Creating order sets
Ordered sets are used with computerized physician order entry (CPOE)
Introduction to process
The general process is proposal by a clinical group. They have their needs thoroughly examined by their practice management oversight group, nursing, support staff and anyone who might be affected by the order set. The proposal then goes to a multidisciplinary Order Set Oversight committee that examines and assigns a publications and/or IT specialist/liaison to work with order set creation proponents. Those liaisons have knowledge of the standards that are expected to be applied and develop the actual manifestation with the proponent group.
Order Set oversight group
The Order Set oversight group (Order Set/Protocol Advisory Group-OSPAG)is made up of about 15 individuals (3-4 physicians, physician chair) Pharmacy, Nursing, Nursing informatics, Publications, Quality Office, and our EMR systems and IT folks. It is from the nursing support group, the quality office and others from a division at Mayo known as "Systems & Procedures" who serve in the liaison role.
Many organizations provide clinicians with a template for an order set. This template drives the order of orders and give providers an idea of the amount of detail required for each order. Basically all components of the order sets have specified format, page positions, header titles, user interface designs, etc., etc. This makes a new one basically just an assembly of components (widgets) in most instances. Several organizations have the ability to post evidence, policy, procedure, and risk assessment tools, for example, on a intranet web site that can be accessed by using a task bar button pointed toward the web page related to the content of the order set.
Order Set management committee
The Order Set management committee then brings the proposal to a centralized institutional group (Record Coordinating Committee) that oversees all components of the record (mostly electronic now). The Record Coordination Committee has been in existence at Mayo Rochester for >50 years in some form. At this time an MD chairs the Coordinating Committee Operations group which is also made up of some physicians, and basically a similar group as the Order set/Protocol organization above. OSPAG reports to this committee. These Coordinating Committees report directly to our institutional Practice Committee. The Record Coordinating Committee does an additional review and also looks at the order set to see if it may have more broad use/value than what the original proponents anticipated. That is often discovered in the Order Set management committee prior to that. That step is quite valuable as very good evidence-based order sets often end up having more global application outside of the user group who began its origination. This takes care of look-alike or quite similar sets being deployed and elimination of conflict as a patient may move through several care groups during a hospitalization. This committee sees ALL ordersets and reviews and approves/rejects every single one of them. By virtue of this single committee (we were initially worried about a bottle neck effect which has not surfaced thus far) our order sets have been consistent in structure, content, layout and order.
This group also carries the responsibility of tracking all version changes to any order set over its lifetime from initial implementation to obsolescence/discontinuation. That is done through a somewhat elaborate centrally-managed indexing scheme. This indexing also allows for the discovery process to be able to represent the state of the medical record in respect to order sets at any previous point in time (We do the same for all components of the medical record).
Each order sets also has a prescribed life-cycle with the expectation that the proponents will periodically review the set to re-validate its currency and clinical practice merit. That review is expected at least on a 18-month cycle based on centralized institutional policies. The proponents are periodically messaged reminding them about the review need.
As additional guidance we also have a centralized repository of institutional accepted abbreviations. There are also extensive guidelines/policies about, e.g., medication terminology/representation on paper and computer screens.
Lastly, many order sets also carry some detailed clinical guidelines or related information, flow diagrams, etc. (on the backside in the case of paper -or-URL reference in the case of electronic).
Related Article Reviews
Payne TH, Hoey PJ, Nichol P, Lovis C. Preparation and use of preconstructed orders, order sets, and order menus in a computerized provider order entry system. J Am Med Inform Assoc. 2003 Jul-Aug;10(4):322-9.