Implementation and Evaluation of Standing Orders Using Health Information Technology

Standing orders authorize nurses and other appropriate medical staff to provide services or order tests, procedures, or services outside of the office without specific physician authorization on a given patient. Standing orders are based on office policies which follow strict protocols. This project implemented and examined the effectiveness of an electronic standing order process. A health maintenance template within the local electronic medical record (EMR) was used for the process. Research has shown that the use of traditional paper-based standing orders increases utilization of preventive care such as immunizations. The use of electronic standing orders was therefore hypothesized to similarly enhance quality improvement (QI) by further improving preventive and chronic care measures. The main objectives of the project were to:

• Facilitate the initiation of an electronic standing order system and its incorporation into daily workflow in eight primary care practices, identifying best methods and strategies.
• Determine barriers and facilitators to the uptake and sustained use of electronic standing orders in these practices.
• Document changes in quality of care indicators and practice time management resulting from the use of electronic standing orders.
• Disseminate findings to the rest of the research network and publish results in a peer-reviewed medical journal.

There were 15 outcome measures utilized in this study which included: four screening measures (total cholesterol, HDL-cholesterol, mammograms, and osteoporosis); six adult immunization measures (tetanus, zoster, and two measures each for influenza and pneumonia); and five diabetes measures (HbA1c, urinary microalbumin, HDL-cholesterol, LDL-cholesterol, and triglycerides).

The project used a mixed-methods design. Quantitative data measures were calculated from quarterly extracts from the EMR, and qualitative data were obtained through observation and interviews during practice site visits, network meetings, e-mails, and phone correspondence.

Improvements in template presence, template use, and QI performance were found for 14 measures across all practices, demonstrating that the practices applied the health maintenance templates to their EMR system. Median improvements ranged from six to 10 percent in screenings, eight to 17 percent in immunizations, and zero to 18 percent in diabetes measures. Larger changes in template presence were noted in testing for HDL-cholesterol, influenza vaccinations for individuals' 50-plus years-of-age, and zoster vaccinations for individuals' 60-plus years-of-age, indicating that reminders were not commonly used for these patients prior to the project.

Qualitative methods were used to determine the barriers and facilitators to the adoption and continued use of a new electronic standard orders system within each practice. Facilitators included establishing practice protocols, editing and activation of health maintenance templates, use of nursing note templates, and dissemination of patient update forms. Barriers included staff perceptions, limited staff education and followup, EMR technical issues, reimbursement policies for some services, and patient refusal. Two of the eight practices had difficulty incorporating the standard order protocol because of larger practice size and diversity (multispecialty and an internal medicine group) of clinicians.