Transcript Document

Clinical 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
Presentation Outline

Our experience - Acute Coronary
Syndrome Guideline/Order-sets
The Guideline/Order-sets
 Physician survey
 Ordering behavior


Perspective
Other reports
 Published issues

Clinical 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

Patterns of Guideline Adherence and Care Delivery for
Patients with Unstable Angina and Non–ST-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 2006;98[suppl]:30Q–35Q
CRUSADE
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
Acute Coronary Syndrome (ACS)
ED Guideline / Order-sets


Joint effort - cardiology and EM over 6 months
Preprinted paper order forms




Four forms – each 2-3 pages


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Check-off orders
Fill-in-the-blank
Embedded guideline information
Initial care and risk stratification – all patients
Three risk-specific forms
Expected use

Initial order set form + one risk-specific order set form
Problem:
Released the paper forms just a few months
before CPOE implementation was to
eliminate all paper orders
BACKGROUND

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
What 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 pdf’s of the paper forms there
Unopened 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
+ 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
+ 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 @ 2L/min NC sat LT 90
CXR-PA/lat
CXR-port (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
Anonymous Surveys

Pre-CPOE - paper version
Post-CPOE - CPOE version

Surveys distributed


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At an EM weekly conference
Mailboxes
Survey Regarding the BJH-ED Chest Pain / Acute Coronary Syndrome Guideline
The following questions are in reference to the HMED Chest Pain / Acute Coronary
Syndrome (CP/ACS) order sets and the incorporated guideline information that have
been in use since CPOE was implemented in May 2003. This is an anonymous survey
aimed at determining the usefulness of the guideline and order set.
1. Please circle one of the following:
Attending
R1
R2
R3
R4
2. Are you aware of the Chest Pain / Acute Coronary Syndrome Order Set in HMED?
YES
NO
3. Please rate the ease of use of the current HMED guideline:
Difficult to use
1----2----3----4----5----6----7----8----9----10 Easy to use
4. Have you had any experience with the preprinted paper version of the CP/ACS order
sheets in the BJH-ED?
YES
NO
5. Skip if your answer to 4 was NO. Please compare the ease of use of the current HMED
order-set guideline to the previously used paper order sheets / guideline:
Paper guideline easier 1---2---3---4---5---6---7---8---9---10 HMED guideline easier
6. How useful are the abbreviated stratification criteria on the order set tab?
Not useful 1----2----3----4----5----6----7----8----9----10 Very useful
7. How useful are the expanded risk stratification criteria available from the “globe”?
Not useful 1----2----3----4----5----6----7----8----9----10 Very useful
8. How useful are the intermingled prompts that are imbedded in the orders?
Not useful 1----2----3----4----5----6----7----8----9----10 Very useful
9. Do you agree with this statement?
“The HMED CP/ACS guideline assists me by prompting organized and complete
orders."
Disagree 1----2----3----4----5----6----7----8----9----10 Agree
10. Do you agree with this statement?
"The HMED CP/ACS guideline (order set) leads to better patient care"
Disagree 1----2----3----4----5----6----7----8----9----10 Agree
11. Additional comments (Please feel free to use the reverse side if necessary):
Mean Survey Responses – Attending vs. Resident
Pre- or
PostCPOE
Attending
mean (SD)
Resident
mean (SD)
Sig of
Difference
Pre
5.2 (4.0)
5.9 (2.3)
p = 0.70
Post
5.4 (2.3)
7.4 (1.6)
p = 0.02
Pre
4.8 (3.5)
6.3 (2.8)
p = 0.39
Post
5.5 (2.5)
7.0 (2.1)
p = 0.10
Pre
4.6 (2.3)
6.2 (2.6)
p = 0.17
Post
6.2 (2.5)
7.1 (2.4)
p = 0.30
Compare the ease of use of the current CPOE
order-set guideline to the previously used paper
order sheets/guideline
Post
6.6 (2.0)
7.3 (2.2)
p = 0.46
How useful are the abbreviated stratification
criteria on the order-set tab?
Post
3.8 (2.4)
6.4 (2.0)
p = 0.01
How useful are the expanded risk stratification
criteria available from the “globe”?
Post
4.1 (3.0)
5.8 (2.4)
p = 0.13
How useful are the intermingled prompts that
are imbedded in the orders?
Post
4.2 (2.7)
6.6 (2.3)
p = 0.02
Please rate the ease of use of the current
guideline
The current CP/ACS guideline (order-set) assists
me by prompting organized and complete orders
The current CP/ACS guideline (order-set) leads
to better patient care
Risk Stratification Criteria
Opened 6 times in 97 patients
 Only 3 times with expected use pattern

Correlation with level of training
Spearman’s Rho (p-value)
Pre- or
PostCPOE
Correlation
with Level
of Training
Pre
-0.18(0.40)
Post
-0.42(0.01)
Pre
-0.37(0.08)
Post
-0.42(0.01)
Pre
-0.49(0.02)
Post
-0.26(0.13)
CPOE Easier Than Paper
Post
-0.17(0.37)
Abbrev Criteria Useful
Post
-0.38(0.02)
Expanded Criteria Useful
Post
-0.35(0.06)
Integrated Prompts Useful
Post
-.046(0.01)
Ease of Use
Organized Orders
Better Patient Care
Chart Reviews
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Selection criteria - ED diagnosis of MI, ACS, or
unstable angina
Four one-month periods:
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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
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Risk-stratification criteria
Order-set use
Compliance with the guideline recommendation for
β-blocker use
Order-set use by phase of study
None
Initial or
Advanced
(not both)
Initial and Multiple
Advanced Sets
Initial and One
Risk-Specific
(simple preprinted
form in Phase 1)
Phase 1
33/45 (73%)
12/45 (27%)
Phase 2
36/66 (55%)
20/66 (30%)
Phase 3
12/48 (25%)
17/48 (35%)
3/48 (6%)
16/48 (33%)
Phase 4
8/49 (16%)
14/49 (29%)
8/49 (16%)
19/49 (39%)
10/66 (15%)
Beta-Blocker Orders by Order-Set Use and Phase
Initial or
Advanced
(not both)
Initial and
Multiple
Advanced Sets
Initial and One
Risk-Specific
(simple preprinted
form in Phase 1)
N
% βBlocker
None
Phase 1
21
81%
88% of 16
Phase 2
37
68%
68% of 22
70% of 10
Phase 3
26
69%
33% of 6
88% of 8
100% of 1
73% of 11
Phase 4
26
77%
67% of 3
43% of 7
80% of 5
100% of 11
60% of 5
60% of 5
Patients without contraindication to a β-Blocker (heart block, hypotension, or bradycardia)
Summarizing 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
On the Other Hand
Improving 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
Results – Paper Order Sets
Blank Order
Pages
Order
Sets
DVT prophylaxis
9.6%
36.2%
Documentation of Allergies
9.6%
54.6%
Documentation of Code Status
10.2%
57.4%
Allied Health Consultations
Standardized Insulin Scale
12.7%
7.6%
62.8%
19.1%
Potassium Protocol
0.5%
63.8%
Ordering of Urea
59.4%
39.4%
Conclusion
“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.”
Congestive 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 O’Shaughnessy,
Robert Plant, David Schleinkofer, Michael Mirro
Fort Wayne Cardiology / Parkview Research Center
Fort Wayne, IN
Results

ACE Inhibitor use increased:


Beta Blocker use increased:


From 52.3% (508 of 971) to 85.2% (248 of 291)
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)
The Role Of Computerized Order
Sets In Pediatric Inpatient
Asthma Treatment
Pediatr Allergy Immunol 2006: 17: 199–206
Chisolm DJ, McAlearney AS, Veneris S, Fisher D,
Holtzlander M, McCoy KS.
Columbus Children's Research Institute
Ohio State University
Results
PreOrder Set
N=261
Order set
not used
PostN=63
Order
Order set
Set
used
N=466
Systemic
Steroids
MDI
Pulse
Oximetry
75.1%
47.9%
78.9%
77.8%
39.7%
82.5%
94.4%
55.6%
90.8%
Other Order Set Successes
DVT prophylaxis
 Peri-operative antibiotic compliance
 Pain management
 Glucose management
 Anticoagulation management

Integrating "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. 2006;13:188-196
Asli Ozdas, PhD, Theodore Speroff, PhD, L. Russell
Waitman, PhD, Judy Ozbolt, PhD, Javed Butler, MD
and Randolph A. Miller, MD
Vanderbilt University Hospital
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)
A Survey Of Factors Affecting
Clinician Acceptance Of Clinical
Decision Support
BMC Medical Informatics and Decision
Making 2006, 6:6
Dean F Sittig, Michael A Krall, Richard H Dykstra, Allen
Russell and Homer L Chin
Kaiser Permanente
Factors Considered

Patient




Provider



age, gender
number of years with Kaiser Permanente
Alert



reason for visit – acute vs. chronic
severity of illness – number of medications, number of
chronic conditions
age
type of alert
number of alerts received
Environment
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
presence of a computer in exam room
clinician behind schedule
Pertinent Results

Patient factors



Environmental 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)
Clinicians often behind schedule
CDS less acceptable when behind schedule
In principle – CDS most helpful when clinician is
least apt to remember…
Specificity Of Computerized Physician
Order Entry Has A Significant Effect On
The Efficiency Of Workflow For
Critically Ill Patients
Crit Care Med 2005; 33:110 –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
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
Reflecting 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”.
Reflecting 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”.
Viewpoint: Controversies
Surrounding Use of Order Sets for
Clinical Decision Support in
Computerized Provider Order Entry
J Am Med Inform Assoc. 2007;14:41-47
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
#1
… 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
Related 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?

#2
…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
#2
“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’ levels—little progress
may be made”
#3
… there remain significant limitations to
what CPOE-based order sets can do
Desirable Functionality

Linked orders





Patient-specific dose calculations based on
weight, age, or body surface area
Ideally would also consider



Begin together e.g. monitoring lab orders
Discontinue at same time e.g. PCA, heparin protocols
Mutually exclusive – alternate AB
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
#4
…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
Then 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”
#5
…Allow individual clinicians to develop
their own "private" order sets?
…Potentially removes the evidencebased nature of order sets, and
introduces other maintenance issues
CRUSADE
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.
CRUSADE
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.
CRUSADE
Among the strongest predictors of blood
transfusion use in patients with NSTE ACS:
•
•
renal insufficiency
advanced age
CRUSADE
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
Desirable Functionality

Linked orders





Patient-specific dose calculations based on
weight, age, or body surface area
Ideally would also consider



Begin together e.g. monitoring lab orders
Discontinue at same time e.g. PCA, heparin protocols
Mutually exclusive – alternate AB
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
CRUSADE
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.
In 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



Clinician acceptance important




Focus attention on critical decisions
Provide additional information at key decision points
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
Phil Asaro
Washington University in St. Louis
[email protected]