PP&P: How should pharmacists begin
the process of building order sets for Computerized Physician Order Entry (CPOE)?
Chad Lowry: When designing medication orders for an order set, keep in mind the user who will be entering the order. Pharmacy personnel are experienced with what must be evaluated when entering a medication order (e.g., route of administration, the appropriate dosage form for the route, the appropriate dose for the dosage form strength, whether pharmacy or an ADC will dispense the medication). Expecting CPOE users to be aware of all these details is unrealistic. Best practice is to set up the medication orders so that the user only needs to edit the dose, route or frequency, or order comments. Everything else should be pre-populated.
PP&P: How do you determine which order sets should be built first?
CL: Determining which order sets to build first depends on how your organization has chosen to roll out CPOE. If you are taking the unit-by-unit approach, then the unit manager should provide a list (along with paper copies) of all the order sets that a particular unit will be using. If CPOE will be rolled out facility-wide, then the designated facility CPOE lead, who will be helping to facilitate implementation, should contact all unit managers and obtain all order sets. Additionally, each order set must include the nurse and the physician who are assigned to review and approve that order set. These individuals are the designated “order set owners.” If the order set has medications, then a copy is sent to a designated pharmacist for review as well.
PP&P: What is the next step after all order sets have been received?
CL: Once all order sets are received, they are reviewed by the unit manager or CPOE facility lead on a regular basis (usually every two weeks) to keep the build process on track for the go-live date. During the first few meetings, the order sets are reviewed for complexity and ranked based on go-live requirement. Sometimes an order set is developed after the go-live date due to its complexity or if the date does not allow for adequate build and test times. Generally, if time allows, all requested order sets are built prior to go-live.
PP&P: How do you ensure a true multidisciplinary approach to building order sets?
CL: You want to make sure that information systems and technology (IS&T), nursing, pharmacy, and physician groups are involved during the entire order set building process. Nursing involvement helps to ensure the order set is built with the appropriate nursing and lab orders. Pharmacy makes sure the medications are correct and require minimal physician alterations. Physician involvement helps to obtain buy-in.
The IS&T analyst communicates with nursing, pharmacy, and the physician, and then builds the order set based on their collective input. Users can request changes to the order set during build or testing. Changes are then reviewed and approved either via e-mail or in a meeting. Disagreements are discussed until a resolution is found. If a resolution cannot be reached, the order set build is halted until a viable solution can be agreed upon.
PP&P: Do you have tips for ensuring the buy-in of other clinicians?
CL: Ensuring physician buy-in is paramount to the success of CPOE and order set use. By involving a physician in the design and build process, you give “ownership” of the order set to the physician. It is also important that your physician owner is either the department head or a frequent user of that order set. Residents or fellows are not ideal candidates for order set ownership.
PP&P: What design issues should you consider so that order sets do not introduce disruption to the workflow?
CL: Order sets are tools that give users easy access to a set of specific orders. Our system allows us to either have all orders pre-selected for ordering or not selected. For admission or post-op order sets, we pre-select all orders and the users have the option to deselect orders that may not be appropriate for their patient. We did this because most of our admission order forms already had all the orders selected and the physician only needed to remove items they did not want ordered. Mimicking this paper order form design made the transition easier for physicians.
We also use an expert rule that allows us to pre-select certain orders. If the order set was created as a copy of an existing paper form, we pre-selected the same orders that were on the paper form. If the order set was new, then we left it up to the order set owners to tell us during the build and testing phase if they wanted specific orders pre-selected.
If possible, place similar orders into an embedded order set. For example, if an order set has options for seven different labs, these should be placed into their own order set. Medication orders are located in an embedded order set in nearly 99% of our order sets.
PP&P: Do you recommend using a template for building order sets?
CL: Since many of our order sets are built following our paper form design, we do not use an order set template. An example of this is our post-op total knee replacement order set (see Sample Order Set on this page). Since this order set was modeled from an existing paper form, the orders were listed in the same sequence as they were on that form. Our standard basic layout is as follows:
• Nursing care orders first: vital signs, monitoring, etc.
• Diet and activity orders
• Lab orders
• Other types of orders: consults, etc.
PP&P: Are there special considerations for multi-facility organizations?
CL: Yes. If an order set has been submitted by one CPOE facility, then the other CPOE facilities should be involved in the final approval process. The coordination between facilities can be handled by any one of the order set owners. For our organization, we usually ask the nursing or pharmacy owner to contact the other facilities for their input and approval.
PP&P: Do you limit access to certain order sets?
CL: Our current CPOE facility is a university-based teaching hospital where we have medical students, residents, and
fellows who rotate to different services each month. Therefore, we are not restricting access to our order sets. Any user can place any order set. We are relying on the user to only place the order sets that fall within their realm of experience or specialty.
PP&P: How do you avoid the risk of introducing errors during the design phase?
CL: The potential for risk exists if an order set that was designed around a particular nursing workflow in one unit is then used in a unit that does not follow the same nursing workflow. This risk should be minimized by taking into consideration the nursing unit workflow when designing and testing the order set.
PP&P: Are there abbreviations or naming customs to be avoided?
CL: We have an organization wide list of unapproved abbreviations that meet the JCAHO requirements. When an order set is built, no abbreviations from that list can be used.
PP&P: What should not be considered for order sets?
CL: Every order set that is submitted should be reviewed for appropriateness. If it is a brand new, never before used order set, we ask the submitter to obtain approval from the facility forms committee. This is a multi-disciplinary committee with pharmacy and nursing representatives. They review all paper order form requests to make sure they follow organizational standards.
PP&P: What are the safety issues surrounding order sets in the
CL: The main issue is to ensure that the orders are appropriate and valid for this patient population as they might differ from those used with adults. We have placed all neonatal order sets under their own category and we have not seen any adult order sets placed for a neonatal patient. If there is a need to prevent accidental placement of an adult order set on a pediatric/neonatal patient, the order set IS&T analyst should consult with the system programmers for options.
PP&P: What is the process for testing order sets once they are built?
CL: Before an order set goes live, it is reviewed in a testing pathway with the nursing, pharmacy, and physician owners. All owners sign an order set sign-off document (on page 7), indicating that they have reviewed the order set and approve of its design and contents. The order set is then ready to be used in the live pathway. A few key items to look for during the testing process are:
• How do the orders appear on either an electronic or paper “kardex”?
• Does the order set feel fluent when placing the orders?
• Do any of the orders need to be edited, or new orders added?
PP&P: How are order sets evaluated once they are in place? How often are reviews necessary?
CL: Order sets are evaluated on an on-going basis. As the order sets are used, users submit new change requests as necessary to update the order set. Ideally, every order set should be reviewed on a regular basis as determined by the organization. At our organization, order sets (both paper and electronic) undergo a biannual review by the forms committee.
PP&P: What was the biggest challenge you faced during the order set building process?
CL: The biggest challenge was finding time to review the order set with the physicians due to their schedules. To overcome this, we try to meet with physicians at a time and location that is convenient for them. We also send screen shots and, if needed, a video clip of the order set prior to the meeting. This gives the physician ample time to review the order set and provide appropriate feedback.
PP&P: In hindsight, what do you wish you knew before you
CL: The build process for an order set is fluid until it is finally approved. This process can be filled with many roadblocks and unanticipated detours. Looking back, I think some order sets could have gone a bit smoother if the nursing and physician users were more familiar with the process. Now that we have been doing this for a few years, the nursing staff has developed more expertise, so it is much easier.
Chad Lowry, PharmD, earned a doctor of pharmacy degree from Idaho State University College of Pharmacy and currently serves as a CPOE pharmacy consultant at The Health Alliance in Cincinnati, Ohio.
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