Monday, August 9, 2010

Still no order set short cuts

So today I spent a good part of the day with folks from a hospital preparing for their EMR go-live. I went over the role of the CMIO, how to get buy-in, how to develop an informatics platform, and other things that you need to do before you "go-live" with your EMR.
Remember, in the formula for EMR implementation :
  • The CAR = your EMR
  • The GAS = 1/2 clinical IT staff, 1/2 Informatics (IS) staff
So we talked about how to budget for your gas, and other issues in getting physician buy-in.
And then, the subject came up about "the order sets". Especially, all of the work that goes into "fixing" the old order sets.
So they reported to me that they were hoping to save some time by just abandoning their old paper order sets, and using some of the "generic electronic order sets" that come with their EMR.
And then I had to break the news to them : Even this won't save you time.

Q : Huh? Dirk, you have posted about how hard it is to fix the old paper order sets. So why can't you just use the order sets that came with your EMR, and tailor them to your needs?

Here's the reason.
Most of your paper order sets (the ones you made before your EMR go-live) actually have little snippets of protocol in them.

Remember, protocols are the "if/then" conditional statements that help automate some nursing process, generally, so your physicians don't get a phone call. (The most common example is the "Heparin protcol", or the "Insulin Protcol", which most people understand fairly well.)
But you probably have other pieces of protocol in your other order sets. Don't believe me? Look at your paper order sets and look for any text that says "If" or "Discontinue when" or "For use in the _____ only", which are all synonyms for "If _____ then ______" - Or, in other words, these are all hidden pieces of protocols.

So the problem you'll have, if you simply abandon your paper order sets and use whatever came with your EMR, is that suddenly all of those pieces of protocol (which are serving you every day) will disappear from clinical function.

And when those hidden, embedded pieces of protocol suddenly disappear from your clinical setting, your docs will suddenly start getting large numbers of phone calls from nurses to clarify these many clinical scenarios.

And this will lead to your CMIO dilemma : When you have your CPOE go-live, suddenly the docs will sense a "serious decrease in efficiency", and the obvious target of their anger will be your EMR. (This is a good way to lose physician buy-in.)

My advice : Repeat the mantra, "There is no such thing as a free lunch when it comes to order sets". Before you decide to adopt this strategy, take a look at your paper order sets. Highlight any pieces of embedded protocol you find (now that I taught you how to find them.) Realize that these protocols will disappear in the electronic world, unless you have the policy mechanism to re-create them as published protocols.

So if you go through all of your paper order sets, and find a lot of pieces of protocols, I wouldn't advise simply getting rid of your paper order sets - Your docs will suddenly feel a loss of productivity and efficiency when you "go CPOE".

I suppose, if you go through all of your paper order sets, you don't find any hidden pieces of protocols, then you may proceed with caution, but if your paper order sets are that well-designed, and your policy mechanism handled protocols well in the past, then these paper order sets won't be too hard to "make electronic" anyway.

(I have yet to meet anyone who has old paper order sets that are built to that level of engineering, but your story may be different.) :)

My closing take-home points :
  1. If Informatics were easy, you wouldn't get paid to do it.
  2. If Informatics were easy, there wouldn't be schools for it.
  3. There is no such thing as a free lunch.

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