clinical it project manager, visn 3 clinical product suppor

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139 Diagnosis CPRS Get Your Feet Wet

• Christy Gagliano-Zelo Elaine Stoker, IT
  Specialist
• Clinical IT Project Manager, VISN 3 Clinical
  Product Support, Clin 2
• Vikie Schwartz, IT Specialist Duane Mawhorter
• Clinical Product Support, Clin 2 Clinical
  Applications Coordinator Jackson, MS

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Objectives

• Outline best practices in using tools available
  in CPRS to better manage disease processes
• Demonstrate real examples of CPRS components in
  use at VA Medical Centers

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Questions

• This class is being presented as a live meeting
• Live meeting participants cannot hear questions
  from the audience
• Please write your questions down on the index
  cards provided and pass them to the room
  assistants
• Presenters will read your questions and their
  responses
• Any questions that cannot be addressed at the end
  of the presentation will be posted on the VEHU
  website

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CPRS ToolsA Practical Application

• Christy Gagliano-Zelo MS, RD
• Clinical IT Project Manager
• VISN 3

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Request

• The VISN 3 Laboratory Medicine Council
  recommended moving from paper to electronic
  Tissue Examination Request forms
• At the facility level, a request was submitted by
  the laboratory to the CPRS office to create these
  forms.

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Reason for Change

• Old way Paper forms, handwritten, attached to
  specimen and sent to lab
• Hard to interpret handwriting
• Not all fields complete
• No trail if paper is lost
• New way electronic forms found on orders tab,
  typed, printed, attached to specimen and sent to
  lab
• Easy to read
• Templated all required fields complete
• Generic order stored on file if retrieval is
  needed

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Creation of the Template

• Generic Order
• Resides in the Laboratory display group
• No orderable item attached order does not go
  anywhere
• Created series of prompts to build the order.
  Free text prompts
• Start date/time prompt
• Specimen prompt
• Word Processing prompt
• Stop date/time prompt

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Spreading the Word

• Hi Again email
• In person visits to high use services

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Challenge

• Dr. VEHU

If I had a dime for every time someone said to
me But its just a few extra clicks!!!
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Dilemma

• Lab needs staff to use Electronic Tissue
  Examination Request forms
• Dr. VEHU and some of his colleagues dont want to
  use them
• We really want to avoid using words like
  directive and mandate

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Solution

• CAC Dr. VEHU, what if there is a way for me to
  SAVE you a few extra clicks?
• Would you be willing to use the electronic
  tissue examination request forms if I could save
  you some clicks somewhere else?
• Dr. VEHU Tell me more!

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Service Specific Order Menu
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Service Specific Order Menu

• Beware of the pitfalls
• Set guidelines for your providers
• Start with input for all members of the service
• When and how to submit changes
• Electronic format vs paper
• Approved by other members of the service
• Compile all changes and submit dont send one
  change every week (unless you prefer it that way)

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Graphing

• On the fly graphing
• Allows you to compare different components of
  care on one page.

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OR
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Diagnosis Specific Order Menus

• Elaine Stoker, IT Specialist
• Clinical Product Support - Clin 2

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Once upon a time, separate order menus were
developed specific to the service that was
handling the orders, i.e., a Lab Order menu for
Inpatients, a Lab Order menu for Outpatient
clinics, a Radiology Exam order menu, etc. Now we
try to be more provider friendly and have order
menus and order sets specific to the diagnosis
and include protocol and guidelines in the orders
so providers have everything they need on one
screen, just a click away. This does save time
every saved click adds up to making ordering a
more pleasant experience!
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This example of a Lipid Management Menu
provides a reminder to access the At Risk
Calculator from the Tools bar, or click directly
on the orders to view guidelines. Additionally,
the lab panels are available and relevant
consults all on one screen.
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The space on the Tools bar is limited therefore
it is highly valuable real estate. Consider the
needs of your providers when approving of links
to be added. At our facility we wanted 3 At
Risk calculators, and links to various Clinical
Practice Guidelines sites. It was also handy to
place a link to the VISN/VAMC Directory for quick
reference, the VDL for quick access to individual
package manuals, and a list of unacceptable
abbreviations.
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This is one of the At Risk Calculator links on
the Tools bar
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The Lipid Management Guidelines can be viewed at
any time. This is useful when your internet may
be sluggish or down providers can also
initiate orders from this guideline screen
they do not have to click out and return to the
previous order set menu!
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Continued from previous screen..
This text screen includes links to the Lipid
Lowering medications list, consult orders and lab
panel orders that are used to monitor lipid
control.
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The medications suggested in the guidelines are
listed in quick orders some of them set to
auto-accept. Comments and notes are included
for guidance, and again, the relevant consults
and lab orders are also included on this
screen. The repetition of having the same orders
on the different screens allows the provider to
use whichever screen they is most familiar or
comfortable with and still be able to click as
many orders as needed without having to bounce
back and return to an initial order menu.
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A little customization makes the menu very
useful. For example, a simple Diabetes Order
Menu should include medications, supplies,
consults, education orders, labs, and follow-up
appointment text orders one stop shopping!
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Text Screen View of the GUI Diabetic Order menu
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Toggle view of the Quick Orders
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Now for a more complex Order menu, created to
assist in Performance Monitoring of MDD Major
Depressive Disorder

• The Chief, Mental Health Service Line provided
  the CAC with a copy of the MDD policy and asked
  for it to be turned into an order menu with
  alerts triggering to Health Admin staff when
  initiated, and for help setting it up so
  providers could not easily bypass the MDD order
  set if they were ordering an antidepressant
  medication.
• So wave the magic wand and
• make it happen!

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The MDD menu is placed on the Order Sets/Pathways
order menu, and on the Write Order listing of
Medication menus.
The text screen describes the requirements and
provides links to menus that are developed
specific to the location of care if patient was
an inpatient, outpatient, etc.
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BOLD TEXT !!
UNDERLINE TEXT !!
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This menu contains different order sets under
each Yes/No selection. These 5 customized order
sets default to quick orders that are filled in
specific to the patient being seen as an
Inpatient or Outpatient and whether they will
receive their FU care at a CBOC or at the home
facility, It took quite a bit of time to develop
and build, but made the ordering essentially fool
proof and very quick to properly initiate. Lets
look at some of these patient status specific
orders
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The first order triggers an Alert to a team in
Health Administrative Service who monitored the
prompt scheduling of all needed appointments.
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And now the Performance Measure Clock starts
ticking . . . . . . . .
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This HAS Alert as a generic order populated with
default text and uses template fields for quick
selection of Inpatient or Outpatient status and
entry of the expected discharge date. The
Orderable Item created is MDD INDEX VISIT
CRITERIA MET.

• NAME _____ GTX MDD INITIAL VISIT CRITERIA MET
• DISPLAY TEXT MDD INDEX VISIT CRITERIA MET
• TYPE dialog DISPLAY
  GROUP NURSING
• SIGNATURE REQUIRED ORES
• PACKAGE ORDER ENTRY/RESULTS REPORTING
• AUTO-ACCEPT QUICK ORDER YES
• SEQUENCE 1 ITEM OR
  GTX ORDERABLE ITEM
• ISPLAY TEXT NOTE REQUIRED
  YES
• ASK ON EDIT ONLY YES INDEX
  S.NURS
• ORDER TEXT SEQUENCE 1 ASK ON
  CONDITION I 0 uneditable
• SCREEN I ACTIVEORDD43(Y) DEFAULT
  S Y5426
• SEQUENCE 2 ITEM OR
  GTX WORD PROCESSING 1
• DISPLAY TEXT ALERT REQUIRED
  YES
• ORDER TEXT SEQUENCE 2 START NEW
  LINE YES
• WORD-WRAP DON'T WRAP
• DEFAULT WORD-PROCESSING TEXT
• H.A.S. to receive an alert, triggered after
  signing this order, that effective this date,
  patient has met Index Visit Criteria for Major
  Depressive Disorder. Patient diagnosed during
  FLDOPT/INPT D/C2.

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Set up the FLAG!
Next step, the orderable item was flagged in the
Notifications menu using the following
option Flag Orderable Item(s) to Send
Notifications (This menu allows you to set the
flag for Inpatients, Outpatients or if needed for
both, you can set it at each level
separately.) 1. Flag INPATIENT
orders/results/expiring orders. 2. Flag
OUTPATIENT orders/results/expiring orders. 3.
Flag Lab tests for Threshold Exceeded
alerts. Select Orderable Item MDD INDEX VISIT
CRITERIA MET Orderable Item MDD INDEX VISIT
CRITERIA MET// MDD INDEX VISIT CRITERIA MET
MDD INDEX VISIT CRITERIA MET Send alert for ALL
inpatients? YES//
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Order Set continues

• The remaining components of the Order set are
  auto-populated and are triggered by only two
  clicks from the provider. Ten orders with only 2
  clicks sounds like MAGIC! This could make you
  the providers new BFF!
• geek speak (Best Friends Forever!)
• Less is more less clicks more smiles!

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So, after only 2 clicks, the following 5 orders
are ready for signature!
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Overview.The 3 Ts .

• Making diagnosis specific menus takes time,
  thought, and teamwork.
• Time to get all of the orders and order prompts
  filled in as completely as possible so there are
  fewer edits and clicks needed, saving the
  provider time.
• Thought work thru the process so you know all
  needed pieces and options. Possibly use a Time
  line or Flow Chart to ensure all processes are
  covered. Determine WHO needs to do WHAT and WHEN.
• Teamwork cover all bases by getting input from
  the patient care team.

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Diagnosis Specific Templates

• Utilizing the dialog template editor for creating
  progress notes that can be Diagnosis specific

Duane Mawhorter, CAC GV Sonny Montgomery
VA Jackson, MS
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REPEAT AFTER ME

• Current functionality does not permit us to
  create what you are asking for in your template,
  however there has been an E3R submitted
  requesting that feature be added to a future
  version of CPRS.

Sounds much better than We cant do that
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Providers Dream List

• OMG
• WDIDN?
• (Dont worry)
• Its nbd

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Diagnosis Specific Reminder Dialogs

• Vikie Schwartz
• Clinical Product Support - Clin 2

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Allows the clinician to accomplish multiple
functions within a single template

• Allows inclusion of additional text for
  documentation
• Provides a mechanism for ordering
• Includes the use of health factors to document
  information and facilitate co-managed care

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Ordering From Clinical Reminders
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Generating a Medication Order
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Customizing Consults
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Using Health Factors for Documentation
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Getting More Information
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Clinical Maintenance
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Documenting Allergies
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TO SUM IT ALL UP

• Be creative!!
• Be innovative!!
• Creation of reminder dialogs is complex and
  requires hard work, planning and coordination,
  but the result is well worth the effort.