# Presentation: 528050

## 812 Innoventions“Innoventions – Innovators making inventions” 

- Divya Shroff, MD:  Cairo Handoff
- James Edwards, MD:  Portland Surgery Case Manager
- Jasbir Mavi, MD:  SupraVista

## Things to Remember

- Questions will be answered at the end of the 3 speakers’ talks
- 3 x 5 cards are available around the room
- Please jot down questions for the end
- All talks will be available on the Web after the lecture is over

## CAIRO Shift-Change Handoff Tool for Physicians 

- Divya Shroff, MD, Senior Hospitalist
- Washington DC VAMC
- Richard J. Sowinski, Chief of Application Development, Roudebush VAMC, MSCS, BSEE
- Charlet Lynn Cottee, Senior Developer,
- Roudebush VAMC, BSCS

## Why is Handoff important?	

- Reduce likelihood of medical errors and misinformation
- Prevent lost or missing clinical information
- Maintain a high level of medical care
- Increase efficiency/flow
- Decrease cost of multiple tests/length of stay
- Key issue for across all levels of medicine -                MDs/RNs/Clerks
- Nursing shortage; therefore, temporary staff
- House staff shift guidelines
- Larger surgical teams due to advanced technology

**Notes:**
Per recent IOM report, 44000-98000/yr die in US hospitals because of errors
Australian study of 28 hospitals found communication errors leading cause of adverse events (2x more than clinical inadequacy)
2005 study found 70% of preventable hospital mishaps occurred because of communication problems
Two of three RCAs list communication problems as a  cause of the adverse event. 

## Barriers that lead to need for Standardized Handoff

- In today’s climate of short hospital stays and complex patients, need for timely and effective communication
- Work hour limits for residents lead to increased number of patient handoffs and potential for communication breakdown
- Decrease in continuity of care/miscommunication/increase in cross-coverage
- Missing information in a non-standardized system
- High variability –
- ex) Code status/allergies missing in 80% of recent studies

**Notes:**
Increase use of hospitalists/ multiple docs with one patient /nursing shortage

## What does a handoff need to address?

- Standardized
- Written and Oral patient summaries
- Communicate in effective and efficient manner during sign-out
- Demonstrate “read-back” skills when communicating
- Evaluate all up to date medications
- Anticipating what may go wrong with patient after a transition in care occurs

**Notes:**
3. (create a solid foundation)

## Key points to remember

**The physical setting** – confidential/ quiet/ minimal distractions
**The social setting** – comfortable along all levels of hierarchy
**Language barriers** – avoid colloquialisms/ only accepted abbreviations
**Medium of communication** –  * face to face vs. phone vs. email / * written vs. oral
**Time / convenience issues** – standardized system will increase efficiency
**Education issues** – formal curriculum to demonstrate effective handoffs
- Ref: _Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs_, *Academic Medicine*, Dec 2005

**Notes:**
Emphasize with voice/tone/facial expressions which influences a reaction / at the bedside if needed
Avoid copying/pasting – making sure updated

Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs

## What should be in a successful handoff?

**Team Identifiers** - Staff names, phone numbers, covering staff contact info, distinctive team name/color
**Appropriate patient identifier **-** **2 forms of identification
- 1-2 sentence of **patient presentation**
**Active problem list** - pertinent past medical history
**Medications **– all active listed
**Allergies**
**Access **- Venous / Arterial Access and what to do if changes
**Code status**
**Pertinent labs**
**Concerns** over next 18-24 hours and what to do in those situations (problem vs. system based)
- Long term plans / family questions that could arise if indicated
- Psychological concerns
- Ref: _Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs_, *Academic Medicine*, Dec 2005

## Everyone’s talking about handoffs...

- VHA National Findings and Recommendation For Improving Patient Handoffs
- 2007 National Patient Safety Goals
- 2007 Joint Commission Frequently Cited Standards
- VHA FIX/Flow Effort
- “**SBAR**” - **S**ituation/ **B**ackground/ **A**ssessment/ **R**ecommendation

##  CAIRO’s History

- Created by Indianapolis (Roudebush) VAMC with inputs from pilot testers at the following VAMCs: Washington, DC; Iowa City; Des Moines; Ann Arbor; Loma Linda; Dallas; White River Junction
_**December 2005:**_** **
- Paper published in *Academic Medicine* by Indianapolis VAMC:   _Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs_*, Academic Medicine*, Dec 2005
_**January 2006:**_
- New JCAHO Patient Safety Goal to standardize Handoffs goes into effect, and NCPS issues summary advice to VAMCs on topic.
_**July 2007:**_
- CAIRO Tool installed & being tested and/or used at 12 facilities.
- Several other VAMCs expressing interest.
- Communications with New Service Request submitted by NCPS to VHA OI to plan to upgrade software from Class 3 to Class 1.

**Notes:**
Started 9 years ago in Indy – Center for Applied Informatics and Research Organization (VISN 11)

* Paper describes attributes of good physician shift-changes, and implementation efforts  at Indianapolis VAMC.  Staff contacted by NCPS and information acquired on locally-developed software tool for physician shift-change handoffs.

Additional 4 sites: Altoona/Denver/San Antonio/Puget Sound

Specify class 3 vs. class 1 – homegrown vs. nationally released / nationally available

##  CAIRO Hand-off ToolUser Guide  Version 5.5

- CAIRO Hand-off is a form of communication tool for transferring care of patients among physicians for example when one physician leaves at the end of the day and hands off his patients to a physician on call.

-  CAIRO Hand-off ToolUser Guide  Version 5.5

## Slide 12

## Slide 14

## Slide 15

## At any point, you can start over with your selection by pressing this key

**Notes:**
It will not delete or modify any list, it just removes it from your selection

## Click on the provider name that is desired for the sign-out 

- Click on the provider name that is desired for the sign-out
- (i.e. will show up on right sided column)

## H.O.T. = Hand-Off Team List

**H.O.T.** = **H**and-**O**ff **T**eam List
- CAIRO specific list where various team names
- can be created based on site requirements

**Notes:**
Interchangeable/defined users with various levels of access

## Identical format to CPRS in retrieving patient’s name 

- Identical format to CPRS in retrieving patient’s name

**Notes:**
Last initial and last 4 vs. whole name

## Double click on patient’s name to add to right side

- Three choices on saving the new patient addition to the current sign-out list

## This list will save in both CAIRO and CPRS

## Slide 22

## Slide 23

**Notes:**
Bright yellow are free text/modifiable fields (can have auto delete or character limits)

Pale yellow are retrieved from CPRS

## Slide 24

**Notes:**
Can site specify identifiers etc.

Pale yellow are retrieved from CPRS

## Slide 25

**Notes:**

Pale yellow are retrieved from CPRS

## Slide 26

**Notes:**
Patient toggle – was on ONE/now on SIX
CODE STATUS clarification
Dosages/administration of medications

## Slide 27

**Notes:**
Titles can be modified at sites – ex) consults/labs/radiology
Auto-delete feature if fields not modified within set amount of days
Can set character limit if desired

## Slide 28

## Slide 29

**Notes:**
landscape

## Slide 30

## Slide 31

## Slide 32

## For the administrators:

- To create HOT lists and identify users
- To create team headers with names/titles/numbers
- Designate field preferences

## To specify who can access / modify specific HOT teams

## Slide 35

## Slide 36

## Slide 37

**Notes:**
Medication – summary/detail. IV or not
Printing options
Sorting option
Additional boxes can be added (total 6) – consults/labs
Patient demo – some mandatory/some optional
DNR – site specific

## Pros for CAIRO

- Uniformity
- Built within VA
- Works with CPRS
- Med reconciliation
- Legible
- Forces updates
- Site/service tailored
- Time saving
- Paperless in future

**Notes:**
Handoff talk on W at 10:45 – I’m Covering...what do I do now
Temporary Data Fields – JCAHO does not mandate making part of chart/documenting/audio tapes
Compliments CPRS chart – does NOT replace CHART
DNR issues – lack of standardization...

- For further information about CAIRO,
- please contact:
- Noel Eldridge – noel.eldridge@va.gov
- Rich Sowinski – richard.sowinski@va.gov

## References

- Wall Street Journal, Tuesday, Nov 14, 2006 “ A Hospital Races to Learn Lessons of a Ferrari Pit Stop”
- Academic Medicine, Vol. 80, No.12/Dec 2005, “Lost in Translation: Challenges and Opportunities in Physician-to-Physician”, Sollet, DJ; Norvell, JM; Rutan, GH; Frankel, RM
- The Hospitalist, March 2007 “Hospitalists and Handoffs”

## VeHU Class 812 InnoventionsSURGERY CASE MANAGER

- PRESENTED BY THE
- PORTLAND VA MEDICAL CENTER
- OPERATIVE CARE DIVISION
**James Edwards MD**
**John I Thomas, programmer (retired)**
**Evelyn M Braibish, RN (retired)**

## Surgery Case Manager

- Rationale – VISTA surgery package is not user friendly, not graphical, often requires double entry of data
- Goals
- Minimize data entry – once only
- Allow audit of time from entry to operation
- Allow tracking of issues that need to be resolved prior to operation
- Graphical surgery scheduling

## Surgery Case Manager

- Not a complete surgery scheduling package
- Not meant to supplant VISTA surgery package rewrite
- Could be modified for clinics and other procedure areas
- Still beta, and class 3

## Surgery Case Manager

- Talk will cover
- Data entry into CPRS
- Various lists
- Scheduling
- Administration

## CPRS Request for Surgery Note

## CPRS Request for Surgery Note

## CPRS Request for Surgery Note

## CPRS Request for Surgery Note

## CPRS Request for Surgery Note

## Slide 50

## Slide 51

## CPRS Request for Surgery Note

## Slide 53

## Surgery Case Manager

## The Surgery Case Manager (SCM) is specialty based using parsed data stored in a signed TIU ‘Request for Surgery” progress note. Once that note is acted on in the SCM it stores data in the surgery file.

- While management of surgery data is the focus at this time the SCM format could be utilized by other services that need to schedule and track procedures.

## Slide 56

## Surgery Case Manager

## Slide 58

## Direct Entry

- Use of the Request for Surgery progress note, rather than a direct entry, parses out most of the  required data elements.  This allows for a quicker entry with no repetitive data entry.

**Direct Entry**

## Currently scheduled cases

**Currently scheduled cases**
**A scheduled case is one that has been put on the surgery schedule but the procedure has not been completed.**
- The user has been able to move data from one list to another without repetitive data entry.  Movement from one list to another is maintained and viewable from the audit trail.

## Slide 61

## Surgery Case Manager

## Slide 63

## Surgery Case Manager

## Surgery Case Manager

## Tool bar functions

**Tool bar functions**
- Settings for each surgical specialty are identified here.  Each site is able to individualize basic data regarding the specialty utilizing two categories; basic and surgeons.

- When a name is entered the position can be identified.

- Provider’s position can be edited and the name can be inactivated.

## Site Parameters found undertools in the tool bar.

## Audit Trail

- Displays all entries or changes to the record with date, action taken and name of individual who made the changes of movement.  This information is retained at all times, even after the procedure has been completed.

## SURGERY CASE MANAGER

- TECHNICAL  INFORMATION
- V2.6

## The SCM uses the VA Broker to communicate with the Vista database.  Log-in is done using the standard Vista access and verify codes.  At the present time the application is made up of the following pieces:

- Mumps routines (APT namespace) – 10
- RPC calls – 111
- Vista files (648 number series) – 8
- SCM executable (Delphi) – 1.53mb

## The SCM makes no modifications to national Surgery package routines.

- A new cross-reference is added to the “Requested” field in the Surgery file (#130) in Vista.
- There are two optional cross-references added to the New Person file (#200) in Vista that are used to limit the number of users displayed when selecting User names and Provider names.

## Summary

- Surgery Case Manager allows tracking of surgery cases that need to be scheduled and that are scheduled
- Auditable
- Double entry is eliminated
- Graphical scheduling of surgery cases
- Extendable to other clinics or procedural areas

## VeHU Class 812 InnoventionsSupraVistA

**Jasbir Mavi, MD**
**Salem VAMC**

## Managing Clinical Errors, 

**Managing ****Clinical Errors, **
**Patient Safety and**
**Provider Efficiency with****Automated Clinical Decision Support**

## We need to do the same for outpatient clinical errors. 

**prevent ****inpatient**** errors.**
**We need to do the same for**** **_**outpatient clinical errors**_**.**** **

**Today, more and more health care is provided on outpatient basis.**
**VHA Model:  ****Primary Care Clinics**

**“****Be Careful...”**
**“****Do more...”**
**More Policies**
**Do NOT help providers prevent error or improve efficiency.**

## Therefore,High quality, error-free decisions requireefficient and effective data access and analysis

**A clinical error represents **
**“****a faulty decision”**** **
**rooted in **
**“****faulty data analysis.”**
**History, Physical Exam, Various clinical elements**

## A Typical EHR is NOT designed ...

- To prevent clinical errors
- To actively seek out abnormal findings
- To correlate information from multiple areas the way clinicians think (e.g., interaction of vitals, lab, imaging, etc)
- For user efficiency

## Facts

-  Most *clinical errors occur because the** **provider **	**did not "****see****"* a finding.
-  *It is** ****impossible to manually analyze**** all the **	**clinical data because of the* **large volume** of 	data in CPRS and the **limited time** during a	a clinic visit.

**Facts**

**SupraVISTA addresses ****all these elements.**

##  Numerous tasks and distractions during typical Primary Care clinic visit increase risk of missed findings and clinical errors.

 ACA:  Due to reduced frequency of  visits/year, more needs to be done on each visit.

 ACA:  Due to increased RVI – a clinical finding missed today will not be  “caught” for 6 + months resulting in delayed diagnosis and poor outcome.

** **_**ACA:**_**  **Due to **reduced frequency of **** visits/year**, more needs to be done on each visit.
** **_**ACA:**_**  **Due to increased RVI – a **clinical**** finding missed today will not be **** “caught” for 6 +** **months** resulting in delayed diagnosis and poor outcome.

**Impact of systems issues**

## Typical Primary Care Visit 8 steps @ 4 min/step

- Obtain **medical history** regarding acute and chronic medical problems.
- Perform **chart review & *****manual***** data analysis.**
- Perform **physical exam.**
- Discuss and **document clinical findings**.
**Write orders** and **discuss plan** with patient (100% provider order entry).
**Clinical Reminders and EPRP** issues.
- Plan and explain **follow-up visit**.
**Care coordination**, **answer patient’s questions,** fill-out **forms...**

## Why Provider may fail to “see” an important finding?

- Amount of data to review: **50 printed pages**.
- Clinical findings to evaluate: **about 200.**** ****	****	****	****	****	****(at various locations in CPRS)**.
- Average time to evaluate each finding: **30 seconds**.
**Total time required for an ****“effective” chart review: ****90 minutes****.**

**Time available: **
**4 minutes**

## What is SupraVISTA?

## SupraVISTAis a systematic approach to Clinical Error Reduction

## Fact: We simply cannot do it manually anymore. Today’s complex health care environment “Demands” a Clinical DSS.

## SupraVISTA complements and enhances CPRS by adding Clinical DSS capabilities.

**Goal****provide all the facilities that a clinician needs but are not included in CPRS.**

## Techo-Talk

- Stand-alone Windows application.
- At heart, a data analysis and reporting tool
- Delphi programming language
- 4+ years in development
- 100,000+ lines of code (and counting)
- Gets clinical data from a CPRS health summary.
- Provides data security at same level (or better) as CPRS.
**Being evaluated to become a Class-I tool.**

## It does NOT

- make direct connection with VistA database(s) thus it cannot harm anything.
- place orders into CPRS / VistA
- duplicate what CPRS does well
- ...**Can’t think of anything else**...

## SupraVISTA User Interface

## Slide 89

## SupraVISTA Core FunctionalityAlerts and Reports

## Slide 91

## Sampling of SupraVISTA Tools

## Slide 93

## Questions ?