Order sets are a critical component to clinical care and that importance is reflected in the increasing requirements for computerized physician order entry (CPOE) during the next stages of the EHR Incentive Programs beginning with Stage 2 Meaningful Use. But there is much more to these order sets than achieving meaningful use, especially in terms of what they mean to quality care and patient safety.
The life cycle of order sets in a production environment requires periodic review to comply with the Joint Commission standards and to remain current with best practices and medical evidence. The following process flow suggests a method and timeline to accomplish these periodic reviews.
In my previous article, “EHR-based order sets: 7 methods for successful development”, one suggestion for successful order set develop is to create a system for tracking their progress (from design through release) with the capability of creating real-time administrative reports. One such administrative report is the Periodic Review.
It is not unreasonable for a multi-facility healthcare system to develop hundreds of order sets, thereby understandably making it difficult to keep track of order set content updates, versioning, retirements, and new additions. A database application such as MS Access, for example, can be used to track order sets through their various life-cycle statuses and produce reports based on those attributes.
Using the production date and later, the date of last review, a database query calculates age compared to the current date. Thus, “aging reports” can be created to determine the amount of time since last review and to yield advance reports for lead time based upon defined criteria. Organizing order sets into queues at intervals of 90, 60, and 30 days allows reviewers to focus on the most pressing tasks and saves them from becoming overwhelmed by the volume of work.
Periodic reviews can follow a fast track if only minor or no changes have occurred. If the scope of changes have exceeded this level, then a more comprehensive review is necessary. For instance, if providers have made numerous enhancement change requests to be included in order sets, a more thorough review is necessary. “Emergent reviews” occur when patient safety issues arise where the content of order sets must be modified immediately due to drug recalls, or if evidence reveals that an order set no longer follows best practice. In all cases, the review process includes patient safety, regulatory guidelines, best practices, and medical evidence. The schedule of periodic reviews should be at least biannual and more frequent as previously noted.
Designated reviewers can be on call for assignments or be part of a rotating committee of subject matter experts who represent physician practices, nurses, pharmacists, and others participating in patient care. All reviewers should follow clearly defined guidelines and a standardized checklist of review criteria provided from the onset to ensure continuity. For multi-facility systems, representatives across facilities should participate to lessen the perception of compartmentalization (i.e., “our” order sets versus “their” order sets).
Reviewers representing clinical effectiveness should also perform periodic quality measures comparison reviews to determine how the order sets measure up to national quality standards. The oldest order sets should be reviewed first, unless facility requirements allow for, or dictate, exception. A revision to an order set prior to its normal review date can also count as a review as long as the process follows the same described process.
Order sets coming under review should be bundled into like specialties (e.g., cardiology, pediatrics). The number of order sets bundled will be dependent on the number and availability of reviewers. A suggested fast-track timeline for order set review is three days from start to approval; 10 days for a comprehensive review; and one day (or same day) for emergent reviews.
A standardized order set change-control process that tracks modifications to the order sets is vital. This change control can be separate or part of the order set tracking database, based on facility requirements. Having one well-qualified person as the central point of contact for the tracking database, preferably a clinician with database training, is also key. Finally, a comprehensive user/builder guide document describing the database “as-built” is critical. This guide is used to maintain change details and customization of database tables, queries and reports as required by administration. This living document is passed on as personnel changes occur and further ensures process continuity.
Additional benefits of having a standardized review process and associated database are realized during periodic Joint Commission inspections. For example, during an onsite review for the Disease Specific Care Certification Review Process, the Joint Commission requires “Order sets, clinical pathways, protocols, etc., that are used to implement selected clinical practice guidelines.” In a robust order set database system, the life cycle of the order sets under review and their current downtime paper-based versions are immediately available to inspectors. Supporting documents such as medical evidence links can be made available as part of the related data tables.
Designing and implementing an order set process as described above will help ensure success in improving the quality, safety, and efficiency of comprehensive patient care through the application of relevant, up-to-date, quality order sets.
