Title: Clinical Guideline Implementation with Order Sets in a Commercial Emergency Department Information S
1Clinical Guideline Implementation with Order Sets
in a Commercial Emergency Department Information
System
Advancing Practice, Instruction and Innovation
Through Informatics (APIII) Pittsburgh,
Pennsylvania September 11, 2007
- Phil Asaro, MD
- Washington University in St. Louis
2Presentation Outline
- Our experience - Acute Coronary Syndrome
Guideline/Order-sets - The Guideline/Order-sets
- Physician survey
- Ordering behavior
- Perspective
- Other reports
- Published issues
3Clinical Guidelines
- Clinical guidelines can improve care
- Clinicians must be convinced of validity
- Must be delivered in actionable form at
appropriate times - Various methods of presentation
- Pre-constructed order-sets
- Context-specific links
- Patient-specific guidance
- Immediate feedback - alerts and reminders
4Patterns of Guideline Adherence and Care Delivery
for Patients with Unstable Angina and
NonST-segment Elevation Myocardial Infarction
(From the CRUSADE Quality Improvement
Initiative) Pierluigi Tricoci, MD, MHS, Eric D.
Peterson, MD, MPH, and Matthew T. Roe, MD,
MHS Can Rapid Risk Stratification of Unstable
Angina Patients Suppress Adverse Outcomes with
Early Implementation of the American College of
Cardiology/American Heart Association Guidelines
(CRUSADE) A rapid-cycle quality-improvement
initiative American College of Cardiology
(ACC) American Heart Association (AHA) Am J
Cardiol 200698suppl30Q35Q
5CRUSADE
- At the hospital level
- for each 10 increase in the composite adherence
to the ACC/AHA guidelines, there was a 10
decrease in the odds of in-hospital mortality
6Acute Coronary Syndrome (ACS) ED Guideline /
Order-sets
- Joint effort - cardiology and EM over 6 months
- Preprinted paper order forms
- Check-off orders
- Fill-in-the-blank
- Embedded guideline information
- Four forms each 2-3 pages
- Initial care and risk stratification all
patients - Three risk-specific forms
- Expected use
- Initial order set form one risk-specific order
set form
7- Problem
- Released the paper forms just a few months before
CPOE implementation was to eliminate all paper
orders
8BACKGROUND
- Barnes-Jewish Hospital
- Large, urban, academic, tertiary care medical
center - EDIS is Healthmatics ED (HMED)
- Allscripts (acquired with A4 Health Systems)
- Incremental implemention
- Original implementation September 2001
- CPOE including electronic order sets May 2003
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11What We Had To Work With
- Problem oriented order-sets
- Three-level hierarchy
- Order-set name (problem based)
- Orders or Subheading (Lab, Medication, etc.)
- Orders
- Globe - URL link at bottom of screen
- We placed pdfs of the paper forms there
12Unopened Order-Sets Abdominal Pain Chest
Pain Criteria CP/ACS/MI Initial Orders
CP/STEMI Orders CP/ACS High/Mod Risk Orders
CP/ACS Low Risk Orders Extremity Trauma
Female GU
13 Abdominal Pain Chest Pain Criteria Acute
MI w/ ST elev Ischem Sx AND one of ST elev
in 2 contiguous ---precordial leads ST elev,
1mm or more ---in 2 limb leads New/unknown
LBBB ST depr, more than 2mm ---in V1 and
V2 ST elev V2, V3 w/ 1mm ---ST depr II, AVF,
V6 Call MI team 253-1579 ACS High Risk
Criteria ACS Mod Risk Criteria ACS Low
Risk Criteria AMI Fibrinolytic Criteria
CP/ACS/MI Initial Orders CP/STEMI Orders
14 CP/ACS/MI Initial Orders Initial 12 lead ECG
STAT Repeat ECG STAT Cardiac Monitor NIBP Pulse
Oximetry VS prn Notify SBP GT 180 or LT
90 Notify HR GT 120 or LT 50 Diet NPO Activity
Bedrest O2 _at_ 2L/min NC sat LT 90 CXR-PA/lat CXR-po
rt (if unstable) IV Labs Meds ASA 325mg
chewed (if not allergic) ---if ASA allergy,
consider Clopidogrel 300mg po NTG 0.4mg SL X3 prn
Hold if doing SPECT ---for Low Risk ACS NTG
IV 10mcg/min titrate Nitropaste 0.5in q 6hr x
3d Nitropaste 1.0 in q 6hr x 3d Nitropaste 2.0
in q 6hr x 3d Morphine 2mg IV X3 prn Ibuprofen
600 mg po now APAP 1000 mg po now
15Anonymous Surveys
- Pre-CPOE - paper version
- Post-CPOE - CPOE version
- Surveys distributed
- At an EM weekly conference
- Mailboxes
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17Mean Survey Responses Attending vs. Resident
18Risk Stratification Criteria
- Opened 6 times in 97 patients
- Only 3 times with expected use pattern
19Correlation with level of training Spearmans Rho
(p-value)
20Chart Reviews
- Selection criteria - ED diagnosis of MI, ACS, or
unstable angina - Four one-month periods
- Before guideline simple chest pain orders
available - After paper guideline released - before CPOE
- Beginning one month after CPOE implementation
- Beginning three months after CPOE implementation
- Retrospective chart reviews
- Risk-stratification criteria
- Order-set use
- Compliance with the guideline recommendation for
ß-blocker use
21Order-set use by phase of study
22Beta-Blocker Orders by Order-Set Use and Phase
Patients without contraindication to a ß-Blocker
(heart block, hypotension, or bradycardia)
23Summarizing Our Experience
- Minimal actual use of criteria lists
- Suboptimal use of the order sets
- Overall unchanged ordering behavior
- Less than enthusiastic survey responses
- Our attempt at guideline implementation using
CPOE order-sets in a commercial information
system lacking more advanced decision-support
functionality was not effective - However.
- Less experienced physicians appear more open to
guidance offered in the information system - Acknowledgements Amy Sheldahl and Douglas Char,
MD
24On the Other Hand
25Improving Patient Care And Medical Workflow Using
Evidence Based Order Sets
- AMIA Annual Symp Proceedings 2005, 1063
- Chris O'connor , Katherine Decaire , Jan
Friedrich - Trillium Health Center
26Results Paper Order Sets
27Conclusion
- Order sets are an effective method to improve
compliance with evidence based practice and
improve order quality in a voluntary paper based
order system without the need for significant
education.
28Congestive Heart Failure Management Use of
Electronic Order Entry to Enhance Practice
Guideline Compliance
- AHA 5th Scientific Forum on Quality of Care in
- Cardiovascular Disease and Stroke,
- Washington, DC May 16, 2004 (Poster
Presentation) - Raymond Dusman, Carolyn Hart, Doug Horner,
- Jerry Mourey, Karl LaPan, Mark OShaughnessy,
- Robert Plant, David Schleinkofer, Michael Mirro
- Fort Wayne Cardiology / Parkview Research Center
- Fort Wayne, IN
29Results
- ACE Inhibitor use increased
- From 52.3 (508 of 971) to 85.2 (248 of 291)
- Beta Blocker use increased
- From 49.1 (477 of 971) to 80.1 (233 of 291)
- Spironolactone use in eligible Class III and IV
patients increased - From 95.8 (207 of 216) to 100 (75 of 75)
30The Role Of Computerized Order Sets In Pediatric
Inpatient Asthma Treatment
- Pediatr Allergy Immunol 2006 17 199206
- Chisolm DJ, McAlearney AS, Veneris S, Fisher D,
Holtzlander M, McCoy KS. - Columbus Children's Research Institute
- Ohio State University
31Results
32Other Order Set Successes
- DVT prophylaxis
- Peri-operative antibiotic compliance
- Pain management
- Glucose management
- Anticoagulation management
33Integrating "Best of Care" Protocols into
Clinicians' Workflow via Care Provider Order
Entry Impact on Quality-of-Care Indicators for
Acute Myocardial Infarction
- J Am Med Inform Assoc. 200613188-196
- Asli Ozdas, PhD, Theodore Speroff, PhD, L.
Russell Waitman, PhD, Judy Ozbolt, PhD, Javed
Butler, MD and Randolph A. Miller, MD - Vanderbilt University Hospital
34- Existing order entry system with ACS order sets
- Intervention studied -- a CDS mechanism to direct
physicians to appropriate order sets when writing
admission orders - ACS order set use - suspected MI
- 60 (189 of 313) ? 70 (161 of 227)
- B-blocker use
- 70 ? 78 (not quite statistically significant)
35A Survey Of Factors Affecting Clinician
Acceptance Of Clinical Decision Support
- BMC Medical Informatics and Decision Making 2006,
66 - Dean F Sittig, Michael A Krall, Richard H
Dykstra, Allen Russell and Homer L Chin - Kaiser Permanente
36Factors Considered
- Patient
- reason for visit acute vs. chronic
- severity of illness number of medications,
number of chronic conditions - age
- Provider
- age, gender
- number of years with Kaiser Permanente
- Alert
- type of alert
- number of alerts received
- Environment
- presence of a computer in exam room
- clinician behind schedule
37Pertinent Results
- Patient factors
- CDS more acceptable when patient is elderly, has
multiple medications, has chronic conditions - CDS less acceptable when visit for acute
condition (Productivity vs. Prevention) - Environmental factors
- Clinicians often behind schedule
- CDS less acceptable when behind schedule
- In principle CDS most helpful when clinician is
least apt to remember
38Specificity Of Computerized Physician Order Entry
Has A Significant Effect On The Efficiency Of
Workflow For Critically Ill Patients
- Crit Care Med 2005 33110 114)
- Naeem A. Ali, MD Hagop S. Mekhjian, MD P. Lynn
Kuehn, RN, MS Thomas D. Bentley, RN, MS Rajee
Kumar, PhD - Amy K. Ferketich, PhD Stephen P. Hoffmann, MD
- The Ohio State University Health System
39- CPOE deployed in a rapid system-wide approach
- Initially implemented in MICU with generic
order sets not designed specifically for the
ICU - A striking number of problems occurred early and
persistently after implementation in the MICU,
unlike other units in the hospital - MICU returned to paper until further analysis and
development of specific order sets - Subsequently CPOE was implemented in the MICU
with success
40Reflecting back to the paper ordering
world Written orders, by convention, had been
condensed to very simplified shorthand that
facilitated their entry. However, it was with a
combination of nurse interpretation and verbally
issued clarifications that the request was
matched to standard unit practice this
shorthand may have made care more efficient but
also less precise, potentially affecting patient
safety.
41Reflecting on the new CPOE world with appropriate
order sets We believe that streamlined CPOE
ordering aided in standardizing the process of
patient care and both benefited patients by
introducing best practices and practitioners by
facilitating their efficiency.
42Viewpoint Controversies Surrounding Use of Order
Sets for Clinical Decision Support in
Computerized Provider Order Entry
- J Am Med Inform Assoc. 20071441-47
- Anne M. Bobb, BS Pharm, Thomas H. Payne, MD
- and Peter A. Gross, MD
- From a collection of manuscripts in the Jan/Feb
2007 issue of JAMIA produced by a 2005 conference
on CDS in CPOE
431
- most CPOE systems make the utilization of order
sets for any given patient voluntary for
clinician-users - patients do not benefit when their care
providers bypass evidence-based order sets usage
44Related Comments
- Smart system to suggest an order set based on
complaint or other patient-specific information
in the electronic record - Default orders within an order set
- All orders
- Select orders
- Medication orders?
452
- CPOE vendors and free-standing vendors supply
"evidence-based" order sets for CPOE customers - it is difficult for institutions to adopt order
sets from other institutions
462
- Until a national-standard set of defined CPOE
orderables is developed, to which each vendor or
institution can map their own "orderables at
both the order name and individual fields
levelslittle progress may be made
473
- there remain significant limitations to what
CPOE-based order sets can do
48Desirable Functionality
- Linked orders
- Begin together e.g. monitoring lab orders
- Discontinue at same time e.g. PCA, heparin
protocols - Mutually exclusive alternate AB
- Patient-specific dose calculations based on
weight, age, or body surface area - Ideally would also consider
- currently active medications
- current laboratory results
- Pop-up" algorithmic "advisors" that go beyond
the capabilities of order sets to take dynamic
patient states into consideration
494
- While evidence-based order sets can make it
easier for CPOE clinician-users to "do the right
thing," clinical knowledge advances rapidly - When order sets are implemented without
organization standards and clinical review or
inadequately maintained, they become templates
for efficiently practicing outdated medicine on a
widespread basis
50Then Again
- Many times clinical practice changes are
recognized at the clinician level, but never
communicated to the group managing order sets in
the system. Clinicians create standard
work-arounds to meet their needs and train their
residents and others to use the work-around, thus
reverting to reliance on memory and increasing
the risk of error
515
- Allow individual clinicians to develop their own
"private" order sets? - Potentially removes the evidence-based nature of
order sets, and introduces other maintenance
issues
52CRUSADE
- Paradoxical Care
- Patients with higher risk of adverse outcomes are
expected to have a greater absolute benefit from
aggressive therapies. - CRUSADE analyses have reported that the
highest-risk patients are less likely to be
adequately treated.
53CRUSADE
- About 15 of patients with NSTE ACS have
moderate-to-severe chronic kidney disease - These patients are older and have more
comorbidities, such as diabetes, heart failure
and prior history of coronary artery disease - Concerns about complications from antithrombotic
drugs and invasive procedures may at least
partially explain lower guideline compliance - -- data regarding efficacy and safety in these
subpopulations is lacking.
54CRUSADE
- Among the strongest predictors of blood
transfusion use in patients with NSTE ACS - renal insufficiency
- advanced age
55CRUSADE
- Medication overdosing was associated with a
significant increase in major bleeding - --dose response effect
- degree of excess dose
- number of drugs administered in excess
- 42 of patients with NSTE ACS received an initial
dose in excess of that recommended of at least
one of - unfractionated heparin
- low-molecular-weight heparin
- GP IIb/IIIa inhibitor
56Desirable Functionality
- Linked orders
- Begin together e.g. monitoring lab orders
- Discontinue at same time e.g. PCA, heparin
protocols - Mutually exclusive alternate AB
- Patient-specific dose calculations based on
weight, age, or body surface area - Ideally would also consider
- currently active medications
- current laboratory results
- Pop-up" algorithmic "advisors" that go beyond
the capabilities of order sets to take dynamic
patient states into consideration
57CRUSADE
- Even simple and harmless interventions are
underused among patients with chronic kidney
disease - smoking cessation, counseling, dietary
modification, and referral to cardiac
rehabilitation - May reflect the lack of outcome expectancy in
this subset of patients.
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59In Conclusion
- Guidelines can improve care
- Order-sets can make it easier for clinicians to
do the right thing - Technology is exciting and wonderful
- Better tools are needed
- Focus attention on critical decisions
- Provide additional information at key decision
points - Clinician acceptance important
- Convincing evidence of safety and efficacy
- Must be seen as improving clinician workflow, not
interfering - Go for the low hanging fruit
- Keep working on the harder stuff
- Push vendors to improve functionality
- Certification of HIT should help
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61- Phil Asaro
- Washington University in St. Louis
- asarop_at_msnotes.wustl.edu