Evidence-Based Order Sets and CPOE: One Clinician Discusses His Organization's Transition to CPOE

Christopher Stolle, M.D., vice president-medical affairs at the three-hospital Riverside Health System in Newport News, Va., has been helping to lead clinical transformation at that organization. He has helped put the emphasis on evidence-based order sets as he and his colleagues have moved forward with computerized physician order entry (CPOE), supported by evidence-based order sets from the Los Angeles-based Zynx Health. Those 177 order sets were used to help facilitate the standardization of the hospital system’s existing order sets. Dr. Stolle spoke recently of the progress that’s been made at Riverside Health System, with HCI Editor-in-Chief Mark Hagland.

Healthcare Informatics: You’ve been implementing evidence-based order sets?

Christopher Stolle, M.D.: Yes, we started in early 2008, and have used the Zynx order sets as a training model as we transitioned into CPOE. We went live on CPOE in November 2009, and we’ve been doing a year-long rollout. We’re at 60 percent now with about 166 doctors, and will be close to 100 percent by the end of this year.

HCI: What are the biggest issues transitioning into CPOE, and how have you handled them?

Stolle: When you start rolling out evidence-based order sets, the perception among most people is that these are physician order sets. But the reality is, this is an opportunity for other folks to decide how they want to receive those orders. So having nurses, pharmacists, lab, radiology, and nutrition, is equally important. I’m an OB-GYN, and I will order an 1,888-kilocalorie diet for my patient, and I’ve done that for years; but the problem is, someone’s always had to interpret that into an order. So this an opportunity for them to make sense of it, so that what’s on the order set is on the computer and is offered by the hospital, so that there’s no communication problem.

HCI: What has the attitude of physicians at your health system been so far?

Stolle: It has been cautious; and that’s been the real value of the Zynx order sets. We said, we want to develop the order sets on paper and make them perfect, so that when we go to CPOE, you’re simply automating those. Having the Zynx order sets on paper for six to 12 months first really smoothed that transition.

HCI: Have there been any differences among specialties, in terms of adopting evidence-based order sets?

Stolle: Different areas have different needs. Our hospital-based physicians, including our hospitalists, were by far our highest users, but also the easiest to implement, because their patients are almost entirely in-house. With the surgeons, they were doing some of their ordering even before the patients were in the hospital, so you had to deal with the transitions into the hospital from outpatient and back again. The challenges were more dealing with different needs than with different attitudes.

HCI: What lessons have you learned from implementing and using evidence-based order sets, that you’d like to share with CIOs and other IT leaders?

Stolle: Most clinicians understand, and sometimes the folks in IT don’t appreciate, how little of what we do there’s actually evidence for. So when you talk about an evidence-based order set, maybe 20 percent actually has evidence to support it, and the other 80 percent is really the art of medicine.

HCI: Thus, it’s really more consensus-based than evidence-based, right?

Stolle: Exactly. And the less evidence there is, the more argument there tends to be. So all the stakeholders have to learn to be flexible; there may not be right way to do it.

HCI: Healthcare is moving through two revolutions at once, its Industrial Revolution and Information Age revolution, and thus, the challenge of automation becomes interwoven with the challenge of standardization and systematization, don’t you agree?

Stolle: I absolutely agree. And with the computer revolution, there are gains in industry; but in patient care, the sell to individual practitioners is a much harder sell, because of loss of productivity. For example, the hospitalists said to us, we’re seeing 30 patients per day, and this [ordering through the CPOE system] is costing us three minutes per patient, which translates to 90 minutes a day. The flip side of that was, it was saving 540 minutes a day on the patient side in terms of medication orders, because of a decrease in the length of time from the moment the doctor entered the order to the moment the pharmacy got the order to the patient. And it was saving 2,900 minutes a day in the processing of the other ancillary [diagnostic imaging and lab] orders, across all patients, per day. But we’ve shifted that time burden to doctors.

HCI: So how do you get their buy-in, then?

Stolle: You focus your sell on the benefit to the patient and say, look, when you write a pain medication order for this patient, the patient is getting that pain medication faster; when you write an antibiotic order for a patient, they’re getting that antibiotic faster. When you talk about outside physicians with only five patients in-house, that’s only 15 minutes a day.

HCI: So they have bought in?

Stolle: Yes, they have bought in. The 90 minutes was very early on; as they became more familiar with the system, and learned the shortcuts in the CPOE, they’ve been able to whittle that time down a little bit.

HCI: As we move away from the lone-wolf model of care in terms of physician practice, are physicians accepting this new, collaborative model of care?

Stolle: I believe doctors have for a long time been moving away from the lone-wolf model. An orthopedist will consult with a cardiologist in a heartbeat. I think that what we see is variation within a particular specialty. Meanwhile, physicians are recognizing that there can be agreement on a particular antibiotic or agreement within a specialty on how to treat pneumonia, and that’s OK to treat the patient the same way. And I think that physicians are getting used to that. But what I say is that as we move into standardized order sets, it actually increases, rather than decreases, my obligation to determine how different a particular patient is—I need to recognize when a particular patient has different needs or a different situation. It will never be an excuse for a physician to say, well, I followed that order set.

HCI: Do you feel pretty confident about the 2011 attestation of meaningful use?

Stolle: Yes, fortunately for us, we started down this path quite early, before we knew about meaningful use. So we feel pretty confident about meeting the requirements for 2011.