Building and maintaining physician order sets can be one of the most important steps a hospital can take in making the use of EMR systems more efficient and creating a culture of structured care. In his book The Checklist Manifesto, Atul Gawande makes a clear case for the use of checklists in all aspects of healthcare. But checklists alone can create an additional burden to the already busy hospital physician if they are not connected to the process of physician ordering.
The art of building appropriate levels of structure and details into an Electronic Clinical Document (ECD) involves a multidisciplinary approach that includes workflow, activity and interface design as well as deciding what to include and exclude from a clinical perspective. While we might at first believe that clinicians should be the sole arbiters of ECDs, it turns out that people with user graphic and interface design should also be a part of the design team. Clinical educators should also weigh in because the point of order sets, nursing forms, and other clinical documents is not just to capture data but also to teach best practices.
HarmoniMD, EHRI’s hospital EMR system, includes a unique system for creating and storing Electronic Clinical Documents that can also serve as physician order sets. These documents are built in an XML format, which describes each discrete element of the form as an XML element. When the document is saved, the data entered is inserted into the XML document and the XML document is saved in its entirety as an XML field in the patient’s chart. In this way, each ECD can be displayed in its original format without versioning issues yet the data elements within the document can be reported on as discrete elements.
Newer features of this system greatly enhance the physician ordering process by making orders a single click process and pre-selecting orders where appropriate. In this way, a hospital can have pre-defined order sets that include pre-selected orders as defaults. For example, a General Admit order set can have PRN medications for bowel care pre-selected so the physicians do not have to choose these items every time they use the order set. Of course, they can deselect items and add items not on the order set (if this is consistent with hospital policy).
With order sets, checklists, and other clinical documentation design overseen by a multi-disciplinary team, documentation can become more efficient and accurate over time as workflows and ECDs are perfected. The Checklist Manifesto gives clear insight into the application of structure to the clinical care process and is a must read for anyone working in the modern hospital environment. Gawande points out that hospitals are often far behind other industries in perfecting the process of healthcare delivery with the emphasis often placed on documentation for billing and legal requirements rather than improving care.