Order set is a an electronic protocol that is derived from evidence based practice guidelines. Standardized order set provide the physician with all relevant orders and reduce their reliance on memory ,The use of order set reduce medical errors especially omission errors ,ease access to linked guidelines, Integrate evidence based guidelines into daily physician ‘s point of care-practice ,they also facilitate ordering of routine parts of patients acre enabling the physicians to focus on unique need of Each patient .but what are the current controversies related to order sets?
There are many reported benefits of order sets. Order sets represent a potential solution to the time constraints of busy physicians and may even improve quality and safety. Obstacles to overcome would include physician acceptance, costs of creation and maintenance, and user interface issues. 
- Reduction of transcription errors.
- Promotion of adherence to consistent standards of care
- Focus attention upon unique features of a patient.
- Quicker order entry
- Reduction in delays due to inconsistent or incomplete orders
The First Controversy:
When order set is implemented in health care organization, the clinician are not forced to use them, they have the choice to use them or not , so patients do not benefit when their care provider bypass order set usage , so presence of order set in a system does not guarantee that clinicians will use them Health Care organization implementing CPOE should provide creative mechanisms to make physicians aware of order set usage. The First approach is to provide a group of relevant order set at time of writing admission orders based on patients’ department (specialty unit). The Second approach is made by linkage between admission diagnosis and relevant order sets.
The Third approach is made by comparing admission orders as they are written to existing order sets to diagnose which order set might be applicable.
The three approaches represent ways or mechanisms to make order seta usage efficient and effective.
The Second Controversy
Paper based order set had limitations that CPOE based order set can overcome. Paper based order sets have achieved the goal of standardized care and decrease reliance on clinician’s memory , the electronic order sets have achieved the same benefits and information can be delivered easily to clinician when it is needed.
Paper based order set may not be available at the time the physician need it , there is also lag between physical change to paper based order set and practices changes and more efforts are needed to standardize health care across organization. for Example , an effort to standardize the management of post operative nausea and vomiting based on available evidence require updates to every surgical post operative order set.
The old version of paper based order set may be available in patient care area for months. Several CPOE developing organization have implemented “pop up” algorithmic “advisor” to customize order set to current patient state for Example , implementing heparin therapy advisor should take into consideration the current medication of patient(e.g., not adding heparin if the patient is already on streptokinase) and most recent laboratory results .it’s not always easy to determine when to implement a given protocol as an order set or as “pop up” advisor.
The Third Controversy
Order set implementation without organization standards and inadequate maintenance leads to practicing outdated medicine.
Implementing order set within the system may present a challenge , Naming of order set should be designed effectively to help clinician to locate order set in the system . it is better to name the order set with name of department (e.g., pediatric surgery )followed by procedure and make order set searchable by department, procedure name , pre/ post operation. Order set maintenance represent significant challenge in face of updating clinical knowledge, s o lack of communication between formulary and quality committees can lead to order set inconsistent with recommended evidence based practice.
The Fourth Controversy
As clinical knowledge advances rapidly , clinician should develop their own order set that can use for their patients , because organization may take some time to develop updating for new order set request , but allowing clinician to develop their own order set will remove the standardization of order set Northwestern Memorial Hospital, VA Puget Sound, and Hackensack university medical center have avoided building personal order set. It was realized that personal order set were neither valued nor often used .
Order set may improve clinician efficiency and provide decision making guidance .Order set should be considered the basic building block of a clinical decision support system So the controversies discussed above should be taken into account as they may partially degrade the order set usage.
submitted by Shaimaa Hussein Abd Elghani