order set development

Executive Performance Webinar Series: Clinical Leadership Education Sessions

Order Set Development

Managing the Transition from Paper to Electronic Order Sets

Brian D. Patty, MD CMIOHealthEast Care System

St. Paul, MN


Key Steps

• Take Complete Inventory of Existing Paper Order Sets• Standardize Order Set Development Process• Standardize Order Set Format and Nomenclature• Develop Suggested OS’s for MD Review• User Acceptance Testing • Move Paper Order Sets On-Line• Promote Order Sets• Develop Feedback Mechanism, Maintenance Schedule

and Tracking Log


Take Complete Inventory of Existing Paper Order Sets

• Locate “pockets” or collections of order sets• Identify “owner” of each order set collection• Move all order sets into a secure master

database• Create a master list of order sets• Begin the process of identifying duplicate and

unused order sets• Match existing order sets with their counterpart

from your content provider


Key Steps


and Tracking Log


Standardize Order Set Development Process

• Establish a clear process for new order set development and existing order set revision

• Identify core team (MD, nurse and pharmacist) for review and initial build

• Establish/identify “Order Set Coordinator” to police the process

• Leverage existing department and service line committees for order set content development and review

• Identify key MDs for early order set review• Use email and online review tools (ViewSpace) to cut

down review turnaround time


Standardize Order Set Development Process

• More on the “Core Team”– Keep team small

• One team for all order sets: MD, RN, Pharmacist • Or one team for each OS group (IM, Surg, Peds,

CV, Ortho etc.) Depending on size of your organization and your resources

– This team will get OSs “90%” complete


Key Steps


and Tracking Log


Standardize Order Set Format and Nomenclature

• Identify format used by CPOE vendor (if known) and mimic this as much as possible

• ADC VAAN DIMSLE is format familiar to most MDs:Admit DietDx IVsCondition MedsVitals Studies (Radiology, etc.)Activity LabsAllergies ExtraNursing


Key Steps

• Take Complete Inventory of Existing Paper Order Sets• Standardize Order Set Development Process• Standardize Order Set Format and Nomenclature• Develop Suggested OS’s for MD Review• User Acceptance Testing • Move Paper Order Sets On-Line• Promote order sets• Develop Feedback Mechanism, Maintenance Schedule

and Tracking Log


Develop Suggested OS’s for MD/Committee Review

• Use core team(s) to:– Merge duplicates– Merge internal OS’s with content provider OS’s– Get content feedback from quality leaders– Develop suggested Evidence-Based Orders Sets

(EBOS’s) to present to MDs

• Get EBOSs 90% done and then apply your review process with Key MDs, RNs, pharmacists, ancillaries, committees etc.


Key Steps


and Tracking Log


User Acceptance Testing

• Test usability of final EBOS’s in mock live or live environment

• Script: “You are admitting a patient with a diagnosis of X, using this admission OS for X, what works, what doesn't work”

• Process works best if you use MDs who were NOT involved in the development of the OS– Get a naive set of eyes looking at OS– Engenders more buy-in -> sense of ownership ->

advocacy -> OS use


Key Steps


and Tracking Log


Move Paper Order Sets On-Line

• Advantages– Version Control– MD “Buy-In”– Access

• Disadvantages– Training– Process change


Order Set Retrieval Sight


Key Steps


and Tracking Log


Promote Order Sets

• Don’t assume that if you build it they will come– Use MD newsletters and bulletins to promote quality

outcomes from EBOS– Announce release of OSs at key committee meetings– Get them on the chart

• If clear admit dx, unit clerk places appropriate OS in orders section of the chart

– MD to MD follow-up for high target EBOS’s if OS not used for a given admit dx

– Leverage MDs who “own” the OSs as advocates for their use


Key Steps


and Tracking Log


Develop Feedback Mechanism

• Ensure end-user feedback on order sets is acknowledged as soon after it is received as possible– Script: “We received your feedback on order set X, thank you.

Once we review your recommended change with other stakeholders we will get back to you on the status of this request.”

• Ensure final decision on that feedback is communicated back to the end-user as soon after the decision is made as possible, including the reasoning behind the decision – especially if the recommended change is rejected


Develop Maintenance Schedule

• “When order sets are…inadequately maintained, they become templates for efficiently practicing outdated medicine on a widespread basis”

—A. Bobb et.al., JAMIA v14 Jan/Feb ’07 pp 41 – 47


Develop Maintenance Schedule (continued)

• Develop a triage protocol for change requests– Emergent: “core team” identifies change as patient

safety issue and initiates change immediately—change is communicated to stakeholders

– Urgent: request for change is broadcast to stakeholders (via email or online tool) with expectation that final decision is made in 2–4 weeks

– Routine: request for change is put into queue for routine review schedule for order set


Develop Maintenance Schedule (continued)

• Determine frequency of routine review for your EBOS’s

• Tie maintenance schedule to your existing committee meetings

• Start order set review process 6-8 weeks prior to associated committee meetings

• Track progress using milestones


Develop Tracking Log

• Tracking log for your order sets should include:– Date order set first put into live environment– Dates changes to live order set were put into live

environment– Routine Review dates: most recent and next– Associated order sets– Key stakeholders for order set: MD’s, committees etc.– Key contacts– Evidence sources for order set


Key Steps


and Tracking Log


Final Points

• By establishing and mastering the order set development and maintenance process while on PAPER, you will not only be introducing less change to your organization at the time of CPOE go-live, you will also have more stable order sets to build into your CPOE system.

• Online retrieval of paper order sets ensures that most recent versions of your order sets are being used at all times throughout the organization.

• Engage MDs often in all stages of OS development to ensure Buy-in which leads to Ownership which leads to Advocacy which leads to OS usage

• Changing order sets on paper is infinitely easier than changing coded and mapped order sets in your CPOE system

order set development

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