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Friday, May 27, 2011

What are order sets?

Due to the Keystone Collaborative of Michigan, Michigan hospitals are now the envy of the nation, and have even caught the eye of President Obama. One of the key features of the commission is to encourage hospitals to install order sets for each particular diagnosis (DRG).

In the past order sets were rejected by doctors mainly because they viewed order sets as cook book medicine. So, what is cook book medicine?

Cook Book Medicine: Treating all patients with a given DRG the same way.

Obviously this wasn't thought to be a good idea. While the main goal of the commission is to help hospitals improve patient outcomes and reduce costs, I believe the main goal is to make sure a patient meets the criteria for receiving a reimbursement check from the Centers for Medicare and Medicaid Services (CMS).

As you know, CMS has set standards for minimal care they will reimburse for. It doesn't come down to the personal opinion of the doctor treating each patient according to what is best for the patient. What it comes down to is the fact CMS decided in order to reduce it's cost (not the hospital's cost), it will only reimburse if it's own reimbursement criteria is met (see this post).

Thus, if order sets were to the benefit of the patient, they would have been enacted many moons ago. The truth is, order sets were never enacted until CMS increased it's standards on what patients will meet criteria for reimbursement.

So based on Keystone Recommendations, many hospitals in Michigan have adopted Order sets. So what is an order set?

Order sets: This is a sheet of paper a nurse pulls from a drawer that has on it all the procedures that are recommended for that particular diagnosis. It pretty much lists anything a doctor might want to order, plus anything CMS might recommend for that patient to meet criteria for reimbursement (this is key). This type of order set would be ideal because it simply acts as a reminder of what the doctor might want to order to help the patient.

Pre-checked order sets: Many of the boxes on order sets at many hospitals are pre-checked. This means they are ordered automatically and are mandatory whether the doctor thinks they are needed or not. Due to government criteria, many hospitals have had no choice but to resort to doing this.

  • Puts the doctor, nurses and all other staff (including RT) on the same page
  • Assures best practice medicine is met for this patient
  • Makes sure doctors don't forget to order what is recommended or needed
  • Allows hospital to modify care based on evidence based practice
  • Increases organization so you know what will be ordered for a patient
  • Everyone knows their role in regards to that patient
Disadvantages of order sets (unintended consequences):
  • Treating all patients the same
  • Decreases doctor autonomy
  • Decreases incentive to think outside the box (critical thinking)
  • Many unnecessary orders
  • Causes burnout due to too many procedures
  • Causes apathy due to burnout and lack of ability (or lack of time) to do critical thinking

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