# Presentation: 248956

## #258-Women Veterans Health Carethe “XX Files”

**Peggy Mikelonis  ARNP-C, MS, CNA**
- Tampa
**Cheryl Knowles RN, MSN**
- Canandaigua/Bath
**Kathy Prividera RN, MS**
- Albany

## OBJECTIVES

- Present brief overview of history of women in the military
- Address women veterans using VA health care system
- Apply functionality in CPRS to facilitate the delivery of care to women veterans
- From national to local level

## WOMEN VETERANS 

- The important role of women in our nation’s defense and as part of the veteran population over the years cannot be over-stated
-  Women now comprise 17% of active duty deployed forces- and are becoming veterans at an increasing rate
- During Gulf War I (1991) Women were 10% of Deployed Active Duty, 5% of forces overall
- From WWII- Vietnam era, women comprised between 3-5% of Active Duty

**Notes:**
Their history is a glorious one and sadly one not always acknowledged or appreciated. 

## THEN AND NOW

## Women’s Health Moves Forward

- Dr Kussman approved change from Women Veteran Program to Women Veteran Health Strategic Healthcare Group- March, 2007
- Moves focus beyond gender-specific care such as Pap Smears to comprehensive care of women- and women’s health as a subpopulation of all veterans
- Increase focus on quality of care issues and comprehensive longitudinal care for women veterans

## Women Veterans Using VA

**Notes:**
Data demonstrates the younger age of our women veterans

## DEMOGRAPHIC DIFFERENCES

- Women VA users are younger
-  Mean Age  49.5 years
- Men: Mean age 70 years
- Women users have more education (65% have college, 35% of males users do)
- Less likely to be married (25% of women, 48% of men)

**Notes:**
Some differences between women and men who use VA services.

## Slide 8

**Notes:**
First all women air squadron in Gulf- Reserve re-fueling group, 2003 over Baghdad

## VA Women Veterans

**Notes:**
The blue line is the number of users of VA healthcare, the cranberry is the number of Enrollees
The Number of women VA users  of heatlhcare in FY 2006 was 239,000.  By February, 2007, the VA had already seen 213,000 women

## THE NEW XX FILES

- National
- Women’s Health Software
- Military Sexual Trauma (MST) Software
- WVSHCG Website  http_://vaww1.va.gov/wvhp/_
- VISN
- Osteoporosis
- Pregnancy/Lactation Flag
- Local
- HPV vaccine
- Templates for gender specific exams

**Notes:**
There are a wide variety of CPRS tools specifically available for clinicians who are  providing care for women

Today Cheryl and I are going to review the major ones currently available from the national level to some local initiatives

I have listed the Women Veterans Health Strategic Health Care Website for those of you interested in other programs, links and reports available that Cheryl and I are not presenting today.  Such things as
     Clinical Inventory of Care (listing of gender specific programs, services at 	each VA facility .
     Videos available
     Directory of all WVPM’s
     Variety of useful links

We welcome the opportunity to be here today presenting the XX files ....

## Presenter: Peggy Mikelonis ARNP-C,MS, CNA
Master’s prepared  ANCC certified  Adult Health Nurse Practitioner employed at the Tampa Veterans Hospital.
ANCC certified Nursing Administrator 
Has been working in the area of women’s health specifically since 1993 (been at Tampa many years before in variety of nursing roles).
Presently is the Lead Women Veterans Program Manager for VISN 8 and the WVPM for Tampa.
Actively involved in women veterans health program development, assessment and implementation at national, VISN and local levels.
Recipient of the Dept of Veterans Affairs  Fourth Annual WVPM of the New Millennium Recognition  Award(2004)

- Master’s prepared  ANCC certified  Adult Health Nurse Practitioner employed at the Tampa Veterans Hospital.
- ANCC certified Nursing Administrator
- Has been working in the area of women’s health specifically since 1993 (been at Tampa many years before in variety of nursing roles).
- Presently is the Lead Women Veterans Program Manager for VISN 8 and the WVPM for Tampa.
- Actively involved in women veterans health program development, assessment and implementation at national, VISN and local levels.
- Recipient of the Dept of Veterans Affairs  Fourth Annual WVPM of the New Millennium Recognition  Award(2004)

## 	Additional Presenter: Kathryn W. Prividera, MS, RN

Master of Science: Community Health CNS & Gerontological  Nurse Practitioner.

Lead Women Veterans Program Manager VISN 2 -1996-2007 

Women Veterans Program Manager Stratton VAMC, Albany since 1994

Actively involved in development and implementation of Women’ Health Software; MST software; and Integration of Women’s Health software with CPRS having served on the National Tags' for all of these initiatives. 
Member of Team CPRS/WH Integration Usability Testing CAMP CPRS 2003. 
Total nursing experience >43 years

- Master of Science: Community Health CNS & Gerontological  Nurse Practitioner.
- Lead Women Veterans Program Manager VISN 2 -1996-2007
- Women Veterans Program Manager Stratton VAMC, Albany since 1994
- Actively involved in development and implementation of Women’ Health Software; MST software; and Integration of Women’s Health software with CPRS having served on the National Tags' for all of these initiatives.
- Member of Team CPRS/WH Integration Usability Testing CAMP CPRS 2003.
- Total nursing experience >43 years

## NATIONAL WOMEN VETERANS HEALTH SOFTWARE

- Optional software for sites to utilize
- Every site _must install the new clinical screening reminders whether they use this software or not._
- Screening reminders designed to work for all sites, whether they use the WH package or not  (NATIONAL)

## Each site needs to decide whether review reminders should be installed and released to the staff

Review reminders facilitate 
Sending WH results letters
Updating WH needs due dates so WH reminder letters can be generated

**Review reminders facilitate**
- Sending WH results letters
- Updating WH needs due dates so WH reminder letters can be generated

**Notes:**
It is suggested that you do not install and release PAP Smear Review reminder to the field if PAP cytology results are not recorded in the VistA Lab package and are not updating WH package.

Demonstration of the functionality of utilizing notification letters will be presented later in this presentation

## Military Sexual Trauma (MST) Screening 

- VHA Directive 2005-015 outlines the MST program (dated March 25, 2005)
- MST national software
- Allows  tracking of VA’s screening of veterans
- MST Coordinator at every VAMC
- Ensure all enrolled veterans screened for MST
- Provide staff education and training
- MST Resources website
- _[http://](http://vaww.collage.research.med.va.gov/collage/E_behav/MST/)__[vaww.collage.research.med.va.gov/collage/E_behav/MST](http://vaww.collage.research.med.va.gov/collage/E_behav/MST/)__[/](http://vaww.collage.research.med.va.gov/collage/E_behav/MST/)_

**Notes:**
Historically Public Law 102-585  authorized the Dept of VA to provide outreach and establish MST Counseling and treatment programs for women veterans who experienced incidents of sexual trauma while on active duty.
Public Law 103-452 authorized VA to provide MST counseling and treatment to men as well as women.
The Women Veterans and Mental Health Strategic Groups utilize the national MST report to respond to Congressional inquiries and for expansion of MST programs and initiatives.

## MST Reminder Resolution

## MST Status

-  MST status is dynamic and can be changed
-  Example:
*A veteran is screened in primary care and denies any MST experience.  Later, the veteran discloses their MST to their mental health care provider.*
- In order for this veteran to be eligible for free
-  care,  you must change the MST status

## How to Change MST Status

- Open the veteran’s medical chart in CPRS
- Begin writing a progress note
- Open the “Reminders” drawer.  You will see any reminders that are currently due.
- To access old reminders, click on the “Applicable” folder.
- Open MST screening
- Mark “yes”

## 3. Open the “Reminders” drawer

## 4. Click on the “Applicable” folder

## 5. Open MST Screening

## 6. Mark “yes

## Impact of Changing MST Status

- This will change the reminder record AND the encounter form for each visit will now ask whether service provided was MST-related
_**Very important**_:  visit must be marked MST related on the encounter form for the veteran to receive free treatment and record that MST treatment was provided

## Noted on the encounter form

## Using Patient Record Flags in Women’s Health

**Notes:**
Picture is clipart

## Why Have a Patient Record Flag for Pregnancy/Lactation Status ?

- Pregnancy and/or lactation status in CPRS
- Medication management and safety for women who are pregnant or breast feeding
- Reminder reports every 3 months/Documentation in CPRS
- Summary report of all patients assigned the flag.

**Notes:**
It is a mechanism to assure immediate access to pregnancy and lactation status information in  CPRS
It supports overall improvement in medication management and safety for women who are pregnant or breast feeding and improved safety for their babies. (JCAHO safety ) 
Reminder reports every 3 months. WVPM/designee contacts patients or reviews clinical record, updates status.  Documentation in CPRS
It provides a summary report of all patients assigned the flag.

## Flag implemented and maintained by the WVPM

- Identified responsible person
- designates an alternate
- Coordinates care with Fee Basis Office
- Assigns patient record flag
- Menu assigned by Health Administration Services
- Menu includes
- Record Flag Reports, Record Flag Assignment and Record Flag Management

**Notes:**
Each facility (or VISN) must implement a policy statement identifying overall responsibility for this program
Category II flags are locally established by individual VISNs or facilities. They are not shared between facilities. 
At each facility there is a designated individual in Health Administration Services (HAS) who is assigned overview of Patient Record Flags.  

## Step One: Set the Flag

- After determining who is appropriate for this record flag, you must first use your VISTA menu options to set the record flag:

## Select the patient

## Assign the flag

## Select the Flag

## Select a flag for this assignment: L.PREG  PREGNANT OR LACTATING     ACTIVE     CLINICAL
        ...OK? Yes//   (Yes)
Enter Owner Site: SYRACUSE VAMC//     NY  VAMC  528A7  
Approved By: PRIVIDERA,KATHRYN W       KWP     11W     Women Veterans Program Manager

-         ...OK? Yes//   (Yes)
- Enter Owner Site: SYRACUSE VAMC//     NY  VAMC  528A7
- Approved By: PRIVIDERA,KATHRYN W       KWP     11W     Women Veterans Program Manager

**At the ‘Approved By:’ prompt, enter your name.**

**In this field you type something very brief:**
**Please use care when prescribing or filling prescriptions for this pregnant patient.**

**Notes:**
Pregnancy verified.
This is what appears initially when CPRS opened
Policy per facility for verification

**You must define the review date, which is defaulted to 90 days.**
**You are then shown a summary of what you’ve just done.**

**Once you say YES to this prompt, the flag is set.**

## Display to Providers in Radiology and Pharmacy 

- Do you want to continue processing this patient record? No// yes  (Yes)
- >>> Active Patient Record Flag(s):
-      <PREGNANCY LACTATION STATUS>   CATEGORY II
- Do you wish to view active patient record flag details? YES//

**Notes:**
This is the screen capture that appears is VISTA for Pharmacy and Radiology providers when processing orders
If click yes, will display the record flag details

## STEP TWO: WRITE THE NOTE

**Notes:**
Every Patient Record Flag in Patient’s record is accompanied by a TIU Progress Note.  The  TIU titles utilized must be PRF Category II (for pregnancy flag used here). 
( Per VHA Directive 2003-048 dated August 28, 2003)

## Note: this is a special title that needs to be associated with a flag. You must click on the flag that appears below the title listing.

## The title is connected to this template.

**The title is connected to this template.**
**When writing the note, click in the appropriate boxes.**
**All boxes have been clicked in this example so that all choices are evident.**

## Here is the flag as it appears when the patient is selected in CPRS:

**If the user clicks on the note listed in the lower box, the electronic progress note appears.**

## STEP THREE: REPORTS

**You have also been given the Record Flag Reports Menu.**

**Notes:**
This menu provides the WVPM with a means to identify number of women with 

## Slide 43

## This is the flag assignment report for all patients with this flag.

**Note: This software is not multidivisional, so the only way you can separate the patients by site is by looking at the “Owning Site”.**

## The report option “Assignments Due for Review Report’ will tell you who needs to have their flags reviewed in the future:

## This is the report, showing that the patient’s flag is due for review on March 11, 2007. 

## Renewing, editing or removing the flag:

- Record flags must be reviewed on a periodic basis. The Pregnancy Lactation flag is set to be renewed every 90 days, with a notification time of 5 -7 days.
- You will receive e-mail notification in VISTA of patients whose flags are due for review.

## Renewing the flag:

**This action is taken in Vista, using the Record Flag Assignment that was used to set the flag initially.**

## You can renew the flag, inactivate the flag, or correct a flag set in error.

**You can renew the flag, inactivate the flag, or correct a flag set in error.**

## FEE  BASIS CONSULTS

- Provider enters consult to Fee Basis
- Alert generated to WVPM and designated alternate
- Mechanism for establishing the record flag
- Capability for Interfacility electronic consults  (VISN 8)

## Reason for request

## Slide 53

## Women’s Health staff are responsible for the setting, reviewing, editing and removal of these record flags in a timely manner.

**If you have any questions about using the software, please contact the Clinical Application Coordinators at your site.**

## HPV Clinical Reminder

## Background

- In June 2006, the FDA approved the first vaccine for prevention of cervical cancer and genital warts.  Over 200 women veterans at the Tampa VAMC met age criteria for CDC guidelines for HPV vaccination.

## Why is HPV Important?A Virus our Women Veterans Needed to Know About

**HPV = Human Papilloma Virus**
- Genital human papilloma virus is common in the United States.
- 20 million people in the U.S. are infected with HPV
- (1 in 4 women, ages 15-59)
- Infections don't cause any symptoms and go away on their own.
- HPV can cause genital and upper respiratory warts
- There is no treatment for HPV infection.
- HPV is important because it can cause CERVICAL CANCER.
**Cervical Cancer**
- 10,000 women get cervical cancer every year in the U.S.
- 3,700 die from it every year in the U.S.
- 2nd leading cause of cancer deaths among women around the world.

##     Where do you start?

**Guidelines – Developed by Infectious Disease, **
**Gynecology, Pharmacy**

**Implementation Team**
-  Gynecology, Primary Care, Women's Health, Nursing, Clinical Informatics,
-  Pharmacy

## Clinical Reminder Logic

- Patient Cohort Logic:
- Due once for all women ages 11-26
- Not due if this health factor is on file in VistA:
- HPV VACCINE CONTRAINDICATED-ALLERGY
- Reminder Resolved by one of the following:
- Immunization finding: PAPILLOMA VIRUS
- Drug finding: HUMAN PAPILLOMAVIRUS VACCINE (Gardasil)
- CPT Code: HPV (PAPILLOMA VIRUS) VACCINE
- Health factor: REFUSED PAPILLOMA VIRUS VACCINE (for one year)
- Health factor: HPV VACCINE DEFERRED  (for 6 months)

## Clinical Reminders

**Goal: ** To identify candidates for HPV at the time of the primary care clinic visit.

- Clinical reminders for “Consider HPV Vaccination” and “HPV Education” display on the CPRS Cover Sheet
- Reminder Dialogs standardize progress note entry and collection of patient education and/or immunization data elements

## Consider HPV

## Slide 62

## Slide 63

## HPV Education

## Order Set

**Orders to schedule appt, consult to Nursing Intervention, follow up Beta HCG lab tests, and Medication Order**

**Notes:**
Poster Session

- Presenter: Cheryl Knowles RN, MSN, HNC
- Master of Science in Nursing, Registered Nurse
- National certified holistic nurse (HNC) - demonstrates competency and expertise with integrating holistic approaches into nursing practice
- Lead Women Veterans Program Manager at VA Healthcare Network Upstate New York (VISN 2)
- Women Veterans Program Manager VA Healthcare Network Upstate New York at Bath and Canandaigua
- Specializing in women’s health since 1995
- Federally employed for 26 years in Nursing; 34 years total experience in field of nursing

## Mammograms and Pap Smears

**CPRS GUI interfaces with the Women’s Health (WH) VistA software package (2005)**
**Provides reminder dialogs that update WH package at the same time that clinical care is recorded in CPRS GUI, thus eliminating the need for dual data entry**
**Produces a signed progress note that documents Pap Smear and mammogram procedures, and WH patient notifications**

## Closing the Loop

**New computed findings resolve Mammogram and Pap smear screening reminders when procedures are:**
- Recorded in VistA Radiology package
- Automatically uploaded into WH from the VistA Radiology package
- Manually entered into WH
- Recorded in VistA Lab package
- Automatically uploaded into WH from the VistA Lab package
- Manually entered into WH

## 2005 Changes

**Every site should have installed the screening reminders because they replaced the old cervical cancer and breast cancer screening reminders (2005)**
**Every site should have at least installed and configured the Women’s Health package so the PAP smear screening reminder works**
**Screening reminders designed to work for all sites, whether they use the WH package or not**

## For Review reminders to work:

**Your site must have procedures entered & verified in VistA Radiology and/or Lab packages**
- Set up a default Case Manager
- Map SNOMED codes from VistA Lab to WH
- Identify/Create quick orders and map them to mammogram and PAP smear  reminder dialog elements
- Map radiology procedures to mammogram screening reminder

## Set Ups Needed:

**Reminders package**
**Determine if your site will use Print Now functionality**
**Women’s Health package**
**Customize default copy of WH letter with address data**
**Customize text of each WH result & reminder letter**
**Set up WH site parameters**
**Do not set up WH diagnosis translations**

## Mammogram and Pap SmearCoversheet - Screening Reminders

## PAP Smear Screening and Frequency

**Encounter Information**

- Progress Note Text

## Mammogram Screening & Frequency

## Mammogram and Pap Smear Results Review Reminders

## Pap Smear Review Results

## Procedure Report within Reminder

## Clinical Review & Pt Notification

## Mammogram Review Results

## Sample Letter Notification

## Review Reminder – Not Due

## Notification Letters

**If your site plans to send WH letters, you will need to customize each result letter before you begin to use the review reminders**
**Before you customize individual letters in the WV NOTIFICATION PURPOSE file, someone should edit the default letter format in the WV LETTTER file using FileMan**
**The Integration with Women’s Health setup guide tells you how to use notification functionality and alerts even if you do not plan to actively use the WH package**

## References

**CPRS: Integration with Women’s Health Installation & Setup Guide***** *****during installation and setup of WH software**
**Power Point 2005 titled “CPRS Integration with The Women Veterans Health Program”**
- Pre-Install Worksheet helpful – lists quick orders and Radiology procedures you will be prompted for during installation

## Entering Outside VA Mammogram Reports into CPRS

- Outside report is faxed to a centralized location in clinical health area (WVPM)
- Report is directly scanned into the EMR and attached to the consult progress note
- Ordering/primary provider is added as an additional signer to the scanned note

## Provider and Clerk Responsibilities

- Ordering/primary provider reviews the scanned mammogram report, initiates an addendum to the same note with completing the mammogram review clinical reminder, signs note
- Clerk prints reminder and/or notification letters and mails to pt

## 	 FLOWCHART 	

- Loop starts Here:
- Patient reports for mammogram testing

- Mammogram is performed at a community site

- Mammogram is read and verified by the NonVA Radiologist

- WH Staff in Primary Care Team (Nurse/Clerk) print and mail letter or call pt to  follow-up with patient notification
- Loop is Closed:

- Report is scanned into EMR and attached to consult note with Provider and WH Staff as additional signers

- .

- Report is faxed to a centralized location at VA facility

- Alert sent to Provider and WH Staff
- Both sign note with Provider completing Mammogram Review Clinical Reminder

## Osteoporosis

- Silent, progressive, debilitating disease
- Robs bones of mass, results in weakened bones, creates high risk of fractures
- Preventable and treatable
- Under-recognized and under-treated

## Bone Density Screening

- Dual-energy x-ray absorptiometry (DXA) - Gold standard in measuring bone mineral density (BMD)
- 80% of those affected by osteoporosis are women *(NOF 2007 www.nof.org/osteoporosis)
- Due once in a lifetime for women 60 years and older.

## Clinical Reminder Resolution:

- Cover Sheet of Patients record in CPRS lists “due” clinical reminders
- Bone Density Screen		DUE NOW will be shown on cover of record
- Select new note, then reminders drawer to find and click on “Bone Density Screen”

## Overall dialog:After clicking on “Order Bone Density Screening Tests” then Clicking on “FINISH” presents an order menu.

## Historical EntryEnter results, date, location, screening method.

## OptionsPatient can refuse: resolves for 1 monthLife Expectancy <6 months : turns off reminders

## Screening IntervalCan change screening interval; set up to reappear according to selection  checked. If nothing is checked, screening will default to once in a lifetime.

## Further CPRS Capabilities

- Local templates, quick order, and consults for gender specific care, such as GYN, Breast Care Management, etc. can be created and mapped to applications such as clinical reminders
- Recommendations are to work closely with content experts, such as the Women Veterans Program Manager, Clinical Applications Coordinator, Compliance Officer, HIMS staff, Coders, and Women’s Health Care Providers

## Questions?