to have very similar functional definitions, so we need to figure out if they are true synonyms, or if there is some kind of a difference between them.
  • Procedures and Plans also have similar definitions - So we will need to figure out how to separate them. In this case, I've taken the liberty of separating them in time, suggesting that procedures describe current tasks, and plans describe future tasks
Given the similarities between protocols and standing orders, it's helpful to separate them by considering their risk - and thus their initiation/triggering mechanisms, FOR EXAMPLE
  • Standing Orders = Used for common, LOW-risk clinical scenarios in which the benefit to the patient of rapid evaluation and care outweighs any known risks. Standing orders may be initiated ('triggered') by a clinical POLICY (e.g. 'All clinic patients will be screened and potentially administered for pneumonia vaccination, according to the Standing Orders for Pneumonia Vaccination.) All orders and outcomes of standing orders will be attributed to the attending provider.
  • Protocols = Used for common, HIGH-risk clinical scenarios in which the benefit to the patient of improved care standardization outweighs any known risks. All protocols must be initiated ('triggered') or discontinued by an ORDER (e.g. 'Initiate Ventilator Liberation Protocol' or 'Discontinue Ventilator Liberation Protocol'). All orders and outcomes of clinical protocols will be attributed to the ordering provider.
While you undergo this exercise, it's important to look at your regional, state, and federal regulations, and to speak to experts (like Sue Dill Calloway, BSN MSN JD as I mentioned above). If there are no regulations to guide you in this grid, then you and your clinical and administrative leadership will have to make local decisions about how your organization wants to define these tools.  

As you work on these definitions, keep in mind other things you can do to improve safety and clarity, e.g. "Orders are documented instructions [ that ] must be signed within 24 hours."

As you start to build out this grid for your own organization, talk to people who use these tools, and you'll start to better understand the form, function, and other issues related to their design. And once you think your grid is complete? Bring it back to your senior leadership for review, discussion, and formal approval. Voila! You now have your own organizational glossary that will help you develop the templates, procedures, and education that create a greater understanding, and improved standardizationpredictability, and efficiency, for both your clinical and administrative teams. 

Hope this is helpful in guiding you to build your own workflow glossary! If you have any other tips, suggestions, or comments, leave them in the comments section below!

Remember - This blog is for educational discussions only. Do not use any of these definitions without formal review and discussion with your own informatics, legal, administrative, and clinical teams. Have any other clinical terminology tips you'd like to share? Feel free to leave in the comments below!