Radiology

1. Radiology Judy Iskandar, RTR

2. Objectives for this Session • Finishing the Radiology order in RPMS • Process Changes • Pros and Cons

3. Registering the Patient in the Radiology Package

4. Registering the Patient in the Radiology Package

5. Entering the Exam

6. Radiology Reports in EHR

7. Process Changes • Using RPMS Radiology Package • Providers order the exam electronically • Radiology orders print out automatically

8. Pros and Cons • LMP? • Modifiers?

9. Questions?

10. Practical Transition and Practice: The Pharmacy and EHR CAPT Steven C. Doane Chief Pharmacy Services

11. Elements of Transition • Clinical Transformation • The redesign of clinical process involving the adoption of information technology • Fundamental Changes • New business model for health care • Pharmacy/clinic workflow • Mental process changes – paper to electronic • Planning/Preparation • Standardization • Staff Preparation

12. EHR/Pharmacy Goals • To make patient data available across the spectrum of care • Improve the care provided • Improve the efficiency of care • Improve patient safety • Maintain and/or expand pharmaceutical care practice

13. Preparingthe Pharmacy

14. Personnel • Assess ability to accept and handle change • Problem solve • Address concerns and issues • Adapting as the process evolves • Creation of new procedures – some transitional • Involve staff • Make assignments to accomplish tasks • Training and communication • Staffing levels and placement

15. Equipment - 1 • Review current department status • Availability of computers/workstations • Staffing ratio and availability to equipment • Type of terminals • Number of workstations • Placement of workstations • Age of equipment and terminals • Availability and placement of printers and automated counting equipment

16. Equipment - 2 • Needs Assessment for EHR/Ver. 5/7 • Computers/workstations and work areas • Placement of equipment for effective operation • Need for multiple points of entry? • Expense to upgrade systems • Ability to maintain systems • Placement of personnel • Electronic signature capability?

17. Workflow - 1 • Transition phase • Maintaining continuity and safe practice • Managing two systems simultaneously • Map workflow: present and anticipated • Future processes • Managing patients and prescriptions without a physical chart • Processing prescriptions: Assurance of accuracy, safety, verification, etc • Process for documenting interventions and notes • Pharmacists finish – Technicians fill? • Patient signature capture – changes?

18. Workflow - 2 • Policies and Procedure Review • Standardization • Uniformity – electronic systems highlight weaknesses in operation • Managing CII prescriptions • Managing “outside” prescriptions • Providing the insurance audit trail • Patience • Allow time to adjust, adapt, and evolve to new practice and business model • Allow time for pharmacy preparation prior to EHR – Familiarity with Pharmacy RPMS Version 5/7

19. Practice Considerations andBest Practices

20. Finishing the Prescription • Prescription order transfers from EHR to pending file on pharmacy prescription screen • Pharmacist involvement and intervention • Opportunity for pharmaceutical care • Review process • Cover sheet for ADR and other key data • Provider notes • Review prescription and make changes • Send for filling

21. EHR Prescription Orders -1 • New orders • Use of quick order lists • Individualize for facility • Make quick orders for key drugs and dosages • Consider multiple refills • Renewal • Pros • quick • No changes in previously written prescription • Cons • Inability to modify Rx • Previous errors will remain • Do not used until on 5/7 for period of time

22. EHR Prescription Orders -2 • Refill requests • Benefits • Can be prompted to pharmacy from EHR • Shows up as “refill request” in pending file • Processes similar to other refills • Problems • What if refill is too early? • Process, hold, pending file, or discontinue? • Cannot undo request

23. Partial Fill Function • Advantages • Can fill limited amount based on previous prescription order • Does not affect order with refills currently in system • Disadvantage • Does not show on patient profile • Consideration of policy change • Provide for multiple refills (up to 1 year) • Decreases workload for pharmacy • Decreases partial fills • Decreases changes to current prescriptions which affect provider’s efficiency with EHR

24. Hold – Unhold Function • Used to place a prescription in a hold category for further/future follow-up • Common use – placement of an order on the system until next or additional refills needed by patient • Can edit prescription when released from hold • Problematic • Individual sites need to set standards for use • Overwrites current prescription items • Providers cannot affect held prescriptions • Can write comments, but only visible through EHR

25. Return to Stock and Reissue • Previous Prescription(s) • Adds additional refill to the prescription • Process reissues by refilling • Original Prescription(s) • “R” Designation given • To Reissue • RP – Reprint prescription(s) • Edit Fill Date (optional) • RL – Release prescription(s) • Problem • Retains original fill date on the reissued prescription and profile unless changed

26. Paperless Refill • Simple process to turn on and use • Consider workflow changes • No progress notes, PCC(s), etc. • Direct patient interaction • Procedure • Select drug(s) to be refilled • System asks for POV on each drug • POV chosen from sequence of 3 lists – Problem list, POV list, then free text narrative entry • Prescriptions print as previously • Refill line prescriptions are handled similarly

27. Documentation • Pharmacy Note • When? Each refill, significant interventions, other? • How? Free text, template, other? • Education Coding • Where? Wellness Tab • When? Complete patient education prior to a note • How? Select education topic, level, plan, time • Create visit if different day than original provider visit • Add name as a provider • No POV usually needed except for counseling V68.1 • Can create POV pick list to aid in process

28. Implementation Christopher Lamer Grant Rogers

29. New Terminology POE – Provider Order Entry CAC – Clinical Application Coordinator GUI – Graphical User Interface OE/RR – Order Entry/Results Reporting PIMS – Patient Information Management System TIU – Text Integration Utilities Server side applications – roll and scroll; back end applications CPRS – Computerized Patient Record System VueCentric Framework Vista – Veterans Health Information System & Technology Architecture

31. Leadership, Commitment, Buy-in • Confirmed Leadership support • Tribal Endorsement • Area Office Support • Patient Awareness • Clinician driven

32. Force Analysis What factors will encourage EHR implementation? What EHR implementation barriers exist?

33. Hire a CAC • The incumbent is responsible for the implementation and support of multi-service software packages that automate the capture of clinical encounter information and its subsequent retrieval. The application coordinator manages the customization of the site parameters and addresses integration issues with other software packages. The incumbent assists in the implementation of new software products obtained by the facility that cover these functions. • Analyzes and evaluates processes related to information flow and serves as liaison between service lines concerning these processes…Assists staff in the efficient use of the current software. • Provides training to clinical staff … emphasizes timeliness, accuracy, security and the importance of these functions on every other clinical application. Coordinates classes with IRM training section and serves as backup for basic training classes. • Incumbent promotes an awareness of the importance of data validity and data security and coordinates efforts to correct deficiencies and errors that occur in the electronic record..,provide secondary support on related software modules…

34. Develop training plan for CAC • Training for CAC & Implementation Team, • Basic Site Manager, • Fileman, • PCC Outputs, • Lab Package, • Radiology Package, • Preparing Pharmacy for EHR • Advanced EHR trainings, • Site Visit to EHR site Training Site Webpage

35. Implementation Team • Clinical Champions from each discipline (Lab,RN, RPh,MD,etc) • Administration/Executive Leadership • Information Technology • Include Area IRM representation • Clinical Application Coordinator

36. Implementation Team Roles • Identify and define Policies and Procedures • Address staffing and scheduling during transition • Peer Training & Marketing • Monitor and Execute Implementation Plan • Design and Approve templates, menus, and ordering lists for E.H.R.

37. Hardware • Evaluate current hardware needs • Evaluate network needs • Begin procurement process for hardware • Hire additional IT staff if necessary • Install new equipment and test it before using

38. Upgrade Hardware/Infrastructure • RPMS server • Training server • Network • Lab Interface Upgrade • Workstation Access - Everywhere • Backup Power

39. Assess utilization of RPMS "Point-of-Service" packages • Assure packages are being used correctly before going to EHR • Immunization 8.0, • Women's Health, • Diabetes Management, • Behavioral Health System v3.0, • Behavioral Health GUI, • Dental, and • Case Management • Implement or assure correct usage to appropriately capture required data.

40. Identify go-live clinic or location • Address staff concerns • Identify all affected staff: lab, pharmacy, nursing, radiology, medical records… • Schedule an overview of EHR training • Publicly promote the EHR implementation • Discuss with all parties: hospital, tribal, labor union, etc.

41. Setup Implementation Plan/Timeline

43. Implementation Strategy • Implementation-Who and When • Everyone at once - one at a time? • Lab ordering , then radiology ordering, then pharmacy ordering, then notes • Bring up one team/dept at a time

44. Implementation Sample Schedule

46. Document Plans • Assess risk and effects of initial changes in productivity • Develop contingency plan • Provide area office with a copy of implementation plan

47. Prepare for Installs • Review CAC and User Guides • Coordinate with consultants • Prepare a plan for providing staff with training on new RPMS packages

48. Ancillary Packages PIMS 5.3 patched to support CPRS v20 Part of EHR suite: Dietetics 5.0 Nursing 4.0 Surgery 3.0 Medicine 2.3 Problem List 2.0 I/O Package 4.0 Vitals 5.0 Scheduling GUI (9/30/04) Vista Imaging v3.0 (Optional) (Requires Radiology 5.0) Pharmacy Package (OE/RR 3.0 Inpatient Pharmacy 5.0, Outpatient Pharmacy 7.0, Consults 3.0) with PSG mods Controlled Substances 3.0, Drug Accountability 3.0, Auto Replenishment 2.3, Pharmacy Benefit Management 3.0, BCMA 2.0 Lab v5.2 p18 TIU v1.0 (requires PIMS 5.3) Electronic Health Record Functionality Radiology v5.0 (requires PIMS 5.3) Pharmacy Data Management- PSS v1 p1 Clinical Queue, Services tab, Provider POV, Health Maintenance (Wellness), Nursing triage, CPT codes, Problem List, Immun. IHS-EHR Graphical User Interface (GUI) Electronic Health Record Update Your Software Site RPMS System Baseline applications: Cache 5.0.12 (FM22, F200 conversion, K8), Laboratory v5.2 p17, Radiology v4.0/4.5 p10, Outpatient Pharmacy v6 p5, Pharmacy Inpatient Suite v4.5, Immunization v8.0 p1, Women’s Health v2 p9, Patient Chart v1.4 p1, Patient Registration v7.0 p4, MAS v5, p8 Current patches of the following: AUT, AUPN, ACPT, AVA, XB; (ER package) - VA Lexicon v2.0 - VA Health Summary v2.7 - Visit Tracking/PCE/ Clinical Reminders (requires PIMS 5.3) PCC Data Entry v2.0 P7 Fileman 22 (1002), HL7 v1.6 p1005, Kernel Toolkit v7.3 p1002, Kernel v8 p1009 - Integrated Billing 2.0 - Auto Info Collection Systems 3.0 - Generic Text Generator 3.0 Kernel 8 (1010), Mailman 7.1 p1004 patched to support CPRS v20

49. PIMS • Patient Information and Management System • Scheduling • ADT • security

50. Begin Work flow Analysis and Business Processes • Follow the paper chart from patient registration to the billing office • What processes will change with EHR? • What processes will not work with EHR? • Make sure everyone is on the same page!