5 Steps to Effective Order Set Integration

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An integral part of any hospital's care processes, order sets have long provided clinicians with a standardized set of evidence-based treatment guidelines to assist with the patient encounter. They bring together established clinical protocols, proven best practices and medical content for a number of clinical scenarios and treatment plans, and provide clinicians with the information they need to make educated care decisions at the point of care.

For decades, order sets have been primarily paper-based and typically enjoyed high adoption rates. Now, with the dawn of electronic order set solutions, many hospitals are struggling with how best to integrate this valuable clinical decision support technology into their organization's care processes without disrupting physician workflows.

However, there are five steps hospitals can follow that will help eliminate or significantly diminish the integration challenge and facilitate high clinician adoption and satisfaction rates.

1. Identify software solutions that fully address clinician needs and expectations
The issue of clinician adoption of order set solutions lies not with resistance to the software. Rather, it is that decision support software often does not offer the features that clinicians desire or need to simplify their processes. As a result, it can disrupt clinical workflow, negating the benefits that could otherwise be derived from electronic order set solutions.

According to a recent independent study of order set utilization among U.S. hospitals, conducted on behalf of Wolters Kluwer Health, the five features/functionality clinicians most desire of an electronic order set solution are:
  • Ease of use (56.5 percent)
  • Customization of pre-built order sets (44.4 percent)
  • Ability to build orders from scratch (31 percent)
  • Continuous monitoring (35 percent)
  • Integration into CPOE (59.3 percent)

To ensure maximum clinician adoption, identifying order set solutions with these five elements should be a priority in the selection process. In fact, to ensure that clinicians' needs and expectations are adequately addressed by the software solution ultimately selected, they should be involved in the evaluation process from the outset.

2. Ensure the order set solution provides the authoring features and functionality that appeal to a diverse user group
When it comes to authoring capabilities, order set software must be designed to streamline and accelerate the development process in a manner that is cohesive with the everyday workflows of a highly diverse group of participants. In fact, 42 percent of respondents to the Wolters Kluwer Health survey identified customization of pre-built order sets as a top required feature in an order set solution, and 37 percent identified the ability to build order sets from scratch.

In order to overcome time and resource challenges, this means the software must include a sizable library of prebuilt order sets that are based on nationally recognized best practices, which will significantly reduce the need to draft order sets from scratch.

Each prebuilt order set should also link directly to sources of supporting medical evidence so authors and reviewers can quickly validate that it is clinically appropriate. Intuitive clinical decision support capabilities are also key considerations, and require a carefully balanced combination of medical evidence and decision support tools capable of evaluating data within its specific context and delivering useful – rather than disruptive – advice.

3. Select a solution that provides the highest possible levels of automated integration into CPOE/EMR
The ability to integrate order sets into CPOE for point-of-care access is highly valued by clinicians. In fact, 56 percent of survey respondents indicated that integration was their top required feature when selecting an order set solution.

Though it is impossible to fully automate order set integration and deployment into CPOE, there are features that can significantly reduce the need for manual intervention during the process. Specifically, look for order set solutions that feature: 1) a comprehensive catalog of orderable items; 2) an underlying data-based structure; and 3) the use of standard identifiers (i.e. SNOMED CT, ICD9, CPT, RxNorm, LOINC, etc.).

Without a substantial catalog of orderable items, authors must manually enter each before it can be mapped into the order set. On the other hand, a data-based structure enables a higher level of automation when it comes time to integrate order sets with a hospital's CPOE or EMR system. Utilization of standard identifiers further reduces the need for manual mapping to CPOE/EMR.

4. The order set solution should streamline rather than disrupt clinical care processes
Even if an order set solution succeeds in accelerating development and deployment, things will quickly fall apart if physicians do not embrace it at the point of care. To increase the likelihood of clinician adoption, it is imperative that the software does not interfere with the care process; it should enhance rather than disrupt workflow and deliver recommendations that make clinical sense and truly advance the practice of evidence-based medicine.

As with the authoring capabilities, the decision support provided by the order set solution at the point of care should provide easy access to medical evidence that assists physicians in determining the most appropriate course of care. It should only deliver information that is important to the case at hand.

Appropriate flexibility is also critical at this stage. Software should allow the physician to deviate from the pre-selected orderable items when appropriate, but cannot be so flexible that standardization is jeopardized.

5. Ensure the solution offers the features and architecture to streamline and automate maintenance

Creation happens once; maintenance is forever. That is why the single greatest long-term challenge hospitals face with evidence-based order sets is keeping them current.

That is evident in the responses to the order set utilization survey, in which 47 percent of respondents who used paper-based order sets indicated maintenance was a moderate to significant challenge. Further, 77 percent of paper order set users identified automated monitoring of medical evidence and streamlined updates as a feature that would factor significantly in the purchasing decision.

As such, it is important that the order set software provide a powerful maintenance component that includes automated monitoring of medical evidence and regular updates that alert users when changes might trigger the need for updates. Ideally, the software should provide the ability to quickly review new evidence and update all order sets based upon that evidence in just one or two steps.

It should also include a verifiable audit trail of any changes made to an order set and archive of past versions, which will go a long way toward instilling confidence in the physicians who are expected to integrate order sets into their care practices.

Ultimately, ensuring seamless integration of order set software into the clinical care processes requires active clinician end user involvement in the selection process. With their input, and these five steps, clinician adoption is likely and successful integration will be a reality.

Linda R. Peitzman, M.D., is chief medical officer for Wolters Kluwer Health and executive vice president of clinical development and informatics for its Clinical Solutions division. For more information, visit www.pointofcareapplications.com.

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