Clinical order sets are a key component in building an electronic health record and advancing the development of a planned Computerized Provider Order Entry (CPOE) system in Island Health.
A clinical order set provides support in making clinical decisions for a specific condition or medical procedure, through a standardized set of orders for treating a patient and managing their medication requirements. Clinical order sets in Island Health are developed for regional use by clinical experts with a multi-disciplinary approach using the best evidence available. They are used by physicians, midwives or nurse practitioners with prescribing authority to order tests, medications and procedures for patients.
While Island Health works toward building a CPOE system, clinical order sets are currently stored electronically but printed off for use. Unlike the existing paper system, it is anticipated that the CPOE system will offer opportunity for just-in-time changes, easy access to additional evidence, links to decision support tools and alerts to assist the prescriber in their ordering practices.
By introducing a computerized clinical order set system through a CPOE, Island Health aims to:
• Facilitate quality patient care with improved safety and reduction in the risk of errors
• Support evidence-based best practices
• Improve workflow with standardization of content and form
• Increase legibility and decrease transcription errors
• Support and foster best practice
• Reduce phone calls to clarify orders
• Incorporate standards and enable compliance with regulatory bodies and practices such as accreditation, operating room checklist requirements, Safer Healthcare Now!, and Ministry of Health requirements (also known as key result areas).