Many clients have asked Patton Healthcare Consultants to help them clarify the blurry lines of distinction between the terms standing orders, protocols, “favorites,” and order sets. The CMS interpretive guidelines make it clear that CMS’s intent is to establish a vetting or review process involving medical, nursing and pharmacy leadership for any “standing order” which would authorize a nurse to take action prior to the order from a practitioner. While the regulation uses the terms interchangeably, the interpretive guidelines specifically state: “Not all pre-printed and electronic order sets are considered a type of ‘standing order’ covered by this regulation.
Where the order set consists solely of menus of treatment or care options designated to facilitate the creation of a patient specific set of orders by a physician or other qualified practitioner authorized to write orders, and none of the treatment choices and actions can be initiated by a non-practitioner clinical staff before the physician or other qualified practitioner actually creates the patient-specific orders, such menu options does not create an order set that is a standing order covered by this regulation.”
Recently we asked CMS about physician “favorites” which are now used commonly within the CPOE utility of any Meaningful Use-compliant EMR system, and they responded that as long as the physician favorite does not include any actions to be taken before the physician authorizes their orders, then this would not be subject to the review process by medical, nursing and pharmacy leaders.
Given the potential for confusion by reinforcing the current lack of distinction between standing orders, protocols and order sets, we are suggesting that some group of experts try to define a nomenclature that is clearer and differentiates these types of orders. Many years ago there was some distinction that has gotten lost over the years and perhaps Joint Commission through its PTAC which includes CMS representatives as well as medical, nursing and pharmacy leaders could re-establish some distinct terminology. As a starting point for discussion, many years ago we defined these types of orders as follows:
Standing Orders: Orders which could be initiated by a nurse for a patient based on medical staff approval of a screening criteria and indication for all patients who meet the screening criteria and are not contraindicated. Classic examples might include influenza vaccine, pneumonia vaccine, hepatitis B vaccine, erythromycin eye ointment and vitamin K in newborn, or aspirin for individuals presenting in the ED with symptoms of an MI. Standing orders were rare, limited use situations.
Protocols: Detailed guidance on how to administer, dose or adjust a medication after an order to implement the protocol was authorized by a physician (or LIP). For example, vancomycin, dosing per protocol, heparin drip per protocol, ventilator management per protocol, etc. In these situations, the medical staff was asked to approve the (usually) evidence-based guidance in the protocol in advance of its use, usually through a review and recommendation of the P&T committee to the MEC, and then once approved, whenever indicated for a particular patient an LIP is required to order the protocol prior to the protocol being acted on (by pharmacy, nursing, radiology, respiratory therapy, etc.)
Order Sets: Compilations of orders on paper or electronic that may be ordered as a group by a physician or specific orders to be selected on the order set could be authorized by the physician. In either case nothing was administered until ordered. CMS would describe these as “menus of treatment or care options designated to facilitate the creation of a patient specific set of orders by a physician or other qualified practitioner authorized to write orders.” Practitioner “favorites” created within an electronic CPOE system would fit into this category, we believe.
While readers may recall from their practice slightly different terminology, creating an understandable lexicon seems like a worthwhile issue to pursue. If you agree, bring it up when TJC hosts its consultant forums, executive briefings, corporate forums, hospital advisory groups and the previously mentioned PTAC. Putting some distinction in the CAMH glossary seems like it might be helpful.
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