Effect of default order set settings on telemetry ordering

Abstract

Objective: To investigate the effects of adjusting the default order set settings on telemetry usage.

Materials and methods: We performed a retrospective, controlled, before-after study of patients admitted to a house staff medicine service at an academic medical center examining the effect of changing whether the admission telemetry order was pre-selected or not. Telemetry orders on admission and subsequent orders for telemetry were monitored pre- and post-change. Two other order sets that had no change in their default settings were used as controls.

Results: Between January 1, 2017 and May 1, 2018, there were 1, 163 patients admitted using the residency-customized version of the admission order set which initially had telemetry pre-selected. In this group of patients, there was a significant decrease in telemetry ordering in the post-intervention period: from 79.1% of patients in the 8.5 months prior ordered to have telemetry to 21.3% of patients ordered in the 7.5 months after (χ2 = 382; P < .001). There was no significant change in telemetry usage among patients admitted using the two control order sets.

Discussion: Default settings have been shown to affect clinician ordering behavior in multiple domains. Consistent with prior findings, our study shows that changing the order set settings can significantly affect ordering practices. Our study was limited in that we were unable to determine if the change in ordering behavior had significant impact on patient care or safety.

Conclusion: Decisions about default selections in electronic health record order sets can have significant consequences on ordering behavior.

Keywords: default order set settings; medical order entry systems; overutilization; telemetry.

Figure 1.

Screen shot of order set change. On Sept 21, 2017, the ECG Monitoring order (“telemetry”) was no longer preselected in Residency Order Set. Reproduced with permission from Epic.

Figure 2.

Percentage of order sets with telemetry ordered over the course of the study. A time series display of the 3 order sets used to admit patients to the medicine house staff service. The vertical line shows the date that the Residency Order Set (red) was changed to not preselect telemetry. There were no changes to the Alternate Order Set (gray) or the Noncustomized Order Set (gray).

Figure 3.

New orders for telemetry after hospital day 1. A time series display of ordering for telemetry after hospital day 1. The color reflects the order set that was used to admit the patient (red is Residency Order Set; gray is Alternate and Noncustomized Order Set). There was no increase in the number of new orders for telemetry after hospital day 1 after the intervention.