117 Earn your comps: CPEP

1. 117 Earn your comps: CPEP/CAPRI Zachary Fain Program Manager, CBO Jackie Bridges Program Manager, CPEP

2. 2 Presentation Objectives C&P Overview CAPRI Background/History CAPRI C&P Exam Templates CAPRI Functionality Supporting CAPRI CAPRI Future First topic � C&P Overview

3. 3 What is C&P? C&P is a core part of VHA�s mission C&P is a �disability examination� in industry terms Affects a Veterans (and family�s) individual monetary and health benefits Establishes service-connection percentages

4. 4 What is C&P? C&P is a core part of VHA�s mission Is often the entry point to VHA Traditionally been undervalued or seen as a not being �real medicine� Emphasis on re-invigorating C&P at upper levels of VA leadership

5. 5 What is C&P? (cont�d�) C&P Examinations Requested by VBA via an electronic �VA Form 2507� in the CAPRI software Can be facilitated by Veteran Service Officers at VA and non-VA locations Disability exams are now being performed at DoD physical locations via DoD and VBA staff.

6. What is C&P? (cont�d�) C&P Examinations Can involve up to 58 claimed conditions Most common conditions include: General Medical, Audiology, Mental Health, PTSD Traumatic Brain Injury (TBI) is one of the more common conditions of newly separated Servicemembers May be performed by VHA providers, fee-basis, or VBA-contracted examiners 6

7. What is C&P? (cont�d�) May be performed around the world All 50 states Puerto Rico Manila, Philippines (US Embassy) Japan Germany Egypt Boliva United Kingdom Spain Italy Belgium Costa Rica Panama S Korea Thailand Australia 7

8. The State of C&P As of January 11, 2010, there were 466,985 claims for disability examination awaiting rating decisions by the Veterans Benefits Administration (VBA) The average claim includes 2+ individual examinations 162,352 (37.3%) of the claims exceeded the 125 day strategic goal. 8

9. The State of C&P In March of 2009, VA�s Inspector General reported that almost a quarter (22%) of all veterans� applications for disability compensation were decided incorrectly in the 12-month period reviewed. In addition, benefit application folders for almost 300,000 veterans were misplaced and the files for 141,000 veterans are lost.

10. 10 VA can make C&P better "We are going to break the back of the backlog this year� It�s a re-engineering process�� VA Secretary Shinseki, during American Forces Press Service Interview, April 6, 2010 Secretary Shinseki is committed to creating a disciplined, high-performing and transparent organization tailored to being more responsive to the needs of these and other veterans. 

11. C&P is not just VBA�s Job Approximately 1,000,000 examinations performed per year by VHA 32,000+ Disability Evaluation System (DES) cases (over 60,000 examinations) to be performed per year for DoD VHA Travel Pay authorized for C&P Examinations Why is C&P important to me? (?Link to VA strategic plan(s) )Delivering C&P benefits in a timely and appropriate manner Often VHA�s first interaction with a service member. First impression lasting impression and may mean whether or not the servicemember will return as a veteran consumer Why is C&P important to me? (?Link to VA strategic plan(s) )Delivering C&P benefits in a timely and appropriate manner Often VHA�s first interaction with a service member. First impression lasting impression and may mean whether or not the servicemember will return as a veteran consumer

12. C&P is not just VBA�s Job Not a cheap exam to perform, often can last 2 hours with multiple ancillaries Intense interest from Congress, media, and Veteran Stakeholders C&P IS IMPORTANT! It�s the right thing to do for Veterans. 12 Why is C&P important to me? (?Link to VA strategic plan(s) )Delivering C&P benefits in a timely and appropriate manner Often VHA�s first interaction with a service member. First impression lasting impression and may mean whether or not the servicemember will return as a veteran consumer Why is C&P important to me? (?Link to VA strategic plan(s) )Delivering C&P benefits in a timely and appropriate manner Often VHA�s first interaction with a service member. First impression lasting impression and may mean whether or not the servicemember will return as a veteran consumer

13. 13 Presentation Objectives C&P Overview CPEP Overview CAPRI Background/History CAPRI C&P Exam Templates CAPRI Functionality Supporting CAPRI CAPRI Future Next topic - CPEP Overview

14. 14 CPEP Overview CPEP has been open since 2001 Joint VHA and VBA initiative Focus has been education a quality review process reporting function for performance measures

15. 15 DEMO � A new beginning The Disability Examination Management Office (DEMO) will be opening in St. Petersburg Florida in September 2010. � CPEP in Nashville will be closing by the end of the year. DEMO�s core philosophy will be that we exist to SUPPORT field C&P clinics and the disability process in VA. ��We will retain CPEP functions, applied in a new way and adding new functions. � Key DEMO initiatives: Quality Training Policy DES Forecasting and Resourcing

16. 16 Presentation Objectives C&P Overview CPEP Overview CAPRI Background/History CAPRI C&P Exam Templates CAPRI Functionality Supporting CAPRI CAPRI Future Next topic � CAPRI Background/History

17. 17 CAPRI

18. 18 CAPRI Background The CAPRI application is a joint VHA-VBA initiative that serves as a graphical user interface (GUI) interface into the VHA VistA system First deployed in FY 2001, CAPRI was initially developed as the replacement for the roll-n-scroll VistA AMIE II package used by VBA VBA Ratings Specialists struggled using AMIE-II to access VHA Medical Center computers due to hospital system variability Encompasses a variety of data and functions normally found across several VistA applications CAPRI provides one standardized interface to these applications, regardless of differences found across VHA facilities

19. 19 CAPRI Background Provides access to Veteran�s medical record in read-only format Progress notes, orders, consults, lab data, pharmacy data, nutrition reports, problem list, discharge summaries, vitals, imaging reports Displays patient�s demographic, appointment and admission data Allows ability to directly access other VHA facilities at which the veteran has presented for care Includes an interface to the VistaWeb application Provides access to DoD data, if available Provides ability to electronically record compensation and pension examination results in place of costly dictation/transcription methods

20. CAPRI User Groups CAPRI application is now a valuable tool for numerous user groups: Veterans Benefits Administration (VBA) Board of Veterans Appeals (BVA) VHA Office of Medical Inspector VHA Inspector General (IG) VHA OI MPI Data Quality Team Health Revenue Center (HRC) Veteran Service Organization (VSO) VHA C&P Departments 20

21. 21 Presentation Objectives C&P Overview CAPRI Background/History CAPRI C&P Exam Templates CAPRI Functionality Supporting CAPRI CAPRI Future Next topic - CAPRI C&P Exam Templates

22. CAPRI C&P Templates CPWM � Compensation and Pension Worksheet Module Project Objective Create a �Point-n-Click� examination template system that could produce standardized examination results to ensure veterans nationally receive same quality of examination Spring of 2002 Work began on a system of C&P examination templates at the request of the CPEP office (Compensation and Pension Examination Program) Spring of 2004 Implementation of the CAPRI C&P templates officially began 22

23. The Templates Charge: �It seems to me that we are living in the 21st Century and we are long overdue for software applications that can help the medical evaluation community at the VA to do a better job.� �It seems to me that we should have a physician protocol that takes and converges all of the AMIE worksheet information that physicians receive in the medical center and puts it in a logical format so that the questions that need to be answered are in fact answered.� �I think that this type of software is developable or can be developed by the VA in relatively short order.� �I look to you (conference attendees) or to this new office (CPEP) to help us develop that software, develop those applications, develop the physician protocol that can make life for everyone easier.� 23

24. C&P Exam Templates: Strategy Structured entry to Eliminate errors of omission Ask examiners the �right� questions as determined: In advance, based on the veteran�s claim On-the-fly, based on the examiner�s findings Not ask examiners the �wrong� questions Exam protocols cover a much larger number of compensable conditions as defined by 38 CFR Only a subset of questions may be relevant for the individual veteran being examined 24

25. 25 C&P Exam Templates: Approach Collaboration with OI&T, VHA, and VBA subject-matter experts to generate templates based on AMIE Worksheets that integrate with VistA Template Development & Deployment Tools Aid Developers to rapidly produce templates Allow �multi-template� veteran-specific forms Manage Integration with VistA Packages, e.g. AMIE: C&P exam request and fulfillment system TIU: Document management, including e-signatures

26. 26 CAPRI C&P Templates: Goals Standardization of VHA C&P Exams Standardize what information is collected Standardize how information is collected Eliminate errors of omission Create efficient Veteran-specific �merged� templates based on AMIE Worksheets Merge multiple exam types Ask all the �right� questions, avoid the rest Collaboration between CPEP, OI, C&P

27. 27 Dictation vs. Templates Time-Motion Studies Templates improve quality Templates improve exam turnaround time Templates lengthen patient encounter Templates lengthen documentation time

28. 28

29. CAPRI Template

30. 30 CAPRI Template Process Flow

31. CAPRI � Exam Request and Progress Note Automation When a template is signed in CAPRI, a progress note is created in the TIU Documents file, then a duplicate copy of that signed note is copied into the 2507 Exam file. Duplicate copies are necessary due to VistA architecture and VBA process interactions with AMIE package. CAPRI will automatically release the 2507 to the RO if all exams are completed using CAPRI. 31

32. Dictation/TranscriptionNon-CAPRI Exams Dictated Exams that are entered directly into VistA using the transcription options found in the AMIE package are not automatically stored in TIU C&P Exams that are recorded directly into CPRS require manual process for getting that C&P exam into AMIE exam requests for VBA release Local software has been utilized at some sites to automatically copy C&P progress notes into AMIE exam requests Issues with records copied into wrong exam requests have led to prohibition of use 32

33. 33 Understanding Routes for C&P Exam Entry CAPRI Templates � CAPRI C&P Exam Template reports are automatically loaded into TIU (CPRS) under a C&P note title. Automated Transcription Upload � Locally implemented automated functions that copy exam reports from TIU into the AMIE exam request. Manual Transcription Upload � Dictated exams can be manually uploaded into CAPRI by copy and pasting into the CAPRI BLANK Template. CAPRI will then create both a TIU progress note and the AMIE exam report. Note: If using an automated upload process or manually uploading into TIU/AMIE, do not also use a CAPRI Template as this will create a duplicate report (CAPRI will automatically create the report in both TIU and AMIE upon signature).

34. 34 Presentation Objectives C&P Overview CPEP Overview CAPRI Background/History CAPRI C&P Exam Templates CAPRI Functionality Supporting CAPRI CAPRI Future Next topic - CAPRI Functionality

35. 35 CAPRI Clinical Display

36. 36 CAPRI C&P Templates

37. 37 CAPRI DoD & Remote Data

38. 38 CAPRI � VistaWeb Display

39. 39 CAPRI Remote Login The majority of VHA CAPRI users will access CAPRI using their local VistA user accounts.

40. 40 CAPRI Remote Login This access enters the user's information into the NEW PERSON file (#200) as a visitor, but does not require an Access or Verify code for the user at the remote site. For more detailed technical information on this remote connection method refer to RPC Broker Patch XWB*1.1*45 & Kernel Patch XU*8.0*404. Link to documentation: http://www.va.gov/vdl/documents/Infrastructure/Remote_Proc_Call_Broker_(RPC)/xwb1_1p45_supplemental.pdf

41. 41 CAPRI Remote Login National � �Special User� access to all or certain VistA systems (site access based on permissions defined for each user) If you have questions about special user access to VHA EHRs, please visit http://vaww4.va.gov/hia/ Or, contact the Health Information Access (HIA) program at hia@va.gov.

42. 42 Presentation Objectives C&P Overview CPEP Overview CAPRI Background/History CAPRI C&P Exam Templates CAPRI Functionality Supporting CAPRI CAPRI Future Next topic - Supporting CAPRI

43. 43 Supporting CAPRI Troubleshooting Help and Support: CPWM User Setup CAPRI CPWM File Structure CAPRI CPWM TIU Storage CPWM Template Signing CPWM Template Tips Manage C&P Exam Request Edit Exam List Parameter

44. 44 CAPRI CPWM User Setup Menu Option: All CAPRI users will need the option DVBA CAPRI GUI assigned as a secondary menu option. Security Keys: All users that will be accessing the C&P Worksheet Module to conduct and/or review exams will need at least two security keys assigned. The majority of users will only need two keys, however the users designated to act as Reviewers will need the additional Reviewer key.

45. 45 CAPRI CPWM User Setup First Key to be Assigned: DVBA CAPRI WORKSHEET TAB � This key makes the C&P Worksheets tab visible inside CAPRI. All CAPRI users that may ever need access to the C&P templates should have this key assigned.

46. 46 CAPRI CPWM User Setup Second Key to be Assigned: (controls review process and access to create new templates) Only ONE of these keys should be assigned due to the conflicting functionality supported by each: DVBAB CPWM DISALLOW REVIEW � Users do not need to have their exams reviewed prior to release. This allows the user to directly release their exam without intervention. DVBAB CPWM OPTIONAL REVIEW � Users can choose to either send an exam for review or sign and release the template themselves. DVBAB CPWM REQUIRE REVIEW � Users must have all exams reviewed by a reviewer prior to signing.

47. 47 CAPRI CPWM User Setup Third Key to be Assigned: (potentially) If the site chooses to use the review process (meaning either the OPTIONAL REVIEW or REQUIRE REVIEW key has been assigned to anyone) at least one user must be designated as a reviewer and be assigned the DVBAB CPWM REVIEWER key. If the reviewer process is implemented at a site, it is expected that multiple people will be assigned this key to cover for cases where the primary reviewer is unavailable.

48. 48 CAPRI CPWM File Structure 2507 Request File (396.3) Contains 2507 request that will be released back to VBA with exam results. Can be edited by site if manual corrections are needed (or use Manage C&P Exam Request option in CAPRI). 2507 Exam File (396.4) Contains results for all exam reports, including both transcribed and templated exams. Can be edited by site if manual corrections are needed (or use Manage C&P Exam Request option in CAPRI). CAPRI Template File (396.17) Contains all exam templates created until template is completed. Some fields can be edited to manually manipulate exam status, author, etc. if issues were discovered. CAPRI Template Definitions file (396.18) Contains the definitions for all unique exam templates. As template revisions are released this file will be updated with new entries. SHOULD NOT BE EDITED BY A SITE. TIU Document File (8925) Contains completed/signed C&P Exam Template report that is also stored in 396.4; CAPRI Template File will also contain pointer to TIU Document File for completed templates.

49. 49 CAPRI CPWM - TIU Storage When a template is signed in CAPRI, it is first stored in the TIU Documents file, then the signed note is copied into the 2507 Exam file. Duplicate copies are necessary in order for the C&P exam to be part of the patient�s medical record as well as make it back to VBA for disability rating. Exams that are dictated and entered into VISTA using the transcription options found in the AMIE package are not stored in TIU and are only available as part of the Exam Request.

50. 50 CAPRI CPWM CoSignature CAPRI will respect the CPRS (ASU and TIU) business rules for co-signature The cosigner can then sign in CPRS or CAPRI If co-signed in CPRS, an extra step must be taken to transfer the completed signature back to CAPRI.

51. 51 CPRS C&P CoSignature Transfer If a user co-signs a document in CPRS rather than in CAPRI, the document will appear on the cosignature transfer utility list.

52. 52 CAPRI CPWM Template Tips Features on the C&P Worksheet tab of CAPRI: The Copy button can be used to create a new copy of an already started template that will be pre-populated with all data supplied in the existing template. The Delete button can be used to completely remove any unsigned template. Users will be prompted with a verify code screen to ensure they truly intend to delete.

53. 53 CAPRI CPWM Template Tips Also on the C&P Worksheet tab as well as under the Tools menu, users can utilize the My Unsigned C&P Worksheets option to retrieve a list of their in-progress templates.

54. 54 CAPRI CPWM Template Tips Ability to restore prior saves in instances where: The template did not save properly due to network issues Information was entered under the wrong patient�s template Examiner deletes data they did not mean to

55. 55 CAPRI CPWM Template Tips Also found under the Options button, the Info button can be used to obtain the version/property of CAPRI and each template contained in the latest save.

56. 56 Manage C&P Exam Requests The Manage C&P Exam Requests option available on the Tools Menu can be used to: Reopen a released exam Release an open exam Change the status of an Exam Request Edit the report of an exam that has already been signed and completed in CAPRI or AMIE. This option is extremely useful for correcting exams that were completed prematurely as well as offering examiners an interface to input addendums to recently released exam requests.

57. Manage C&P Exam Requests Completed exam requests can be reopened (**which reactivates the processing time clock), allowing the actual contents of the exam to be modified Per directive 2010-024, the requesting RO should be notified of an exam request that has been modified to ensure they re-print the exam if necessary 57

58. 58 Manage C&P Exam Requests Exam status can be changed to Open, Completed, Canceled by MAS, Canceled by RO, or Transferred out.

59. 59 Edit Exam List Parameter RO�s often request exams at a facility that does not perform that particular exam type; these exam requests then must be transferred out to another facility. The Edit Exam List Parameter utility (located under the TOOLS menu) allows sites to identify the exam types that are performed at each division to help streamline the exam processing and eliminate wasted time.

60. 60 Edit Exam List Parameter To turn off a division so it does not show for selection � select the division on the left of the screen then click the box labeled, �Completely Inactivate this Division�. Default lists will exist for each division at a site the first time this option is used. The user will then be able to add new lists or modify the default lists that were created for each division. Custom lists can be created by clicking the �Add New� button allowing only certain user groups access to request certain exams.

61. 61 Presentation Objectives C&P Overview CPEP Overview CAPRI Background/History CAPRI C&P Exam Templates CAPRI Functionality HIM Interaction CAPRI Future Next topic - CAPRI Future

62. CAPRI � Future Plans Initiative underway to redesign the CAPRI application offering a better solution to overcome current system deficiencies Business Requirement development in process First initial prototypes to be delivered in 2011 62

63. 63 CAPRI � Future (cont) Focus will be on three main business functions of CAPRI: C&P Exam Workflow C&P Exam Templates Remote (non-local) data access CAPRI will no longer exist as an application Functionality offered through CAPRI will be available instead as services

64. 64 CAPRI � Current Architecture

65. 65 CAPRI � Future Architecture

66. References & Resources Release of Information Frequently Asked Questions - VHA OI Privacy Office VHA Directive 2010-024, Changes in Compensation and Pension Examination Reports VHA Handbook 1605.1, Privacy and Release of Information 66

67. For more information� VistA Document Library http://vaww4.va.gov/vdl/ VistA Application Documentation VHA Compensation & Pension Examination Program Intranet http://vaww.cpep.va.gov/ C&P Reports, CAPRI User & Help Guides, CAPRI Training & Reference Videos VBA Compensation & Pension Intranet http://vbaw.vba.va.gov/bl/21/Systems/capamie.htm CAPRI User & Help Guides, CAPRI Training & Reference Videos Health Information Access Intranet http://vaww4.va.gov/hia/ FAQs, Request Access, Help Desk 67

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