# Presentation: 696249

##  235 CIS Role in Performance Measures

**Randy Snider, Miami VA****Christy Zelo, VISN 3****Bryan Volpp, VISN 21**

## CIS Role in Performance Measures

- Learning Objectives:
- At the end of this class you should be able to
**1.  Investigate issues with visits and data collection as it pertains to performance measures**
**2.  Play an active role improving performance measure compliance**
**3.  Utilize different approaches and tools in evaluating performance.**

**Notes:**
Explain 

## Quality of Care & Performance Measures

- Screening
- Education
- Interventions
- Outcomes
- Access
- Outreach
- Disparities in Care

## Implementation – Potential CAC Roles

- Analysis – understanding the expectation
- Data Collection – what data is needed and appropriate
- Process – what processes need to be evaluated or changed
- Tools – how can we help the users to meet the expectations
- Troubleshoot – where can/do things go wrong
- Measure – what reports might help
- Intervene – what can be done to improve

## Examples

-  OEF/OIF and TBI Screening
-  Hypertension
-  Consults
-  Women’s Health Care

## TBI Screening – Northern Cal

- TBI Screening Implemented in March 2007
- Email notices sent out to staff with a link to a short training PowerPoint
- Dental was notified of the need to screen
- Paper questionnaire posted and its use was recommended
- Expectation: Nurse and Clinic Managers would pick up the ball and run with it.

## TBI Screening – Chart Reviews

- Reports on patients seen in NEXUS and Dental clinics who had not been screened with chart review
- Dental was not doing any screening.
- Some C&P patients were on the list of patients who had been missed.
- Patients with only telephone notes were showing as missed opportunities for screening.

## 1. TBI Screening – Dental

- Dental Service does not use CPRS except to review data and to open DRM
- No process in place in Dental Service to do screening or clinical reminders
- Process:
- Provide lists of patients with upcoming appts who need screening
- Use the paper questionnaire and send the completed questionnaires to someone for data entry.

## 2. TBI Screening – C&P

- Some patients only seen in C&P were on the missed opportunity lists
- 1. Visits in regular primary care and mental health clinics
- 2.  Some C&P clinics had a stop code that was not the standard national stop code for Compensation and Pension
- C&P visits to be in C&P clinics only
- Fix the clinic stop codes to use the standard

## 3. TBI Screening - Telephone

- Telephone notes and visits being created in regular (face to face) clinics
- Re-educate those specific providers about the need to use telephone clinics

## TBI Screening – Locations Missing Opportunities to Screen

- Identify clinics where opportunities to screen were missed
- Run a reminder report on patients seen in the past month who were missed
- Create a patient list from that reminder report
- Run a health summary that displays past appointments for one month
- Drop the text name of the clinics into a spreadsheet and do counts on the clinic appointments (not cancelled or no shows)

## Missed Opportunities

## TBI Screening – Pre-visit Reports

- Weekly lists of patients with upcoming appointments who need screening
- Print to the clinic locations for the clerical staff
- Sort by date and include clinic and appt date and time
- Running multiple reports
- Create a text document to respond to all prompts

## Slide 14

## TBI Screening – Prior Diagnosis

- Health factor review showed multiple entries of “TBI-Previous TBI Diagnosis”
- Chart reviews showed no evidence that these patient had been previously diagnosed
- Modified the reminder to ask – “Are you sure...?”

## Slide 16

## Slide 17

## TBI Screening - Consults

- Positive TBI Screens need a consult
- Multiple TBI consult opportunities were missed
- Nursing staff expecting the Provider to order but completion of the reminder by the Nurses resolved the reminder
- Missing the non-required question.

## TBI Screening - Consults

- Modified the TBI Screening reminder
- Does not resolve until the consult order has been placed for any + Screen
- Introduced branching logic so that if the only item remaining to be done is the consult order, then only that option shows in the dialog
- Require consults for patients with prior diagnosis if not already done

## Slide 20

## TBI Screening – Refusal

- Health factor review showed multiple entries of “TBI-Pt Refusal”
- Almost all the entries were from one clinic
- Review of the notes showed that this was one provider
- Patients were called and screened by phone

## TBI Screening – Consult Discussion

- National TBI reminder does not document the discussion of the consult being ordered
- EPRP reviews showed that this was not being documented
- Altered the reminder to document the discussion of the order
*Prioritization of tasks for staff – who decides*

## TBI & OEF/OIF Screening - Reports

- For one-time interventions, as the denominator and numerator grow larger, the rise (or fall) in the overall % requires a large change.
- For TBI, once a site is at 90%, it would take many weeks to see a significant fall even if screening stopped completely
- Create a report to identify “% of due screens being done”

## Slide 24

## Slide 25

## OEF/OIF Related Problems

- Completing all screening but missing 1 or more of the 4 ID/Other symptom questions
- Done at another site
- Actions:
- Report every 2-3 days on screens missed
- Users notified and ask to contact the patient
- 	Encouraged to use the paper form
- Chart reviews for all outside screens – demographics on a patient list shows when and where patients have been seen
- 		Reentered as historical information

## Slide 27

## Control of BP in HTN and DM

- NCHCS does not usually meet these goals
- VISN 21 has missed making these goals partly due to NCHCS being below the VISN average

## Control of BP

## Report by Provider

- Reports by Division show marked variability across the system (~2001)
- Reports by individual provider clinic for all levels of BP control (~2002) show marked differences
- HTN 140/90 and 160/100
- DM 140/90 and 160/100; 130/80 added 2008
- Reports for re-privileging and provider performance include these also (~2005)
- Provider performance reports included in performance pay (~2007)

## Reports – Missed Opportunities

- Identify patients with HTN/DM whose last BP was elevated and who do not have an appointment for recheck in the next 2 months
- Weekly report by site and by provider
- Nursing to call and reschedule patients
- Staff time
- Additional disparities dependant on staffing

## Control of BP

## Compliance with the Consult Performance Monitor

## Stakeholders

- Miami VA – as a Facility
- Chief of Staff
- Quality Management
- Performance Improvement Council
- Business Results Council

## Implementation Team

- Data Management Group
- Service/Section Chiefs and AOs/HSSs
- Consult Managers
- MAS Support Staff
- Clinical Application Coordinators
- Service/Section ADPACs/SuperUsers

## Slide 36

## Results

- Negative impact on the consult performance monitor.
- 		   Consult/Request Performance Monitor
-                       FROM: Jan 01, 2007  TO: Apr 30, 2007
- SERVICE: OUTPATIENT SUBSTANCE ABUSE CLINIC
- Total Requests To Service:                           203
- Total Requests Pending Resolution:                     0
- Total Requests completed:                            203
- Total Requests completed with Results:                30
- Percentage of total requests completed:              100.00%
- Percentage of total completed requests with results:  14.78%

## Problem

- “CLINICIANS” were not linking their notes to a consult.
- Program support staff were administratively closing consults and annotating in Comments, "PLEASE REFER TO NOTE TITLE” on “DATE OF NOTE”.

## What did the CACs do to assist in resolving the problem?

- Created a tutorial on how providers are to complete consults.
- Trained Service ADPACs/SuperUsers and Consult Managers on the appropriate way to complete consults.
- Provided assistance to the ADPACs/SuperUsers in training residents and clinicians.
- Reviewed the Consult Monitor Report with Consult Managers to monitor compliance.

## Results

- Very little improvement...
- 		   Consult/Request Performance Monitor
-                       FROM: May 01, 2007  TO: May 31, 2007
- SERVICE: OUTPATIENT SUBSTANCE ABUSE CLINIC
- Total Requests To Service:                          54
- Total Requests Pending Resolution:                     0
- Total Requests completed:                            54
- Total Requests completed with Results:                11
- Percentage of total requests completed:              100.00%
- Percentage of total completed requests with results:  20.37%

## Implemented a different approach... “Make Corrections to Consults Not Linked”

- Reviewed and explained the Consult Performance Monitor Report.
- Reviewed how to run Consult Performance Monitor Report.
- Assigned the Integrated Document Management menu option.
- Assigned the Consult Managers the “Consult Linker”  ASU Class.
- Created Business Rules to be able to change a progress note title and link the consult to the appropriate consult service.
- Reviewed the process for giving access to consults.
- Reviewed the process for changing a document title to a consult title and linking  to the appropriate consult.
- Reviewed the process for running consult tracking reports.

## How to Run the Consult Performance Monitor Report

- Select Consult Tracking Reports Option: Consult Performance Monitor Report
-                   Consult/Request Performance Monitor - 1QFY08
-                 Fiscal Quarter Dates: Oct 01, 2007 - Dec 31, 2007
-               30 Days Before Start/End: Sep 01, 2007 - Dec 01, 2007
-               60 Days Before Start/End: Aug 02, 2007 - Nov 01, 2007
- SERVICE: AUDIOLOGY
-                                                                             WITHIN       IFC      IFC
-                                                                             FACILITY   SENT     REC'D
- All Requests in 30 Days Before Start/End of Qtr:     943         0             0
- All Requests in 60 Days Before Start/End of Qtr:     999         0             0
- Complete with Results in 30 Days of Request:         780         0             0
- Complete with Results 31-60 Days of Request:        162         0             0
**All Requests Created 60 Days Before Qtr Start:   28110     0             3**
- All Requests Pending 60 Days Before Qtr Start:         0           0             0
- Percent Complete w/Results in 30 Days of Request:  82.71%     N / A    N / A
- Percent Complete w/Results 31-60 Days of Request:  16.22%     N / A    N / A
- Percent Still Pending Created Before Qtr Start:              0.00%     N / A    0.00%

## Delegated Integrated Document Management menu option to Users

- Select Delegate's Menu Management Option: **EDIT A USER'S OPTIONS**
- Select NEW PERSON NAME:
-      SECONDARY MENU OPTION: TIU MAIN MENU MIXED CLINICIAN has been added!
-      SECONDARY MENU OPTION:
- Select NEW PERSON NAME:

## 			
 Create a New User Class

Select User Class Management Option: USER CLASS DEFINITION
Select User Class Status: ACTIVE//  
        Start With Class: FIRST// 
             Go To Class: LAST// 

Searching for the User Classes..................

     Find                      Expand/Collapse Class     Change View
     Create a Class            List Members              Quit
     Edit User Class

Select Action: Next Screen// CREATE A CLASS 
Select CLASS: CONSULT LINKER
Are you adding 'CONSULT LINKER' as a new USR CLASS (the 195TH)? No// YES
   USR CLASS ACTIVE: ACTIVE
NAME: CONSULT LINKER// 
DISPLAY NAME: Consult Linker// 
ABBREVIATION: 
ACTIVE: Active// 
Select SUBCLASS: 
Rebuilding main class list..................

** ****Create a New User Class**
- Select User Class Management Option: **USER CLASS DEFINITION**
- Select User Class Status: ACTIVE//
-         Start With Class: FIRST//
-              Go To Class: LAST//
- Searching for the User Classes..................
-      Find                      Expand/Collapse Class     Change View
-      Create a Class            List Members              Quit
-      Edit User Class
- Select Action: Next Screen// **CREATE A CLASS**
- Select CLASS: **CONSULT LINKER**
- Are you adding 'CONSULT LINKER' as a new USR CLASS (the 195TH)? No// **YES**
-    USR CLASS ACTIVE: **ACTIVE**
- NAME: CONSULT LINKER//
- DISPLAY NAME: Consult Linker//
- ABBREVIATION:
- ACTIVE: Active//
- Select SUBCLASS:
- Rebuilding main class list..................

## Add users to a User Class

Select User Class Management Option: LIST MEMBERSHIP BY CLASS
Select CLASS: CONSULT LINKER     Active
Searching for the User Classes...............

                               CONSULT LINKERs                        No CONSULT LINKERs found                  

          + Next Screen  - Prev Screen  ?? More Actions                  
     Add                       Remove                    Change View
     Edit                      Schedule Changes          Quit

Select Action: Quit// ADD 
Select Another MEMBER: SNIDER,RANDY L       RLS     11     PROGRAM SPECIALIST
MEMBER:

- Select User Class Management Option: **LIST MEMBERSHIP BY CLASS**
- Select CLASS: **CONSULT LINKER     Active**
- Searching for the User Classes...............
-                                CONSULT LINKERs                        No CONSULT LINKERs found
-           + Next Screen  - Prev Screen  ?? More Actions
-      Add                       Remove                    Change View
-      Edit                      Schedule Changes          Quit
- Select Action: Quit// **ADD **
- Select Another MEMBER: **SNIDER,RANDY L**       RLS     11     PROGRAM SPECIALIST
- MEMBER:

## Associating Business Rules to a User Class

- Select User Class Management Option: **MANAGE BUSINESS RULES**
- Select SEARCH CATEGORY: DOCUMENT DEFINITION// **USER CLASS**
- Select USER CLASS: **CONSULT LINKER       Active**
-      Find                      Edit Rule                 Change View
-      Add Rule                  Delete Rule               Quit
- Select Action: Quit// **ADD RULE**
- Please Enter a New Business Rule:
- Select DOCUMENT DEFINITION: **PROGRESS NOTES       CLASS**
- DOCUMENT DEFINITION: **PROGRESS NOTES**
- STATUS:** COMPLETED**
- ACTION: **CHANGE TITLE**
- USER CLASS: **CONSULT LINKER  Active**
- AND FLAG:
- USER ROLE:
- DESCRIPTION:
-   No existing text
-   Edit? NO//
-  			    List Business Rules by USER CLASS
-                         Rules for CONSULT LINKER
- 1  A COMPLETED (CLASS) PROGRESS NOTE may HAVE ITS TITLE CHANGED by a CONSULT LINKER
- 2  A COMPLETED (DOCUMENT CLASS) CONSULT may BE LINKED with a request by a CONSULT LINKER

## Gave the Consult Management Option to Service/Section ADPACs to update users.

**Select Consult Management Option: SERVICE USER Management**
- Select Service/Specialty: OUTPATIENT SUBSTANCE ABUSE CLINIC
- SERVICE INDIVIDUAL TO NOTIFY:
- Select SERVICE TEAM TO NOTIFY:
- Select NOTIFICATION BY PT LOCATION:
- Select UPDATE USERS W/O NOTIFICATIONS:
- Select UPDATE TEAMS W/O NOTIFICATIONS:
- Select UPDATE USER CLASS W/O NOTIFS:
- Select ADMINISTRATIVE UPDATE USER:
- ADMINISTRATIVE UPDATE USER:
- NOTIFICATION RECIPIENT:
- Select ADMINISTRATIVE UPDATE USER:
- Select ADMINISTRATIVE UPDATE TEAM:
- SPECIAL UPDATES INDIVIDUAL:

## Demonstrate how to change the note title and link to the appropriate consult service 

- Select Action: Next Screen// **CT   CT**
- TITLE: DERMATOLOGY PROGRESS NOTE// **DERMATOLOGY CONSULT RESPONSE**    TITLE
- You must link this Result to a Consult Request...
- The following CONSULT REQUEST(S) are available:
**  ****1> Jan 07, 2008 C#1351887  DERMATOLOGY s   0 notes   **
-   2> Dec 05, 2006 C#1138212  AUDIO       c   1 note

## How to change a title and link a consult  

- Run your Service Consults Schedule-Management Report.
- Identify consults that are in a scheduled linked checked out status.
- Review the “notes tab” in CPRS to identify the progress note that is related to the consult in question.
- How to access the progress note in Vista to change the title and link the consult.

## Service Consults Schedule Management Report

**Identify consults with a status of “SCH, LINK, Ck’d Out**

## Identify the consult in question.   The consult information will display on the screen to the right under Facility Activity.

- 	In this section, you are provided with all the activities or actions that occurred with this consult. This consult is in a scheduled status and has an appointment linked to it dated 8/22/07.

## The progress note was linked to the appointment “visit location“ that was used to schedule the consult. This is the reason the status of the consult is Sch, Linked, Ck’d Out.  Before changing the progress note title, make certain the progress note is linked to the correct title.

## To ensure the progress note is linked to the correct visit location, you can use the Cover Sheet, PCE, or Appointment Management to access this information. The fastest way to find out is by clicking on the visit location from the Cover Sheet to see what progress note is linked to that appointment:

## How to access the progress note in Vista to be able to change the progress note title and link the consult.

## Type in a date range or the exact date the progress note was written. 

## To change the title, you will select the option CT.

## After successfully changing the note title, you will be prompted to link this “Result to a Consult Request”.

## Progress note is now linked to the consult.

## Results after implementation

## Professional Service Encounters (Inpatient Encounters)

## Stakeholders

- Miami VA – as a Facility
- Chief of Staff
- Quality Management
- Business Results Council

## Implementation Team

- Neurology and Emergency Department Service Chiefs and AOs/HSSs
- Data Management Group
- MAS Support Staff
- Clinical Application Coordinators
- Service/Section ADPACs/SuperUsers
- Fiscal and Revenue Service

## VHA Directive 2006-026                      May 5, 2006Patient Care Data Capture

- Purpose:  Establishes the policy requiring the capture of all outpatient encounters, inpatient appointments in outpatient clinics and inpatient billable professional services.
- VHA information system have been modified to enable the transmission of all encounters from Patient Care Encounter (PCE) to the National Patient Care Database in Austin, Texas.
- Each clinic must be set up by Decision Support System (DSS) Identifier.
- VHA facilities utilize a variety of software packages to capture inpatient and outpatient workload. All data must also pass or be transferred into PCE (if not directly entered into PCE).

## Workload SolutionsHealth Data & Informatics

- Modify software and business processes to allow inpatient encounters to be transmitted to NPCD.
- Activate interface between Medicine/Surgery Package and Primary Care Encounter (PCE).  Collect all inpatient and outpatient procedures.
- Eliminate the use of paper logs in procedures areas and capture non-operating room procedures in VistA.
- Objective Measure of physicians productivity including physician pay for performance.
- Regular maintenance of Encounter Forms is required at least twice each  year.

## Implementation at the Miami VA Healthcare System

- Physician workload was “mapped” by service and ward assignment, but the majority of the consults and inpatient procedures were not captured. Some sections were partially using Event Capture.
- Inpatient Encounters were piloted in Neurology Service on Oct 1, 2006.   Other specialty services followed.

## Inpatient Clinics Set Up

- Clinic: **NEUROLOGY INPATIENT AM** 	Abbr.: NEURO
- Location: INPT                                             	Telephone:
- Days clinic meets:                                          	Start date: 09/18/2006
- Increments: 30 Minutes                       	Hour display begins: 7 AM
- Appt. length: 30 Minutes                        	Variable length appts.: NO
- Stop Code: 315            		 	Maximum overbooks per day: 0
- Credit Stop Code:                          		Non-count clinic: NO
- Prohibit access: NO        			Maximum days for future booking:

## Neurology Inpatient Encounter

## Neurology Inpatient Encounter

## Neurology Workload

## How Information is Transmitted

## Specialties consulted to the Emergency Department

- Clinics are set up with the naming convention ED/Specialty Service i.e. ED/Neurosurgery.
- Clinics are set up with the stop code 130 Emergency Room and the credit stop code based upon the specialty service.

## Inpatient Clinics Set Up

- Clinic: ED/NEUROSURGERY		Abbr.: EDNS
- Location: ED                                             	Telephone:
- Days clinic meets:                                          	Start date: 09/18/2006
- Increments: 60 Minutes                       	Hour display begins: 7 AM
- Appt. length: 60 Minutes                        	Variable length appts.: NO
- Stop Code: 130            		 	Maximum overbooks per day: 0
- Credit Stop Code: 406                        	Non-count clinic: NO
- Prohibit access: NO        			Maximum days for future booking:

## ED Subspecialty Clinics

## ED Subspecialty Clinics

## Pre-implementation...

- Reviewed Progress Note Templates and Titles
- Reviewed current capture methods (Inpatient Encounters vs Event Capture)
- Reviewed Inpatient Consult Process and Inpatient Documentation
- Run ACRP Reports and Event Capture reports
- Created Training material

## References

- VHA Directive 2006-026, Patient Care Data Capture, May 5, 2006
- John Quinn, National Data Systems, VHA OI Health Data & Informatics, Austin, Texas

## Gender Disparities in Select Performance Measures

- Christy Zelo, MS, RD
- Sarah Garrison, MD, MPH

## Background

- March – 2007:  Dr Kussman approved change from Women Veteran Program to Women Veteran Health Strategic Healthcare Group
- Moves focus beyond gender-specific care to the comprehensive care of women
- Increase focus on quality of care issues and comprehensive longitudinal care for women veterans (with particular emphasis on endocrine measures, Influenza immunization, and colorectal cancer screening)

## Women Veterans

- Currently about 7% of veterans are women and rising
- Generally younger than their male counterparts
- Generally more educated then their male counterparts
- Top 3 diagnostic categories for Women Veterans in 2006: Post Traumatic Stress Disorder, Hypertension, Depression

- _[http://www1.va.gov/womenvet/docs/WomenVet_History.pdf](http://www1.va.gov/womenvet/docs/WomenVet_History.pdf)_

## Recap:  V03 2007 – 4Q Review

- Reviewed following measures by facility, using Clinical Reminders reports run on NEXUS Cohort
- Influenza immunization
- Colorectal Cancer Screening
- Diabetes control (hgba1c <9)
- Lipid control in diabetic patients (LDL <120*)
- HTN control (<140/90) AND poor control (>160/100)

## Recap:  V03 2007 – 4Q Findings

- In general – women veterans with diabetes and hyperlipidemia had worse performance measures than their male counterparts in V03
- Some facilities had greater gender differences than others
- Clinical reminders reports, when run on the NEXUS cohort, provide important information about our performance, and should be ongoing

## 2008 V03 Gender-Specific Data

- Instructions to CACs:
- Run reminder reports on NEXUS Cohort, by gender, for 1st and 2nd quarters  potential for redundancy in data w/ over-reporting of patients w/ multiple visits
- Not all facilities have Clinical Reminders for each measure looked at  missing data points
- Where available, VISN EPRP data included (pre-release report) for comparison

## Influenza Immunization rates   FY08 1+2Q Data (age 50 – 64)

## Influenza Immunization rates   FY08 1+2Q Data (age >64)

## Colorectal Cancer Screening   FY08 1+2Q Data

## Diabetes – HgbA1c <9 FY08 1+2Q Data

## Diabetes Lipid Control  FY08 1+2Q Data

## HTN - BP <140/90 FY08 1+2Q Data

## Findings – 1St & 2nd Q 2008

- More consistent gender disparities seen than suggested at end of FY07
- Substantial gender differences seen:
- influenza immunization rates
- colorectal cancer screening
- HgbA1c
- LDL in diabetics

## Brainstorming

- _Why the differences exist?_
- Focus on family before individual needs
- Competing life demands
- Inflexible clinic schedules
- open access may be better but inconsistency across clinics isn’t
- Possible disproportionate # of women with Mental Health diagnosis
- Women more likely to seek out Alternative instead of Traditional medicine
- Some women polled – identified following barriers:
- Eating on the run
- Children/Husbands/Family/Jobs come first
- Some w/MST history felt colonoscopy was too invasive and humiliating
- Disease acceptance – “this runs in my family, that’s just the way it is”

## Brainstorming

- _Potential solutions / interventions_
- Cooking classes
- MOVE! Program for women
- Support groups
- Share barriers / fears
- Invite women veterans who have overcome to share their experiences
- Education should focus on their barriers
- How to eat while on the run, better sources of fuel for a busy lifestyle, importance of putting yourself first – why you can’t take care of others if you aren’t taking care of yourself.
- How can we help those who are non-compliant due to MH diagnosis?
- How can we help those who fear invasive tests due to MST history?

## Implications and future directions

- As a network, we are not achieving goal for our women veterans in several quality measures
-  Next steps. . .
- Raise awareness
- Proposal to involve graduate students to interview women veterans and determine barriers to receiving care
- Continue to drill down data and look for more opportunities for improvement

## Special Recognition to  
~
Dr. Sarah Garrison and the 
VISN 3 Women Veterans 
Healthcare Council!

- ~
- Dr. Sarah Garrison and the
- VISN 3 Women Veterans
- Healthcare Council!