5 Steps to Customize Clinical Decision Support Order Sets for Hospitals
Clinical decision support is a tool hospitals can use to standardize protocols in the delivery of care. CDS can provide standard order sets, alerts and evidence for different practices. However, for this tool to be useful, hospitals need to customize their CDS system to their organization.
Eliminating "noisy" alerts
The amount of data CDS provides for different conditions can be overwhelming and may slow buy-in and adoption by physicians. "The barrier to use increases the longer the order set gets, the more alerts it has," says Hemant Gupta, MD, CMIO of Lourdes Hospital in Binghamton, N.Y.
In addition, not trimming down the evidence presented by CDS' order sets can jeopardize patient safety if clinicians have difficulty identifying the important information — alerts that affect mortality, readmissions and quality — among alerts that present more abstract and "did you know?" information. "Too much evidence is perceived as noise," Dr. Gupta says. "When you open up a set of instructions for a patient, there has to be guidance as to what is critically important to review and click on and what is not."
Pruning clinical decision support information
Dr. Gupta led Lourdes Hospital's local customization process with Zynx Health CDS. He shares a five-step process hospitals can use to tailor their CDS order sets to their unique needs.
1. Specialist review
First, a specialist in the field related to the order set reviews and comments on the appropriateness and content of orders. For an example, a representative from the cardiology department, such as a cardiologist, manager or staff member, would review an order set on heart failure. If a hospital has three cardiology groups, one representative from each group should have the opportunity to review the order set, Dr. Gupta says.
He suggests specialists consider the following questions when deciding what orders to keep:
• Is the order an important quality measure, such as a measure reported to CMS or a measure required by an accrediting agency? For instance, the Hospital Consumer Assessment of Healthcare Providers and Systems survey, which affects hospitals' reimbursement under healthcare reform, includes a question on whether the patient received post-discharge instructions in writing. An order on discharge education should accordingly be kept in the order set.
• Is there strong evidence the order affects cost, efficiency, safety or quality? For example, giving patients an antibiotic within one hour before surgery has been shown to reduce the risk of infection. An alert reminding physicians to give patients an antibiotic should remain in the order set.
• Does the order apply to the majority of patients? For example, Dr. Gupta says an average heart failure patient does not need a transesophageal echocardiogram — a type of echocardiogram in which a probe is passed into the patient's esophagus. The test carries more risks and is more expensive than a regular echocardiogram, but may have benefits for a small number of patients who meet certain criteria. Since the order applies to only a minority of patients, the hospital can eliminate the order, Dr. Gupta says.
2. Order set agreement
After a specialist comments on the orders, a group of medical staff leaders collates the specialists' comments and agrees on what orders to keep in the order set and which ones to eliminate.
3. Committee review
Once the leadership group agrees on the orders that are clinically appropriate for the order set, a committee that includes a pharmacist, a lab representative, a nurse and a radiologist reviews the orders for relevance to the hospital.
The committee should consider the following questions, according to Dr. Gupta:
• Does the hospital have the drug on the order? If a hospital does not have a drug due to a shortage or other reasons, the order set should not include an order for that drug.
• Does the hospital perform the lab test on the order? Similarly, if a hospital does not perform a certain lab test, the order for the test would not be able to be filled and should therefore be cut from the order set.
• Is the order already included in nurses' protocols? Some orders may contain instructions that are already part of nursing protocols at the hospital. For instance, a nursing protocol may include educating a heart failure patient on smoking cessation. An order recommending smoking cessation education would be redundant and should be cut from the order set.
4. EMR integration
After the order set has been trimmed of clinically inappropriate and irrelevant orders, the hospital then builds the order sets into the electronic medical record.
5. Order set review
When order sets are integrated into the EMR, the specialists should go back through the order sets and provide feedback on what orders they use and which orders are not valuable. "Engage the users, and [encourage them] to continue to give feedback when the order sets go online," Dr. Gupta says. One way hospital leaders can incentivize specialists to provide feedback on the order sets is to offer continuing medical education credit for reviewing and commenting on the orders, he says.
By continuing to refine the order sets, the hospital can ensure clinicians have easy access to the most important information they need to provide safe, high-quality care.
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