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Order Set and OPA Governance

This is the full policy and procedure. For how to submit a request, see OPA and Order Set Requests.

Freeman Health System, Clinical Informatics. Drafted September 4, 2026. Modeled on the Inova Health System order set review program (XGM 2026, ClinAC097) with Inova's permission to adapt. Part A is the policy: the standing rules Freeman adopts for order sets, SmartSets, and OurPractice Advisories (OPAs). Part B is the procedure that carries the policy out.

Version 1.0. Approved by the Provider Advisory Council September 17, 2026, and by the Pharmacy and Therapeutics Committee and the Medical Executive Committee October 13, 2026. The official policy is on the Freeman Policies and Procedures site (Freeman network only).

Part A: Policy

A1. Purpose

To define how order sets, order panels, ambulatory SmartSets, and OPAs are requested, approved, built, validated, released, reviewed, and retired at Freeman Health System, so that clinical decision support content is current, evidence-based, safe, and maintained without unnecessary burden on clinicians.

A2. Scope

Applies to all Freeman facilities and clinics using Epic, to all physicians, APPs, pharmacists, nurses, and staff who request or review this content, and to the Information Systems teams that build it. Applies to inpatient order sets and panels, ambulatory SmartSets, and OPAs. Does not apply to personal preference lists, user versions of order sets, or single order and medication records governed by their own application teams.

A3. Policy statements

1. All requests for new, changed, or retired order sets, SmartSets, and OPAs are submitted through the IT Service Request system. Requests received by other means are redirected there and are not acted on until submitted.
2. Every request is triaged by the Clinical Informatics team before assignment. Triage determines scope, duplication, form, required approvals, and completeness.
3. Epic Round Table is the system of record for all review, decision, build, and validation documentation. Instructions, comments, and issues not documented in Round Table are not acted on by the build team.
4. Clinical content decisions belong to the designated clinical owner for the specialty. Build teams implement approved decisions and do not interpret unresolved discussion.
5. The Pharmacy and Therapeutics Committee reviews any order set that contains medications, and any other request at the discretion of the Pharmacy P&T Coordinator. Adding a medication to an order set is an order set change: it goes through the Round Table review process and P&T review of the medication content. Adding a medication to the Freeman formulary is not an order set change: it does not go through Round Table, but it does go to P&T. A medication that is not on formulary must be approved by P&T before it can be built into an order set. The Pharmacy P&T Coordinator determines which path applies when the requester is unsure.
6. New OPAs and material changes to existing OPAs require approval by the Decision Support Committee before build. Retirement of an OPA that reduces alert burden without patient safety risk may be approved electronically.
7. All content is validated in a non-production environment and released only after open review comments are resolved and build is marked complete in Round Table.
8. Release dates are scheduled and published in advance. Off-cycle release requires Clinical Informatics approval and is limited to patient safety.
9. Every order set, SmartSet, and OPA is reviewed on a scheduled periodic cycle: annually for protocols, in keeping with accreditation standards, and every three years for all other content. Content with negligible use is retired on recommendation of the Round Table Coordinator and confirmation of the clinical owner.
10. Communication of released changes is shared: Information Systems issues the release notice to all affected disciplines, not providers only; the requesting department provides education to its own staff.
11. Requests outside the scope of this policy, or that duplicate existing content, are declined at triage with the reason documented in the request.

A4. Responsibilities

The roles in Part B, section 3 are defined by this policy. They are not changed, added, or removed without approval of the Provider Advisory Council, Medical Executive Committee, Pharmacy and Therapeutics Committee, and Decision Support Committee. Assignment of individuals to roles is an operational decision of the CMIO.

A5. Definitions

• Order set: a grouped collection of orders, panels, and instructions for a condition, procedure, or care phase in the inpatient setting.
• Order panel: a small reusable group of orders that can be placed alone or inside order sets. Panels are requested through the order set request type in ITSM, not a separate type. A panel goes through Round Table review when it affects more than one order set. A panel used inside a single set is reviewed with that set. Panels carry no periodic review cycle of their own; they are reviewed with the sets that contain them.
• SmartSet: the ambulatory equivalent of an order set, grouping orders, diagnoses, and follow-up.
• Protocol: an order set or order group that authorizes nursing or other licensed staff to initiate or adjust care under defined conditions without a provider order for each instance. Protocols require annual review under accreditation standards.
• OPA (OurPractice Advisory): an Epic alert that fires on a rule to prompt or restrict a user action. Formerly BestPractice Advisory.
• Round Table: Epic's activity for structured review, comment, approval, and build tracking of order sets and OPAs.
• Clinical owner: the physician or APP accountable for a specialty's order set content or for an alert.
• Clinical Informatics team: the CMIO and staff designated to perform intake and triage. Until the team is developed, the CMIO performs this function.

A6. References

Inova Health System, ClinAC097 Improving Order Set Review with Round Table, XGM 2026. Epic Round Table documentation. Freeman P&T Committee charter. Freeman Decision Support Committee charter.

Part B: Procedure

1. Purpose and scope

This process governs how order sets and OPAs are requested, approved, built, validated, released, and reviewed over time.

In scope from go-live:

• Inpatient order sets and order panels
• Ambulatory SmartSets
• OPAs (OurPractice Advisories, formerly BestPractice Advisories): new, changed, and retired

Out of scope, with examples of requests that will be declined at triage:

• Personal preference lists and user versions of order sets (built by the provider in the User Settings Lab, not through this process)
• Shared building blocks used across all admissions, such as code status and ADT orders
• Single order records, medication records, and lab build that belong to their own application teams
• Requests that duplicate an existing set or alert

2. Principles

1. Round Table is the source of truth. If a request, comment, decision, or issue is not documented in Round Table, it is not getting built. Email and Teams messages are not instructions to the build team.
2. One intake. Every request starts as an IT Service Request in ITSM. No side channels.
3. The Clinical Informatics team triages every request before anything is assigned. Until the team is developed, this is the CMIO.
4. Clinical owners decide. Analysts build. The build team does not interpret discussions or chase answers. Every comment thread ends in a clear decision before build starts.
5. Fixed, published dates. Review, build, validation, and release windows are set in advance and held.
6. Pharmacy review follows the P&T rule in section 5. Not every order set goes to P&T.

3. Roles

Roles, not names. People change; the process does not.

Owners are instructed not to close review periods. Builders close them when records move to production.

4. Intake through ITSM

All requests are submitted through IT Service Request at fhsitsm.saasit.com ↗. Four request types:

1. New Order Set or SmartSet
2. Order Set or SmartSet Change
3. New OPA
4. OPA Change or Retirement

Required at submission:

• Requester name, specialty, and department
• Request type
• Name of the existing set or alert (for changes) or the proposed name and clinical purpose (for new)
• One paragraph on what should change or be built and why
• Whether any new medication, dose, or route is involved (yes, no, unsure)
• Clinical owner, if known
• Urgency: routine, or patient safety with a one-line justification

Detailed line-item changes do not go in the ticket. They go in Round Table once the review period is opened, so the requester enters them once.

The ticket routes to the Clinical Informatics team for triage.

5. Clinical Informatics triage

Within five business days of submission, the Clinical Informatics team completes five checks and records the outcome in the ticket.

1. Scope. Is this an order set, SmartSet, or OPA request within section 1? If not, decline with the reason and, where one exists, the correct path.
2. Duplication. Does a similar set or alert already exist? If yes for a new set, the existing set becomes the starting point. If yes for a change, the request is merged into the existing record.
3. Form. Order set, order panel, or SmartSet. All three arrive on the same order set request type; triage decides the form. Panels are preferred for small reusable groups of orders that belong inside several sets. A panel that affects more than one order set gets its own Round Table review period; a panel used inside a single set is reviewed with that set.
4. Approvals. Apply the P&T rule below and, for OPAs, the DSC path in section 8. Identify the clinical owner.
5. Completeness. Is there enough detail to route? If not, return to the requester with the specific gap.

The P&T rule. P&T reviews any order set that contains medications, and any other request at the discretion of the Pharmacy P&T Coordinator. Two things are easily confused. Adding a medication to an order set is an order set change: it goes through the Round Table review process, with pharmacy review and P&T review of the medication content. Adding a medication to the Freeman formulary is a separate action: it does not go through Round Table, but it does go to P&T. A medication that is not on formulary must be approved by P&T before it can be built into an order set. The Pharmacy P&T Coordinator makes the determination when the requester marks "unsure." This rule is policy statement A3.5.

After triage, the Clinical Informatics team routes the ticket to the Epic Inpatient Lead or Epic Outpatient Lead for analyst assignment.

6. Workflow A: order set or SmartSet change

1. ITSM request submitted (section 4).
2. Clinical Informatics triage (section 5). Ticket routed to the Epic lead.
3. Epic lead assigns the orders analyst and, when medications are involved, the pharmacy analyst. The ticket is the parent record for the orders build; a child task tracks the pharmacy build.
4. Round Table Coordinator opens an ad hoc review period on the set and assigns the clinical owner, reviewers, and builders.
5. Requester and reviewers enter the change details in Round Table as comments at the correct level: set-level comments on the set, order-level comments on the specific order or panel. Each comment includes order name or ID, dose, rate, frequency, and priority where applicable.
6. Pharmacy P&T Coordinator reviews the medication content in the set and documents the outcome in Round Table, routing to P&T where the medication is not yet on formulary.
7. Clinical owner approves or rejects each comment. Coordinator adds a final summary comment stating exactly what will be built.
8. Owner submits to builders. Build is completed in POC (adjust environment as needed).
9. Build migrated to the validation environment. Reviewers validate against the approved comments and document any issues in Round Table by reopening the relevant comment. No issue reported outside Round Table is actioned.
10. Analysts fix issues and mark build complete in Round Table.
11. Migration to PRD on the published release date. Builder closes the review period.
12. Communication and education (section 10).

Ad hoc review periods are short, typically two weeks, because the requester already knows what they want. Comments not entered by the close of the period wait for the next opportunity.

7. Workflow B: new order set or SmartSet

Follows Workflow A with these additions:

• Similar set exists. The analyst copies the existing set as the starting point (for example, a pediatric version of an adult set). A Round Table review period is opened on the copy and the requester documents the differences there.
• No similar set exists. The Clinical Informatics team, clinical owner, and analyst hold a scoping meeting to convert the ticket's attachments and description into a build plan. This is the one step in the process where a meeting is expected.
• P&T. Any new set containing medications goes to P&T. Anything not yet on formulary must be approved by P&T before it is built. Apply the rule; do not assume.
• Validation. Reviewers sign in to the validation environment with generic logins, practice the set as a user would, and document feedback in Round Table before the first release. A new set is not released until its review period shows approved comments and completed build.

8. Workflow C: OPA new, change, or retirement

1. ITSM request submitted with the alert-specific detail: trigger, target population, action requested of the user, acknowledge and override reasons, and expected firing volume. For changes and retirements, current firing and override data if available.
2. Clinical Informatics triage. Safety-critical requests are flagged for electronic DSC vote.
3. Decision Support Committee reviews at its next monthly or bimonthly meeting, or electronically for ad hoc items. Outcomes: approve, approve with changes, defer for data, or decline. The decision is recorded in the ticket.
4. Approved requests route to the Epic lead for analyst assignment, and the Coordinator opens a Round Table review period on the alert.
5. Build, validation, and release follow Workflow A steps 5 through 12, with the clinical owner and DSC representative as reviewers.
6. Post-release check. Thirty days after release, the Coordinator pulls firing count and override rate and posts them in Round Table. The DSC reviews alerts with override rates above 75 percent for revision or retirement.

Retirement requests that reduce alert burden without patient safety risk may be approved electronically without waiting for a meeting.

9. Validation and release

• Validation happens in POC (adjust environment as needed).
• Reviewers use generic role-based logins. Feedback goes in Round Table only.
• Analysts fix issues before migration. No build moves to PRD with open comments.
• Release dates are published on the master schedule. Off-cycle releases are limited to patient safety fixes approved by the Clinical Informatics team.

10. Communication and education

Responsibility is shared.

• IT owns the release communication. The analyst confirms migration; the Coordinator posts the change summary from Round Table to the Medical Staff Hub (freemanmedstaff.com) and to the Freeman Epic and Provider Education SharePoint sites. The notice goes to every discipline the change touches, not providers only: physicians, APPs, nursing, pharmacy, and ancillary teams.
• The department owns education. The clinical owner and department leadership teach their own staff what changed and why, using the Round Table summary. Champions and Super Users support at the elbow.

11. Periodic review

The full library is reviewed at go-live. That review is the baseline for the periodic cycle. Order panels have no periodic cycle of their own; they are reviewed with the order sets that contain them, and on request.

• First periodic cycle begins January 1, 2027. All content was refreshed for go-live with last review dates no later than June 2026.
• Cadence: protocols are reviewed annually. All other order sets, SmartSets, and OPAs are reviewed every three years, divided into Year A, Year B, and Year C by service line and specialty.
• Review year: eleven months. December is held open for no scheduled review.
• Schedule: published a year in advance. Each review month has fixed windows: reviewer initial review (four weeks), owner approval due date, build (three to four weeks), reviewer validation (two weeks), fix period (two weeks), migrate and test (one week), communication, release. Buffer is built around holidays and ad hoc load.
• Electronic review: when a month's scheduled volume is high, or one or two urgent reviews are needed outside the schedule, the Coordinator may open an electronic review period in Round Table without waiting for the next scheduled month.
• Target turnaround: 60 days from review close to release.
• Volume (estimates, to be adjusted as the library grows): approximately 175 order sets at go-live, of which about 25 are protocols. Annual protocol review plus one third of the remaining 150 sets yields roughly 75 reviews per year, or about 7 per month across the eleven review months.
• Specialties: Freeman has 31 specialties, of which roughly 10 own inpatient order sets. The published schedule defines which specialties fall in each review month. Specialties are grouped so that each one reviews in one month, or at most two, per year.
• Just-in-time training: the Coordinator posts a top-level comment in every review period with usage data for the set, its synonyms, and the review instructions. Low-usage sets are flagged as retirement candidates in that comment.
• Retirement: sets with negligible usage over the prior year are recommended for retirement by the Coordinator and confirmed by the clinical owner. Retired sets are recorded in the master spreadsheet.
• Master spreadsheet: the Coordinator maintains the list of active and retired sets and alerts with service line, specialty, owner role, review year, last review, and next review. It is the schedule record; Round Table remains the content record.

12. Decision rights and escalation

13. Metrics

Reported quarterly by the Coordinator:

• Mean days from build start to release, by request type
• Mean days from ticket submission to triage
• Open comments per review period at close
• Reviewer completion rate per period
• Sets and alerts retired
• OPA firing counts and override rates
• Meeting hours avoided (scoping meetings held versus requests processed)

14. Phasing around go-live

• Through October 23: library build is complete; changes are limited to safety fixes and go-live readiness.
• October 24 through December 31 (stabilization): ad hoc Workflow A only, with shortened review periods. No periodic review. Expect a surge of change requests; triage prioritizes patient safety, then high-volume sets.
• January 1, 2027: first periodic review month opens per the published schedule. Ad hoc requests continue alongside.

15. For providers: how to request a change

Submit an IT Service Request for a new or changed order set, SmartSet, or OPA. Describe what you want and why in a paragraph. The Clinical Informatics team reviews every request within five business days and tells you the next step. If your request moves forward, you will be added to a Round Table review period in Epic where you enter the specific changes and can see progress, approvals, and the release date. Anything you want built must be written in Round Table; a message to an analyst does not count. Release dates are published in advance, and your department leads your colleagues' education on the change.

Version 1.0. Approved by the Provider Advisory Council September 17, 2026, and by the Pharmacy and Therapeutics Committee and the Medical Executive Committee October 13, 2026. The official policy is on the Freeman Policies and Procedures site (Freeman network only).