Fade to black. The curtains part to reveal a large screen—crystal clear, a blank slate. The magician enters from stage left and arrives at a small table. With an exaggerated motion, he pulls a string of connected letters from a hat and throws them toward the waiting screen. The crowd oohs and ahhs as the word “CLEARLY” magically attaches to the screen. The waiting cursor blinks; suspense builds as the magician returns to the hat, reaches in, and flings the next set of letters toward the screen. Applause breaks out as the audience reads “ACCURATELY” across the screen. Silence. The hand dips into the hat again and whirls the magic letters toward the spotlight. The third word joins the others; the audience goes wild. Electronic order sets begin to populate screen after screen, all meeting the magician’s directives: CLEARLY, ACCURATELY, SAFELY. Full of wonder, I lean closer to examine the medications listed, and the letters suddenly vanish as I am startled awake in my bed. Foiled again!

If only order sets could be created that easily. Depending on what survey data you look at, computerized provider order entry (CPOE) has been implemented in anywhere from 9% to 31% of hospitals in the United States. The Institute of Medicine (IOM), the Leapfrog Group, and CMS recommend implementation of CPOE as an important patient safety strategy. Developing order sets for CPOE helps to optimize this technology’s safety functionality and creates efficiencies for users. While the goals of electronic and paper-based orders are similar—clarity, accuracy, and safety—there are additional complexities that need to be addressed when automating this function.

Creating a System for Order Set Development
Winchester Medical Center (WMC), a 411-bed, non-profit hospital in Winchester, Virginia, is one of six hospitals in the Valley Health System. As part of a comprehensive patient safety initiative—which includes other medication management technologies currently in place such as eMAR, bar code medication administration, and smart pumps—we decided to implement CPOE in all of our hospitals. WMC was charged with developing a system and standardized procedures for the order set build at our hospital that could be used when expanding CPOE to the other hospitals in our system.

Standards for Order Set Development
The primary objectives that all well-designed order sets, whether electronic or paper based, should meet include patient safety, clarity, optimization of care, cost effectiveness, and efficiency. We employed a list of customized standards based on these principles for the order set teams to keep in mind during development and review. The following is an overview of the standards we created.

• Safety—Orders must be consistent with legal regulations and organizational policies, as well as meet the standards of care established by professional and accreditation organizations and medication safety recommendations from organizations such as ISMP.
• Clarity—Strive for consistent interpretation of orders by all caregivers. State an order simply and clearly. Eliminate ambiguity in ordering: Test interpretation of orders with interdisciplinary caregivers if necessary. Medication decisions are to be made by the prescriber, not shifted to other caregivers. “If, then” orders are not acceptable. For example, the order “if patient allergic to penicillin, give vancomycin” would be reformatted into two separate choices for the prescriber to select from:

• penicillin (ordered regimen)
• patient allergic to penicillin, give vancomycin (ordered regimen)

• Optimize care—Ensure orders are evidence based, and consult published guidelines, protocols, and literature. Subscription-based resources may be considered. Our electronic order sets were developed using a commercial evidence-based order set tool.

• Reduce cost—Strive for cost effective options. Reduce redundancy in orders by limiting PRN medication choices. Unnecessary redundancy reduces efficiency for all caregivers involved, and may lead to adverse outcomes for the patient. Encourage use of oral routes instead of injectable when appropriate. Consider safety and effectiveness first, followed by cost.
• Promote efficiency—Use the 80/20 rule; keep the focus of the order set on those issues most commonly seen (80% of the time). Consider removing a medication if it is used less than 20% of the time.

Finally, if you perceive a potential safety concern with any order, you should address it, even if it is outside your professional role. For example, nurses should question medication doses, and pharmacists should question laboratory monitoring if something does not seem right. The focus of the review is on medication management (think of the comprehensive medication-use process), and the purpose of this process is to enhance patient safety.

Development Considerations
While many of the same rules for developing paper order sets apply to the creation of electronic order sets, there are some functionality considerations that are unique to electronic ordering systems.

Using CDS
Clinical decision support (CDS) rules may be applied during the ordering process. Consider the same precautions used for alerts and warnings in pharmacy information systems such as alert fatigue, accuracy of information, and presentation of messages. We chose to minimize the use of CDS initially, activating only allergy and contraindication warnings. We focused on achieving acceptance and successful implementation of the system, with attention to performance improvement during go-live. Expansion of CDS will be explored after implementation of CPOE is completed.

Appearance
Consider using the order set features available in your system to customize the appearance of order sets to enhance workflow. For example, we chose to build orders sets that appear similar to the paper orders physicians are used to using (see Figure B). Orders can be organized into sections such as diet, activity, nursing orders, and medications. Medications may be further subdivided into segments by therapeutic use (pain management, anticoagulation), administration type (scheduled, PRN), or other topics. 

Selection
When including a list of medications for selection within a heading, it is possible to select a medication using radio buttons or a check box. Use of a radio button enables the prescriber to select only one medication from that group. For example, when there are several choices for statins, we use radio buttons to ensure only one is selected. This feature helps avoid duplication of therapy, whether within the same class of medications or those used for the same indication.

Click here to view a larger version of this Table

A check box will allow selection of all medications within a segment. Check boxes are pre-selected when those choices are used more than 80% of the time, with the ability for de-selection when individualized therapy is needed.

Multiple Choice Options
Multiple choice options may be built into order sets, and selections can be presented in the form of drop-down options. This improves accuracy and safety, with the ability to guide the prescriber toward preferred choices. Most commonly used for medication doses, IV rates, and frequencies, drop downs also can be employed for duration of therapy, elimination of range dosing (eg, number of tablets linked to a specific pain scale), or other order parameters.

Resources
Electronic order sets can include helpful information at the time of prescribing that would not be possible with paper orders due to space limitations. Helpful messages can be included that remind providers to reduce doses for specific populations or provide precautions for medications with black box warnings. Unlike their paper cousins, electronic order sets can include hyperlinks for easy access to additional information during the ordering process. Links to resources for drug information or evidence-based practice can be customized for each order set.

Testing
Testing is essential for safe patient care. Every medication order in the set must be tested for accuracy, and for proper information flow from the time of prescribing, to the pharmacy system, to the medication administration/documentation system. As the order enters each micro-system, assess for clarity (Is it possible to interpret the order another way?), accuracy (Is the information correct for patient care and is it what was intended?), and safety (Are high-alert medication warnings intact?). Some of the questions that should be answered include:

• Does the order give correct and adequate information?
• Are calculations and rounding correct for all medications?
• How does the order look when you review it after activation and can you easily follow the order sequence from original order to modifications todiscontinue?

Each discipline using the system must be satisfied with the results of this testing process before order sets are released for use.

Lessons Learned
While the procedures we put in place streamlined the order set development process significantly, there were some lessons learned along the way. Take care not to exceed the functionality of the order entry system. For example, the preferred dosing of a medication may be based on a calculation using ideal body weight. However, if the order entry system is only capable of calculating doses based on actual body weight, you will not achieve your intended result. Also, keep in mind the limitations of the system when building orders. It is never a good idea to rely on manual recalculation of a dose once it is entered into the system.

Assess the system for completeness of order tracking. You should be able to easily follow an order from its original entry, through any modifications, to discontinuation. A transaction log should identify the individual making entries during each step of the ordering process. This type of transparency is critical for pharmacists during problem solving and order assessment for patient care. It also is essential for error management and performance improvement.

Determine handling of medication-related orders not linked directly to products, such as pharmacy consults or patch removals. These orders must be communicated, documented, and completed just like traditional medication administration orders. Assess what worked well in your previous system as well as improvements needed, and apply this knowledge in your CPOE design.

In addition, consider training the teams involved in CPOE build on human factors engineering principles. Recognizing safety hazards, then designing counteractive safety into the system can prevent harm to our patients. Finally, provide feedback to your vendor. Field recommendations for improvement are critical to improving CPOE systems to support patient care. Our active participation in the big picture will help preserve patient safety today, and help build better systems for tomorrow.

Conclusion
Unfortunately, developing order sets is not as easy as pulling magic letters out of a hat; however, taking the time to create support systems and develop standardized procedures can help streamline this involved process and ensure that the technology designed to improve patient safety, does just that.

_____________

Key Questions for Order Set Reviewers

• Does the title adequately describe the intent of the order set?
  If the order applies to a limited population, state this in the title (eg, adults, critical care).
• Is the order flow logical and easy-to-follow? Try to group similar types of orders together, such as IV fluids. Use headers for sections, especially if there are multiple options for ordering such as beta blockers or PRN pain medications.
• Have you checked the spelling of all medication names?
  If used, make sure the brand and generic names are correctly linked. Medication abbreviations are not acceptable. Our standard format is: generic name (brand name).
• Did you complete the medication checklist? (See Figure C.)
• Does it make sense? Read it through again.

_____________

Figure C. Medication Order Checklist

• All medications are on formulary
• Dosage units are safest for ordering (avoid mathematical conversions)
• Metric system used for all dosage units (eg, Celsius for temperatures, kg for weight)
• Dosage units are consistent with infusion pump libraries
• Performed risk-benefit assessment of therapies (eg, droperidol vs. ondansetron)
• Significant drug interactions are not present
• PRNs include a frequency for dosing and the indication
• Look-alike/sound-alike drugs include an indication
• Titratable IV infusion orders include initial dose, specific outcome for titration, and maximum dose and titration parameters if not part of approved standards
• Followed all safety strategies listed in the High Alert Medication Policy
• Used the Valley Health list for tall man lettering
• Dose ranges have been minimized; if used, tied to a specific outcome
• Administration instructions have been included for complex therapies
• All calculations have been double checked
• Duplicate therapies have been minimized; if used, first choice specified (eg, use drug B if drug A is ineffective)
• Discontinued dates for medications are built into the order set if appropriate; for example, ketorolac x 24 hours
• Checked medication consistency with core measures.
  For example, appropriate antibiotic choice and number of doses.
• Pediatric orders—see additional requirements (eg, weight-based prescribing)
• No blanket orders/unapproved abbreviations/range frequencies
• If restricted drug or REMS, all required documentation included in order set
• Listed specific dose choices as “drop downs” rather than fill-in-the-blank

_____________

Sarah Householder, PharmD, is the pharmacist clinical content analyst at Valley Health/Winchester Medical Center. She is responsible for the medication build of the CPOE system as well as developing and designing evidence-based content for the system.