Clinical decision support

Solving a Clinician’s Greatest Problem with Order Sets

March 14, 2018

Tags: , , , , , , , , , ,

By Dr. Chris O’Connor

This blog is part one in a three-part series on the evolution of Order Sets.

I came across Order Sets almost by accident. I started my internal medicine critical care practice at Trillium Health Partners in 1999. Freshly graduated from my specialty training – 6 years of internal medicine/respirology/critical care – I was very keen to start being an actual physician. It was, as everyone who has made the transition from medical resident to practice knows, a steep learning curve. However, by 2001 I was starting to settle into the routine of practice.

Actual medical practice was different from residency in many ways, but two things really stood out for me: I was much busier than I had ever been as a resident because I was seeing much larger volumes of patients; and I realized that much of medical practice could be somewhat routine. Not that there weren’t many interesting cases (there were!), but as my experience developed, more and more cases started to become familiar or standard.

Dealing with the Daily Grind

In those days ordering was done on paper. For my patients to get the medications, lab tests, x-rays, intravenous fluids, and consults they needed, I had to order them. All of those orders had to be written by hand, from memory, one order at a time. A complex patient might have as many as 30, 40 or more orders, and on a busy night on-call, I might see 20 or more patients. That was a lot of writing! Often, I’d be writing the same order: acetaminophen 325 to 650 mg PO Q 4 hour PRN. Imagine, this was being written over and over again for multiple patients. That was not only a lot of work, but also deadly dull. How many times in my life did I want to write “acetaminophen 325 to 650 mg PO Q 4 hour PRN”?  Did I want to do that for the next 30 years? The question answers itself.

That is when I got the idea which later turned into the Order Sets that thousands of clinicians use today. What if, rather than writing the same orders over and over again, I could just select them from a list of some sort that contained the most common orders? That would be easier and faster. This was the core idea for building my first Order Set.

Saving time was my main motivator; after all, it was the main problem most clinicians faced. The concept of Order Sets seemed intuitive enough. I would have thought that Order Sets would be commonplace, but that was not the case by any means. While not completely unknown, the use of Order Sets was very sporadic at the time. They were viewed as uninteresting and unimportant.

This meant that if I wanted to use an Order Set for my ICU practice, I was going to have to build it myself. This is exactly what I did in 2001: I created an ICU General Admission Order Set. By today’s standards it was a rather poor one, but it worked exceptionally well for my needs then. The effect was immediate! This Order Set made the process of admitting a patient to hospital much faster than if I was writing each order by hand. It was easier as well: it required less effort to remember what was needed, and resulted in fewer call-backs from nursing and pharmacy about forgotten or hard-to-understand orders.

 Eureka!

I still remember the feeling of using the first Order Set to this day: it felt great! Many aspects of medicine require tremendous amounts of work and effort, and here I had just found something that actually saved me time in my day-to-day practice. I loved it!

The good news is that I am not the only person who likes to save time. This need for efficiency led to the adoption of the Order Sets I had created across the ICU, and soon after, the entire hospital. As more Order Sets were developed, they too were adopted in the ICU, and then across the hospital. I did not know it at the time, but the Order Set journey had just begun.

Have a look at this short video where I discuss my Order Sets journey.

Moving From Then to Now

While our Order Sets have evolved significantly since that day in 2001, and our organization has grown immensely, what remains the same are the problems we’re solving with our Order Sets. Now it’s no longer about moving from hand-written notes to an expedient checklist system. What we’re helping clinicians with now is much more complex, and includes aspects such as resource utilization, healthcare data coding, and regulatory framework. Our Order Sets have evolved based on the changing needs of the clinicians we work with, and the fluctuating healthcare environment in Canada.

Our advanced clinical system can be deployed on any Healthcare Information System, or on Think Research’s own platform. With this kind of flexible approach, we can accommodate hospitals regardless of what kind of backend system they use. All of the hospitals in the network are able to see each other’s Order Sets, enabling them to access a vast ecosystem of knowledge and data. Hospitals are able to access data in real time, and these analytics are critical for hospitals to report on programs, clinician engagement and the ongoing improvement of Order Sets.

We’ve come a long way since I started developing Order Sets. Think Research is growing quickly with many new projects on the horizon. We’re established across Canada, and expanding into the US and Europe.

Now more than ever, we at Think Research are keenly focused on the behavioural aspect of Order Sets and develop them based on how we know clinicians will get the most use out of them. We value the clinician’s time and their need to access vast amounts of expert recommendations because we have stood in their shoes. Our Order Sets turn simple referential knowledge into actionable executable knowledge. In my next blog I will discuss how Order Sets actually impact the level of patient care.

4 likes