Development of Order Sets Vicki Moritz, June 2005

Why do Computerised Physician Order Entry? (CPOE) US evidence suggests CPOE: Reduces costs by containing repeat test ordering Reduces costs by guiding ordering Reduces adverse events when used for medication orders

Issues around CPOE implementation US uptake of CPOE at approx 5-15%: Difficulties of implementation include Clinician rejection due to additional time needed to order Clinician rejection due to poor user interface Clinician rejection due to lack of hardware ($$$ issue) Clinician resistance to change

Why Order sets? Orders can be placed as favourites, order sets etc: Order sets: Streamline test ordering Provide decision support in terms of recommended orders

What is an order set? An order set is a prefilled ordering template, or electronic protocol that is derived from evidence based best practice guidelines HL7, 2003 HL7 EHR SIG Functional Descriptors Draft Document.

HL7 proposes 4 layers of order sets Layer 1- the example given is the American College of Pathologists requirement to generate a repository of problem based order sets to be used by its members Reduces costs by guiding ordering Layer 2- In this example (Use Case) order sets are downloadable for sharing and include decision support

Scope of the current project Layer 3- introduces order sequencing- orders which must be selected all at once, OR orders which are mutually exclusive when selected Layer 4- is presented by the SAGE work where SAGE order sets employ embedded decision logic features which may turn orders on or off within the set at the time of order processing (sanction logic).

Building on past experience Austin currently have order sets live in ED: 24 Order sets Mix of diagnosis based and procedural order sets eg Abdominal pain Angina Pectoris Unstable Bloods/ECG Open wound

Types of order sets Generic: Will need buy-in from the appropriate specialty area Departmental/Specialty: Implementation will need to be specialty based to meet specific needs and assure Buy in

Electronic ordering

Order sets

Data from Austin ED Order sets

Most orders placed individually, rather than through order sets Where the patient condition is more unusual nurses valued Order Sets as a reminder or guidance whereas physicians valued this criteria less The more experienced the physician the less they rely upon order sets as a reminder or guidance in their practice

Data from Austin ED Order sets

Further order set development Commenced with pilot areas: ICU Oncology Others specialties where there are clinical champions Renal Endocrinology etc Then the balance!!

Challenges Anticipated challenges: Lack of acceptance if no immediate return Lack the Point of care hardware for the immediate return General resistance to change!

Challenges Workflow issues: Pathology orders still being printed- where are the printers? Who collects the order forms from the printers? Do the Radiology order forms print out in the Radiology Department? Is the person placing the order authorised to do so? ?Electronic signatures? ?Interface with Pathology/Radiology systems ?What about other departments- Cardiology/ Nuc Med etc

Sustainability Need to know: Where is the evidence for the contents of the order set Who is the owner? When to review? Linked evidence bases Processes/software needed to manage this additional data Impact on clinical practice/ordering patterns

HL7 work on order sets HL7 are working on 2,500 order sets XML based front end to manage these Web based front end allows clinical staff to make modifications At IHC (US) there are 4 doctors and 5 nurses working on order sets- 82 created so far!