Ordering is an activity of healthcare prescribers whereby tasks are identified, allocated and timed so that investigations, medications and other interventions support patient care goals. All orders have a request component and an action component.
Orders can be placed for immediate, future or ongoing action within an encounter (e.g., inpatient admission). This is the default understanding when orders are entered in a specific context. Inpatient orders relate to inpatient and emergency encounters, and outpatient orders relate to ambulatory care.
It is possible to enter orders in one care context with expectation that they will be actioned within another context. A typical example is "external orders" entered during an inpatient encounter. The external orders become active after discharge or during a procedural leave of absence. External orders are frequently used for post-discharge tests, procedures, home care and referrals. They are also commonly used for diagnostic imaging performed at facilities outside the inpatient's current facility.
External order workflows are different from typical inpatient workflows, and are entered in a different ordering activity.
Orders can span multiple encounters and contexts when placed as part of an therapy plan or multi-encounter episode of care. They can also be attached to specific phases of care, such that they activate when a specific event occurs (e.g., post-operative recovery room).
Sometimes orders are placed in a particular context (e.g., community, long term care) but are to be acted upon by a service that spans inpatient, outpatient and continuing care contexts. A"Mobile Integrated Healthcare" (MIH, a community paramedicine program within AHS Emergency Medical Services) leverages paramedics to provide interventions in settings where such services would not otherwise be available. This includes:
Minor surgical procedures (e.g., laceration repair, suture removal, wound debridement)
Point of care testing and diagnostics
Parenteral therapies and transfusions
Orders for these interventions might be placed from virtual hospital, long term care or remote clinic settings. There are some special considerations. The best way to enter the right MIH orders is to select interventions from within Connect Care MIH Order Sets (virtual hospital and Connect Care LTC facilities) and Smart Sets (community, clinic and non-Connect Care LTC facilities).
The Connect Care clinical information system (CIS) enables ordering of all medications, procedures, investigations and interventions available anywhere in Alberta. Understandably, orderable items may be subject to local restrictions, availability or other constraints. For the most part, the CIS is able to help with default values that are aware of the current context. Even so, orders can have great impact and therefore deserve attention to detail. The good news is that once context-sensitive details have been specified, the configured order can be saved as a personal preference with all typical settings pre-filled. Personalizing orders is one of the best ways to speed Connect Care workflows.
A variety of circumstances can make inpatient ordering more complicated. Urgent transfers – to or from emergency, critical care, operating room, dialysis, inpatient and reactivation services – can contribute to order litter in the form of duplicate, orphaned (not associated with a phase of care) or inactive orders that have not been cleared by prescribers on either side of a care context shift. Stray orders can make it harder to recognize and manage important orders. They can also bloat summative documents, such as transfer reports, that automatically pull in order lists.
Periodic “deOrderizing” should be done to find and remove inappropriate, unnecessary or misleading strays. Prescribers may be asked to do this by other healthcare team members who struggle to manage patients’ orders. Tips describe activity-based processes that can restore order to orders:
There may be situations in which protocolled orders are placed by non-prescribers. Allowed CPOE exceptions are addressed within Connect Care Ordering Norms, which include reference to a process for requesting new exception types. Some delegated ordering workflows have unique requirements.
Ambulatory "Second Sign" Orders
Orders placed in ambulatory settings by AHS clerical staff and non-AHS Medical Office Assistants (MOAs) for medications, procedures, laboratory testing, diagnostic imaging procedures, cardiology procedures and surgical procedures (with some exceptions) must be "Second Signed".
With Second Sign, orders are not visible and cannot be carried out until the second signature is obtained electronically from a responsible prescriber. Once the second signature is applied, the affected orders can be acted upon. Compared to verbal orders needing co-sign, this adds an extra layer of patient safety. It also speeds up booking processes when clerical staff or MOAs initiate timely order workflows.
Clinical decision supports (e.g., duplicate test alerts) are active at the time of the Second Sign.
Pre-operative Orders Facilitated by Surgical Medical Office Assistants
Orders for upcoming operations initially entered by surgical medical office assistants (MOAs) must be "Second Signed" by a responsible surgeon.
Excluded from this workflow are: Case Request, Admission, Gastroenterology and Referral orders which follow a "Co-sign" workflow. The difference is that orders set up for co-sign are immediately visible in the system to other stakeholders, who can continue order-aware work while the order awaits the required co-sign.
MOAs entering orders for upcoming operations will see a pop-up alert reminding of Second Sign requirements and providing for confirmation of the intended authorizing provider.
Applicable orders will not be released (and so are not visible) until the second (surgeon) signature is placed (electronically).
Orders pending Second Signatures appear in a "review orders" section of Op Time navigators.
Responsible surgeons receive notification of orders with "Second Sign Needed" via In Basket messages, where they can be quickly signed.
Once the second signature is applied, the affected orders can be acted upon.