HIMSS: Linking med orders gets results
ORLANDO, Fla.—Several years ago, hematology and oncology orders at Partners Healthcare Brigham & Women’s Hospital in Boston were mainly on paper, subject to a manual ordering process and orders within orders that were hard to follow. “We had over 800 protocols, regimens and treatment plans in the system, which had to be found and transcribed,” said Michael P. Sweet, team lead at Brigham & Women’s, during a Feb. 21 presentation at HIMSS11 titled "Linked Orders: Improving Safety in Scheduling and Administration of Medications."

The facility decided to make changes to its electronic medication administration record (EMAR) system to increase the safety of ordering chemotherapy agents, increase efficiency of ordering, and standardize templates and increase safety in administering chemotherapy and supporting medications.

The project added two applications to Brigham & Women’s System, took 36 months from start to finish, and cost about $3 million, said Sweet.

At the start of the three-year process, the hospital formed a governing committee and work groups that totaled 72 members, including physicians, pharmacists, nurses, analysts, developers and builders, said Sweet. In meetings, work groups looked at ordering systems and ordering review. They recommended taking orders out of orders and building standardized templates across the system.

“Step 1 was to come up with new chemo order entry system,” said Sweet. Brigham & Women’s developed a web-based system available across the organization, able to use templates and with standardized enterprise ordering, he said.

Access to the order entry screen is limited to ordering attendants, and screens for diagnosis, regimen, protocol and standard order information are included, along with an option for exception orders. “When this order gets to the pharmacy system, they know when to start scheduling,” he said. The orders screen contains templated folders that hold the chemotherapy orders, he said.

The ordering review had uncovered four types of order administration types:
  • Mutually exclusive: medications can’t be administered together
  • Mix together: medications should be combined
  • Sequential: medications should be administered in a certain order
  • Time offset: medications should be administered with time between

“Our system could handle sequential and time offset, but we wanted to make sure they weren’t administered out of sequence,” said Sweet. Therefore, Brigham & Women’s deployed a tool that links medication orders to the appropriate administration types—if an order for one medication changes, it affects all linked medications as well.

Once the work groups had figured out what they wanted the new system to do and how, “we were able to develop this from start to finish in three and a half months,” said Sweet.

Following extensive training that was tailored to each group affected by the new system, pharmacy and chemotherapy order entry was piloted first in hematology and oncology areas, and was implemented in a phased rollout with onsite support, he said. The complete EMAR rollout took 10 weeks, with four weeks of tailored support onsite and an additional month via pager.

Now the results are coming in. For 2010, the number of linked orders were:
  • Mix together medications: 851
  • Mutually exclusive medications: 2,500
  • Sequential medications: 6,947
  • Time offset medications: 13,570

“I can’t share with you what the alerts were yet … but suffice it to say there were a lot of alerts tracked in the system; things that were not sequenced, or timing offset,” he said.

Sweet concluded with this advice:
  • Never believe "never or "always." "When we got to the units, we developed a system based on what they never did and what they always did, and ended up making significant changes because it wasn’t the real practice on the units,” he said.
  • Know and understand the work flow. “Outpatient folks didn’t participate in the new orders program, and we didn’t make them, because it didn’t impact them a lot. But they didn’t understand what we were doing, and initially were entering orders wrong."
  • Hands-on training is best.
  • You can never communicate enough.