Implementing Electronic Standing Orders in Primary Care
Implementing Electronic Standing Orders in Primary Care
Background: A standing order (SO) authorizes nurses and other staff to carry out medical orders per practice-approved protocol without a clinician's examination. This study implemented electronic SOs into the daily workflow of primary care practices; identified methods and strategies; determined barriers and facilitators; and measured changes in quality indicators resulting from electronic SOs.
Methods: Within 8 practices using the Practice Partner® electronic health record (EHR), a customized health maintenance template provided SOs for screening, immunization, and diabetes measures. EHR data extracts were used to calculate the presence and use of these measures on health maintenance templates and performance over 21 months. Qualitative observation/interviews at practice site visits, network meetings, and correspondence enabled synthesis of implementation issues.
Results: Improvements in template presence, use, and performance were found for 14 measures across all practices. Median improvements in screening ranged 6% to 10%; immunizations, 8% to 17%, and diabetes, 0% to 18%. Two practices achieved significant improvement on 14 of the 15 measures. All practices significantly improved on at least 3 of the measures.
Conclusions: A small sample of primary care practices implemented SOs for screening, immunizations and diabetes measures supported by PPRNet researchers. Technical competence and leadership to adapt EHR reminder tools helped staff adopt new roles and overcome barriers.
A standing order (SO) in primary care practice authorizes nurses and other staff to carry out a medical order according to a practice-approved protocol without a provider's examination or requirement for approval. By establishing SOs and empowering staff to complete them, practices can improve efficiency and quality of care. Success with the implementation of SOs is related to the education and enthusiasm of both clinicians and staff in the practice, as well as performance feedback and reminder systems. Previous research on SO use in primary care resulted in increased immunization rates for children and older adults in practices with paper-based medical records. To improve the delivery of preventive services, the strongest interventions have focused on organizational change that includes delegation of prevention activities. Research on the effectiveness and sustainability of other disease-specific SO systems is limited, however, and extending the repertoire of practice-approved protocols may improve overall quality in primary care.
Inherent within different electronic health record (EHR) systems are a variety of features to embed clinical guidelines to improve the quality of care, yet these are often only partially adopted by practices. Reminder systems offer good potential to prompt the delivery of preventive services, but ineffective training and technical support and competing demands in primary care may result in inadequate delivery of preventive services and chronic care management. Evidence is needed for the optimal use and impact of multifunctional, commercially available EHR systems. The purpose of this pilot demonstration study—Standing Orders-Translation of Research into Practice (SO-TRIP)—was to implement electronic health maintenance (HM) reminders for screening, immunizations, and diabetes care monitoring as SOs in a subset of PPRNet* practices.
Abstract and Introduction
Abstract
Background: A standing order (SO) authorizes nurses and other staff to carry out medical orders per practice-approved protocol without a clinician's examination. This study implemented electronic SOs into the daily workflow of primary care practices; identified methods and strategies; determined barriers and facilitators; and measured changes in quality indicators resulting from electronic SOs.
Methods: Within 8 practices using the Practice Partner® electronic health record (EHR), a customized health maintenance template provided SOs for screening, immunization, and diabetes measures. EHR data extracts were used to calculate the presence and use of these measures on health maintenance templates and performance over 21 months. Qualitative observation/interviews at practice site visits, network meetings, and correspondence enabled synthesis of implementation issues.
Results: Improvements in template presence, use, and performance were found for 14 measures across all practices. Median improvements in screening ranged 6% to 10%; immunizations, 8% to 17%, and diabetes, 0% to 18%. Two practices achieved significant improvement on 14 of the 15 measures. All practices significantly improved on at least 3 of the measures.
Conclusions: A small sample of primary care practices implemented SOs for screening, immunizations and diabetes measures supported by PPRNet researchers. Technical competence and leadership to adapt EHR reminder tools helped staff adopt new roles and overcome barriers.
Introduction
A standing order (SO) in primary care practice authorizes nurses and other staff to carry out a medical order according to a practice-approved protocol without a provider's examination or requirement for approval. By establishing SOs and empowering staff to complete them, practices can improve efficiency and quality of care. Success with the implementation of SOs is related to the education and enthusiasm of both clinicians and staff in the practice, as well as performance feedback and reminder systems. Previous research on SO use in primary care resulted in increased immunization rates for children and older adults in practices with paper-based medical records. To improve the delivery of preventive services, the strongest interventions have focused on organizational change that includes delegation of prevention activities. Research on the effectiveness and sustainability of other disease-specific SO systems is limited, however, and extending the repertoire of practice-approved protocols may improve overall quality in primary care.
Inherent within different electronic health record (EHR) systems are a variety of features to embed clinical guidelines to improve the quality of care, yet these are often only partially adopted by practices. Reminder systems offer good potential to prompt the delivery of preventive services, but ineffective training and technical support and competing demands in primary care may result in inadequate delivery of preventive services and chronic care management. Evidence is needed for the optimal use and impact of multifunctional, commercially available EHR systems. The purpose of this pilot demonstration study—Standing Orders-Translation of Research into Practice (SO-TRIP)—was to implement electronic health maintenance (HM) reminders for screening, immunizations, and diabetes care monitoring as SOs in a subset of PPRNet* practices.
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