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Service Delivery Innovation Profile

Electronic Standing Orders Highlight Care Gaps and Allow Nonphysicians to Address Them, Leading to Increased Provision of Preventive Services


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Snapshot

Summary

Eight primary care practices adopted standing orders authorizing nonphysician clinical staff to provide preventive care services such as vaccinations and preventive health screenings. At the beginning of every visit (including sick visits and wellness examinations), clinical staff view a template in the electronic medical record that highlights gaps in care for 15 preventive services. During the visit, nonphysician staff discuss preventive care needs with the patient and then administer or provide a referral for all services the patient agrees to receive. The program significantly improved the ability of the practices to accurately identify care gaps before visits and discuss and address those gaps during them, leading to significant increases in the percentage of eligible patients receiving needed services.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons for each of the 15 targeted services of the median percentage of eligible patients who had care gaps accurately identified in the electronic medical record health maintenance template and actions recorded in the template related to the identified care gaps, and who had received the service in question.
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Developing Organizations

Practice Partner Research Network (PPRNet)
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Date First Implemented

2008

Problem Addressed

Primary care physicians generally lack the time, resources, and support to ensure the provision of all recommended preventive, screening, and chronic care services to patients. As a result, many patients do not receive needed services.
  • Insufficient time, resources, and support: The typical primary care physician would need to devote 18 hours each day to provide a panel of 2,000 patients with all recommended screenings and chronic disease care. This large time requirement stems in part from a lack of resources in most primary care offices, which tend to have few support staff and little access to electronic systems and tools to identify and address care gaps.1,2 Even practices with electronic medical records (EMRs) may not have standardized functions and processes that highlight a patient’s preventive care needs when patients visit for acute problems (rather than routine checkups) and that allow nonphysician staff to provide services without a physician order.3
  • Failure to provide recommended care: Because of these time and resource constraints, primary care practices often fail to provide patients with needed services. In fact, only about half (54.9 percent) of adult patients receive all recommended preventive care services.4
  • Unrealized potential of standing orders: Standing orders authorize nurses and other nonphysician clinical staff to provide services according to a preapproved protocol without a physician’s examination. Although they have been shown to improve provision of vaccinations and other health screenings,3 many practices do not routinely use them.

What They Did

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Description of the Innovative Activity

Eight primary care practices adopted standing orders authorizing nonphysician clinical staff to provide preventive care services such as vaccinations and preventive health screenings. At the beginning of every visit (including "sick" visits and wellness examinations), clinical staff view a template in the EMR that highlights gaps in care for 15 preventive services. During the visit, nonphysician staff discuss preventive care needs with the patient and administer or provide a referral for all services the patient agrees to receive. Although process steps vary by practice, key program elements generally include the following:
  • Review of preventive care needs: A nurse or medical assistant brings the patient to the examination room and retrieves the patient’s EMR. Regardless of the reason for the visit (e.g., acute health need, wellness visit), the staff member opens a summary “health maintenance” template that highlights in red the gaps in care related to 15 preventive care services; identified gaps are based on generally accepted recommendations from various outside organizations (see subbullets below for more details). In some practices, the template automatically opens, while in others the list of needed services appears in a progress note template so that staff can easily order them. In some practices, receptionists provide patients with an “update form” at check-in that lists needed preventive services. Targeted services include the following:
    • General preventive screening: These four services, based on screening recommendations from the U.S. Preventive Services Task Force available at the time (2008), include total and high-density lipoprotein (HDL) cholesterol screening in patients 20 and older every 5 years; mammogram for women 40 and older every 2 years; and bone mineral density screening for women 65 and older.
    • Adult immunizations: These six services, based on recommendations from the Centers for Disease Control and Prevention Advisory Committee on Immunization Practice, include tetanus/diphtheria for people age 12 and older in the last 10 years; a Pneumovax for patients 65 and older and for high-risk patients age 18 to 64; annual influenza vaccination for patients 50 and older and for high-risk patients age 18 to 49; and one-time zoster immunization (for shingles) for patients 60 and older.
    • Preventive screening for patients with diabetes: These five services, based on guidelines from the American Diabetes Association, include annual measurement of urine microalbumin, biannual measurement of hemoglobin A1c, and annual measurement of fasting triglycerides, HDL cholesterol, and low-density lipoprotein (LDL) cholesterol.
  • Provision or ordering of accepted services: During the initial part of the visit, the nonphysician staff member discusses all gaps in care with the patient and asks if he or she would like to receive the needed service(s). Standing orders authorize the staff to administer the service or provide referrals for those not available within the clinic (such as mammography) before the physician enters the room. If the patient is uncertain about one or more services, the clinical staff member notifies the physician so that he or she can discuss them further with the patient during the visit.
  • Documentation of action taken: The clinical staff member documents the action taken on each needed service by checking an appropriate box on the template. Potential actions include service provided (“Done”), referral provided (“Ordered”), service declined (“Refused”), service postponed (“Postponed”), or service already received at another location (“Elsewhere”). After the visit, staff update the template by changing “Ordered” actions to “Done” once test results have been received by the office.
  • Followup at next visit: Needed services continue to be highlighted in red until the “Done” or “Elsewhere” box has been checked. Staff followup with the patient about these services (and any new care gaps that arise in the interim) during the patient’s next visit.

Context of the Innovation

The Practice Partner Research Network (PPRNet), established by the Medical University of South Carolina in 1995, includes 193 physician practices in 42 states that collectively have more than 1,000 providers and serve approximately 2 million patients. PPRNet participants use a common EMR (Practice Partner® by McKesson, Inc.), submit quarterly data, receive benchmarking and performance improvement reports, and participate in research studies. PPRNet launched the standing order project after successfully responding to a request for proposals from the Practice Based Research Network Task Order of the Agency for Healthcare Research and Quality (AHRQ). The eight PPRNet practices participating in the program include five family practices, one internal medicine practice, and two multispecialty practices located in rural and urban regions in eight different states. Clinics range in size from 2 providers serving 1,200 patients to 25 providers serving 28,800 patients. Before launch of this program, these practices had never participated in a PPRNet study, meaning that they had not previously been exposed to the network's quality improvement methods.

Did It Work?

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Results

The program significantly improved the ability of the practices to accurately identify care gaps before visits and discuss and address those gaps during them, leading to significant increases in the percentage of eligible patients receiving needed services.
  • Better identification of care gaps: The percentage of eligible patients with gaps accurately listed on the health maintenance template increased for all targeted services, with inclusion rates reaching 90 percent for most services. For example, the percentage of eligible patients accurately identified as being in need of an HDL test increased from 21 to 95 percent after implementation of the program.
  • Improved ability to discuss and address identified gaps: The median percentage of eligible patients for whom providers discussed identified care needs and then documented the actions taken increased across all 15 targeted services. Representative improvements include cholesterol testing (which rose from 41 to 56 percent), mammography (35 to 60 percent), pneumococcal vaccination (40 to 66 percent), and hemoglobin A1c testing (6 to 54 percent). Overall, 7 of the 8 participating practices exhibited improvements in this area.
  • Increased provision of services: The program increased the provision of preventive care services. Six of the fifteen measures showed were statistically significant changes over the 21 months of this project: osteoporosis screening (increase from 44.6 to 52.0 percent); pneumococcal immunization in adults older than 65 (50.5 to 61.9 percent) and in high-risk patients (13.9 to 30.9 percent); tetanus immunization in patients older than 12 (35.3 to 46.1 percent); zoster immunization in patients older than 60 (3.1 to 16.1 percent); and urinary microalbumin screening in diabetes patients (34.3 to 52.7 percent). All other measures other than hemoglobin A1c in diabetes patients showed positive improvement trends.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons for each of the 15 targeted services of the median percentage of eligible patients who had care gaps accurately identified in the electronic medical record health maintenance template and actions recorded in the template related to the identified care gaps, and who had received the service in question.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Participant meeting: A PPRNet research team hosted a meeting of physician and nurse representatives from the eight participating practices in October 2008. During the session, team members taught participants about the standing orders, presented associated evidence supporting their use, and discussed strategies for implementing them. Participants also learned how to customize the health maintenance template to fit clinician needs and preferences in their own practices.
  • Implementation plan: Each practice developed an implementation plan, which involved working with technology-savvy staff to make changes to the template, creating a standing order protocol for staff, and developing a communication plan.
  • Educational efforts: Each practice held meetings to educate nonphysician staff about the standing orders and related care processes. These sessions included a demonstration on how to use the template. Some practices adopted the phrase “Get the Red Out” to emphasize the need to eliminate the gaps in care highlighted in red on the template. Some practices developed a form listing the patient’s completed and required preventive services for the patient to review in the waiting room.
  • Site visits: The research team made a site visit to each practice within 2 months of the initial meeting to help address implementation issues. A second site visit occurred in mid-2009 to review implementation and address ongoing technical issues.
  • Participant followup meeting: The research team held a followup meeting in September 2009 so that participants could share their experiences, challenges, and best practices and revise their implementation plans if necessary.
  • Final site visit or phone conference: The PPRNet research team held a final site visit or evaluation phone conference in March 2010 with each site to determine participants’ final lessons learned and opinions regarding sustainability.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
  • Costs: Upfront costs include travel-related expenses for practice and program staff (covered by grant funding) and revenue losses for participating practices during site visits from PPRNet staff. Each visit required the practices to close their doors to patients for 2 to 4 hours. Program-related operating expenses are minimal.
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Funding Sources

Agency for Healthcare Research and Quality
AHRQ funded this program through a 2-year grant totaling $458,000 (contract number HHSA29007100152 TO #2).end fs

Tools and Other Resources

The clinical practice guidelines used in the program can be found on the National Guideline Clearinghouse as follows:

General screening guidelines from the U.S. Preventive Services Task Force:

Adult immunization recommendations from the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices: http://www.cdc.gov/mmwr/pdf/wk/mm62e0128.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Diabetes screening guidelines from the American Diabetes Association:
http://www.guideline.gov/content.aspx?id=45153.

Adoption Considerations

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Getting Started with This Innovation

  • Sell benefits to physicians: Physicians may need to be convinced of the merits of standing orders, which authorize nonphysicians to order and administer services. To win their support, emphasize the potential of standing orders to increase practice capacity (and hence revenues) and improve the provision of needed services.
  • Identify project champions to set a positive tone: Informal leaders can help ensure buy-in from other clinicians by demonstrating the template and generally supporting use of standing orders.
  • Ensure that staff believe in prevention: Larger practices often face competing demands related to care provision and quality improvement. As a result, preventive care may not be viewed as a top priority. Education regarding the importance of preventive care services can help overcome this problem, but may not be enough. In fact, several participating practices ultimately parted ways with staff not amenable to providing preventive care services.
  • Provide adequate training: Most staff feel comfortable ordering and providing vaccinations, but may be unsure about certain tests, such as cholesterol screening. Staff training about the appropriateness of these tests should alleviate any concerns.
  • Embed program into existing workflow: Embed preventive service reminders into existing forms and templates so that clinical staff see them as part of their normal workflow.

Sustaining This Innovation

  • Reinforce value of system on ongoing basis: Practices should continually discuss and reinforce the benefits of preventive care and the value of the standing order system. Sharing data on the program's impact can help keep staff engaged.
  • Quickly address barriers: By quickly identifying and addressing technological and other barriers to ongoing operation of the program, program leaders can ensure sustained use of the standing orders.

More Information

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Contact the Innovator

Lynne S. Nemeth, RN, PhD
Associate Professor
Medical University of South Carolina
College of Nursing
Practice Partner Research Network (PPRNet)
99 Jonathan Lucas St
MSC 160
Charleston SC 29425
(843) 792-9122
E-mail: nemethl@musc.edu

Innovator Disclosures

Dr. Nemeth reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Final Progress Report: Implementation and Evaluation of Standing Orders Using Health Information Technology. Manuscript provided by the project developer.

Innovation Manuscript: Nemeth LS, Ornstein SM, Jenkins RG, Wessell AM, Nietert PJ. Implementing and Evaluating Electronic Standing Orders in Primary Care Practices: A PPRNet Study. J Am Board Fam Med September-October 2012; 25; 5 594-604 10.3122/jabfm.2012.05.110214.

More information about PPRNet is available at: http://academicdepartments.musc.edu/pprnet.

Footnotes

1 Ostbye T, Yarnall KS, Krause KM, et al. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005;3(3):209–14. [PubMed]
2 Yarnall KS, Pollak KI, Ostbye T, et al. Primary care: is there enough time for prevention? Am J Public Health. 2003;93(4):635–41. [PubMed]
3 Electronic standing orders in primary care offices boost the delivery of adult vaccinations and other health maintenance services. In: Schneider K, Nichols L, Stevens C, et al. Success stories from the AHRQ-funded health IT portfolio. Agency for Healthcare Research and Quality, 2009.
4 McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635–45. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: July 20, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 16, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.