Benjamin Anderson, PharmD, MPH
Configuration Analyst-Informatics
HealthEast Care System
St. Paul, Minnesota

As HealthEast Care System transitioned from paper order sets to a computerized prescriber order entry (CPOE) and began attesting to stage 1 of the Centers for Medicare & Medicaid Services’ meaningful use requirements, informatics team members identified several order sets and processes that could benefit from clinical decision support (CDS). One of the key areas was related to ordering and documenting venous thromboembolism (VTE) prophylaxis.

A specific order set for VTE prophylaxis for medical patients existed at HealthEast, but several medical admission and postoperative order sets also had separate sections containing VTE prophylaxis orders. These sections often did not have key components for compliance, such as exclusion criteria for mechanical/pharmacologic prophylaxis, risk stratification guidance, and listings of appropriate medications with consistent dosing parameters.

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Figure 1. VTE electronic order set link.
© 2013 HealthEast Care System

The health system addressed this with a few workflow changes between March 2010 and February 2012. first, most of the individual VTE prophylaxis sections were removed from other order sets and were replaced with a link to the VTE prophylaxis order set (Figure 1). For a few postoperative order sets (orthopedic, cardiovascular, and bariatric procedures, as well as stroke admissions), the VTE sections were left within the order set but additional CDS was applied to guide ordering. Second, the VTE prophylaxis order set was standardized to cover medical and postoperative patients. finally, several CDS tools were introduced into the VTE order set. The process resulted in 3 phases or iterations of the order set to allow full incorporation of provider feedback and address any issues that arose.

Phase 1 went live in March 2010, with changes focusing primarily on the introduction of CDS into the existing VTE prophylaxis order set and the addition of an expandable section for risk stratification (Table). This visually enhanced the order set and showed the provider only the recommended options that correlated with the stratification that was selected, thus removing the possibility of selecting prophylaxis options from the incorrect risk stratification. A required free-text field for “No pharmacological prophylaxis” was added. Under the new order set, enoxaparin doses were automatically adjusted based on the patient’s renal function and current health-system policy and orders were automatically placed for laboratory tests based on the medication selected for prophylaxis. Providers were receptive to these enhancements, which helped prepare them for subsequent changes.

Table. VTE Risk Stratification © 2013 HealthEast Care System
? No ? Low Risk ? Moderate to High Risk ? Very High Risk
Pharmacologic prophylaxis ordered at this time No VTE risk factors
  • Age >60 y
  • CVA, including PICC
  • History of COPD, CHF, IBD, respiratory failure
  • Family history of thrombosis
  • Medical patient with additional risk factor (MI, sepsis, COPD, CHF, respiratory failure, or history of malignancy)
  • Major surgery planned with additional risk factor (MI, sepsis, COPD, CHF, respiratory failure, or history of malignancy)
  • Morbid obesity (BMI ≥40)
  • Anesthesia time >60 min
  • Active cancer
  • Hip, pelvis, or leg fracture (<1 mo)
  • Stroke (<1 mo)
  • Acute spinal cord injury or major trauma (<1 mo)
  • Admit to ICU
  • Personal history of DVT, PE, or clotting disorder
  • Extended immobility (≥4 d)
BMI, body mass index; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CVA, central venous access; DVT, deep vein thrombosis; IBD, inflammatory bowel disease; MI, myocardial infarction; PE, pulmonary embolism; PICC, peripherally inserted central catheter

Phase 2 went live in June 2011 and focused on increasing use of the VTE prophylaxis order set and enhancements of the order set to ensure appropriate documentation and improve Clinical Quality Measures (CQM) metrics for VTE prophylaxis. The order set linking to an integrated link was changed, which automatically directed the provider to the VTE prophylaxis order set from medical admission order sets and prevented providers from bypassing the VTE order set. The free-text field with an expandable list of approved reasons for “No pharmacological prophylaxis” and “No mechanical prophylaxis” also was replaced. Based on the risk stratification selected for the patient, required field logic was introduced to ensure the correct therapies were ordered for the patient or appropriate documentation for “No prophylaxis” was recorded before the order set was submitted. These workflow changes were not reviewed with provider groups first and education about the new requirements was not provided, so subsequently there was some pushback from providers. This led to the temporary removal of the integrated linking functionality, but links to the VTE order set still remained.

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Figure 2. VTE patient selection and VTE addressed acknowledgment.
© 2013 HealthEast Care System

The primary goal of phase 3, which went live in February 2012, was to increase use of the standardized VTE order set for both medical and surgical patients admitted to the health system. The major changes included the introduction of a surgical patient option and a method to denote that VTE prophylaxis was already addressed for the patient (Figure 2). By including workflow for “VTE already addressed,” providers were open to the reintroduction of the integrated linking that automatically took them to the VTE order set from admission order sets. The addition of the surgical patient options allowed surgical admission patients to benefit from all the enhancements made to the order set. Additionally, per Surgical Care Improvement Project (SCIP) guidelines, instructions to the pharmacist to verify surgery end times before verifying pharmacologic prophylaxis orders were included. Order start times were offset by the appropriate number of hours from the time the order set was placed in the patient’s electronic medical record.

A final enhancement was the introduction of CQM VTE tracking orders. These unique orders for “not ordering pharmacological or mechanical prophylaxis” recorded the selected reason for not ordering a medication or therapy option to address VTE during the patient’s hospitalization; they also provided a convenient method to extract exclusion criteria and a mechanism through which pharmacists could follow up with providers who required additional education regarding use of the order set.

Based on prior feedback from providers, during phase 3 interactive demonstrations were conducted of the updated functionality for key provider groups to obtain provider buy-in. The changes that would allow for increased compliance with SCIP and CQM measures related to VTE prophylaxis were emphasized. Provider educators were asked to construct a brief 1-page document for providers, explaining the required fields in the form, how to address these fields, and how to bypass the order set if the patient’s VTE status was previously addressed during the hospital encounter.

In March 2012, the order set became available with all the phase 3 functionality, except for integrated linking from admission order sets. At that time, the electronic order set was used for 85% of all new admissions. This high rate of use during go-live was attributable to an increased visibility and volume of support staff available to help encourage use of the system. Once support returned to normal levels, usage of the form dramatically decreased. The availability of the order set with the absence of integrated linking reduced use of the order set. Then, once provider buy-in was achieved and the integrated linking was added back to the facility’s admission order sets in December 2012, VTE prophylaxis order set use returned to rates that were consistent with the overall CPOE usage for the facility. Overall, integrated linking proved to be a valuable tool for increasing the use of the standardized VTE order set (Figure 3).

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Figure 3. Percentage of new admissions using CPOE VTE order set.

SCIP VTE measures also showed improvement after the reintroduction of the integrated linking and automatic offsetting of start times for ordered medications.

Conclusion

Integrated linking, standardization of VTE prophylaxis ordering, and CDS have helped improve CQM and SCIP compliance throughout the HealthEast Care System. During the implementation of these changes, the health system learned about the importance of stakeholder buy-in for electronic workflows and education about new or enhanced functionality in the CPOE environment. Despite health-system leadership requesting enhancements to improve CQM and SCIP VTE measures, the initial attempt did not succeed due to lack of end user buy-in and education. A revised release, which involved the engagement of the stakeholders and used more integrated discussion, focused education, and a rollout plan allowed for a successful deployment of integrated linking and use of required fields for documentation of VTE prophylaxis in patients at HealthEast Care System.