Reminder Dialogs and National Reporting

1. Reminder Dialogs and National Reporting Session # 227 CHUCK TALKS FOR INTRODUCTION, Housekeeping issues: Questions,CHUCK TALKS FOR INTRODUCTION, Housekeeping issues: Questions,

2. Faculty Charles Zeilman, III, PhD, ARNP, BSN, Chief Clinical Informatics Service Russell Jacobitz, BSN, RN Operations Manager Clinical Informatics Service Karl Sault, BSN, RN Clinical Applications Coordinator Debbie Trost Clinical Reminder Project Analyst, OI&T SLC

3. Overview Demographics Performance Measures Oryx Hedis Directives/Informational letters Clinical Reminder System Implementation Reporting/Feedback What’s Ahead for Reminders Package?

5. Organizational Chart Clinical Informatics Service COMMENTS About Structure- Own Clinical Informatics Service, Gained Access, As the largest facility in the Nation……..COMMENTS About Structure- Own Clinical Informatics Service, Gained Access, As the largest facility in the Nation……..

6. Performance Measures Oryx Measures developed by Joint Commission to meet the data reporting requirement associated with accreditation. Based on workload and mission, an accredited facility may use (3) core measures (AMI, PN, HF, SIP) or (9) non-core measures (developed by the organization) or a combination of both. Joint Commission will want to see data and QI as it relates to the ORYX measures. Hedis Health Plan Employer Data and Information Sets - a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans

7. Directives and Informational Letters Directives Establish mandatory VHA policies Example- VHA DIRECTIVE 2007-004 COLORECTAL CANCER SCREENING Informational Letters Release nondirective information of one-time interest or short duration; i.e., applications for training opportunities, describing new programs, announcing meetings, reminders etc. Example- ABDOMINAL AORTIC ANEURYSM (AAA) SCREENING IL 10-2007-011 Will discuss Directives and Informational letters along with issues to address with each the examples.Will discuss Directives and Informational letters along with issues to address with each the examples.

8. Process for Colorectal Cancer Screening Discussion of Directive: VHA DIRECTIVE 2007-004 COLORECTAL CANCER SCREENING Screening Test Options Positive Screening Test NFSG VHS Process OVERVIEW SLIDEOVERVIEW SLIDE

9. VHA DIRECTIVE 2007-004 COLORECTAL CANCER SCREENING Screening Tests: a. Home fecal occult blood test (FOBT) alone every year (three consecutive stool samples). b. Flexible sigmoidoscopy alone every 5 years. c. Home FOBT every year combined with flexible sigmoidoscopy every 5 years. d. Double Contrast Barium Enema (DCBE) every 5 years. e. Colonoscopy alone every 10 years.

10. VHA DIRECTIVE 2007-004 Positive Screening Test “For any positive screening test, the provider responsible for initiating follow-up must develop a follow-up plan or must document that no follow-up is indicated, within 14 calendar days of the screening test (day of laboratory receipt of FOBT, day of test for sigmoidoscopy, or DCBE). If a diagnostic colonoscopy is indicated, the colonoscopy must be performed within 60 calendar days of the positive screening test.”

11. VHA DIRECTIVE 2007-004 Positive Screening Test “FOBT results (positive) must be conveyed to the patient in writing or orally within 14 calendar days from day of laboratory receipt of FOBT” “Written reports of verbally-transmitted positive test results must be sent to the patient within 14 calendar days of the test date, unless the patient has already been scheduled for follow-up of the positive test.”

12. NFSG Process Colorectal Cancer Screening Collaborated with Key Stakeholders Associate Chief of Staff for Quality Improvement (Performance Measures) Chief, Clinical Informatics Service Gastroenterology Section Ambulatory Care Service

13. NFSG Process Colorectal Cancer Screening Issues Consistent documentation FOBT positive results and plan of care. Volume of FOBT positive lab results. Monthly average of 250 Positive FOBT Lab results. Identification of FOBT positive consults for colonoscopy. Volume of colonoscopy requests. Monthly average of 940 colonoscopy consults. Correlated to 250 (27%) FOBT Positive colonoscopy consult requests.

14. NFSG Process Colorectal Cancer Screening Issues Tracking and reporting of documentation for FOBT positive lab results and plan of care. Patient notification of positive screening test (FOBT) result. Tracking and reporting of consult completion time.

15. Process for AAA Screening Discussion of Informational Letter: ABDOMINAL AORTIC ANEURYSM SCREENING IL 10-2007-011 Recommendations from the VA National Center for Health Promotion and Disease Prevention (NCP): Men between the ages of 65 and 75 who have ever smoked need to be offered one-time screening for AAA, preferably with ultrasonography. Repeat Screening Recommendations: AAA Size less than 3.0 cm (normal) do not need repeat screening. AAA Size 3.0 to 3.9 cm need to be followed every 2-3 years. AAA Size 4.0 to 5.4 cm need to be followed every 6 months. AAA Size greater than 5.5 cm, referral for surgical intervention needs to be considered. In conjunction with this directive we downloaded the AAA Reminder from the Clinical Reminders Website.In conjunction with this directive we downloaded the AAA Reminder from the Clinical Reminders Website.

16. NFSG Process AAA Screening Collaborated with Key Stakeholders Associate Chief of Staff for Quality Improvement (Performance Measures) Chief, Clinical Informatics Service Surgical Service Chief and Vascular Section Chief Ambulatory Care Service Radiology Service OIT-Local CPRS Programmer

17. NFSG Process AAA Screening Issues Deployment of AAA Reminder for Screening. Pilot at Gainesville Facility to estimate demand on Vascular Service Consults and Radiology US & CT Scans. PCP Follow up Screening for Positive AAA. Tracking and reporting of positive screening to meet clinical standards. Concern for demand on Vascular Consult Service. AAA Download was modified to assist in PCP follow up for Positive Screening US.AAA Download was modified to assist in PCP follow up for Positive Screening US.

18. Russell Jacobitz BSN, RN Reminder Dialogs as a Solution The Clinical Reminder System Overview of reminders Advantages of using dialogs Application in regards to mentioned directives/initiatives Templates Form Letters

19. The Clinical Reminder System Clinical Reminders Overview: “The Clinical Reminder system helps caregivers deliver higher quality care to patients for both preventive health care and management of chronic conditions, and helps ensure that timely clinical interventions are initiated.” Primary goal to improve care for Veterans Assists in clinical decision-making, documentation and follow-up Place relevant orders within the reminder

20. The Clinical Reminder System Benefits for Clinical and Administrative Purposes: Provides data for clinical decision-making Reduces duplicate documentation Targets special patients populations Assists with compliance with VHA performance measures Assists with Health Promotion and Disease Prevention guidelines.

21. The Clinical Reminder System Reminder Dialogs “Reminder Dialogs comprise a predefined set of text and findings that together provide information to the CPRS GUI, which collects and updates appropriate findings while building a progress note.”

22. The Clinical Reminder System Functionality Can be linked to the following Clinical Reminder Shared Template Progress Note Title Advantages Ability to pass information into record Ability to track, collect and report data Ability to enter orders from the notes tab

23. Fecal Occult Blood Results (T)

24. Template contents of the progress note

26. Dialog Components

27. 2nd choice, intended to meet local need

28. 3rd choice, intended to meet directive

29. 3rd choice, intended to meet directive

30. 3rd choice, intended to meet directive

31. Colonoscopy orders differentiated by facility

32. Consult Service reason for request

33. Results Letter as a Progress Note

34. Form Letters Patch TIU*1*222 SEQ #217 TIU Work Copy Modification & Form Letter Functionality Brief discussion applying to today's process.

35. Use TIU Document Parameter Edit

36. Prompts pertaining to Heading

37. Prompts pertaining to Footer

38. Same note in Form Letter Format

39. Same note in Form Letter format & printed

40. Karl Sault BSN, RN, CAC NFSG VHS AAA Screening and F/U Process Utilizing a combination of tools: Computed Finding Radiology Reports Reminders

41. Computed Findings “Computed findings provide the ability to create custom findings for situations when none of the standard findings will work.” Computed Finding (CF): Radiology created standardized report. Local CPRS Programmer created CF based on the standardized report. CF utilized in reminders to resolve or initiate follow-up care.

42. 1st choice documents Historical Data PCP initiates the Screen for AAA. First choice has 4 options to document historical data which are made as Examinations. Exams create an Historical encounter at the date entered and activate the appropriate follow-up reminder from that date.PCP initiates the Screen for AAA. First choice has 4 options to document historical data which are made as Examinations. Exams create an Historical encounter at the date entered and activate the appropriate follow-up reminder from that date.

43. 2nd Choice is Imbedded Order PCP has option to order ultrasound from the reminderPCP has option to order ultrasound from the reminder

44. Specific pre-built order Rads procedure built specifically for national AAA Screening reminderRads procedure built specifically for national AAA Screening reminder

45. 3rd Choice reflects patient’s desires This meets local facility needsThis meets local facility needs

46. 4th Choice provides “OUT” for provider Depending on which box provider chooses passes one of these HF’s.Depending on which box provider chooses passes one of these HF’s.

47. Defined report in Radiology package CF looks for this exact number in this exact location on the defined report that the radiologist use to interpret the ultrasound ordered by the PCP. Depending on the number entered, this CF kicks off the appropriate reminder in the same way that entering the historical data does so.CF looks for this exact number in this exact location on the defined report that the radiologist use to interpret the ultrasound ordered by the PCP. Depending on the number entered, this CF kicks off the appropriate reminder in the same way that entering the historical data does so.

48. AAA Follow-Up 3.0 to 3.9 This reminder is triggered to be due in 3 years based on the CF. It can automatically reorder the ultrasound or provides an OUT for the provider. This reminder is triggered to be due in 3 years based on the CF. It can automatically reorder the ultrasound or provides an OUT for the provider.

49. AAA Follow-Up 4.0 to 4.9 CF triggers this reminder to be due in 1 year (IL states 6 months but Vascular service felt 1 yr was clinically appropriate and size was decreased from 5.4 to 5.0). It also provides for F/U Ultrasound or none indicated.CF triggers this reminder to be due in 1 year (IL states 6 months but Vascular service felt 1 yr was clinically appropriate and size was decreased from 5.4 to 5.0). It also provides for F/U Ultrasound or none indicated.

50. AAA Follow-Up greater than 5.0 CF triggers this reminder to be due in 3 months. This is the nationally mandated time frame. We are exploring the idea with leadership to have this be DUE immediately. It is a back up reminder as Radiology is instructed to initiate oral communication for urgent Vascular consult and same day follow-up which includes a CT scan. (the NO is the name of a menu pathway we use to get the ct ordered)CF triggers this reminder to be due in 3 months. This is the nationally mandated time frame. We are exploring the idea with leadership to have this be DUE immediately. It is a back up reminder as Radiology is instructed to initiate oral communication for urgent Vascular consult and same day follow-up which includes a CT scan. (the NO is the name of a menu pathway we use to get the ct ordered)

51. Radiology Order

52. Implementation The Clinical Informatics Service Chief discusses new processes at various meetings/forums with stakeholders: PC Council Outpatient Chief’s Meeting Professional Council CPRS Super User Committee Service Staff Meetings CPRS Advisory Committee Examples of committeesExamples of committees

53. Education of Process Sharing the information with the end users: Power Point CPRS Newsletters Link created off of the Clinical Informatics Home Page

54. Poster # 41 “A Multidisciplinary Approach Utilizing Computed Findings to Initiate Follow Up Care and Screening Reminders for Abdominal Aortic Aneurism.” Authors: Bryan King BSN, RN, CAC & Charles J. Zeilman, III, PhD, ARNP, CS

55. Reporting/Feedback So, What do we do with this information? Data gathered using reminder reports Within NFSG, timely feedback to the end user is very important to help guide practice. FOBT: Weekly Report created to identify patients to our PCP who need the letter documenting the communication of results. Reminder Reports: Information is compiled into excel spreadsheets biweekly. Excel Imbedded Macros provide statistical analysis of Data. Switching gears: REPORT FOBT not in 14days weekly report, ao or super user gets info for clinic. Reminder reports for all 28 Performance measure related reminders Switching gears: REPORT FOBT not in 14days weekly report, ao or super user gets info for clinic. Reminder reports for all 28 Performance measure related reminders

56. Reporting Folder for End User Shared Folder on Network drive holds “Clinical Reminder Reports” Accessible by CMO, AO and Super user Contains specific patient data by clinic location of any veterans who need follow up. Example: Previously mentioned FOBT Positive test documentation letter that is required within 14 calendar days of the test date.

57. NF/SG VHS INTRANET

58. NF/SG VHS OQP DATAMART SITE

59. CIS DataMart SharePoint Site

60. Hyperlinks to Individual Provider Report Card Aggregate score for providers and Facilities. Ability to match low performer to high performer. Providers names are hyperlinked to their individual report cardAggregate score for providers and Facilities. Ability to match low performer to high performer. Providers names are hyperlinked to their individual report card

61. Biweekly Updates Hyperlink directs provider to their report card which is updated BiweeklyHyperlink directs provider to their report card which is updated Biweekly

62. Debbie TrostProject Analyst, OI&T SLC

63. What’s Ahead? General Maintenance - Summer 2008 Support Terminology Standardization and Exchange Tool Modifications - Fall 2008 Support Class 3 to Class 1 projects OEF/OIF Phase II Extract Reporting Other Projects 2008-2009

64. General Maintenance Patch - Summer 2008 PXRM*2.0*11 Add/Modify Computed findings Modify Location List exclusion functionality Modify national reminder definitions and dialogs Modify Reminder Test output Fix My HealtheVet reminders function finding pointers

65. General Maintenance Patch - Summer 2008 Add/Modify Computed Findings: Service related Computed Findings (12) Combat Service OEF,OIF or Unknown Combat Vet Combat Vet Eligibility Status and End Date Service Branch Last Service Separation Veteran, POW, Purple Heart Agent Orange, Radiation Exposure

66. General Maintenance Patch - Summer 2008 Modify Location List exclusion functionality: Exclusion location list can be defined once Any location lists can reference the pre-defined Exclusion location list

67. General Maintenance Patch - Summer 2008 Changes to national reminder definitions and dialogs VA-IRAQ & AFGHAN POST-DEPLOY SCREEN Change reminder to use Combat Vet Eligibility when possible for screening (not included in the national monitor) Change reminder dialog to fix branching logic Substitute the 'Other symptom' question to inquire about embedded fragments New reminders to help clerks reconcile HEC data and self-reported VA-IRAQ/AFGHAN SERVICE health factor

68. Support Terminology Standardization - Fall 2008 PXRM*2.0*12 will support standardization Immunizations Skin Test Automated changes to findings in reminder definitions, terms, and dialogs One for one match conversions Reminder Terms automatically created with old and new standardized terms Messages created to inform the Clinical Reminder Mailgroup of changes made and any follow-up needed Other functionality included:

69. Exchange Tool Modifications - Fall 2008 PXRM*2.0*12 will include some great exchange tool modifications Ability to pack up any combination of reminder related file entries separate from a reminder definition. Reminder Terms, Dialog, Group, Element, Location List, Computed Finding,… Ability to pack up TIU/HS Object (if meets rules) Ability to display text of what is in order dialog and TIU/HS Object if not shipped Ability to pack up multiple branching logic reminders in one entry

70. Support Class 3 to Class 1 Projects VANOD Fall reminders and reminder dialogs Extensive field testing occurred before sending to OI&T Not sure which patch yet (11, 12, or other) VA/DOD Transfer Summary Not sure if patch or available on web site VA and DOD Nurses will use standard format to document transfer summary progress note VA will use reminder dialog template to format a progress note which is sent to DOD DOD will use their own tools to create a progress note in the same format which is sent to VA. VA nurses will see the DOD/VA Transfer Summary progress note in Remote Data Views

71. OEF/OIF Phase II Extract Reporting December 2008? Create new OEF/OIF extract definition Enhance extract reporting tools to send results, using HL7 messages, to an Excel Spreadsheet on SharePoint OEF/OIF Screening reporting totals TBI Screening reporting totals Enhancements to support new ways sites are using extracts – weekly, daily, etc…

72. Other Projects 2008-2009 Polytrauma Marker New reminder to identify patients that meet a diagnosis algorithm and need to be evaluated for Polytrauma Marker (health factor). New Reminder Dialog to review diagnoses and make a clinical decision to add a Polytrauma Marker for the patient.

73. Additional VEHU 2008 Reminder Classes Tuesday 1:30-3:00 319HR1Clinical Reminder CSI 3:30-5:00 272H Unleash the Power of Reminder Dialogs 3:30-5:00 235 CIS Role in Performance Measures Wednesday 9:10-10:30 237 Unlocking Reminder Logic – Findings the Right Combination 1:30-5:00 318H Clinical Reminder Extracts – Making life Easier Thursday 1:30-3:00 319HR2 Clinical Reminders CSI 3:30-5:00 235 CIS Role in Performance Measures

74. Questions?