Podcast interview with Dr. Chris Stolle re:Zynx order sets (transcript)

This is the transcript of my recent podcast interview with Riverside Health's Dr. Chris Stolle.David Williams: This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I'm speaking today with Dr. Chris Stolle.  He is VP of medical affairs at Riverside Regional Medical Center in Virginia.  Dr. Stolle, thanks for your time today.Dr. Chris Stolle: My pleasure.Williams: Tell me a little bit about Riverside and your role there.Stolle: Riverside Health System --when we started down our path with Zynx-- was three acute care facilities, a behavioral health rehab, multiple life long care.  Since that time we've acquired a fourth acute care facility and have just gotten a certificate of public need to build a fifth.We are going through the process of working with hospitals that have been involved with it for a while, working with a brand new hospital that we're bringing on that we'll be able to develop from the ground up, and then also working with a hospital that already had another system in place that we're trying to get converted over.  So we're really dealing from all the different perspectives of trying to bring up an electronic medical record and using the Zynx order set to help do that.Williams: Give me a sense of how you've handled order sets up until this point.Stolle: We actually started down the path of converting our order sets about two years ago.  We started out with about 470 order sets.  Since that time we completely redid the order sets using Zynx order sets.  We have about 170 Zynx order sets currently.Williams: What was it that made you decide to make the changes?  I understand you've got more facilities that you're bringing together, new ones that you're opening, but what was wrong with the status quo?Stolle: When we were looking at the old 470 sets of orders, they were usually physician specific.  They were not necessarily evidence based.  In addition to not being evidence based they were not updated on a regular basis.  Some of them hadn't been updated since the mid 1990's; although we know medical knowledge has changed since then the physicians were not particularly good at updating their own order sets.  We also had a very long and arduous approval process for our order sets. When we started making the conversion that was the first thing that we had to modify: how we get our order sets approved in a more timely fashion.Williams: What kinds of challenges did you encounter in terms of trying to standardize the order sets or reduce the number that are associated with specific physicians? Probably in some cases the evidence is clear cut and you can make an evidence based order set, but in other cases you still may need to have more of a consensus approach.Stolle: I think you make a very good point.  I would say even when there is evidence available, on any given order set there's probably only 30% to 40% of what we do that is actually supported by evidence. The rest of it is the art of medicine.As we all know different physicians are going to practice that art differently and wanted to reflect what their particular style is.  We made a couple of decisions early on in our design of these order sets.  The first decision was that there was not going to be any physician specific order sets. Everyone was going to use the same total replacement order set and so the order sets had to be the same for all the physicians. They had to be the same across all the hospitals so your pneumonia order set at Tappahannock is the same as a pneumonia order set at Riverside Regional.Those were some of the basic assumptions we started out with: no physician-specific order sets, standardization across disease processes and standardization across facilities.  That required us to get together with the doctors and get their input into the order set, but I don't think that that was the big key in moving forward.  The key with moving forward was making sure that the other folks knew that they had an important role to play. By “other folks” I mean the nurses and pharmacy and dietary and respiratory therapists.There was reluctance for the ancillary folks to get involved and for the nurses to get involved.  The thought process was these were physician order sets, so let the physicians decide what goes in them.  We sat down with them and said, “Look, this is your opportunity to smooth out the process for how orders are delivered to the nurses.  If you want the order to say a certain thing, in order accomplish a certain thing for your patients, you have input early on into what that should say.”For example, I'm an OB/GYN. I've written orders for an 1800 calorie diet for years and it wasn't until we started doing this process that I realized that the hospital didn't have an 1800 calorie diet.  They use something called a low carbohydrate diet. So I said when I write for an 1800 calorie diet and the patient ends up with a low carb diet, somehow it was the unit secretaries making that decision on what the doctor really wanted and how to translate that into what the hospital actually had.  So we said if we can get an alignment between the doctors’ orders and what the hospital actually carries and we can do that in dietary, we can do that in pharmacy, we can do that in lab. Once we got that part across to the lab people and to dietary and to pharmacy, the light sort of went off. They said, “Hey, this is how we do business and how we change our processes.  It's not just about order sets.”Williams: From what you're describing here it's a fairly broad initiative. It includes not just technology but also processes and culture when you bring everybody into the mix.Stolle: Absolutely.  I think that what started out as a project to make evidence based standardized order sets really ended up being a project of improving the processes that we have within the hospital and also getting a much better corporate image rather than being a bunch of different hospitals under the same brand logo.  There really is now a common practice from hospital to hospital.Williams: You mentioned at the start that you're in the midst of electronic medical record implementation.  Can you tell me a little bit about what you're doing with EMR, CPOE and how this ties in with the era of HITECH?Stolle: Absolutely.  From the very beginning we told physicians that our Zynx paper order sets were a stepping stone to the electronic medical record.  We developed the order sets within Zynx and put them out in paper form. First we used a non-PDF format and now an interactive PDF format for the physicians to use.We wanted to get the order sets very refined before we put them into the electronic medical record. With the paper format we had a link right next to the order set for the physician to give immediate feedback. If they wanted a different dosage of the medication or a medication added or taken away they had the opportunity to give immediate feedback on the order set.We wanted the order sets to be complete before we moved over to CPOE, because with CPOE it is much more difficult to change the order sets.  We also want the physicians not to be struggling with the orders sets when we got to CPOE, but just to be learning the computer portion of it.We were able to take our Zynx order sets and move our orders sets directly from Zynx using a bridge.  We were able to directly load the order sets from Zynx to the CPOE so that doctors were able to see exactly what they've been using in Zynx before the CPOE.Williams: What lessons have you learned that would be worth sharing with peer institutions? You've gone through what sounds like a broad and ambitious process.Stolle: It's turned out to be far broader than I think anyone ever expected at the beginning. It really has not just changed order sets but the actual way care is being provided to patients on the floors. It's also helped forge our corporate identity.As far as lessons learned I think there are a couple of important lessons to take away.  Number one is there has to be leadership buy-in to this.  There will be physicians who are resistant to moving to standardized order sets.  There will be physicians that are resistant to electronic medical records.I sat down with our corporate CEO, CMO, and COO and said, “Look, are you willing to lose physicians?  Are you willing to lose your busiest orthopedic surgeon or your busiest neurosurgeon if they refuse to move to standardized order sets or CPOE? Are you willing to say you can no longer practice at this facility?” The answer from them was a unanimous yes.Once we had that buy in, the physicians understood. We want your input as we move but if you don't join then all that's going to happen is you're going to have to use something that you haven't had an input into.  We're not going to slow down the process, we're not going to stop the process based on individuals trying to obstruct.Once you have that leadership buy-in everything falls much more neatly into place.  There has to be a statement from the top saying we are going to do this and there will be no exceptions to this policy.  That's the first lesson learned.The second lesson learned is although we call them physician order sets everybody has input into it and everybody has a say into how the practice of medicine in done in the hospital. The nurses’ input into the nursing portions of the orders are just as important as physicians’ input into the physicians’ portion of the orders and dietary’s portion is for dietary and lab is for lab and pharmacy is for pharmacy.We let the people who are responsible for that particular area of the order set take the lead.  The doctors really shouldn't be deciding on diets.  The doctor should order the diets but the hospital decides what diets are available based on best practice and based on usage. All 80 diets that are listed or that the hospital has available don't need to be listed on every order set.  Keep the order set small, keep it pertinent to what the doctor needs to order.The third lesson learned is that you need to have someone like our special projects coordinator.  Everybody is busy. If it’s left to individuals who are doing this as a collateral duty it won't get done.  You have to have somebody whose job is to make sure that they can coordinate between lab and dietary and nursing and the physicians and to set up the meetings and to facilitate the meetings to get these things done.  If it's just done as a collateral duty it will take forever.Williams: Those are very valuable pointers both on the strategic side and the more tactical side. To reinforce your first point about the leadership buy-in, it sounds very risky at first when you talk about willingness to lose doctors. But then as you said, once you get the leadership buy in you can really make things flow smoothly. If you don't do that you're probably subject to greater risk of failure because people don't take it seriously or they think they can just resist it and succeed.Stolle: You know we have seen that in the past.  When we first started a number of years ago to do this it would take a year to get a single order set done. That was essentially due to delaying tactics of individuals who chose not to participate.  Once you have that leadership buy-in that this is the corporate direction that we're heading and the willingness to say everybody is going to participate, it makes the whole process flow much more easily.Williams: Anything else?Stolle: Order sets are for everybody in the hospital and everybody should have an input.  The doctors, they're the ones doing the orders, but everyone else has to have a say as well.You don't want to get all the general surgeons in a room at one time talking about the general surgery order set.  You want to get a champion or maybe a couple champions per specialty to develop the order set and then put it out there for everybody to use and have an easy feedback mechanism for them to say I would change this or I would change that.    If you're trying to get 10 general surgeons or 12 orthopods or 6 neurosurgeons in a room to agree on anything it's just not going to happen.  Pick a couple of champions, develop the order sets and then put them out for use and be prepared to modify those order sets a