The healthcare industry is sitting at the threshold of a unique point in time where the convergence of many technological advances could truly impact the future of care delivery in a dramatic way. When point-of-care clinical decision support (CDS) strategies are positioned to work in tandem with EHRs, clinicians are ultimately armed with the best information to impact care delivery and outcomes.

While many elements should be considered as part of a greater CDS strategy, leading research groups such as KLAS and The Advisory Board increasingly point to the use of electronic, evidence-based order sets as an important foundational element to support standardized care and uptake of industry best practices. In theory, the need to leverage these proven tools is easily understood, but the real-world realities to effectively deploying and maintaining order sets for the long-term keep many healthcare organizations from realizing the full potential of this point-of-care strategy.

All challenges converge into two huge obstacles — time and resources. Aside from the mammoth undertaking of authoring and deploying order sets in an electronic form — that is, computerized physician order entry (CPOE) — healthcare organizations must have a comprehensive clinical knowledge management program in place to keep the strategy relevant for the long-term.

Simply put, there is a resource expenditure in terms of time, staff and hard dollars at every point of the order set deployment and maintenance process. For ThedaCare, a five-hospital system based in Appleton, Wis., the answer came through a combination of solid governance processes implemented alongside an advanced clinical content management solution.

Here is a look at three major challenges most healthcare organizations will have to overcome to support a successful order set and CPOE strategy and how ThedaCare overcame each.

The challenge of efficient authoring and governance
Comprising three 25-bed CAHs and two larger facilities (160 and 250 beds, respectively), the first challenge that ThedaCare faced was the implementation of a governance process to identify order set needs and build consensus around what would be included in the final product for each order set.

The CPOE steering committee determined that at least 450 evidence-based order sets were necessary to satisfy clinician demand and advance standardized care, a substantial increase from the organization’s existing paper order set inventory. Since the pre-formatted order sets available within ThedaCare’s existing CPOE  system were not prolific enough to position the organization for success in the current performance-based healthcare climate, it became apparent that a better, more efficient way to address authoring and deployment would have to be identified.

To accelerate the development process, the decision was made to leverage the expertise of an advanced order set authoring and management solution. The availability of a robust project management function within the solution resulted in the development of 400 evidence-based order sets in less than a year. Because multiple stakeholders are able to review and edit order sets in real-time through online interfaces, the time-consuming process of scheduling team review processes — which can often take weeks or months as order sets move through various hospital committees — is minimized.
Like ThedaCare, most hospitals have their own unique workflows and face their own unique challenges requiring flexibility in a content management solution and approach. A one-size-fits-all attitude would not work as the healthcare system needed to address the specific needs of both its CAHs and larger acute settings. Fortunately, the adaptability of its order sets solution enabled ThedaCare to catalog and reuse a subset of order sets for its CAHs;  for example, because there are no NICUs in its CAHs, ThedaCare is able to suppress order sets specific to those services, saving physicians valuable time by preventing the need to sort through unnecessary order sets.

Overcoming integration roadblocks
Deployment of Epic’s inpatient CPOE system was a critical first step in ThedaCare’s greater point-of-care CDS strategy, but it was clear from the start that the order sets to support CPOE workflows would have to come from another source. This scenario is typical for the average hospital looking to EHRs to lay a foundation that supports the quality expectations of the current and future healthcare landscape. While EHRs are great repositories of information, they were not designed to address the deep content needs that ensure a foundation of the latest industry evidence.
Integration between third-party order set vendors and EHRs is a critical issue now and going forward, as one of the greatest challenges to the use of decision support at the point of care is the ability to refine content to meet the needs of clinicians. Ease of deployment remains a stumbling block in the industry as vendor interfaces vary widely, and there is currently no EHR solution on the market that will integrate easily with all third party CDS vendors.
While integration remains a work in progress for both EHR and CDS vendors, there are infrastructures that are currently more conducive to achieving interoperability. One of the most effective ways to overcome integration challenges is to use order set solutions founded on a structured content approach, as opposed to unstructured.

When data is shared, it has to be recognized across and between systems. Because structured content is tagged or coded data that resides in a fixed field, it can be easily located, identified and understood, simplifying the process of integration. In contrast, unstructured content, such as free text, is more difficult to decipher and harder to interpret between systems. In the case of ThedaCare, its solutions of choice had provision of a structured design ensured that the need to build costly interfaces was minimized.

Because many clinicians still prefer the narrative of unstructured content, the best solution going forward will be thoughtful clinician-designed systems that provide for limited unstructured content alongside a structured infrastructure.

Tackling the overwhelming task of maintenance
Likely the greatest challenge to an order set deployment and management strategy is the facet of ongoing maintenance. The goal of designing point-of-care decision support workflows to support higher quality is meaningless if the end-product does not deliver the latest industry best practices. Plus, if clinicians do not trust that the content is current, adoption rates, and use of order sets will also suffer.

Without an automated method of regular content updating, healthcare organizations must devise their own internal systems of maintenance, which can either be a huge draw on resources or result in a haphazard approach at best. For hospitals attempting to manage content on their own, it is not uncommon for clinicians to be pulled off the floor to participate in days or weeks of review meetings to ensure order sets are current.

Keeping up with the rapid pace of clinical advancement is simply too daunting for most hospital systems to manage on their own effectively. At ThedaCare, it was important to identify a content source that was not only trusted by clinicians but also could provide regular updates to evidence. UpToDate was the answer in that it featured direct links to supporting medical evidence and an automated maintenance tool. Most importantly, the software’s interfaces allow for fast deployment into the CPOE system.

Order set strategies and point-of-care CDS deployed as a foundation to greater health IT strategies have great potential to impact quality and clinical outcomes going forward. To fully achieve the potential of CDS, healthcare organizations will need to weigh the challenges that still exist to deployment and implementation against the value of leveraging advanced order set technology and expertise.

For many hospitals, the resource commitment involved in effectively authoring, deploying and maintaining evidence-based order sets is simply overwhelming, but the end result has the potential to address numerous federal initiatives in tandem. By laying a foundation that standardizes best practices as the focal point of care from the initial order, quality metrics and performance improvement begin to fall into place automatically, leading to better patient outcomes and lower costs of care.


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