Order Set Management

Chris George - Regional Collaborative Practice Lead

Kristen Vaughan - NBRHC Site Lead, Manager of Information Systems and Informatics

Vai Khanna - Physician Systems Consultant, Tegria

Dr. Alexis Lemmex - NBRHC CMIO - ED Physician

Purpose of Presentation

• To provide an overview of the Computerized Provider Order Entry (CPOE) and Expanse Physician systems platform
• To provide an overview of the Regional Standardized Order Sets catalogue
• Summarize Regional and Local governance of Order Sets and Medical Directives

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Agenda

Introduction to CPOE

• CPOE - Computerized Provider Order Entry
• The process in which providers enter and send treatment instructions - including medication, laboratory and radiology orders via a computer application rather than paper, fax or telephone

Why CPOE/Order Sets?

• Reducing care variation. 
• Preventing medication errors before they happen. 
• Improved medication reconciliation.
• Eliminating illegible notes.
• Reducing transcription errors. 
• Reducing the need for patients to repeat their history.
• Improving access to patient info at the point of care to support timely clinical decision making and workflow efficiency

Helps provide safer care by:

Introduction to Order Sets

Order sets are an evidence-based clinical decision support solution for hospital sites to reduce clinical variation, optimize clinical processes and improve patient outcomes.

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Expanse features a comprehensive order set library of over 340 standard order sets with interventions that drive care standardization and are shown to improve key patient outcomes. These order sets are currently being utilized by the 3 live sites (NBRHC, SAH and WPSHC)

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For the ONE project our Scope is:

• Adopt existing order sets where possible (to support standardization)
• Localize order sets in situations where complete standardization is not possible e.g., a service is not available, or a medication is not available at a particular site.
• Develop new order sets only for the programmatic gaps in the existing library e.g., Cardiology

Current State of Order Sets - ONE

• 344 Standardized Order Sets used across 3 sites
• Anesthesia
• Cardiology
• Critical Care
• Emergency
• ENT
• Maternal Child
• Medicine
• Mental Health
• NICU
• Pediatrics
• Surgical
• Orthopedics
• Urology
• Plastics
• Procedure

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Convenience Sets

There are also 206 Convenience Sets. These convenience sets are subsets of orders which could be used as a stand-alone smaller order set or embedded within a larger order set.

Convenience Sets : Breakdown

Convenience set are utilized to advance 3 main goals:

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1. Standardization: Use of standardized convenience sets within larger regional order sets ensures standards orders for disciplines such as Dietary services, Respiratory services etc.
2. Localization: Use of convenience sets as a variant allows for minor variations in an otherwise standardized order set at a regional level e.g., medication convenience sets.
3. Adaptability: Stand alone convenience sets could be used to resolve any workflow specific ordering needs for a particular site or program e.g. Cardiology clinic labs, Renal Hemo initial labs

Convenience Sets: Standard Sections

All Expanse order sets have some standard components built in. These standard components are built in as Convenience sets and can be embedded into multiple larger order sets across various programs and sites. Project team is advised to continue to utilize this structure for order set development to drive standardization.

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Below is an example of one such standardized convenience set currently used across all three sites.

Medical Directives

Medical Directive are Indirect Orders that are approved by responsible providers. They give authority to a care provider to implement the order on a specific patient population. i.e. ED Adult Asthma. Expanse currently has 33 medical directive order sets built for use in Emergency Department (ED).

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The Wave 2 sites are expected to develop or adopt local policies if they wish to use these medical directives.

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ED Abdominal Pain Medical Directive

Regional Order Set Development : Wave 1

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Order Set Working Group

• Regional Physician User Advisory Committee
• Order Set Core Team
• Site Leads
• Subject Matter Experts
• External CPOE Consultant
• Ministry of Health and Long Term Care HIS Benefits and Adoptions Team (no longer)

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Regional Order Set Change Request and Approval Process

Proposed Order Set Review Process: Wave ll

Meditech Expanse Change Request Process

NBRHC has developed a robust Meditech Expanse change request process, including a standard change request form.

Meditech Expanse Change Request Workflow

• Staff have one central location to submit change requests
• Reviewed and approved locally first!
• For regional requests, Informatics will submit a ticket to servicedesk@necare.ca
• Informatics staff act as a liaison between requester and regional team members and will provide regular communication updates.
• Change Request algorithm

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Tracking Change Requests

• Developed a change request tracker in utilizing the Gsuite

https://docs.google.com/spreadsheets/d/18JQKPwtwXuQmO7-Gw9VkbuRP3UoCdP0E/edit#gid=664674142

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• New requests and status updates are reviewed/discussed biweekly at Informatics Roundtable meeting

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• If not proceeding with the submitted change request, an Informatics team member will advise the requester of status and rationale

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• Established spring 2021, completed Plan Do Study Adjust (PDSA) cycle, 30, 60 and 90 days.

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Local Physician SME Roles and Responsibilities

• Subject Matter Expert (SME) is considered a clinician who exhibit high level of expertise in their clinical area of interest and excels in evidence-based standards of care in their clinical area of interest.
• Represents their clinical area of interest at the Regional One Level when called upon by the Region to review/create/optimize Order Sets.
• Liaison with CMIO/IS team for local HIS issues
• Represents local hospital when order sets are sent back from the Region for local review.

Order Set Review

• SME responsible to ensure clinical content appropriate for local NBRHC workflow
• Discuss Regional Order set changes with Department members and field any concerns/questions
• Emphasize a regional standardized approach is the aim when creating or editing order sets.
• Consider choosing wisely initiative and good use of resources
• Provide feedback to Region if major red flags from local perspective.
• SME responsible for completing order set review and provide feedback within a reasonable amount of time (10 business days of request).

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NHBRC Local Approval Process: CPOE/Medical Directives

NBRHC enhanced local approval process for CPOEs and Medical Directives. The following considerations were reviewed:

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• Eliminate redundancy of work lead by the Region e.g. Subject Matter Experts (SME) engagement;

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• Developing new and/or updating existing CPOEs, Medical Directives to meet best practice standards;

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• Recruiting 28 local Subject Matter Experts on a annual basis including defining their roles and responsibilities as well as estimated time commitment.

NBRHC – Local Approval Process

Approval Ratings of Regional Order Sets at NBRHC

~90%

Acceptance

Typically, only <10% Order Sets and/or Medical Directives developed regionally may require additional SME review/feedback to be sent back to the Region

Order Sets and/or Medical Directives developed regionally move through local NBRHC committee structure for formal approval

Local CPOE Tracking Tools

Local CPOE Tracker

• Utilizing the Gsuite, created a CPOE/Medical Directive tracker;
• Facilitated by Manager of Informatics Information Systems;
• Shared document with Regional Collaborative Practice Lead and NBRHC CMIO

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E-Signatures through Panda Doc

• Leveraging a electronic solution, NBRHC is piloting Panda Doc software for one year.

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• Obtaining an e-signature by a SME (minimum one). The document is submitted to is to Pharmacy & Therapeutics (P & T) and Medical Advisory Committees (MAC). At each stage of the approval the Chair is able to sign the document.

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• Access to the document is all through Panda Doc software (no attaching documents).

NBRHC Utilization Rates

Regional Order Set Committee

Purpose: Responsible for Communication and Decision making for regional order set governance, coordination, customization and integration.

Membership:

• Physicians from various disciplines/specialties
• Regional CMIO
• Nursing/Clinical Informaticians
• Professional Practice representatives
• Pharmacy
• Lab
• IDM

Function:

• Review and approve requests for new order sets
• Review and approve change requests to existing order sets
• Periodic review of existing order sets

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Order Sets Review Process: Pilot

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The Physician systems team is undergoing a pilot review of the order sets process with 3 sites and 4 order sets (2 general admission and 2 emergency order sets)

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Why?

• Pilots will provide an opportunity to manage risks associated with the approach prior to any substantial resources being committed
• Will allow to refine the review process prior to opening it up to the larger group
• Gives us a chance to choose pick and choose motivated stakeholders and sites

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When?

June-July

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Who?

• Manitoulin Health Centre
• Health Sciences North
• Timmins and District Hospital

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Order Sets: Pilot Review Process

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• 3rd party vendor which provides standard content for Meditech Expanse
• Library of more than 500 evidence-based medical, surgical and nonsurgical order sets
• Zynx Knowledge Analyzer - Collaboration tool for Subject Matter Experts to view and provide feedback. Very user friendly which improves engagement

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Summary Closing Notes

Contact Information:

Chris George - chris.george@necare.ca

Kristen Vaughan - Kristen.Vaughan@nbrhc.on.ca

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