# Presentation: 528059

## #402 What’s New and What’s Coming?- Shift Handoff Tool- Medication Reconciliation- CPRS V27 VBECS- Surgery Case Manager

## Things to Remember

- Questions will be answered at the end of the 4 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

## Shift Handoff Tool

- Divya Shroff, MD, ACOS, Informatics
- 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 missing or loss of 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

## VHA National Findings and Recommendation For Improving Patient Handoffs

- Goal – Improve the quality and safety of handoff process
- Objective – Meet the requirements of JCAHO National Patient safety goal 2E:
- Implement a standardized approach to “handoff” communications including an opportunity to ask and respond to questions
**Standardization** of shift-change processes necessitates a written summary and/or flowchart of the standardized handoffs processes.
**Physician to Physician** – a special-purpose written report or “sign out”, checklist or other aids may be needed to **standardize** the quality and sort of pertinent patient information communicated from shift-to-shift

## 2007 National Patient Safety Goals

- Improve the effectiveness of communication among caregivers (2)
- Requirement 2E– implement a standardized approach to “hand-off” communications, including an opportunity to ask and respond to questions
**Rationale** – the primary objective of a “hand-off” is to provide accurate information about a patient’s care, treatment and services, current condition and any recent or anticipated changes.  The information communicated during a hand off must be accurate in order to meet patient safety goals

**Notes:**
Rationale

## Implementation Expectations for Requirement 2E

- The organization’s process for effective “hand off” communication includes: _Interactive communications allowing for the opportunity for questioning between the giver and receiver of patient information_
- The organization’s processes for effective “hand off” communication includes: _Up-to-date information regarding the patient’s care, treatment and services, condition and any recent or anticipated changes_

**Notes:**
ALL

## 2007 National Patient Safety Goals Cont. 

- Accurately and completely reconcile medications across the continuum of care (8)
- A process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization (8A)
- A complete list of the patient’s medications is **communicated **to the next provider of service when a patient is referred or **transferred** to another **setting, service, practitioner, or level of care** within or outside of the organization.  (8B)

## 2007 Joint Commission Frequently Cited Standards

- Req. 8A
- Patients are most at risk during transitions in care (**hand-offs**) across settings, services, providers, or levels of care.  The **development, reconciliation and communication** of an accurate medication list throughout the continuum of care is essential in the reduction of transition-related adverse drug events.
- Implementation: The medications ordered for, administered to, or dispensed to the patient while under the care of the organization are compared to those on the list and any discrepancies are resolved

## 2007 Joint Commission Frequently Cited Standards

- Req. 8B
- The patient’s accurate medication reconciliation list (complete with medications prescribed by the first provider of service) is communicated to the next provider of service, whether it be within or outside of the organization
- The next provider of service checks the medication reconciliation list again to make sure it is accurate and in concert with any new medications to be ordered/prescribed.

## 2007 National Patient Safety Goals

- Many sentinel events can be avoided
- Look-alike, sound-alike
- Delay in treatments
- Dangerous abbreviations
- Medication reconciliation
**All above are addressed by Handoffs**

## VHA and Handoffs

- 2e: Implement a standardized approach to "hand off" communications, including an opportunity to ask and respond to questions. (All Settings)
- Why?  To improve transfer of patient information and improve overall patient care and patient safety.
**Most RCAs** cite **communications** as a contributing factor.  This addresses a subset of situations where communications lapses can be especially hazardous.
**VACO Status** – National VHA Workgroup established, recommendations prepared, pilot test(s) starting for locally developed electronic template(s), no current plan for a VHA Directive.

**Notes:**
2/3 of all RCAs identify specific communication issues as one of the causes of the particular adverse event under review.

## VACO/NCPS Recommendations

- Standardizing requires something in writing
- Flowcharts, tables, or text describing shift-change handoffs for nurses, physicians, and physicians-in-training (if present)
**Standardizing does not mean it needs to be same VA-wide, VISN-wide, or VAMC-wide, but processes should be consistent at the unit-level**
- Methods and tools for interfacility transfers
- Processes and tools for transporting patients from one area to another within a facility (unit to radiology, unit to ICU, etc.)
- Inform staff on methods to get questions answered across shift changes, even if seemingly obvious

##            Developing a Standardized Approach to                                             Hand-off Communications

- A standardized approach should identify :-
- The “hand-off” situations that it applies to
- Who is, or should be, involved in the communication
- What information should be communicated
- Diagnoses and current condition of the patient
- Recent changes in condition or treatment
- Anticipated changes in condition or treatment
- What to watch for in the next interval of care
- Opportunities to ask and respond to questions
- When to use certain techniques (repeat-back; SBAR)
- What print or electronic information should be available

##              Shift Handoff Tool’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.
_**February - July 2007:**_
- CAIRO Tool installed & tested and/or used at 12 facilities.
- Communications with New Service Request submitted by NCPS to VHA OI with plan to upgrade software from Class 3 to Class 1.
_**November 2007- June 2008: **_
- Tool renamed Shift Handoff Tool (Class 1)
- National release in June 2008 after tested at 5 sites

**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

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## Take Home Points

- Handoffs are the future
- Patient safety
- JCAHO/NCPS/VHA/FIX
- Handoffs do not replace your chart
- Handoffs emphasize communication
- VHA developed Shift Handoff Tool
- Now available as a Class 1 solution
- JCAHO recognized
- Can apply across specialties / services

## Successful Implementation of Shift Handoff Tool

- IRM
- check Vista to ensure CRHD*1.0 kids file is installed
- install Shift Handoff Tool.exe on appropriate desktops and/or network drive
- Clinical services
- Appoint clinical leaders in various departments / services for specifying preferences / roll-out / buy-in
- Ex) Chief residents, Hospitalists, Clinical Informatics
- Appoint ADPACs to ensure access
- Quality Management / Patient Safety Manager
- Monitor clinical practice
- Create handoff policies if needed

## References

- WSJ, 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”

## MEDICATION RECONCILIATION CLASS I SOFTWARE RELEASE

- Rosemary Grealish, RPh
- Outpatient Pharmacy Program Manager
- VA Pittsburgh Healthcare System
- With major contributions from:    Rob Silverman, PharmD
- Pharmacy Informatics Specialist
- Hines VA Hospital

## Patient Safety Goal #8, 8A, 8B

- PSG 8 requires medication reconciliation.
- Doesn’t specify how or who.
- Every medical center established Med Rec Patient Safety sub-committees (MRPSSC) to address issue and develop a process.
- VA had limited tools initially, but has been committed to continuously working on an electronic process.

## Previous CPRS Software Enhancements

- July 2004
- Non-VA Medications
- Summer 2007
- Remote Data Interoperability [RDI]
- Health Data Repository [HDR]
- Remote Medications
- Summer 2008
- Medication Reconciliation

## New CPRS Software Enhancement

- MEDICATION RECONCILIATION
- Contains tools useful in the medication reconciliation process
- Not Interactive
- Reports only, no data entry
- Technologies Used
- TIU Data Objects
- Health Summaries

## Medication Reconciliation Tools

**Tool #1 – Medication Reconciliation Report**
- Health Summary Component
- Active Inpatient, Outpatient, Non VA and Active Remote Meds.
**Tool #2 – Medication Worksheet**
- Health Summary Component
- Includes Active, Pending, NonVA and Recently Expired Meds.
**Tool #3 – Active/Pending/Expired Med**
- TIU Data Object and Health Summary Component
- Includes Active (w Suspended), Pending and Expired Meds
**Tool #4 – Remote Active Meds & Allergy/ADR**
- TIU Data Object and Health Summary Component
- Stand alone tools to retrieve information from other VA** **facilities

## Slide 46

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## Slide 49

## Medication Reconciliation Comparison Chart

## Medication Reconciliation –Refining the Tools

- Develop an ‘Actionable’ report to allow changes
- Improve capture of changes to enhance monitors
- Allow for site-specific modifications of header/footer
- Allow for patients’ self-documentation of discrepancies
- MyHealtheVet?
- Kiosk?
- Include documentation of Dual-Care Provider contact information.
- WILL NEVER REPLACE the CLINICIAN!

## CPRSv27 & VBECS (VistA Blood Establishment Computer Software)

- Tom Saunders – Clin2

## What is VBECS	

- New Blood Bank System in Lab
- Totally Encapsulated system
- It is an FDA Medical Device
- Releasing to the Field in 2008
- Phased Release

## Blood Bank Orders for VBECS

- Blood Bank Orders will be electronic through CPRS
- Additional text order for administration instructions needs to be built by Clinical Application Coordinator
- Orders need to be accessioned in Lab Package in order to be available in the VBECS package

## Blood Bank Orders for VBECS

- The VBECS Order Dialog must be placed by the CAC appropriately in the sites Order menus
- ‘VBECS BLOOD BANK’
-  DESCRIPTION:   This dialog creates an order for blood components to be made available by the VBECS system, as well as any supporting diagnostic tests
- 6 components
- 5 diagnostic tests
- When creating QO (Quick Orders) a new Display GROUP NAME is added with VBECS/CPRS
- BLOOD PRODUCTS
- Component or Test
- Blood Components
- Diagnostic Tests

**Notes:**
This new VBECS BLOOD BANK order dialog is an important aspect.  There is no back door to Laboratory.  CPRS will be the only way to order blood products and test.  CAC’s will need to use the new Display Group Name “Blood Products” using the Blood Components and/or Diagnostic test to create QO.  This is the only way to create quick orders, can no longer use the file 60 to create Blood Bank tests

## Blood Bank Orders for VBECS

- The VBECS Order Dialog that is released is a unique structure
- During use, it has direct communication with the VBECS Package
- HL7 & Vista Link
- Secondary Menu: VBECS VISTALINK CONTEXT - Lab
- The Dialog has 3 parts to it
- Patient information tab – displays Blood Bank information
- Orders tab – ordering dialogs
- Lab results tab – displays lab results defined in the VBECS parameters

## VBECS Blood Bank Order Dialog

**Notes:**
This screen capture of the VBECS BLOOD BANK order dialog in its collective state, 3 tabs
Screen Capture of Blood Component and Diagnostic Test Order Form, arrows pointing to the three important tabs- Patient Information, Blood Bank Orders, and Lab Results

## VBECS Blood Bank Order Dialog

- Patient information tab of VBECS Order Dialog

**Notes:**
Screen capture of patient information tab of VBECS order dialog, displaying blood bank information including Name, SSN, ABO/RH, available specimen, antibodies, transfusion requirements, transfusion reactions, and units available.
Below Units Available you will see the blood units numbers with the Status of the blood, assigned, crossmatched, autologous, or directed.  These units are removed from the screen when they have been issued to the patient.
Lessons learned at testing site is that this is not be reviewed by practitioner, resulting in duplicate specimens being drawn 

## VBECS Blood Bank Order Dialog

- Blood Bank Orders (Tab)

**Notes:**
This  screen capture is of the Blood Bank Orders and is broken into 3 section, Personal Quick Orders, Blood Components, and Diagnostic Tests

## VBECS Blood Bank Order DialogBlood Bank Orders (tab)

- Two sides
- Components
- Diagnostic tests

**Notes:**
This is a capture of the Blood Component and Diagnostic Test Order form, which is the Blood Bank Orders Tab of the VBECS order dialog.  The capture shows a dotted line down the middle of the dialog to distinguish the 2 sections of the ordering process, the Blood Components and the Diagnostic Test.
Blood Components
Modifiers of Blood Components
Washed, irradiated ect
Date and Time Blood Components wanted
Diagnostic Tests
Collection Type
Collection Date/Time
Note that required fields are indicated with an asterisk

## Blood Bank Orders for VBECS

- Diagnostic tests and components are automatically added as they are selected to the Selected Components and Test box.
- Certain components cannot be ordered alone if there isn’t an available specimen.
- Accomplished by communications between CPRS order dialog and VBECS system

**Notes:**
When ordering, as these components and diagnostic tests are added, they get added to the Selected Components and Test Box.  I like think of the Selected Components and Test Box as the Blood Bank Shopping Cart, similar to the shopping carts that is often seen with electronic on-line ordering 

## VBECS Configure Components

*This is in VBECS, not CPRS and maintained by LAB personnel.*

**Notes:**
The Blood Bank maintains these settings, usually working with the transfusion committee to determine which lab results are evaluated at the time of order. 
The lab tests are assigned  for each component class locally.
The requirement for a Type and Screen with the component is also set here.
A Type and Screen is required for Red Blood Cell and Whole Blood orders by default and is not configurable. The other component classes are optional.
The various thresholds for ordering are also entered here.

## Blood Bank Orders (tab) Blood Components

**Notes:**
VBECS order dialog is component centric – that is, physicians will be able to focus on what blood products they actually want.  VBECS will indicate if the provider needs to add a diagnostic test like TAS.
These 6 components are what are listed in the VBECS BLOOD BANK order dialog, and can be used by a CAC in creating quick orders for components

## Blood Bank Orders (tab) Blood Components

- Based on the component that is being ordered and the local configurations that have been setup in VBECS
- The 3rd tab may be active/available with laboratory data
- The user will be alerted to this by the change on the tab it self
- The provider can review that tab to review the laboratory results without leaving the order dialog process

## Blood Bank Orders (tab)  Diagnostic Tests

**Notes:**
This is a capture of the VBECS order dialog, with the Lab Results Available Tab highlighted.  It is showing the laboratory results that are indicated based on the components that are being ordered.

## Blood Bank Orders (tab) Blood Components

**Notes:**
This is a capture of the VBECS order dialog, with the Blood Bank Orders Tab highlighted and the listing of the Modifiers  that are available for selection for the component order.                                  This is controlled by a CPRS parameter OR VBECS MODIFIERS      List of Component Modifiers

## Blood Bank Orders (tab)Blood Components

**Notes:**
This is a capture of the VBECS order dialog, with the Blood Bank Orders Tab highlighted, showing the reason for request as managed by the local hospital with the new parameter OR VBECS REASON FOR REQUEST  for Package: ORDER ENTRY/RESULTS REPORTING -

## Blood Bank Orders (tab)Blood Components

**Notes:**
This is a capture of the Blood Component and Diagnostic Test Order Form, of the Blood Bank Order tab.  Because there is a connection between Vista and VBECS, when a component is selected that requires a specimen, VBECS communicate back to the order dialog that the particular component needs a specimen for testing.  When the Type + SCREEN is completed in VBECS, the comment “TYPE + SCREEN must be added to the order” will not appear.  It does not prevent adding another type and screen order.

## Blood Bank Orders (tab) Diagnostic Tests

**Notes:**
Five Diagnostic tests are listed here that can be chosen for a blood component as is need.  These diagnostic test can be used to create quick orders.

## Blood Bank Orders (tab) Diagnostic Tests

**Notes:**
This is a capture of the Blood Bank Orders Tab highlighted and the section highlighting the Diagnostic Tests, and the other information needed for that section of the order.  Collection Type,  Collection date/time and Urgency.  It the patient has any surgery scheduled, it will allow the order to associated to that surgery to check the MSBOS.  Note the Surgery is grayed out.

## MSBOS

- Maximum Surgical Blood Order Schedule

**Notes:**
Maximum Surgical Blood Order Schedule is maintained in VBECS
Clicking on Pre-Op under the Urgency box results in highlighting the Surgery box and clicking the down arrow will list the surgeries set up in VBECS.  As the surgery is selected the “Reason for Request” is automatically populated with the surgery.

## VBECS Maintain MSBOS

*This is in VBECS, not CPRS and maintained by LAB personnel.*

**Notes:**
The MSBOS, Maximum Surgical Blood Order Schedule, is maintained in VBECS by Lab Personnel and is usually the number of units of blood required for a surgery as determined by a transfusion committee.

## MSBOS

- Maximum Number of Units Exceeded

**Notes:**
This warning message “Maximum Number of Units Exceeded” was triggered by entering the number 4 for units wanted for a surgery that the transfusion committee set the quantity at one. The warning displayed in this screen capture of the MSBOS gives the provider the opportunity to change the number of units needed to the recommended number or he can over ride the warning to request whatever number he requires.

## Blood Bank Orders (tab)Components & Diagnostic Tests	

**Notes:**
This is a screen capture of the Blood Bank Orders Tab highlighting the Selected Components and Tests box with the compiled order of the component and diagnostic tests.  The Accept Order button is also highlighted, which when selected will put the order on the orders tab.

## Text Order Requirement

- The Blood Bank Order dialog ‘does not’ include the administration order
- This is either order separately
- Made part of a quick order or order set
- This can be turned off
- OR VBECS SUPPRESS NURS ADMIN

## Text Order Requirement

**Notes:**
“The nursing blood administration order must be entered separately.”  warning automatic display for an order. OR VBECS SUPPRESS NURS ADMIN, a new parameter can be turned off if the site has added in the administration order as part of either the quick order, order set.  

## Blood Bank Orders

- The VBECS order dialog can be used to create
- Order Sets
- Quick Orders
- Personal Quick Orders

## VBECS Quick Orders

- Order Menu Management
- Enter/edit Quick Orders
- Select QUICK ORDER NAME: *** Your VBECS QO***
- Are you adding ‘**VBECS**’ as a new ORDER DIALOG? No//y (YES)
- TYPE OF QUICK ORDER: **?**
- Answer with DISPLAY GROUP NAME:**   *****BLOOD PRODUCTS<<<NEW***** **
- Component or Test
- Choose from Blood Components:
-    CRYOPRECIPITATE
-    FRESH FROZEN PLASMA
-    OTHER
-    PLATELETS
-    RED BLOOD CELLS
-    WHOLE BLOOD
- or Diagnostic Tests:
-    ABO/RH
-    ANTIBODY SCREEN
-    DIRECT ANTIGLOBULIN TEST
-    TRANSFUSION REACTION WORKUP
-    TYPE & SCREEN

## CPRS Parameters (new)

- OR VBECS MODIFIERS
- OR VBECS SUPPRESS NURSE ADMIN
- OR VBECS REASON FOR REQUEST
- ORWDXVB VBECS TNS CHECK
- RPC: ORWDXVB VBTNS
- OPTION: ORCM VBECS OI EDIT
- Edit VBECS item display names

**Notes:**
OR VBECS MODIFIERS – allows for the combing of the different modifiers so they will be a choice since this isn’t currently a multiple
OR VBECS SUPPRESS NURSE ADMIN – this allows for the reminder type dialog about a nursing order to be turned off 
OR VBECS REASON FOR REQUEST – allows for the defining the Reasons for Request
ORWDXVB  parameter and RPC are for the order check of the cprs order for the blood bank tests
The option ORCM VBECS OI EDIT allows the site to re-define the names used in the order Dialog

## Add Order Menu example

**Notes:**
This is a screen capture of a Add Order Screen that was created to show how the Blood Bank Order Dialog can be broken down into individual quick orders.

## VBECS and Personal Quick Orders

**Notes:**
This is a screen capture the Blood Bank Orders tab has been selected.  There is a box that is highlighting the Personal Quick Orders drop down box.
This will only be populated after a practitioner has created their own personal quick order 

## VBECS and Personal Quick Orders

- VBECS Personal Quick orders
- Must have the component or Diagnostic test fields entered
- Must be added to the “Selected Component and Test” window of the VBECS order dialog
- Using CPRS Options Pull-down menu
- Save as Quick Order

## VBECS and Personal Quick Orders

- Adding Blood Bank Personal Quick Order

**Notes:**
Enter the name of a new quick order and click Ok save.

## VBECS and Personal Quick Orders

- As Personal Quick Orders get created they will be added to the drop down box

**Notes:**
This is a screen capture of the Personal Quick Orders drop down box is highlighted showing the personal quick orders that have been created.

## VBECS QO added

**Notes:**
This screen capture is the result of selecting the Quick Order on the previous slide. Click the Accept Order highlighted to complete it.

## ORDERS TAB

**Notes:**
This is the Screen capture of the Orders Tab displaying the Blood Bank order with the T&S, component and the Reason for Request with the type of lab collection eg Lab collect.

## Communication

- Identify all the stakeholders
- Look at your process and see what staff are involved from order placement to final transfusion
- Use your Blood Utilization Review Committee to help identify people
- Look at all areas of the medical center
- Review IRM Support
- Need VistA Application Support
- Need Networking Support

## Communication

- Review processes and identify those that will change
- Review the ordering process – there may be people who write the orders on paper but wouldn’t be able to write electronically
- Review the blood drawing/labeling process – there may be changes needed to account for noting of the phlebotomist’s initials
- Review Lab processes to see if any adjustments need to be made

## SURGERY CASE MANAGER

**PORTLAND VA MEDICAL CENTER**
**OPERATIVE CARE DIVISION**
**James Edwards MD**
**John I Thomas, programmer (retired)**
**Evelyn M Braibish, RN (retired)**
**LeAnn Snodgrass, Program Analyst**

## Rationale

- Limitations – VistA
-  Surgery package has command line interface
-  Request for surgery requires entries into 38+ fields
-  Scheduling requires an additional 7+ fields
-  Moving scheduled operations is not an easy task

## Rationale

- New Requirements
-  No tracking capabilities
-  Wait times
-  Audit trail
-  Electronic wait list
-  Outsourcing
-  Patient medical evaluation
-  Paperless
-  No scheduling books
-  No paper forms

## Goals

-  Minimize data entry – once only
-  Allow tracking of issues that need to be resolved prior to operation
-  Seamless movement between all possible patient status types (wait list, action required, surgery request, etc.)
-  Graphical surgery scheduling
-  Allow audit of time from entry of consult to operation

## Surgery Case Manager

- Enhancement to Surgery Package
- Not a complete surgery scheduling package
- Could be modified for clinics and other procedure areas

## Surgery Case Manager

## CPRS Request for Surgery Note

## CPRS Request for Surgery Note

## CPRS Request for Surgery Note

## Slide 98

## CPRS Request for Surgery Note

## Surgery Case Manager

## Surgery Case Manager

- 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) – 72
- RPC calls – 136
- Vista files (648 number series) – 10
- SCM executable (Delphi) – 1.71mb

## Surgery Case Manager

- 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.

## Surgery Case Manager

## Slide 104

## Slide 105

## Consult Matching

## Consult Matching

- Significant issues
- Consult time to surgery influenced by
- Patient choice – “after hunting season”
- Trial on medical therapy – PT, injections
- Consult to specialist with stabilization or Rx of issue – new cardiac meds, angioplasty
- System delays and inefficiencies
- SCM tracks only total time, not reason

## Surgery Case Manager

## Slide 109

## Direct Entry

- It is possible to utilize a direct entry option to place a patient on any of the lists (action required, wait, and requested).  These options require that all required elements be hand entered before an entry is successfully made.
- 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.

## 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.

## Surgery Case Manager

## Slide 113

## OR Scheduling Matrix

## Surgery Case Manager

## Reporting

## Reporting

## Reporting

## 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.

## Site Parameters 

**(found under tools in the tool bar).**

## Summary

- Surgery Case Manager allows tracking of surgery cases
- Tracking of time from consult to entry of surgery request and then to surgery date possible
- Auditable
- Double entry is eliminated
- Graphical scheduling of surgery cases
- Extendable to other clinics or procedural areas

## Value

- Timeliness is easily tracked
- No “cracks” for patient to fall through
- Multiple employees can see where Veterans are in the process and provide that information to the Veterans
- Providers outside of surgery can be given access to see where patients are in the system

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QUESTIONS?

- QUESTIONS?