Summary
Objectives: Unwarranted variance in healthcare has been associated with prolonged length of stay,
diminished health and increased cost. Practice variance in the management of asthma
can be significant and few investigators have evaluated strategies to reduce this
variance. We hypothesized that selective redesign of order sets using different ways
to frame the order and physician decision-making in a computerized provider order
entry system could increase adherence to evidence-based care and reduce population-specific
variance.
Patients and Methods: The study focused on the use of an evidence-based asthma exacerbation order set in
the electronic health record (EHR) before and after order set redesign. In the Baseline
period, the EHR was queried for frequency of use of an asthma exacerbation order set
and its individual orders. Important individual orders with suboptimal use were targeted
for redesign. Data from a Post-Intervention period were then analyzed.
Results: In the Baseline period there were 245 patient visits in which the acute asthma exacerbation
order set was selected. The utilization frequency of most orders in the order set
during this period exceeded 90%. Three care items were targeted for intervention due
to suboptimal utilization: admission weight, activity center use and peak flow measurements.
In the Post-Intervention period there were 213 patient visits. Order set redesign
using different default order content resulted in significant improvement in the utilization
of orders for all 3 items: admission weight (79.2% to 94.8% utilization, p<0.001),
activity center (84.1% to 95.3% utilization, p<0.001) and peak flow (18.8% to 55.9%
utilization, p<0.001). Utilization of peak flow orders for children ≥8 years of age
increased from 42.7% to 94.1% (p<0.001).
Conclusions: Details of order set design greatly influence clinician prescribing behavior. Queries
of the EHR reveal variance associated with ordering frequencies. Targeting and changing
order set design elements in a CPOE system results in improved selection of evidence-based
care.
Keywords
Asthma - children - CPOE - decision support - framing - heuristic - order sets
