Lon Setnik, MD FACEP, MHPE Date: [[2022-12-02]] #note/sharing | #on/emr %% # MOC Concept Why do I want to make this MOC? MOC Process: > - _**Cluster**_ ideas/notes together. > - Add lines between clusters (add the gaps). > - _**Chart**_ the empty spaces between clusters (map the gaps). > - _**Create**_ a new “thing” note. > - _**Create**_ a new “statement” note. > - _**Collide**_ your ideas. > - _**Clarify**_ your note titles. > - _**Connect**_ your notes. > - _**Cut up**_ a note into two. > - _**Combine**_ two notes into one. > - _**Cast aside**_ notes that are no longer relevant. > - _**Categorize**_ the notes in the MOC. _Mapping Concepts_ includes mostly creating links to other ideas. It is a higher order of note making. Creating Maps of concepts include finding the [[emergence]] and [[Convergence]]. This is an inherently [[Constructivism]] way of creating knowledge and storing ideas. It mirrors the way our brain works. It is a way of organizing and [[dealing with complexity]] [[Knowledge Value Making]] allows us to keep each note small, but to create meaning in and between each note. ```toc style: number min_depth: 2 max_depth: 6 ``` %% ## What's the big idea here? Order sets are an opportunity to clarify orders so they are neat, legible, and trackable as well as to reduce cognitive load of decision making by providing decision support for the orderer. However, they take synchronous care and make the ordering process asynchronous, pulling our teams apart and making it more difficult to create shared mental models and share case specific knowledge across roles. “Ultimately the system must create “meaning” (or information that can be acted upon) in the same way that the people do.” (“Making Sense of Clinical Practice: Order Set Design Strategies in CPOE Laurie L. Novak, PhD, MHSA”, p. 572) ### There are tradeoffs “Predefined order sets can improve the efficiency of computerized ordering by reducing the excess number of mouse clicks and keystrokes. However, the efficiency of computerized ordering can be significantly impaired by usability problems due to vague and incorrect system messages, unfamiliar language, and non-informative system feedback.” (Khajouei et al., 2010, p. 690) ### [[Nudge to allow choice and mold behavior]] “Default and chart redesign interventions reported the most substantial improvements in adherence to evidence and guideline-based practice.” (Lamprell et al., 2021, p. 175) “A simple intervention of retaining only “urinalysis with reflex to microscopy’ and removing all other urine tests from the “frequently-ordered” window of the ED electronic order-set decreased urine cultures ordered by 46.6% after accounting for temporal trends.” (Munigala et al., 2018, p. 2) ### Perceptions of the system evolve over time “Initial perceptions were driven by unfamiliarity with the system. As users became more proficient and efficient in using the CPOE system, additional safety benefits become apparent. However, accompanying increased reports of benefits were reports of usability problems and new types of errors arising from CPOE use. Reports of workarounds appeared for the first time at 6-month interviews. These workarounds were adopted to allow routine work to continue and to attenuate some of the perceived negative consequences of CPOE, including delayed medications and reduced patient interaction.” (Baysari et al., 2018, p. 5) ### Consider the different approaches to creating order sets based on the interaction between the end users and the state of knowledge ![[Approaches to order set development]] - #### Empirical - #### Local Consensus - #### Departmental %% ## Unrequited notes (by link) _update when creating MOC to point to this note_ These notes point directly to this note. But this note doesn't point back. ```dataview table file.mtime.year + "-" + file.mtime.month + "-" + file.mtime.day as Modified from [[Order Sets]] and !outgoing([[Order Sets]]) sort file.mtime desc ``` ## Associated notes (by tag) _Update when creating MOC to point to this tag_ These notes have this associated tag: `#MOC Template`. ```dataview table file.mtime.year + "-" + file.mtime.month + "-" + file.mtime.day as Modified from #on/ordersets and !outgoing([[Order Sets]]) sort file.mtime desc ``` %% ## Sources: Agrawal, A. (2009). Medication errors: Prevention using information technology systems. _British Journal of Clinical Pharmacology_, _67_(6), 681–686. [https://doi.org/10.1111/j.1365-2125.2009.03427.x](https://doi.org/10.1111/j.1365-2125.2009.03427.x) Ammenwerth, E., Schnell-Inderst, P., Machan, C., & Siebert, U. (2008). The Effect of Electronic Prescribing on Medication Errors and Adverse Drug Events: A Systematic Review. _Journal of the American Medical Informatics Association_, _15_(5), 585–600. [https://doi.org/10.1197/jamia.M2667](https://doi.org/10.1197/jamia.M2667) Baysari, M. T., Hardie, R.-A., Lake, R., Richardson, L., McCullagh, C., Gardo, A., & Westbrook, J. (2018). Longitudinal study of user experiences of a CPOE system in a pediatric hospital. _International Journal of Medical Informatics_, _109_, 5–14. [https://doi.org/10.1016/j.ijmedinf.2017.10.018](https://doi.org/10.1016/j.ijmedinf.2017.10.018) Beuscart-Zéphir, M.-C., Pelayo, S., Anceaux, F., Maxwell, D., & Guerlinger, S. (2007). Cognitive analysis of physicians and nurses cooperation in the medication ordering and administration process. _International Journal of Medical Informatics_, _76_, S65–S77. [https://doi.org/10.1016/j.ijmedinf.2006.05.022](https://doi.org/10.1016/j.ijmedinf.2006.05.022) Chan, A. J., Chan, J., Cafazzo, J. 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The Impact of CPOE Medication Systems’ Design Aspects on Usability, Workflow and Medication Orders: A Systematic Review. _Methods of Information in Medicine_, _49_(01), 03–19. [https://doi.org/10.3414/ME0630](https://doi.org/10.3414/ME0630) Khajouei, R., Peek, N., Wierenga, P. C., Kersten, M. J., & Jaspers, M. W. M. (2010). Effect of predefined order sets and usability problems on efficiency of computerized medication ordering. _International Journal of Medical Informatics_, _79_(10), 690–698. [https://doi.org/10.1016/j.ijmedinf.2010.08.001](https://doi.org/10.1016/j.ijmedinf.2010.08.001) Koppel, R. (2005). [No title found]. _Critical Care_, _9_(5), 427. [https://doi.org/10.1186/cc3804](https://doi.org/10.1186/cc3804) Kujala, S., Hörhammer, I., Kaipio, J., & Heponiemi, T. (2018). Health professionals’ expectations of a national patient portal for self-management. _International Journal of Medical Informatics_, _117_, 82–87. 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Impact of order set design on urine culturing practices at an academic medical centre emergency department. _BMJ Quality & Safety_, _27_(8), 587–592. [https://doi.org/10.1136/bmjqs-2017-006899](https://doi.org/10.1136/bmjqs-2017-006899) Reckmann, M. H., Westbrook, J. I., Koh, Y., Lo, C., & Day, R. O. (2009). Does Computerized Provider Order Entry Reduce Prescribing Errors for Hospital Inpatients? A Systematic Review. _Journal of the American Medical Informatics Association_, _16_(5), 613–623. [https://doi.org/10.1197/jamia.M3050](https://doi.org/10.1197/jamia.M3050) Shamliyan, T. A., Duval, S., Du, J., & Kane, R. L. (2007). Just What the Doctor Ordered. Review of the Evidence of the Impact of Computerized Physician Order Entry System on Medication Errors: Just What the Doctor Ordered. Review of the Evidence. _Health Services Research_, _43_(1p1), 32–53. [https://doi.org/10.1111/j.1475-6773.2007.00751.x](https://doi.org/10.1111/j.1475-6773.2007.00751.x) Wang, S. Y., & Groene, O. (2020). The effectiveness of behavioral economics-informed interventions on physician behavioral change: A systematic literature review. _PLOS ONE_, _15_(6), e0234149. [https://doi.org/10.1371/journal.pone.0234149](https://doi.org/10.1371/journal.pone.0234149) Watbled, L., Marcilly, R., Guerlinger, S., Bastien, J.-M. C., Beuscart-Zéphir, M.-C., & Beuscart, R. (2018). Combining usability evaluations to highlight the chain that leads from usability flaws to usage problems and then negative outcomes. _Journal of Biomedical Informatics_, _78_, 12–23. [https://doi.org/10.1016/j.jbi.2017.12.014](https://doi.org/10.1016/j.jbi.2017.12.014) Weiner, J. P., Kfuri, T., Chan, K., & Fowles, J. B. (2007). “e-Iatrogenesis”: The Most Critical Unintended Consequence of CPOE and other HIT. _Journal of the American Medical Informatics Association_, _14_(3), 387–388. [https://doi.org/10.1197/jamia.M2338](https://doi.org/10.1197/jamia.M2338)