CPOE & Order Set Management
Putting the Puzzle Pieces Together

By Molly Procuniar BSN-RN, BA, FF-P

When Computerized Physician Order Entry (CPOE) hit the scene several years ago, doctors and unit secretaries alike thought they had found the “silver bullet” to all their order entry nightmares. Indeed, CPOE has been successful in eliminating a host of headaches, including deciphering terrible penmanship, waiting on STAT orders to be entered and the inefficiencies related to tracking down misunderstood entries.

However, it is only by pairing CPOE with Clinical Decision Support Systems (CDSS) that we begin to reap the full benefits. CPOE essentially streamlines the order management process by enabling practitioners to enter their orders directly into the computer, bypassing the need to write or dictate their requests and then wait until a third party enters and routes the orders to the appropriate departments.  CDSS acts as the quality control cop. It operates behind the scenes, guiding the practitioner in making the appropriate choices – thereby bolstering patient safety. Without this Clinical Decision Support, CPOE would not only be less efficient, but it would be unsafe for hospitals and their patients.

Some reports have cited instances where CPOE and CDSS have together decreased medical errors by as much as 86 percent. The state of California saw enough merit in this combined system that it mandated every urban hospital to implement CPOE by 2005. Eleven other states have since followed suit. With Central Pharmacy, Lab and Radiology representing the largest number of orders in the hospital, CPOE is critical in assisting hospitals with order management and patient safety. This paper will discuss some of the common pitfalls and puzzles seen today in implementing CPOE while offering a unique solution that works to bring these pieces together in a way that facilitates a smoother, more efficient CPOE rollout.

Order Sets – Covering All Your Bases
 As with other great technological advances, you can expect to experience some bumps in the road when rolling out CPOE.  One of the major slowdowns to its implementation is the way in which facilities handle order sets. To fully discuss this issue, we first need to define what order sets entail. When clinicians refer to order sets, we typically think of three types:

1. Clinical Pathways (e.g. the Stroke pathway, the Rule-Out MI pathway, or even the Knee Replacement pathway)
2. Department Order Sets (e.g. the multiple Sliding Scales for Insulin, the Portland Protocols, or maybe weight-based Heparin)
3. Doctor’s Order Sets or Personal Order Sets

These three types of order sets are sometimes left “homeless” when CPOE is implemented, putting hospitals in the unenviable position of having to decide just how to manage and store them.

Order set management challenges are often governed by the choice of HIS vendor.  The hospital has a choice of selecting an HIS vendor that offers full order sets or one that does not. At first glance, it would seem that the first choice would be the best.  However, the decision’s not that simple.  If order sets are going to be programmed into the CPOE, a hospital has to consider how easy it will be to keep them updated.  

I’ve known of facilities that tweak their Clinical Pathways as frequently as every two months to stay abreast of Core Measures and evidence-based practice.  Where changes are frequent, a hospital may prefer the HIS vendor without order sets in CPOE. They may opt, instead, for a hybrid approach and place Pathways and Personal Order Sets on an intranet site, while continuing to use preprinted Department Order Sets to reference as needed. However, this method is not perceived as completely safe. Some Safety Management officers fear that practitioners may take the opportunity to download order sets stored on the intranet site, save them locally, make any changes they wish, and then use the “new and improved” order sets without legal review.

Two Journeys of Discovery
Consider two hospitals and their similar experiences with a CPOE rollout. When Hospital A went “live”, their CPOE had 100 built-in order sets, but they quickly discovered they needed more. They made the difficult decision to shut down their CPOE for two months in order to re-investigate how order sets were being used throughout their facility. They formed a team of physicians to scout out every version of order sets across the hospital. They were amazed at what they found. Over 400 order sets were discovered. Some were outdated. Some didn’t follow evidence-based practices. Some were using prohibited medications. They even found multiple sets for the same disease classes. In the end, they reviewed the pertinent ones, approved them, and entered those into their CPOE.  As it turned out, over 300 order sets were needed in their CPOE.

Now consider Hospital B. They initially estimated they would need only 35 order sets on rollout for CPOE!  The first indication that something was wrong was lack of physician adoption. When they investigated why, they found the root cause to be a lack of order sets. When the hospital spent the time and money to implement the appropriate order sets, they discovered they needed nearly 500 to make their facility operate at maximum efficiency.  It was a tough lesson.  However, once they addressed the full range of order set needed, they were able to turn a former physician antagonist into their primary champion. Time will only tell if paying to have the full order sets included will truly maximize their technology and order set use throughout the facility. However, there is a more cost-effective way of managing order sets without compromising the decision to implement an effective CPOE.  We’ll discuss that solution at the end of this paper.

The Pitfalls of Hybrid Storage Solutions
The problems and fears related to hybrid storage solutions are five-fold.  First, physician push-back on CPOE implementation can be fierce and detrimental to overall acquiescence. One of the single-most cited reasons for lack of physician involvement is deficient order sets.

Second, order set changes can pose both legal and version control problems. If doctors are able to access an intranet site for order sets, the fear is that they could download a set of orders locally, make changes to them, and then start using these “new and improved” set of orders as their own. These “new” order sets have bypassed the normal review and analysis process that all hospital forms must endure --especially order sets.  Without legal review, the hospital leaves itself open to liability.

The third problem is one of organization and access. Keeping forms in so many locations causes heartache and inefficiency for three groups of people: the practitioners who use them, the clinicians who take verbal and telephone orders from the practitioners, and the people responsible for managing the content on the forms.

Fourth, version control is always an issue. Even minor changes to order sets can become costly.  Updating fields within CPOE translates to a huge programming expense because, frankly, order sets require constant change. When a facility has a hybrid solution, the pain of updating order sets is even more acute.  It requires tracking down each version of the order set which is typically stored in multiple locations.   And if there is one thing you can rely on it is change. As Joint Commission and CMS collect data sets and impose new standards related to Core Measures and Disease-Specific Certification, hospitals are constantly challenged to keep the most current Pathways accessible for care providers. The ability to quickly and easily make changes to these order sets in an efficient and affordable way is essential for hospital wanting to provide evidence-based practice at the point of care.

Finally, downtime operations need to be addressed. If system integrity and continuity of patient care are to prevail, there needs to always be a back-up system that will fluidly handle the needs of practitioners and their patients in the downtime environment.

Puzzle Solved — A More Effective Approach to Order Set Management
Standard Register’s SMARTworks® Clinical Enterprise offers a simple approach that brings these pieces together in a way that facilitates a smoother, more efficient CPOE rollout. This technology solution assists hospitals in consolidating order sets into a single location to help organize your clinical floor and keep version control under lock and key.

By making order sets easily accessible in an electronic environment, hospitals can further eliminate paper. At the same time, this unique approach gives your clinical staff the flexibility to print needed order sets on-demand when and where they are needed, regardless of their complexity. That means Clinical Pathways, Department Order Sets, Doctors Personal Order Sets and Care Plans alike can be easily produced.
 
This is a more affordable approach to order set management than including full order sets in CPOE.  It provides one secure, centralized location for order sets for those facilities currently struggling with hybrid management.  Moreover, this solution offers a seamless interface with both the CPOE and HIS technology you’re currently using, which helps in two ways. First, it makes work practices more efficient by linking these “technological partnerships” behind the scenes. Secondly, a streamlined interface helps bolster clinician buy-in, turning resisters into champions of using CPOE and HIS enterprise-wide. With a hybrid system and everything working together, clinicians can fully appreciate the more complete healthcare picture that CPOE provides.  

For guidance in putting all the pieces together and for a fuller understanding of how SMARTworks Clinical Enterprise can support your CPOE implementation, contact us today for more information.