Clinical Decision Support TC Order Set Proposal

1. Clinical Decision Support TCOrder Set Proposal September 14, 2005

2. Why are order sets important? • Organize units of work for clinicians; critical for effective management of time in CPOE • Can be a medium for sharing clinical knowledge / structured actions • Commonly used to support protocols, care plans and critical paths • Important element of clinical guideline support

3. History of Proposal • American College of Physicians promoting order sets for implementation of care standards within member base • University of Nebraska and Intermountain Health independently created web-based order set environments for promoting CPOE • SAGE guideline consortium seeks interoperable order set definition as action element for guideline execution platform; now proceeding with implementation of guideline support for dynamic order sets • HL7 CDS technical group has sponsored convergence standard to support varied interests • Harmonization meetings with Patient Care and Structured Documents • Interim conference calls

4. Order Sets: Use Cases and implementation • Publication and localization: • I: Metadata for publication control • II: Orders specification for localizations into CIS • Clinical deployment • III: Presentation for clinical use • Interoperation • IV: Encoded order sets for • Guideline execution engine • Care plan support Order set exemplar: CA Pneumonia

5. Directions • August 2004: • Expand and develop proposal for layers I and II: supporting publication and localization • Advance demonstration project with ACP for order set dissemination • Begin work on layers III-IV with RIM harmonization supporting clinical presentation and interoperation • January 2005: • Reorganize help functions to “resource links” and avoid conflict with Infobutton discussions • Include observation events as order body item • Meet with CDA for convergence and harmonization

6. Directions • Noordwijkerhoot meeting • Involvement with Medical Care and CDA • Structural features proposed by Partners and IHC integrated within draft • Inclusion of goals and observations within order set body as order set items • June-July conference calls • Care plan integration • Expanded definitions • Order (set) session as one use case within care plan concept

7. Directions • June-July conference calls • RIM harmonization discussion: • Clinical statements RMIM proposed as integration model • Lloyd, Heath and Craig to participate in harmonization • XML model development • Support for dynamic layer III features • Integration of XML formulation into SAGE guideline engine for knowledge modeling and order set localization

8. CAP Guideline: For Class IV admissions, decision logic then recommends non-ICU admission order set

9. Working document: Version 10 changes • Relationship to care plans • “Care plan is an ordered assembly of expected or planned Acts, including observations, goals, services, appointments and procedures, usually organized in phases or sessions, which have the objective of organizing and managing health care activity for the patient, often focused upon one or more of the patient’s health care problems. Care plans may include order sets as actionable elements, usually supporting a single session or phase.” p 4

10. Working document: Version 10 changes • Relationship to care plans • “The order sets are prepared in (order) sessions as multi-disciplinary templates, including nursing, medical, pharmacy and allied health action items. The order sets have been reviewed by professional service organizations and are organized into problem oriented care plans wherein each order set serves to organize one session or phase of the overall plan of care. Problem and session encoding of order sets assure that order sets are employed in relevant clinical contexts and care plans, and that order sessions may be merged when multiple guidelines apply to a single patient.” p 3

11. Working document: Version 10 changes • Exclusion flag modified and expanded in scope, redefined as Boolean collective and moved to layer III to support manipulation and restrictive selection of collectives of orders • “Boolean collective [BooleanCollective; AND, OR, XOR supported] is a feature of layer III which identifies named sets of orders (collectives) to be manipulated and controlled at time of order set presentation. This supports menu options which may enforce exclusivity/concurrency of order set item at the time of order session processing.” p 5

12. Work items: near term • RMIM harmonization plans (Craig, Lloyd and Heath): • CDA Implementation guide development to begin • Clinical Statements pattern to be employed as reference source • Expansion and completion of XML model for integration into CDA implementation guide

13. Action items: Clinical decision support TC • Tool kit development for XML order set authoring • Validation plan employing institutional order sets from partners: • UC Davis • IHC • Micromedex • Stanford • ACP • Pick lists/structured input to be developed for value fields