Clinical decision support

Moving Beyond Order Set Content: Mergers, Clusters and Localization 


March 19, 2018

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By: Felicia Ulloa, Chris O’Connor

Think Research’s acute care Order Sets currently serve a large number of hospital sites in Ontario – 103 to be exact – so it’s no surprise to us when we sometimes have clients that merge. As a result, these hospitals often look to standardize their clinical content across sites. In this blog we’ll discuss our experiences in the areas of mergers, content standardization and localization.

Hospital mergers have been occurring regularly across Ontario for a number of years. In several of these cases, we had installed Order Sets at both hospital sites using the same (or similar) Reference Order Sets, but with different Order Sets in Practice. While the best case scenario during a hospital merger is to move everyone to the same Hospital Information System (HIS), it’s not always immediately possible. That level of migration can be a multi-year process. As a result, a strong and sustainable interim solution is required. By standardizing clinical content across hospital sites, we can feed the different Hospital Information Systems the same (or similar) Order Sets in Practice.  This can aid with governance alignment across the hospital Medical Advisory Committees (MACs).

The Need for Standardization

It’s worth spending a moment differentiating between Reference Order Sets (ROS) and Order Sets in Practice. Think Research maintains a library of approximately 850 Reference and 11,000 In Practice Order Sets.  Both the “parent” and “child” order sets are available on our TxConnect Hub to all of our clients. This Hub has had more than 2.8 million downloads in the last decade and is a key component of clinical practice. ROS are based on the best available clinical content adapted for the Canadian context.  Our R&D team works with an ‘alphabet soup’ of Canadian organizations and their guidelines and standards to create Reference Order Sets with traceable Canadian content.

Order Sets in Practice are customized to each hospital under the MAC or delegate by our 50-person client success and client services teams – hence Order Sets in Practice.  There are at least five reasons that MACs customize the Reference Order Set to their hospital:

  1. Formulary
  2. Available medical technology
  3. Available personnel
  4. Legitimate practice differences
  5. Illegitimate practice differences

Clearly the first three elements can be relatively clear cut. For example, you can’t order a CT scan or an OT consult at a hospital that doesn’t have easy availability. The last two elements require judgement calls, which are appropriately the domain of the MAC (or delegate). At Think Research, we have a clearly stated opinion in our Reference Order Set but the ultimate decision rests under the Ontario Hospitals Act, with the hospital site MAC.

When two hospitals merge or agree to collaborate, one of the key governance questions is how the MAC will be organized across the sites within the new merged organization. Standardizing Order Sets is one of the biggest projects during a hospital merger because they are so closely connected to day-to-day patient care. By working with our hospital partners we can standardize across sites based on existing Order Sets and knowledge of existing practice patterns.

Creating Cohesive Governance

We believe a close collaborative relationship with each of our partners is vital to a seamless and sustainable clinical harmonization project across recently merged facilities. A cohesive program governance structure with clearly delineated responsibilities and accountabilities is vital to supporting clinical harmonization and standardization across multiple facilities. Our team works closely with partners to develop an agile and efficient governance structure that leverages and adapts existing processes. Our program management governance methodology is rooted in ongoing communication to ensure project members, across all levels, are aligned on program objectives and knowledgeable of project progress and results. We believe it is only through a coordinated and collaborative effort that meaningful outcomes – ones that truly impact the quality of patient care – are achieved, and the future state envisioned by project sponsors is realized.

The Importance of Localization

Our ‘made-in-Canada’ approach to knowledge translation ensures that leading best practices are made accessible, actionable and impactful for each unique care environment. We custom tailor every solution to the localized needs of front-line users and their patients while being mindful of the standardization and clinical harmonization required in a post-merger environment.

All of our clinical content is built using an evidence-based approach that ties the latest medical research to practical interventions. Our development methodology not only drives the latest evidence to the point-of-care, it does so in a manner that converts medical knowledge into actionable, structured decision support tools that guide a clinician through a patient interaction in a logical, evidence-based process. Our library of Order Sets and associated decision support tools are specifically designed for the Canadian environment, regulatory systems and payment systems.

Implications for Clusters and HIS Renewal

The ability to standardize content across multiple Hospital Information Systems can enable clusters and regions to standardize clinical practice in advance of, or in parallel with, the system selection process. A group of hospitals running older versions of Meditech, Cerner, Quadramed and other systems can use this process to standardize content in their older systems. When the product selection is made and implementation has begun, the standardized clinical content can then be written into the next generation HIS. More importantly, Order Set content does not change with the system change, and data reporting continues across the implementation timeline. This means that the mixed system, which inevitably exists during these 2-5 year implementations, does not lose clinical standardization or data reporting functionality during this time period. As a result, any solution should work with the legacy HIS while creating a strong foundation for advanced clinical systems in the next generation system.

Most of the value in next generation HIS implementations is derived from the clinical content side.  Some estimates are as high as 75%. Standardizing content in advance of or in parallel with the implementation mitigates risk and promotes clinician adoption. Working with best practice clinical content across different HIS with different levels of maturity allows Think Research to provide standardized clinical content and data reporting to more than 100 hospital sites in Ontario alone, and supports these HIS standardization and clustering initiatives.

In a future blog we will discuss how cluster-based content standardization can lead to standardization at and across LHINs, and how we are building a truly province-wide content and reporting infrastructure for acute and long-term care.

Felicia Ulloa, BA, PMP is Director of Client Success at Think Research.
Chris, O’Connor, MD, FRCPC is the Founder and President of Think Research.

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