Healthcare system replaces time-consuming review process with a content-management system for developing and maintaining evidence-based order sets.
In the spring of 2008, Aurora Health Care experienced tremendous growth and was set to launch two healthcare facilities. The creation, adoption and maintenance of clinical order sets within the hospitals and clinics at Aurora was time consuming and inefficient. The process for summarizing clinical evidence, creating, reviewing and standardizing order sets, particularly in reaching a consensus among the physicians, was slow.
“The review process required many of the clinicians to drive for hours to meet at a central location between Wisconsin and Illinois,” says Michael Gorczynski, D.O., director of medical informatics. “Other clinicians unable to join in person participated by teleconference. The healthcare providers might then be required to attend a series of meetings, reviewing the order sets, incorporating changes to reflect the latest clinical research, and coming to consensus on a final system-wide order set. This process would then need to repeat itself periodically to incorporate the more-recent clinical-research data at a later date.”
Aurora Health Care is a not-for-profit integrated healthcare system that includes 13 acute-care facilities, more than 100 medical group sites, home healthcare and pharmacies located in more than 90 communities in eastern Wisconsin and northern Illinois. Aurora offers inpatient care at 12 acute-care hospitals and one psychiatric hospital.
Two of the 13 medical centers have had computerized physician order entry (CPOE) in place since 2005. Aurora also has a well-developed care-management/quality division that is responsible for setting the agenda for quality across the system. This part of the organization leads the effort to create system-wide order set content to support clinicians with evidence-based decision tools.
“Given the time commitment and difficulty in meeting at one location, most clinicians at Aurora did not participate in the all-day process to review clinical order sets,” explains David Smith, M.D., medical director of care management at Aurora Health Care. “We recognized we had to streamline the review process to increase physician participation to incorporate more input and feedback from the clinicians who were using it on the hospital floors.
“They knew this would increase the likelihood of adoption into the work flow, while ensuring that providers had access to the latest, evidence-based best practices built into their CPOE,” he adds. In the summer of 2008, Aurora began examining the process of reviewing and maintaining order sets across the integrated delivery system to streamline the procedure.
“The ability to conduct an online collaborative review process was felt to be conducive to streamline the process of reviewing clinical order sets in the large geographical area where Aurora-affiliated physicians practiced,” says Gorczynski. “Our goal was simple — drive clinical evidence to the point of care, ultimately increasing the number of evidence-based, standardized order sets used via CPOE.”
Online review now possible
Aurora decided to deploy ZynxOrder to achieve its goal and, by fall, Aurora was able to deploy its online solution. ZynxOrder is a content-management system for developing and maintaining evidence-based order sets, alerts and reminders. Clinicians are now able to navigate the review process of standardizing order sets online, rather than at inconvenient meetings.
A team of Aurora pharmacists previewed order-set templates for formulary- and medication-related concerns. They were then forwarded directly to the physicians for review via the online collaborative application. Physicians and other clinicians across Aurora's wide network can share order sets and give their input online. They also can review the clinical evidence supporting their decision in the process.
Requests to review order sets specific to each clinician's specialty also ensured their timely feedback. Input from ancillary departments was obtained as appropriate. Following a two-week online review period, a multidisciplinary core team reviewed the comments, and was empowered to make decisions regarding the final form of the order set.
“Physicians were not only given CPOE templates that were evidence-based, but could also easily reference the clinical studies directly,” Smith explains. “The studies were archived in an electronic library of printable documents that could be easily accessed so physicians could examine the study results directly.”
In a paper system, links to clinical studies and research evidence are not available, but with ZynxOrder integrated into a PowerChart CPOE system, peer-reviewed research became easily accessible via the Aurora libraries Web site. This enabled physicians to review and download materials quickly, a high priority given physicians' work flow.
Physicians as active stakeholders
Aurora also found that the use of common subsets of orders that apply across multiple conditions — nested order sets — became easier. For example, a standardized approach to the tiered use of several medications for the treatment of nausea was created. It was then applied uniformly in a modular fashion to many order sets.
“We provided teaching and training in order sets so that our clinician reviewers understood the process, what needed to be accomplished and how they could participate,” he adds. “With this collaborative review process, physicians became active stakeholders in finalizing order sets. Clinicians found it easy to participate.
“The executive team recognized that with increased clinician participation, physicians would more likely adopt the finalized order sets once a consensus was reached,” says Smith. “Given that the ZynxOrder online collaboration environment was easy to use, there was a culture shift resulting in more physicians participating in the order-set review process. They felt they could directly impact and improve their work-flow process, while contributing their clinical expertise.”
“The ability to conduct an online collaborative review process was felt to be conducive to streamline the process of reviewing clinical order sets in the large geographical area where Aurora-affiliated physicians practiced.”
By late 2009, 220 order-set reviews had been completed within the regional healthcare system. A total of 255 individual physicians are involved in the review process, plus 195 individual nurses, pharmacists and allied health providers conducting several thousand reviews. Aurora experienced a five- to 10-fold increase in the number of clinicians who became involved in standardizing the order sets.
“With ZynxOrder, clinician consensus was reached quickly with a high level of participation from clinicians,” says Gorczynski. “Data was easily collected, reconciled and deployed into the final order set. Virtual teams were created, such as a system-wide group of obstetricians or ED physicians; they were connected directly with specialty-specific order templates to review, relevant to their patient population.”
Aurora also found there was an increase in evidence-based, clinically reviewed order sets, with immediate updates across the system to the order sets that reflected the best practices and the latest research.
“We had committed to leveraging evidence-based medicine in 2004,” offers Smith, “so when the HITECH guidelines for meaningful use were published, the inclusion of evidence-based medicine was easily received by senior leadership, care management and information technology. By ensuring that standardized order sets were accessible across the system with an easy-to-use solution, physicians and providers had access to the latest clinically supported best practices for improved care for their patients.”
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February 2010
