Online form a guide to best clinical practicesby Michael BakerPublic Relations Upon its initiation, the Clinicians’ Order Form Web site's (http://www.musc.edu/cce/ORDFRMS) purpose was to guide MUSC Medical Center employees towards the best clinical practices. After more than three years, the site conquered the challenge. According to John Heffner, M.D., MUSC medical director, and Rosemary Ellis, R.N., director of quality and patient safety, the site began quietly. It provided an online version of an admission order for patients with community acquired pneumonia. Physi-cians could complete the form electronically and print out a copy for clinical use. “Since they didn’t have to write everything by hand, it prevented errors of commission and omission,” Heffner explained. For example, certain boxes on the form always required checking; to prevent physicians from overlooking orders necessary for every patient, the online form pre-checked the required boxes. By letting the physician type information instead of writing, the form also reduced errors due to ambiguous handwriting. What started as a small step to improve clinical practices for one specific condition quickly gained momentum. Medical center employees gradually discovered the benefit of online forms, adding their own to the Web site’s cache. Now the site lists more than 400 order sets for 35 departments, centers, and patient functions. “Overall, we’ve received a very positive response,” Ellis said. “We conducted a limited survey of residents, attendings, pharmacists, and nursing staff, and the employees who used the site gave it consistently high marks.” Using a scale of 1-5, regular users ranked the site’s potential impact on quality of care and patient safety at a level of 4. The site’s ability to facilitate workflow received similar praise. Ellis and Heffner observed the site’s spreading popularity with increasing satisfaction. “We were delighted to see the discovery process, as more departments realized the Web site’s benefits,” Heffner said. “We approached the project with a Field of Dreams concept—if you build it, they will come. “One of the medical center’s continuing goals is to promote the best clinical practices, and the Web site presented a low-cost, low-technology way to improve our processes. Some of our surgeons requested additional printers in the operating room to print forms at the point of care.” The mini-anecdote represents just one example of how the site expanded since its inception. Three years removed from the initial availability of a single order form, the site now offers a variety of features at the point of care, including order forms, educational support tools, and clinical practice guidelines. One such tool is a form for the adult influenza vaccine. Nurses assess all adult patients admitted to the hospital and, when applicable, offer them the opportunity to receive the vaccination. Whereas the forms were not always immediately available, now physicians gain access with a few mouse clicks. “It’s been federally mandated that all hospitals achieve high vaccination rates, meaning that we routinely assess and immunize patients,” Heffner explained. “MUSC’s success rate ranks in the top 10 percent in the nation.” Patient education plays a significant role in the achievement. To help patients decide whether or not to receive the vaccination, the site offers a list of frequently asked questions about the injection. The questions address the benefits, risks, and general information about the vaccine. “It’s a way to hitchhike educational opportunities onto the order sets,” Heffner said. “The site benefits our employees, but we never lose our patient-centered approach.” Medical center employees can learn from the order sets as well. Many forms include helpful reminders—the potential for allergic reactions with certain medications, a viral strain’s resistance to a particular drug, and pharmacy contact information for dosing concerns. “It provides the right measure of guidance and the right measure of flexibility,” Heffner said. “The forms don’t dictate care, but they provide physicians with evidence-based information to guide their prescribing practices toward best care practices.” Adhering to that principle, the order sets represent care guidelines developed through a consensus of MUSC physicians. Physicians make diagnoses using personal judgment; then, the sets guide them to appropriate treatment opportunities. The goal is to decrease what Heffner called unexplained practice variation. “Such variation exists when there’s no good explanation as to why two physicians treat the same problem differently,” he said. “The order sets decrease this provider-specific practice variation and guide practice variation toward what's necessary to address the unique problems of individual patients. The sets make it easier for our physicians to do the right thing based on conclusions drawn from their own judgment.” “It really supports clinical decision making,” Ellis added. Because the medical world constantly updates its information, each order set is logged in a database. If treatment recommendations pertaining to a certain drug or treatment changes, the database can identify all applicable order sets to review and edit accordingly. While the order sets represent the foundation the site was built on, further support comes from the site’s educational resources. Medical center employees will find a link to the Centers for Disease Control and Prevention, which posts breaking medical news and health alerts. Elsewhere, links to the Department of Radiology’s PACS system and a massive electronic storehouse of medical journals and textbooks allow employees to share and obtain information from anywhere with Internet access. Decision support tools such as procedural guidelines—a guide to proper patient sedation, for example—are also available. The supplemental information underscores the importance of evidence-based decision-making. Heffner and Ellis agreed that it’s unrealistic to expect medical center caregivers to know everything, but they need to know where to get information when they need it. “We want our clinicians to have the tools to always do the right thing
at the right time for the right patient,” Heffner concluded.
Friday, July 30, 2004
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