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CDS Physician Order Entry - Workflow Template

Page history last edited by lozeran 13 years, 8 months ago

CDS Physician Order Entry

Physicians play a pivotal role in the process of VTE prophylaxis. By carefully placing CDS interventions in the physicians' workflow it is possible to optimize their workflow so that they are able to achieve VTE prophylaxis on 100% of the patients that are at risk for VTE. One of the biggest challenges is to make sure that those CDS interventions are placed in the right point in workflow.

 

OVERVIEW

Generate orders that effect safe, cost-effective, high quality care.  • Condition-specific order sets

• Standing orders for key interventions / diagnoses (e.g. nurse-initiated mechanical VTE prophylaxis by protocol for certain well-defined patient populations)

• Recommendations on patient specific drug dosing

• Cost-sensitive prescribing recs where clinical effects are otherwise equal

• Automatic alerts for order problems, e.g. allergies/ contraindications/ route/ dose/ interaction/ duplicate; Dx/Rx reference info

• Reminders for indicated interventions not ordered by close of ordering session

 

MODEL PRACTICES

  1. Need mechanism to ensure creatinine clearance is available and appropriate
  2. Have the risk assessment tool in an easy to locate and easy to identify  location as well as easy to use.  Tool should be readily available as soon as patient chart is opened; included in MD favorite folder so there is a visual cue/reminder.
  3. Risk assessment tool should be incorporated into all post-op [perioperative - LO] order sets for at risk patients
  4. "Smart CDS":  Treat risk assessment scores similar to a lab value and use to trigger actual orders. [but only when enough contraindication factors are available to ensure that patients with comorbid conditions precluding or requiring an adjustment to therapy are being measured and considered to "first do no harm". - LO ] Ensure risk assessment are discrete data elements. [Always send an urgent alert to the primary treating physycian and pharmacist that therapy has been initiated. - LO]
  5. Come to consensus as to which risk assessment tool to use, which allow universal adoption.
  6. Communication among team members for optimal workflow is vital.  Agreement is necessary regarding nurse role and physician role for order entry within the risk assessment process and subsequent documentation.
  7. Come to an agreeable timeline for completing risk assessment, based on clinical urgency at the facility level to enable all providers to understand the timing of the assessment in relation to completion/submission of orders.
  8. Performance impact of implementation of risk assessment tool has impact on user satisfaction.  Appropriate monitoring of system impact on IT infrastructure [and patient outcomes - LO] should be measured.

 

Project Description Outline 1_20_10.doc

eRecommendation template and mammography 1 6 10 refinements to Implementation Considerations.docx

Table 20-Interim Final Rule Meaningful Use Quality Indicators.pdf

Table 2-Interim Final Rule Meaningful Use Stage 1 Criteria.pdf

VTERiskAssessmentTools (FL).pdf

CPRS Problem List UM.doc

 

 

 

 

 

 

 

Clin Ops WG recommendations.pdf

MU_matrix.pdf

 

 

 

Opportunities for CDS guide to help implementers meet Meaningful Use criteria.doc

CDS and Meaningful Use- JO notes.doc

Common+Themes_3-23-09_Chuo_Siraj_v4.xls

 

 

 

 

Participants/Workflow step Goals General CDS Strategies Specific CDS Considerations Given Paper/Digital Tools

PI Cycle or Method to Current Process - TESTING

PI Cycle or Method to Current Process - EXECUTION Outcomes/Lessons Learned/Pearls Owners/Stakeholders Metrics
Physician/Orders  Generate orders that effect safe, cost-effective, high quality care  • Condition-specific order sets
• Standing orders for key interventions / diagnoses (e.g. nurse-initiated mechanical VTE prophylaxis by protocol for certain well-defined patient populations
)
• Recommendations on patient specific drug dosing
• Cost-sensitive prescribing recs where clinical effects are otherwise equal
• Automatic alerts for order problems, e.g. allergies/ contraindications/ route/ dose/ interaction/ duplicate; Dx/Rx reference info
• Reminders for indicated interventions not ordered by close of ordering session
Paper:  Paper VTE prophylaxis order sets pertinent to specific circumstances, either as stand-alone documents or integrated with other pertinent condition order sets; includes appropriate lab/nursing follow-up for specific prophylaxis method ordered
• Nomogram-driven dosing for heparin --- reference NPS Goal #29 insert hyperlink

• CDS (e.g. paper/electronic reference) to support renal and hepatic dosing for anticoagulants
• Consider nursing-initiated reminders to physician for ordering based on their risk assessment                                                                                                                                         
• Option for pharmacy dosing after medication order set and based on nomograms                                                                                                                                                                       • In places without pharmacy coverage ensure nomograms and dosing information available to provider at point of care


 

 

 

Need mechanism to ensure creatinine clearance is available and appropriate

 

 

 

Have the risk assessment tool in an easy to locate and easy to identify  location as well as easy to use.Tool should be readily available as soon as patient chart is opened; included in MD favorite folder so there is a visual cue/reminder.

 

Risk assessment tool should be incorporated into all post-op order sets for at risk patients

 

"Smart CDS":  Treat risk assessment scores similar to a lab value and use to trigger actual orders.  Ensure risk assessment are discrete data elements.

 

Come to consensus as to which risk assessment tool to use, which allow universal adoption.

 

Communication among team members for optimal workflow is vital.  Agreement is necessary regarding nurse role and physician role for order entry within the risk assessment process and subsequent documentation.

 

Come to an agreeable timeline for completing risk assessment, based on clinical urgency[SEE IF LITERATURE SUPPORTS some metrics] at the facility level to enable all providers to understand the timing of the assessment in relation to completion/submission of orders.

 

Performance impact of implementation of risk assessment tool has impact on user satisfaction.  Appropriate monitoring of system impact on IT infrastructure should be measured.

 

 

 

 

  Effectiveness of CDS interventions (financial and clinical); Metrics of order set and order item usage;  Consider each of items in Column C as structure metrics; Process measures:  How many times order sets placed on chart, or accessed electronically; was the risk assessment actually completed; was the risk assessment defined by the physician
  Be sensitive to patient economic and side-effect concerns: generate orders for medications that the patient can afford and will comply with Quick medication refill process Digital: (the following are the same as Paper, but integrated into CPOE)                                                                                                                                                                                      • VTE risk assessment combined with check of current orders triggers appropriate VTE prohphylaxis recommendations
• VTE prophylaxis order sets pertinent to specific circumstances, either as stand-alone documents or integrated with other pertinent condition order sets; includes appropriate lab/nursing follow-up for specific prophylaxis method ordered
• Nomogram-driven dosing for heparin --- reference NPS Goal #29 insert hyperlink
• CDS (e.g. paper/electronic reference) to support renal and hepatic dosing for anticoagulants
• Consider nursing-initiated reminders to physician for ordering based on their risk assessment                                                                                                                                          • Option for pharmacy dosing after medication order set and based on nomograms                                                                                                                                                                       • In places without pharmacy coverage ensure nomograms and dosing information available to provider at point of care  integrated into CPOE system.
• Medication CDS integrated into CPOE, e.g. via infobuttons, proactive alerting, dosing recommendations)
• Alert of condition-appropriate prophylaxis and follow-up not ordered by close of session                                                                                                                                                          • Asynchronous methods of notifying the physician that the patient needs prophylaxis (also revisit with "Pharmacists role")

         
      Specific CDS Considerations Given Limited/Digital Tools     Outcomes/Lessons Learned/Pearls Owners/Stakeholders Metrics
    Advocate Paper:   Two sites are non-EMR.  Nursing risk scores and notifies physicians in person or by phone of the score and either has the physician place a written order or takes a T.O.  One site is an LTC.  After the above, they frequently have a d-dimer and/or doppler ordered on high-risk patients.     Pharmacy reviews orders, dose orders, based on nomogram.    
      Digital:  As nursing does the assessment, physicians are required to be contacted with the risk score within 12 hrs. of admission.  They may then give nursing VTE prophylaxis orders when notified or enter them via CPOE.  Alternatively, if the attending or any physician sees the patient before being called and no orders have been entered into the system, but after the VTE assessment is completed, they recieve an alert upon opening up the patient's EMR.  The alert notes the VTE risk score with URLs to the ACCP guidelines and Advocate's internal recommendations.  They must acknowledge on the alert they have seen it before it will disappear.  With our current software, we are unable to directly link the alert to an order set. Initial testing done in MOCK domain which parallels PROD (production).  Testing done primarily to determine no "breaks" in the system when implemented.  Subsequently determined that all SCD types were not included in the mechanical prophylaxis logic and that chemoprophylaxis was determined based on an order.  The latter may have been a one-time order, e.g. Wafarin 5 mg today, and makes the system think there is no "active order".  We are making modifications to corret this.  In addition, we are adding lab parameters for INR or PTT levels that if adequate would also cause the alert to NOT fire.   Retesting will be done with more clinical evaluation, e.g. physicians and/or clinical pharmacists to test our hypotheses.      
    CHOP

Paper:  Surveys used [do have surveymonkey, but do not utilize)

 

Measure how many patients who are at risk and who have received prophylaxis manually

         
     

Digital: 

MD response to assessment completed by nursing staff (high, low, no risk)

 

Prophylaxis orders for at risk patients being collected to unified order set

 

Percentage of at risk patients who receive prophylaxis increasing, from ~50-70% over last couple of years

 

Risk assessment tool needs to be integrated into digital system in order to merge paper and digital processes (marry by transcriber at this point in time)

         
    HealthEast Paper: VTE Order set is placed on 100% of adult med/surg patients.  Form provides some guidance for risk stratification contraindications and precautions for specific interventions.  Pharmacy allowed to adjust dose based on renal clearance (vs physician). Risk specific orders are on the same form.
   

Physicians blow past the order set and do not complete it.

They view that the risk stratification are "gospel" instead of guidelines causing confusion and credibility issues with the orderset.

Surgeons request proceduer specific VTE orderas and want the orders in their pre and post op order sets.

MDs like the risk specific orders on the order sets.

VTE prophylaxis work team.

Pharmacy

P&T Committee.

 
      Digital:          
    MH Paper: Prior to going digital at two of our CPOE community hospitals, a VTE risk assessment form was included in every chart in the Med/Surg units. The form helped with risk stratification but did not indicate what specific orders were needed to be placed. We have a clinician on the floor whose job is to go through all the charts (surgical) after surgery to identify if VTE prophylaxis was given or contraindications were documented. If anything was missing, then this clinician would call up the physician and ask them for prophylaxis or contraindication documentation. We have stopped including these paper forms in the charts to encourage use of our electronic tool.     Will have pharmacy do renal dosing in the near future that will be enhanced by an electronic tool that automatically shows CrCl.    
     

Digital: We have an electronic risk assessment tool that could be brought up in front of the user in two ways:

a) The tool is brought up whenever any of the admission/pre-op/post-op electronic order sets are used. The recommended orders will be included along with the orders within the power plan.

b) The tool could be brought up voluntarily by the physician by selecting the orderable 'VTE Risk Assessment/ DVT Risk Assessment'. Either one of these orders will bring up the tool. Once they complete the risk asessment, the tool provides the recommended orders which are eventually signed and sent for processing.

The physician is expected to complete this risk assessment within the first 24 hrs of admission.

If the physician decides not to use this tool, they could instead order prophylaxis manually. There is a nursing task that makes the nursing staff, usually a nurse manager to call the physician if either the tool is not used or there is no VTE prophylaxis orders. If however, the physician either completes the risk assessment tool or orders VTE prophylaxis orders, this nursing task is automatically canceled. This way, the physician does not get a call from nursing unnecessarily.

I believe we still have a clinician on the floor auditing the charts for VTE compliance specifically for the surgical patients (SCIP compliance).

There are two steps to testing:

a) Initial testing comprises of the CDS team working to see that the electronic tool is working as designed. During this initial phase of testing, some of the key physician stakeholders are shown the tool and how it works. During this time, the workflow process is discussed as well with all key stakeholders (Nursing, Physicians). If there any things that need to be changed based on workflow and is of course reasonable, we proceed with making those changes to the application.

b) Once we have ironed out and finalized the process, we create a communication/education plan in collaboration with all the people who will be involved in the communication/education. Since we were looking to do a facility rollout, we identified all the physicians on roster. That way, it helped us to estimate the effort and time required to put out the communication/education to all physicians. Members of the CDS team were involved in doing educational presentations for medical/nursing staff at several venues. We did lunchtime remote presentations in the physician lounge. At these venues, we gathered feedback to see if there were any elements of the workflow process that may have been overlooked. We set a Go-Live date and based all of our work effort around it.

Once the Go-Live date was finalized, different team members were assigned to support the facilities from 7am to 9 pm. We did not feel that we needed 24 hrs coverage. We had also educated the nursing staff on how the tool works and were confident that they would be able to help the physician.

We currently monitor data around how many of these assessments were started and completed successfully. The data also shows us who completed and did not complete the assessment. We have talked about doing a direct feedback to the physician, but yet to do so. We also found that there was a way for the physician to exit out of the assessment without completing all the questions. We will be receiving a revised version of the tool shortly with which we should be able to overcome this issue. From the lates data that we have, physicians are completing the assessment after they have started it 53% of the time.  

     
    Orlando Paper:VTE prophylaxis orders are included in paper order sets based on high risk indicaitons (hip/knee post op sets, OB order sets) but no formal assessment currently          
      Digital: same as paper - appropriate orders are included in order sets as a reminder but nor formal risk assessment or active CDS at this point.           
    THR Paper:     Pharmacy does renal dosing.    
     

Digital: 4 of 13 hospitals on CPOE

TF in motion to marry paper and digital

No - Do not capture which tool being used; do not currently do MD assessment digitally

Yes - Order entry and prophylaxis

 

Once standardize digital process, MDs will use tool of their choice

 

Much focus on core data elements.  Patients who fall through the cracks are often the non-surgical patients, e.g., those not involved in SCHIP measures

 

Data is not structured, so is a challenge to capture digitally

         
                 
Participants/Workflow step Goals General CDS Strategies Specific CDS Considerations Given Limited/Digital Tools     Outcomes/Lessons Learned/Pearls Owners/Stakeholders Metrics
Pharmacist & patient/Drug Dispensing and Education Double check individual med orders for appropriateness, interactions, dose, route, frequency; screen and document med regimen problems across all patients

Help educate patient about drugs
• Relevant data display/report for situations requiring attention
• Tools for documenting interventions
• Automatic alerts for dosing/route/frequency/appropriateness problems
• Reference information on safe and effective med use for pt and pharmacist
 
Paper: dose range checking/verification for heparin/Lovenox supported by electronic references, e.g., linked to pharmacy system via infobutton         Effectiveness of CDS interventions (financial and clinical)
      Digital: automated dose range checking/verification for heparin/Lovenox integrated into pharmacy system, also supported by Infobutton links to electronic references for when needed          
      Specific CDS Considerations Given Paper/Digital Tools     Outcomes/Lessons Learned/Pearls Owners/Stakeholders Metrics
    Advocate Paper:           
      Digital:          
      Hybrid:          
    CHOP Paper:           
      Digital:          
      Hybrid:          
    HealthEast Paper:           
      Digital:          
      Hybrid:          
    MH Paper:           
      Digital:          
      Hybrid:          
    Orlando Paper:           
      Digital:          
      Hybrid:          
    THR Paper: VTE chemoprophylaxis orders go to Pharmacy for dose adjustments and timing           
      Digital: We present CrlCl to physicians in Lovenox orderable, and we have an orderable for "Pharmacist to adjust dose". We are working to advance functionality in our CPOE system to further facilitate proper osing adjustment by the physician at the point of order entry. Pharmacists also have System lists to monitor pts on UFH, LMWH.          
      Hybrid: Paper order sets get faxed, and electronic processes as described ablove.          

 

 

 

 

 

 

Comments (5)

Donald Levick, M.D., MBA said

at 10:56 am on Aug 18, 2009

LVHN: all digital for order entry, med admin and med bar coding.
Our standard Admission and standard Admit to PACU orders are tied to our VTE orders. Thus, when the clinician enters an "Admit" order, he/she is automatically presented with choices for VTE prophy. The choices are based on current evidence based standards and are consistent with our current formulary. The clinician is required to choose one of the VTE regimens or to choose the "NO DVT Prophylaxis" order. This order then requires the clinician to enter a reason for not giving prophylaxis. The reasons are screened by the verifying pharmacist, who is empowered to call the clinician if more information is required, or if the clinical pharmacist believes the pt should receive prophylaxis.

sirajanwar said

at 3:53 pm on Aug 18, 2009

Thanks for the info Don. We will update the spreadsheet to reflect the workflow at LVHN. Question for you: How does the clinical pharmacist evaluate if the patient needs VTE prophylaxis or not? Do they use some sort of screening tool on all the patients? And also, do the physicians have some sort of screening tool as well to help them make the right choice of prophylaxis regimen?

Donald Levick, M.D., MBA said

at 6:55 am on Aug 19, 2009

I believe that our default is to provide prophylaxis to all patients over 18 yrs old, so we don't use a specific screening/scoring tool. The clinician entering the Admission orders chooses the type of prophylaxis off an initial screen. During verification, the Pharmacist checks the dose for renal function modification. If the "NO VTE Prophylaxis" option is chosen, the clinical pharmacist will double-check for appropriateness. I have screen shots, if there is a way to upload them.

sirajanwar said

at 12:36 pm on Aug 28, 2009

On behalf of Kendall Rogers:
There really should be a risk assessment to decide the correct prophylaxis, otherwise you are achieving 'some prophylaxis' but 'not appropriate prophylaxis.' Many have used scoring systems which disrupt workflow, I support and teach the 3 bucket approach endorsed by the Society of Hospital Medicine (low risk, moderate, and high - should be a <10 second MD evaluation if data available.) Effective CDS should lead a variety of clinicians to the same decision that reaches the patient and without a risk assessment we saw great variability in prophylactic orders, thus the method of just listed the options was highly ineffective. Coming to the right diagnosis or risk assessment is more important than CDS on the backend. The steps in the risk assessment should be outlined and transparent, then it can be replicated by a pharmacist or in audits to ensure the clinician followed it appropriately (to identify good and bad variance and adjust the form as needed.)

lozeran said

at 12:08 am on Jul 25, 2010

I made several suggestions (to 3, 4 and 8). While I expect they will be obvious, this is the brief rationale:
3 - prophylaxis should begin preoperatively and continues intraoperatively
4 - we want prophylaxis therapy not to cause new complications if made automatic and if instituted in error, can be changed or discontinued rapidly
8 - it's all about patient outcomes

I have a hard time reading the spreadsheet here due to the limited UI controls (vertical and horizontal sliders that cannot be seen onscreen simultaneously). I am unclear about column which appears to have the names of institutions. Is this a result of papers, how these institutions currently manage prophylaxis, or something else?

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