Medical Informatics: Order sets are a medical staff leader's best friend

Dear Colleague,

Let’s face it; there’s nothing sexy about order sets. Electronic medical records (EMR) and computerized physician order entry (CPOE) sound a lot sexier, but if the goal is to change how physicians practice medicine and improve patient care, order sets are where it’s at.

An order set is a standardized list of orders for a specific diagnosis. These orders have been carefully developed by a team of physicians who consult medical literature for evidence-based standards. The selection of medications, dosages, and the potential for drug interactions have been assessed in the calm of task force meetings rather the pressure cooker of a physician’s busy day (or night). Issues of quality and cost effectiveness have been thoughtfully addressed with balance and wisdom. In short, the order set represents best practices. And don’t all physicians want to follow best practices?

Well…sort of. The problem is that the consistent use of order sets means for most physicians that they must change how they take care of patients, something physicians resist vigorously. John Kenneth Galbraith, renowned economist, put it best when he said, “Faced with the choice between changing one's mind and proving that there is no need to do so, almost everyone gets busy on the proof.” Physicians are quick to prove why they don’t have to change how they practice medicine. Yet the quality and patient safety movement has taught us that the practice of medicine is rife with variation that not only fails to add value, but also actively contributes to poor care.

Because physicians inherently resist change means that developing order sets that all members of a department or specialty can agree on is a daunting task. As they are busy resisting the adoption of order sets, physicians usually either migrate to the mean (meaning they begin providing average care) or, even worse, to the lowest common denominator (meaning they begin to provide care that at least everyone can agree is not bad).

The alternative to getting all physicians in a department or specialty on the order set bandwagon is to allow every physician to have his or her own customized order sets, as has been done for many years in labor and delivery. This approach creates efficiency for physicians but does little to improve care.

Don Berwick, MD, MPP, FRCP, president of the Institute for Healthcare Improvement (IHI), has challenged us with a different vision of how we should use order sets. He says we should “standardize to excellence.” This isn’t about average care or care we can all agree is not bad. It is about identifying excellence and holding our fellow physicians to this standard. Done well, that’s exactly what order sets should accomplish.

Order sets bring numerous benefits. They can increase physician efficiency; completing an order set with a few check marks and a signature is definitely faster than writing out every order every time. Order sets that include comprehensive checklists also enhance physician documentation. This helps protect hospitals and physicians in the event of a visit from a recovery audit contract (RAC) surveyor on behalf of the federal government. Order sets can also save money. By working with your medical staff to design and implement order sets for your most common diagnoses, you can reap the majority of benefits provided by CPOE at a fraction of the cost and time.

Though order sets can be done manually, we’ve seen a fully robust order set software solution implemented for $100,000 to $200,000 for a typical community hospital, with a 90 day start-to-finish implementation that gains perhaps 70% of the value of CPOE. This sure beats the typical $3 to $7 million price tag and 12- to 24-month work plan for full CPOE implementation.

Finally, using order sets is excellent way to prepare your medical staff for an eventual transition to CPOE. Most of the cultural issues and resistance can be worked through in the process of implementing order sets, including the challenges associated with standardizing to excellence.

If you are interested in designing and implementing order sets, including potential software tools for assisting with this effort, feel free to e-mail me at rsheff@greeley.com.

Remember, done well, order sets can be a medical staff leader’s best friend.

Rick Sheff, MD, CMSL, is chairman and executive director of The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.