Personal order set

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A personal order set is an order set which is defined by the user.

value of personal order sets

A common question is whether an organization should allow individual clinicians to create "personal order sets"? In my opinion the current consensus is NO! for several reasons which are well explained in the text below from the chief medical informatics officer (CMIO) of a leading medical center in central Pennsylvania.

We began creating order sets and note templates 12 years ago. At that time, we told people that one of the benefits of the electronic health record (EHR) was the ability to build tools that fit one's specific style of practice. Our experience was that very few of the tools were used, even in the case of sophisticate tool builders. And with 1500+ order sets, there was no accountable validation process at the outset nor accountable curation process to keep them demonstrably current.

When we began building inpatient note templates and order sets, our organization and the quality-and-safety climate had changed enough that we changed our policy. Now order-set and note-template topics are identified by departmental, service-line, and quality leadership; tool outlines are pre-vetted by medical records, quality, medical education, billing, pharmacy, and informatics; contents are provided by domain experts who are nominated by the appropriate chair and who work on behalf of the department, service-line, or enterprise (in the case of tools that span groups); and the tools are post-vetted by the same vetting groups (who recommend large numbers of changes).

The tools that have been developed this way represent our standard of practice. We have op-note templates and order sets (in one department) that have been live for 2-4 years. The early indications are that providers increasingly appreciate tools that they can rely on to help them achieve the performance measures (internal and external) that are increasingly being required of them. (We are working on setting up a software-supported system that will semi-automate the development and curation processes.)

Someone else says

As a point of order, we have a long "manual" experience in developing best practice order sets on an enterprise wide basis and had no interest in "purely personal" order sets. Not only would that be an administrative and maintenance nightmare (as others have noted), but the potential for best practices to be contravened was too high, in our view.

Specialty based order sets

We therefore have developed "specialty-based" order sets, now at about 325 and counting (we went live 13 months ago with about 240 and have been adding them as new needs are identified). At the discretion of the best practice teams that vet the order sets, we do include convenience or experience based orders within these sets, as long as they do not contradict best practice. Not all orders within an order set are defaulted as "checked", since many order groups include alternative choices for a given condition and other convenience-based options. The individual physician can change the "defaults" and even change the order modifiers (dose, schedule, etc) for checked or unchecked orders before saving this as a "user-defined" version of the order set. We call these personalized order sets. The physician cannot add completely new orders to the order set (which is fine with us, since this would make it too easy to add on-best practice orders), but there is an option on the order set tab beneath the listing of orders in the chosen set for "additional orders" to be entered for a particular patient. We feel this is a reasonable compromise between our mandate for Evidence-Based Medicine and the need to support physician preferences and are pleased that the product supports it.

We use instructions (text placed in order section headers) to suggest best practice and certain other recommendations, but do not mandate (nor have the capability to mandate) that certain orders must be checked off, other than through best practice alerts which might appear and "demand" a specific action based upon the patient's diagnosis, etc. This header information can also indicate whether single or multiple selections are appropriate within the order set section (and we can control that programmatically, so that only one order can be selected within a single-select group)

In the latest upgrade to the application which we just installed 2 months ago, we now have the capability to store order groups, which can then be assembled (as links) within order sets. We now will keep a single diabetes management group, or a DVT prophylaxis group or a pain management group of orders and simply place the link to it within applicable order sets, markedly easing maintenance when modifications are necessary. Note that when the physician opens the order set, he sees the order group as if it had been built within the set, and not just a hyperlink.

Since all order sets are managed and maintained centrally, we do occasionally find the need to 'customize' order sets by facility (we have 5). Although we have strict criteria to allow this unappealing option, our vendor allows us to do this, so that the Hospital A version of the order set only appears to physicians signing on from Hospital A (we can similarly restrict order sets by gender and age, so that neonatologists never see adult order sets and no one can see OB order sets when they are in a male patient's chart).