Therapy plans for therapeutic apheresis in Epic HealthLink

A common required duty of pathology resident physicians while rotating on transfusion medicine is the medical oversight of the therapeutic apheresis service. A task often performed on this clinical medicine service is formulating and writing orders for therapeutic apheresis procedures. The EpicCare tool called the therapy plan provides unique advantages over a standard electronic order set for therapeutic apheresis.


| INTRODUCTION
Organizing various medical orders together in useful categories has long been a goal of many electronic medical record implementations. 1 Electronic order sets are a commonly used tool to combine medical orders, allowing an ordering provider to place multiple orders quickly and accurately for a medical treatment.Despite their advantages and ease of use, order sets make all contained orders immediately active, making them less ideal for more extensive treatment regimens.
A "therapy plan" is a conditionally activated order set in HealthLink (the University of Wisconsin Hospital instance of the EpicCare electronic medical record software from Epic Systems Corporation, Verona, Wisconsin, USA) that aims to address some of the shortcomings of order sets.A therapy plan in HealthLink is a tool that is used to set up a block of standard orders, based on established protocols, to be released and administered multiple times.As opposed to an order set that contains orders that are always active, a therapy plan also hides certain orders until they are ready to be used.
One application of therapy plans is to therapeutic apheresis, where complex treatment regimens extend across multiple occurrences over several days or even months.In this context, a therapy plan has two major advantages over an order set: tidiness and efficiency.First, a therapy plan is tidier than an order set.A therapy plan makes the apheresis orders "active" only during the procedure and pre-procedure preparation.This is an improvement compared with an order set, as those orders remain in the "all orders" section continuously until they are discontinued.In the past, apheresis nurses had to sift through all active orders (often including backlogged unused orders for past apheresis procedures and dozens of inpatient orders that do not pertain to apheresis) to painstakingly pick out all the orders relevant to that apheresis procedure.Similarly, non-apheresis nurses would need to ignore all the apheresis orders that they saw.Moreover, a therapy plan is independent of the patient's inpatient or outpatient status, so changes do not need to be made solely due to a change in this status.
Second, a therapy plan has the potential to be more efficient and less error-prone than repetitively writing order sets for each procedure in a series.This is because one therapy plan may contain the orders to be used for several apheresis procedures across multiple days.At our institution, the ordering physician is the pathology resident rotating on the transfusion medicine service.Previously, they signed order sets every day for patients undergoing a procedure that day.With a therapy plan, the time spent may be dramatically shortened, as all orders are signed at once at the beginning of the apheresis regimen.After the first procedure, the resident verifies that an accurate therapy plan exists for each patient.While therapy plans contain orders for multiple instances, modifications over time are still possible, and the ordering physician only needs to modify the specific therapy plan order and not rewrite the entire set each time.We hasten to add that the therapy plan for every procedure is still reviewed in advance by the physician team.
Despite the perceived benefits of therapy plans for therapeutic apheresis, a literature search yielded no published articles illustrating their use.The only mention of EpicCare therapy plans in general was in an article coincidentally by transfusion medicine colleagues about therapeutic phlebotomy. 2 The relevance of this topic in pathology residency training is important to emphasize, as the most cited clinical pathology curriculum article currently in the medical literature includes a competency for residents to write physician orders for therapeutic apheresis procedures. 3

| MATERIALS AND METHODS
The development of treatment plans on HealthLink was performed by a multidisciplinary team that included representatives from transfusion medicine, apheresis nursing, pharmacy, and information technology.The team collaborated to create therapy plans for three therapeutic apheresis procedures (plasmapheresis, red cell exchange, and photopheresis), using existing order sets as a starting point.We started by creating therapy plans for plasmapheresis, red cell exchange, and photopheresis since these procedures comprise most of our work each year.The developed therapy plans incorporated numerous elements, including the treatment schedule, technical parameters for the procedures, orders for replacement fluid, anticoagulants, laboratory tests, vital signs measurement, communication triggers for contacting supervising physician, and PRN orders for saline and other medications that may be required during apheresis.The full treatment plans developed for each apheresis procedure are provided (Supplementary Materials S1-S3).The development of these therapy plans was IRB-exempt at our institution and did not require informed consent or clinical trial registration.
Technically, in practice therapy plans are required to be electronically signed by the ordering physician.Once a therapy plan is signed, appropriate individual orders are revealed at the time of the procedure by selecting "Begin Procedure" on HealthLink.This "unhides" the orders contained in the therapy plan for that procedure, creates an instance of a collection of orders from the therapy plan, and organizes them in a specific area of the patient chart.
At the end of the procedure, the nurse then selects "End Procedure" in HealthLink.This removes the used orders from the active orders section.If the therapy necessitates multiple instances, for example, multiple therapeutic apheresis procedures performed over several days, then the ordered therapy plan may be reused by selecting "Begin Procedure" at the next appointment.The physician on service also reviews and potentially modifies therapy plans prior to each procedure.

| RESULTS
During the period between October 27, 2015, and October 27, 2021, a total of 613 therapy plans were created and signed on HealthLink for plasmapheresis, red cell exchange, and photopheresis.While the design of this project does not provide for quantification of subjective observations from apheresis team members, anecdotal evidence from both physicians and nurses alike has been uniformly positive.User perception indicated generally increased efficiency and improved morale.
To estimate the benefits of using therapy plans as compared with electronic order sets, which were previously used at our institution, we conservatively assigned each therapy plan to correspond with five procedures, and thus five unique order sets.We estimate that each therapy plan and order set require 5 minutes to place and sign, whereas the review and potential modification of an existing therapy plan before a repeated procedure requires only 2 minutes.Using this calculation across the 6-year period examined, we estimate that 7969 minutes were spent placing and reviewing therapy plans.If order sets were used instead, this estimate would suggest 15325 minutes would have been spent by ordering physicians.Thus, as a rough approximation, using therapy plans may have decreased physician order entry time by just under 50%.These estimates, while crude, illustrate that therapy plans only need to be placed and signed once across repeated procedures, whereas traditionally order sets needed to be placed and signed for each procedure individually.

| DISCUSSION
The use of therapy plans when placing orders for therapeutic apheresis was pursued due to a perceived benefit in both efficiency and accuracy over the previous use of order sets.As indicated above, the implementation of therapy plans was a success at our institution, improving both efficiency and morale at multiple levels of the care team.
For medical residents, the ordering providers at our institution, therapy plans avoided the need to place orders for patients repeatedly.In addition, many residents reported that placing the same set of apheresis orders for the same patient repeatedly over the course of their training provided little educational value.Thus, residents reported that they were able to spend greater time on other patient care activities that added greater value to their training.
Nursing staff reported that therapy plans simplified the patient chart because apheresis orders were hidden until they were needed.Additionally, for apheresis nurses, activating therapy plans during a procedure consolidated the relevant orders in one place, allowing them to focus on the orders necessary for their role in patient care.The issue of backlogged unused orders for nonapheresis nurses was also eliminated, as all apheresisrelated orders were hidden once the apheresis procedure was concluded.
Another important advantage we speculate for this use case is that the use of therapy plans may increase patient safety.The placement of medical orders can cause errors despite many efforts to prevent them.By consolidating the entirety of the treatment regimen into one therapy plan and eliminating the need to place new orders for each procedure, the opportunities for introduction of human error in order placement are reduced.
Despite these advantages, one notable criticism of therapy plans came from some faculty physicians who thought therapy plans decreased resident practice in placing orders for therapeutic apheresis.These concerns were allayed for multiple reasons at our institution.One, there are enough new patients to provide adequate practice for the residents.However, we concede that the impacts and tradeoffs of therapy plans might vary from institution to institution depending on procedure volumes.At our institution, we judge that residents still have sufficient practice to be proficient at this task even with the use of therapy plans.Second, residents continue to review the therapy plans and make occasional necessary edits such as changing the treatment schedule, replacement fluids, and pre-procedure and intra-procedure medications that provide additional practice with the procedure.Third, the therapy plans only last for a maximum of 1 year at our institution.Thus, long-term outpatients that we treat for multiple years are another source of practice since existing therapy plans expire after 1 year and new plans must be written or re-signed.
Despite the novelty of therapy plans for therapeutic apheresis at our institution, the writers remain uncertain about the prevalence of its utilization at other institutions.As such, we do not claim this is the first implementation of therapy plans for this application.However, following a literature review that yielded no results, we present this work for possible adaptation or improvement by others.

| CONCLUSIONS
Herein, we present the implementation of therapy plans for therapeutic apheresis performed at our institution.Therapy plans offer a few distinct advantages over order sets.They separate relevant orders from the rest of a patient's medical orders while organizing them in one convenient place for apheresis nurses.One therapy plan can also be used for multiple procedures.Following their implementation, we anecdotally found an increase in efficiency and morale among both ordering physicians and nursing staff, highlighting the importance of utilizing technology to organize the medical management of specific patient needs.The goals of this article are to raise awareness of the existence of therapy plans and to share the complete content of three representative therapy plans that we created (one each for plasmapheresis, red cell exchange, and photopheresis).The reader may use