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!

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