Implementing and Evaluating Electronic Standing Orders in Primary Care Practice: A PPRNet Study

Lynne S. Nemeth; Steven M. Ornstein; Ruth G. Jenkins; Andrea M. Wessell; Paul J. Nietert

doi:10.3122/jabfm.2012.05.110214

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Table 1. Study Measures Selected for Electronic Standing Orders

Screening^*	Adult Immunizations^{^†}	Patients With Diabetes^{^‡}
1. Cholesterol (≥20 years old in past 5 years)	1. Tetanus-diphtheria^{^§} (≥12 years old in past 10 years)	1. Annual urine microalbumin
2. HDL cholesterol (≥20 years old in past 5 years)	2. Pneumovax (≥65 years old ever recorded)	2. Hemoglobin A1c in past 6 months
3. Mammogram (women ≥40 years old in past 2 years)	3. Pneumovax^{^‖} (18–64 years/ high risk ever recorded)	3. Annual HDL
4. Bone mineral density (women ≥65 years old)	4. Influenza (≥50 years old in past year)	4. Annual LDL
	5. Influenza^{^¶} (18 to 49 years/high risk in past year)	5. Annual triglycerides
	6. Zoster (≥60 years old)

↵* U.S. Preventive Service Task Force recommendation level of evidence A or B (recommended or strongly recommended, benefits outweigh harms).
↵† Centers for Disease Control and Prevention Advisory Committee on Immunization Practices guideline.
↵‡ Expert consensus or clinical experience. Also included in the AHRQ National Healthcare Quality Report and American Diabetes Association 2008 guidelines.
↵§ Tetanus-diphtheria vaccine includes those with an acellular pertussis component.
↵‖ Patients with diabetes, heart disease, congestive heart failure, chronic obstructive pulmonary disease, chronic renal disease, or alcohol abuse.
↵¶ Patients with diabetes, heart disease, congestive heart failure, asthma, chronic obstructive pulmonary disease, chronic renal disease, or alcohol abuse.
HDL, high-density lipoprotein; LDL, low-density lipoprotein.

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Table 2. Characteristics of the 8 Practice Partner Research Network Practices within the Standing Order Translation of Research into Practice Study

State	Location^*	Specialty^{^†}	Adult Patients (n)^{^‡}	Providers (n)
ID	Urban	Family practice	1224	2
MO	Rural	Family practice	3313	4
MD	Urban	Family practice	3578	3
CT	Urban	Family practice	3767	4
WA	Rural	Multispecialty^{^†}	3872	11
NY	Urban	Internal medicine	10,400	11
NC	Urban	Family practice	11,057	14
TX	Urban	Multispecialty^{^†}	28,893	25
		Totals	66,104	74

↵* Rural practices identified through U.S. Census Bureau 2010 Urban and Rural Classification and Urban Area Criteria.
↵‡ Patients are defined as active in the practice if they have had a visit within 1 year and are not designated as deceased, demonstration, transferred, or inactive status.
↵† Multispecialty practices included family/internal medicine, pediatric, and obstetric/gynecology providers.

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Table 3. Practice Performance on Study Measures at Beginning (July 1, 2008) and End of Study (April 1, 2010) and the Number of Practices with Statistically Significant Improvements

Measure	Patients with Measure Present on Health Maintenance Template		Patients with Health Maintenance Template Use		Patients up to Date with Measure		Practices with Significant^{^†} Improvement over Time (n)^{^‡}
Measure	July 1, 2008	April 1, 2010	July 1, 2008	April 1, 2010	July 1, 2008	April 1, 2010
Screening
Cholesterol (≥18 years old)	92 (3789)	97 (3706)	41 (3271)	56^* (3606)	58 (3789)	64 (3706)	6
HDL cholesterol (≥18 years old)	21 (3789)	95^* (3706)	16 (892)	52^* (3357)	58 (3789)	64 (3706)	6
Mammography (women ≥40 years old)	92 (1489)	99 (1367)	35 (1453)	60^* (1359)	47 (1489)	57 (1367)	5
Osteoporosis (women ≥65 years old)	94 (445)	100 (473)	9 (361)	21^* (473)	45 (445)	52^* (473)	7
Immunizations
Pneumococcal (≥65 years old)	91 (712)	99 (763)	40 (650)	66^* (760)	50 (712)	62^* (763)	7
Pneumococcal (18–64 years old at high risk)	63 (354)	79 (392)	8 (139)	35^* (262)	14 (354)	31^* (392)	7
Influenza (≥50 years old)	51 (1763)	99^* (1849)	8 (1318)	37^* (1840)	24 (1763)	33 (1849)	2
Influenza (18–49 years old at high risk)	52 (228)	60 (257)	4 (84)	17^* (135)	14 (228)	22 (257)	3
Td vaccine (≥12 years old)	96 (4,227)	100^* (4139)	26 (3847)	46^* (4139)	35 (4227)	46^* (4139)	8
Zoster vaccine (≥60 years old)	0 (986)	100^* (1072)	0 (1)	28^* (1072)	3 (986)	16^* (1072)	8
Diabetes mellitus measures
Urine microalbumin	68 (400)	80^* (432)	9 (178)	44^* (351)	34 (400)	53^* (432)	6
Hemoglobin A1c	57 (400)	80^* (432)	6 (118)	54^* (351)	66 (400)	66 (432)	5
HDL cholesterol	85 (400)	99 (432)	37 (272)	67 (426)	70 (400)	76 (432)	6
LDL cholesterol	90 (400)	97 (432)	48 (303)	76^* (400)	70 (400)	77 (432)	6
Triglycerides	85 (400)	93 (432)	37 (272)	61 (350)	70 (400)	76 (432)	6

Practice performance measures are expressed as a percentages. The values provided in this table reflect the medians of these percentages across practices (and the median number of eligible patients per practice).
↵* P < .05 for trend over time across all practices using a general linear mixed model.
↵† P < .05 for trend over time within individual practices using a general linear mixed model.
↵‡ Out of a total of 8 practices.
HDL, high-density lipoprotein; LDL, low-density lipoprotein.

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Table 4. Barriers and Corresponding Facilitators Related to Implementing Electronic Standing Orders (SOs)

	Barriers	Facilitators
Staff	Staff perceptions about self-efficacy; liability	Practice policies and protocols
	Inconsistent use/attitudes of providers and staff within practice (spread)	Staff education and follow-up by leaders, liaisons (eg, staff meetings)
	Staff feeling the need to check with providers about order (especially laboratory tests)	Collaboration and good communication regarding expectations
	Time management concerns of some staff regarding new responsibilities	Staff interaction frees provider to address other health priorities
	Staff refusal/lack of follow through to adhere to SO protocol	Recruit staff that support a team based approach to patient care
Data issues within EHR	Health maintenance templates not applied to eligible patients	Technically savvy leader within practice applies set of templates
	Inexperience with customizing/applying templates and rule files	Demonstrate application and use of templates to all clinicians
	Distrust in the data to guide staff in acting on SOs	Nursing note templates and direct entry on health maintenance table
	Technical issues sometimes require vendor support
Patients	Patient refusal/lack of insurance for some services	Consistent practice wide approach/repeated messages
	Incomplete data on services patient received elsewhere	Patient information update forms generated from EHR data
Practices	Limited or no reimbursement for some immunizations	Referrals for patient to receive immunizations elsewhere (eg, public health clinics)
	Legal regulations in some states prohibiting SOs or immunizations by unlicensed clinical staff	Clinicians follow up after order initially discussed by clinical staff
	Competing priorities decrease practice focus on implementing SOs	Leaders and liaisons keep the focus clear, communication channels open