by making changes in the text of the note before signing.
Breaking down the process to 2 separate templates was a critical decision for the continued success of this system. Several other facilities have attempted to develop 1-click templates for each treatment mode. The Kansas City VAMC, however, decided that requiring IRM to install and maintain a full template for each of the > 150 chemotherapy orders was impractical. Because the complex portion of the ordering process was isolated in the first template, the individual treatment templates could be very simple, prewritten forms with a blank field for dose information. These forms were built on a combination of clinical guidelines and local practice, and an oncology provider approved each before installation. Once the note has been generated, providers are free to enter notes and make modifications to the order to reflect the patient’s needs.
Due to the simplicity of the treatment templates, a new one can be installed in the shared file in minutes. Development of the initial library of templates took about 2 months. The order sets were developed from previously written chemotherapy orders and adapted to the electronic format. The new system went live 3.5 months after the concept was proposed, and handwritten chemotherapy orders are no longer accepted.
Creating forms for > 100 orders was a daunting task, particularly considering the need to consider both local practice and guideline recommendations with regards to both dosing of chemotherapy and supportive medications. Extensive physician involvement was required. At first it seemed to be too much work for something that might be an interim measure; however, any thirdparty solution would require a similar process, so now the facility is prepared if third-party chemotherapy ordering software is purchased.
Why Is This A Best Practice?
The ASHP guidelines promote the importance of chemotherapy order standardization. However, done without careful attention, facilities can standardize errors into practice. To prevent errors and double check documents, an additional process for handling the templates was developed. The pharmacy department developed new order templates, incorporating both local practices and accepted guidelines. The template is first sent to the oncology physician for careful review. On physician approval, it goes to IRM for installation into CPRS as well as to the Pharmacy and Therapeutics Committee for final review. This process provides permanent and accessible documentation of pre-implementation review.
The pharmacy and nursing staff are automatically notified when an order is signed. The new order is printed and reviewed by a pharmacist, and the ordered items are entered in the same system for processing. Providers frequently enter the orders in advance, allowing careful review and medication profiling to occur well before the patient arrives. The orders can be processed during off-peak hours, simplifying workload and potentially reducing errors.
The order format also offers an effective communication tool. Since the template is in a checklist format, the nursing staff are instructed clearly from the order how to administer the treatment. In fact, the practice is to take the order to the room and log all treatment times and details on the order sheet, facilitating highquality documentation of administration. This option was not available with handwritten orders.
The orders are templated sequentially; nurses give the medications in the order they are presented, preserving sequencing preferences for certain regimens. Calls and pages to clarify doses are kept to a minimum by prompting the provider to indicate parameters for retreatment and dosing preferences used (ideal body weight, etc).
The treatment templates were locally developed and based on provider practices. Although guidelines are helpful, they cannot be uniformly applied to all facilities. VA practice, for example, requires less aggressive pretreatment for nausea in many cases due to the nature of the population. Since this process was developed locally, it mirrors the prior common practices.
Experience With The Program
Both medical and nursing staff quickly accepted the new ordering system. It is estimated that veterans’ turnaround time has decreased by as much as 45 minutes. There are several ways the process saves patient time. Transportation of written orders has been eliminated, a frequent stumbling block in the process. The orders are now delivered immediately on signing to both pharmacy and nursing staff.
There is no more time lost clarifying poorly written, smudged, or otherwise illegible orders. The finished product is clear, legible, standardized, and readily available in CPRS for all authorized personnel to review. Problems are often identified well in advance of the patient’s arrival. Nurses are seldom surprised with add-on directives, since the orders are entered when the plan is made even if that is a week or more before the start of treatment. Electronic notification of new orders allows
