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Will EMRs help verbal order compliance?
The Centers for Medicare & Medicaid Services (CMS) in 2007 stipulated a five-year period in which verbal orders must be "dated, timed, and authenticated promptly by the prescribing practitioner or another practitioner responsible for the care of the patient, even if the order did not originate with him or her. CMS believes this temporary revision to the authentication requirement will reduce burden and provide flexibility for hospitals until the advancement of health information technology is sufficient to allow the prescribing practitioner to authenticate his or her own orders promptly and efficiently."
After that five-year period, in 2012, only the prescribing practitioner will be able to sign verbal orders. The time frame was given with the assumption that hospitals in 2012 will have the electronic capability to do all orders electronically. But according to a 2009 study in the New England Journal of Medicine by Jha et al, only 1.5% of hospitals "have a comprehensive electronic-records system (i.e., present in all clinical units)" and "an additional 7.6% have a basic system (i.e., present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals."1
Most experts are skeptical that in 2012 widespread electronic systems will be used. But the University of California, Davis, Medical Center has been using an electronic medical record and computerized physician-order entry, and verbal-order compliance has increased.
Alice Zeboski, RN, health information management with the University of California, Davis, along with her colleagues wrote an article in the August 2004 issue of the Journal of AHIMA on the compliance struggle with verbal orders.2 In that article, the authors wrote: "It was obvious that the system of ongoing education, manual monitoring of orders, and the labor-intensive process of flagging orders was not effective. The HIM labor cost for flagging unsigned orders, post-discharge data collection, and supervisory monitoring and reporting totaled approximately $250,000 in 1998. Yet even this type of investment did not result in the level of compliance necessary to avoid Type 1 recommendations from The Joint Commission."
In 2003, fines were enforced — $10 charged to the department for each verbal order not signed. Now the system is electronic. Now, an individual department is fined if compliance is less than 90%. In December 2009, Zeboski says a total of 3,821 verbal orders were given, with 93% compliance.
Now, reports are run by order type. "We can get a count of how many verbal orders were given within that time frame and then the system records when an order is signed," she says. Verbal order with readback is an order type; standard mode is what physicians use when they enter the order themselves.
Unsigned verbal orders are now routed to the physicians' inbasket, and they can read the order and sign those that appear in their inbasket.
"It certainly has helped in that the overall numbers of verbal orders has decreased since we went to the computer order entry, and also as the physicians' workload is now almost entirely, as far as documentation goes, in the EMR. They're in the EMR more and so they're aware of orders to sign, and they don't have to make a special effort to sign on to a separate system to look for verbal orders. They are in the system documenting, reviewing labs, and so it's just a better workflow for them to know when they've got orders to sign or work to do," she says.
Doctors also get electronic reminders if they have unsigned verbal orders. She says she still struggles with some departments that aren't in the EMR as much, such as some of the surgeons, ED physicians, and anesthesiologists. "We work with individual departments, and their administrative support pages them and reminds them to check the EMR for verbal orders."
There was a steep learning curve in going electronic, and fines during that time were not mandated. She says it was daunting to many of the physicians, particularly older ones who hadn't grown up with computers. Sometimes, she says, they would throw their hands up and say, "Forget it. I'm just going to have the nurse enter this for me."
"The nurses had to stand firm and we stuck with a policy that said verbal orders would only be accepted in emergency situations or when it wasn't practical for the physician to enter it themselves."
But the expectation was that physicians would enter their own orders. "And of course with order sets there weren't as many, the need to enter orders wasn't as great anymore because they didn't accidentally forget to order something for nausea or they didn't forget something for pain. It was all a much more structured process for order entry," she says.
"I think you have to make sure that you have a good process in place, that you have good procedures for entering the orders, and of course having the technology, having a computerized system to create and sign the order made it a lot easier on the physicians... And you have to have administrative support," she says.