What Happens When Your Order Entry Dictionaires are not in Order
By John Saulenas, MT (ASCP)

The benefits that can be derived from a successful Provider Order Management (POM) implementation are improved patient care, safety and efficiency. In order to achieve a successful implementation there must be thoughtful planning, flexible training and strong staff involvement. MEDITECH recommends that their sites perform a CPOE readiness assessment in advance of the MEDITECH POM implementation, as well as, an Order Entry (OE) module optimization, Pharmacy module optimization and Nursing/PCS module optimization. Below is an example of what happens when your organization fails to perform an OE module optimization prior to going live with POM.

Physicians will often utter these words, “I can write an order quicker than it takes me to place an order in the computer”. The main purpose of POM is to ensure patient safety and while it may be quicker to scribble the orders on paper, patient safety can be jeopardized because of illegible hand writing or lack of a medication interaction checking. The process of inputting hand written orders into the computer is very time consuming and the orders can be delayed if the nurse or unit coordinator must contact the doctor to clarify the orders. The physicians may complain that it is difficult to find procedures. It may even get to the point where the physicians are threatening to stop using POM and to revert back to writing their orders on paper; this is when an Optimization of the Order Entry Dictionaries should be performed.

Begin by interviewing the physicians to determine the cause of their frustration. Generally, the biggest complaint is the numerous clicks it takes to file an order. There are many questions as to why they have to answer unnecessary queries that have no clinical significance. The number one reason for the large number of clicks is the site's customer defined screens associated with their categories and procedures. For example, a customer defined screen has the following queries: 'campus', 'collected by nurse' and 'hold specimen until collected'. The information that can be filed in behind the scenes will not only prevent the physician from being prompted to answer the questions, but will prevent them from having to view the customer defined screen at all. Another example is when a patient is admitted to the ER and a glucose specimen is taken, either alone or in a panel. Often times these procedures have a question associated with them to determine whether the glucose was either fasting or random. In this case, most likely the blood sugar is random, as the patient just came in through the ER and the Physician is not going to want to respond to this question every time they order these tests.

The next step is to start the lengthy process of reviewing the Customer defined screens (cds), along with the queries that are associated with the categories and procedures. Keep in mind that this may require a great deal of time depending on the number of customer defined screens that the organization has created. Appropriate ancillary staff should be present for the review, based upon the category, such as laboratory and radiology. The team will need to assess the queries based upon the patient's location. Physicians will not have information such as the last administration time and dose when ordering a therapeutic drug level on outpatients and patients presenting in the emergency department. They may not even have that information available when ordering on inpatients. Many times, there are queries and customer defined screens that can be removed. New screens with the necessary queries should be created. The Auto-File functionality can be implemented to auto-file the queries behind the scenes to appear seamless to the providers. As noted above, some of the queries that can be auto-filed are 'campus', 'hold specimen until collected' and 'collected by nurse'. Another thing to keep in mind is that physicians are used to hand writing comments. Consider the use of a comment query that is not required but will allow the provider to type in free text. Customer defined screens without required information can be set up so they do not automatically appear when the physician is ordering and will only appear if they wish to enter a comment.

Part of the Order Entry Optimization is evaluating the use of rules. The use of rules should be kept to a minimum. Depending on how long the organization has been live with OE, the procedure dictionary may have thousand of entries. Clean up some of the entries and determine which procedures you want your providers to be able to order. This will greatly reduce the number of procedures when employing the lookup feature when trying to find a procedure. You may also want to explore the use of aliases to aid the physicians in ordering procedures and tests. Aliases can be used to link all procedures to a certain type of order, such as dietary. Your organization may have thirty different dietary orders and the providers may not know the name of all the orders. They can type the word diet and all the dietary orders will display. Part of the review may require that you take a close look at the use of dummy procedures. Some organizations have the nurse or unit coordinator order a general procedure such as MRI or CATSCAN. The receiving department will then order the correct procedure. The providers will want to order the actual procedure so the dummy procedures will need to be inactivated and the actual procedures created. Another useful tool to consider is reflex ordering. Providers are used to writing an order and then the nurse or unit coordinator remembers what goes along with the procedure. For example, the provider orders a Troponin. The nurse/unit coordinator needs to remember that every time a Troponin is ordered they also must place an order for a Ckmb. A reflex order can be setup so that every time the Troponin is ordered the system will automatically order the Ckmb, no one has to remember.

The last step is to review order sets. The process of reviewing existing order sets and creating new order sets can be very involved and requires a substantial amount of time, especially given the variety of available options. Often order sets are created from scratch, utilizing written orders. The people involved in reviewing existing sets and creating new sets typically include physicians, pharmacists, nurses, risk managers, case managers and IS staff. Working with physicians to ensure that as many sets are built prior to your CPOE live as possible, will prevent them from having to enter multiple orders individually and will increase end user satisfaction.

Typically the Order Entry Optimization can take anywhere from three to six months. Hopefully, once the review and changes have been made the physicians will be saying that POM is easier to use, more efficient and aids in increasing patient safety.

For more information about order entry dictionaries please call us at 610-444-1233 or visit our website at www.getvitalized.com