From Evidence to EHR? Building and Championing Order Sets Nancy Chen, MD FAAP, Veena Goel, MD FAAP, Emily Webber, MD FAAP

Financial Disclosures We have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity

Objectives At the end of this workshop, participants should be able to: Summarize key components in the life cycle of an order set Utilize at least one successful element in order set design Detect at least one design element that needs improvement or one common pitfall

Agenda Introduction to Order Set Life Cycle (20) Small group work (30) Conclusions and call to action (20) Sign in (name, contact, EMR vendor, role) Hands up group assessment

Order Set Life Cycle Needs assessment Design, Build, Test, Implement Iterative improvement

Ten Commandments for Order Sets What are the clinical goals? Who is the clinical champion? Who is my team? What is the plan for sustainable and iterative improvement? Who is the audience? (end user) Does it fit with the workflow? Unintended consequences What is the right technology fit? How will you know if you accomplished your goal? Iterative movements So you think you need an order set…

What are the Clinical Goals? What do you want to accomplish? Clinical pathway implementation Improve prescribing practices Reduce errors of omission Top-down requirement Reactionary to a patient safety event Improve cost savings Is the order set the best format for this goal? Reasons why order set helpful: influence guidelines, treatment outcomes, improve processes of care, efficiency and cost

Who is the Clinical Champion? What is your role in the hospital, and do you need a co-champion? Front-line versus admin Adoption strategy Passing it through the committees Making sure people use it (buy-in) Collaborative leadership Multi-disciplinary team effort Every order set has a clinical champion – sometimes doctor, pharmacist, or nurses Depending on who they are, they may need collaborator. Clinical champion is not always the front-line Getting buy in, adoption strategy

Who is on my team? How many people does it take? Clinical champion (Clinical SME) IT department (Leadership, Analyst, Project Management, IS strategy) Pharmacy Nursing Infection Control Quality Finance Who else needs to be involved? Does a committee/team already exist? Clinical SME – subject matter expert Order Set Committee: Process any request for any order set or revision Associate CIMO – Chair Run by clinical informatics manager (nursing training) Other informatics manager Nursing Pharmacy Invite antibiotic stewardship Quality (informatics manger sits on the Quality)

What is the plan for sustainable and iterative improvement? Governance and Logistics Frequency of updates New evidence or policies Example Clinical pathway Emily to tell her stories from her past experience

Who is the audience? Experienced physician or provider? Where is the complexity? Diagnosis Treatment Transition What is the setting? Academic center Community Setting ED, inpatient ward, several encounters

Fit for real-life workflow?

Two key design concepts Default setting/Pre-selected Clinical Decision Support Two key design to think about

Unintended Consequences

Unintended Consequences Automation complacency Automation bias Automation complacency – assuming computer will take care of something for you. Ex. Provider doesn’t even look through orders and assumes that they want whatever is already selected or suggested Automation bias – people put undue faith in automation and believe the order set over their own knowledge base Carr N. Automation Makes Us Dumb. The Wall Street Journal. 2014.

The 5 Rights Right person (who) Right information (what) Right time (when) At what point in the process? Right channel (where) Right format (how) Rules/alerts Order sets/parameter guidance Smart documentation forms EMR-enabled checklist

Have we accomplished our goals? What is the metric of interest? Improvement in process outcomes (strong evidence) Improvement in clinical outcomes (minimal evidence) Make the best choice the ‘easiest’ choice

Order Set Life Cycle Needs assessment Design, Build, Test, Implement Iterative improvement

Ten Commandments for Order Sets What are the clinical goals? Who is the clinical champion? Who is my team? What is the plan for sustainable and iterative improvement? Who is the audience? (end user) Does it fit with the workflow? Unintended consequences What is the right technology fit? How will you know if you accomplished your goal? Iterative movements Continue

Small group Now it is time to build an order set: New (Start from beginning) Revision (Fix an old order set) In your packet, you should find: Worksheets Pathway or Old Order Set ISMP Guidelines For Standard Order Set Use your Giant Post-it Note/Flip Chart To put together your order set or ideas

Small Group Debrief When building or editing your order set: What was easiest? What was hardest? How would you know if your order set works? When you leave here: What do you plan to do next? What will you take away?

Thanks for coming! Let’s make the best choice the ‘easiest’ choice Nancy Chen @chenny981 nchen1@phoenixchildrens.com Veena Goel @veenagoe vgoel@stanfordchildrens.org Emily Webber @pedshospdoc ewebber@iuhealth.org Let’s make the best choice the ‘easiest’ choice