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, OIT SLC

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Overview

• Demographics
• Performance Measures
• Oryx
• Hedis
• Directives/Informational letters
• Clinical Reminder System
• Implementation
• Reporting/Feedback
• Whats Ahead for Reminders Package?

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NFSG Demographics

• 10 facilities (Clinical care provided for 2
  additional Orlando facilities Daytona Beach and
  Leesburg)
• 2 Medical Centers with OPCS, 2 OPCS, 6 CBOCs
• 3 Future Facilities
• 124,720 uniques (FY2007)
• 1.3 million visits (FY2007)

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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 PXRM24
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 PXRM24
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 TIU1222 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 patients 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 Chiefs 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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Debbie TrostProject Analyst, OIT SLC
Whats Ahead for the Reminder Package?
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Whats 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

• PXRM2.011
• 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

• PXRM2.012 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

• PXRM2.012 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 OIT
• 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
• 130-300 319HR1Clinical Reminder CSI
• 330-500 272H Unleash the Power of Reminder
  Dialogs
• 330-500 235 CIS Role in Performance Measures
• Wednesday
• 910-1030 237 Unlocking Reminder Logic
  Findings the Right Combination
• 130-500 318H Clinical Reminder Extracts
  Making life Easier
• Thursday
• 130-300 319HR2 Clinical Reminders CSI
• 330-500 235 CIS Role in Performance Measures

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Questions?