Nemeth LS, Ornstein SM, Jenkins RG, et al. "Implementing and evaluating electronic standing orders in primary care practice: a PPRNet study."

Nemeth LS, Ornstein SM, Jenkins RG, et al. Implementing and evaluating electronic standing orders in primary care practice: a PPRNet study. J Am Board Fam Med 2012 Sep-Oct;25(5):594-604.
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(R) 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.

To implement an electronic standing order (SO) system into daily workflow in 8 primary care practices, identifying the best methods and strategies utilized and to determine barriers and facilitators to the use of electronic SOs in these practices; and to measure changes in quality of care indicators resulting from use of electronic SOs.

Tools Used
Type Clinic
Primary care and specialty care
Type Specific
Family practice
Small and/or medium
Urban and rural
Other Information
Practices belonged to PPRNet, a national primary care practice-based research network established in 1995. Project was conducted in 8 primary care practices from 8 states, with 2-25 clinicians per practice.
Type of Health IT
Electronic health records (EHR)
Computerized clinical reminders (CRs) and alerts
Type of Health IT Functions
The PP Health Maintenance (HM) system was adapted at the practice level to create templates based on age, sex, diagnoses, and medications. Utilities within the EHR allowed application of templates based on diagnoses and an extensive list of synonyms for the diagnoses. The HM system calculates when procedures are due based on rules created with the template, displaying all procedures relevant for the patient and highlighting overdue items in red. Overdue items also were viewable on a chart summary screen and, as desired by the practice, in a pop-up window when a patient's chart was opened.
Context or other IT in place
All practices use the Practice Partner (PP) patient records as their EHR.
Workflow-Related Findings
Practices with the greatest improvement had established policies and protocols and educated their staff about their new roles.
Study Design
Pre-postintervention (no control group)
Study Participants
Providers in 8 primary care practices.