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Reminder Dialogs and National Reporting . Session # 227. 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

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Reminder Dialogs and National Reporting

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Reminder Dialogs and National Reporting

Session # 227


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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


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Overview

  • Demographics

  • Performance Measures

    • Oryx

    • Hedis

  • Directives/Informational letters

  • Clinical Reminder System

  • Implementation

  • Reporting/Feedback

  • What’s Ahead for Reminders Package?


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NFSG Demographics

Jackson County CBOC in Marianna, Florida Fiscal Year ’08

Camden County CBOC near St. Mary’s, Georgia Fiscal Year ’08

Putnam County CBOC near Palatka, Florida Fiscal Year ’09

South Marion County 90,000 SF Specialty Construction FY '08 Activation FY ’10

  • 10 facilities (Clinical care provided for 2 additional Orlando facilities: Daytona Beach and Leesburg)

  • 2 Medical Centers with OPCS, 2 OPCS, & 6 CBOC’s

  • 3 Future Facilities

  • 124,720 uniques (FY2007)

  • 1.3 million visits (FY2007)


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Chief of Staff

ACOS, Quality Management

Clinical Informatics

Program Support Assistant

Chief, Clinical Informatics

Lake City VAMC Staff

CPRS Support/Education 0.5

CAC 0.5

CPRS Operations Manager

Consult/Procedure Facilitator

Vacancy

Clinical Application Coordinators

Clinical Informatics

Clinical CPRS Educator (GV)

CAC

CAC

CAC

CAC

CAC

Organizational Chart Clinical Informatics Service


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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


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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


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Process for Colorectal Cancer Screening

  • Discussion of Directive:

    • VHA DIRECTIVE 2007-004 COLORECTAL CANCER SCREENING

      • Screening Test Options

      • Positive Screening Test

      • NFSG VHS Process


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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.


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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.”


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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.”


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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


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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.


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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.


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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.


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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


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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.


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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


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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

Clinical Reminders Version 2.0 Patch PXRM*2*4 CLINICIAN GUIDE October 2006


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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.


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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.”

Clinical Reminders Version 2.0 Patch PXRM*2*4 CLINICIAN GUIDE October 2006


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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


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Fecal Occult Blood Results (T)


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Template contents of the progress note


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1st choice, intended to meet directive


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Dialog Components

Components of the dialog include the point and click area for documentation, the progress note text, and the information being passed to the record.


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2nd choice, intended to meet local need


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3rd choice, intended to meet directive


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3rd choice, intended to meet directive


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3rd choice, intended to meet directive


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Colonoscopy orders differentiated by facility


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Consult Service reason for request


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Results Letter as a Progress Note


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Form Letters

  • Patch TIU*1*222 SEQ #217

    • TIU Work Copy Modification & Form Letter Functionality

    • Brief discussion applying to today's process.


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Use TIU Document Parameter Edit


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Prompts pertaining to Heading


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Prompts pertaining to Footer


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Same note in Form Letter Format


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Same note in Form Letter format & printed


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Karl Sault BSN, RN, CAC

  • NFSG VHS AAA Screening and F/U Process

  • Utilizing a combination of tools:

    • Computed Finding

    • Radiology Reports

    • Reminders


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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.

Clinical Reminders Manager Manual December 2007


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1st choice documents Historical Data


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2nd Choice is Imbedded Order


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Specific pre-built order


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3rd Choice reflects patient’s desires


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4th Choice provides “OUT” for provider


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Defined report in Radiology package


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AAA Follow-Up 3.0 to 3.9


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AAA Follow-Up 4.0 to 4.9


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AAA Follow-Up greater than 5.0


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Radiology Order


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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


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Education of Process

  • Sharing the information with the end users:

  • Power Point

  • CPRS Newsletters

  • Link created off of the Clinical Informatics Home Page


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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


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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.


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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.


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NF/SG VHS INTRANET


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NF/SG VHS OQP DATAMART SITE


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CIS DataMart SharePoint Site


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Hyperlinks to Individual Provider Report Card


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Biweekly Updates


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What’s Ahead for the Reminder Package?

Debbie TrostProject Analyst, OI&T SLC


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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


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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


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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


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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


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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


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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:


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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


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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


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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…


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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.


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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


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Questions?


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