**Introducing the VA Quality Improvement Toolkit: Colorectal Cancer Care (“Colorectal Cancer Care Toolkit”)**

>> As I just mentioned Dede Ordin will be beginning today’s presentation.  She is the director of special studies at the VA office of quality and performance.  Today we also have co-presenting Dr. Jennifer Malin who works for the division of hematology / oncology at the Greater Los Angeles VA Medical Center.  And we also have Dr. Steve Asch who is the associate chief of staff for HSR&D at the Greater Los Angeles VA Medical Center.  We also have Joya Golden who is project coordinator, VA HSR&D Greater Los Angeles and she will be helping with today’s presentation.  Also presenting, we have Dr. Adam Powell.  Dr. Adam Powell who is an investigator with the VA Center for Chronic Outcomes Research and an assistant professor for the department of medicine at the University of Minnesota.  And we also have Dr. Andrea Leaf who is the assistant chief, chief oncology for New York Harbor Healthcare System on the Brooklyn campus.  I’d like to thank each of our presenters for taking the time to present for HSR&D today and at this time I will turn it over to DeDe.   Thank you.  I’m sorry Dede, your line is still muted please press unmute to begin.

>> Oh sorry.  

>> Not a problem, and I’ll advance your slides for you.

>>Thank you.  First I have a disclaimer.  The office of quality and performance is no more, with the new reorganization.  So I am with the Office of Informatics and Business Intelligence.  And whatever office I’m with, it is a great pleasure to be able to provide some background on this toolkit which is designed to help anyone in the VA improve the quality and the timeliness of colorectal cancer diagnosis and treatment.  I really hope you’ve all had a chance to at least look at and hopefully use the lung cancer toolkit released last fall.  I think you’ll find this colorectal cancer toolkit is just as excellent and useful.   Could I ask for the first slide please?  No, the first graph.

>>Oh I’m sorry.  Let me scroll down.  There we are.  And Joya is on the call now, Joya you do have presenter access.  So feel free to begin moving the slides.  Thank you.

>> OK.  Does everyone see the --- there it is.  OK thank you.  Colorectal cancer is the third most frequently diagnosed cancer in the VA after prostate and lung.  With approximately 3000 cases entered into the VA central cancer registry per year. So where are our opportunities to improve care for these veterans? Well let’s start with the screening, and this slide addresses screening.  It’s recent data [inaudible] for the proportion of eligible veterans receiving appropriate CSC screening.  Each bar on the X axis represents a VISN and each, on the Y axis is the measure scored which is the percent with appropriate screening.  The VA does really well on this nationally standardized measure, as you’ve read in newspapers.  [laughter]  We consistently perform better than the private sector.  However, we still have some problems.  Dr. Ziad Gellad and his colleagues from the Durham VA  tracked longitudinal CRC screening in a cohort of VA patients rather than the heatis cross sectional measurement, that is this performance metric.  And their analysis demonstrated that this current cross sectional measure overestimates guideline adherence.  So despite the high performance in this measure, we still have opportunity to improve care even on screening.  Next slide please. 

So in fiscal year 2007 through last year there was a Duchamp monitor, it’s not an official performance measure but it is something that is reviewed by the Duchamp with VISN directors looking at the proportion of positive FOBT, colorectoral cancer screening tests that were followed up within 30, 60, and 90 days, and many medical centers rate very high on this monitor and they have impressive improvement.  This slide shows the 2010 results for the 90 day monitor.  I ought to point out some limitations to these data, I think the 100% probably isn’t quite right.  They are self-reported.  They’re likely to exclude some people who refused follow up or who have follow up outside the VA.  But the large variation across medical centers is probably not due to reporting artifact and the probability that at least some of those without documentation of colonoscopy within 90 days might be asked to follow up or potentially cure the disease.  And I think we would all find this pretty worrisome. Next slide please. 

We also have some information about guideline adherence and timeliness of treatment for diagnosed colorectal cancer. OQP, as it was then known, in collaboration with Dr. Dawn Provenzale’s  team at the Durham VA Health Services Research and Development Center of Excellence, conducted a shared abstraction based study on the and we calculated the treatment related quality indicators and timeliness measures for about 3000 incident cases of colorectal cancer from October 2003 through March 2006. Each bar represents a VISN and on the Y axis you can see the scores and the results of one of the metrics which is lymph nodes receptive for stage 2 for colorectal patients who are undergoing curative intense surgery.  I should point out that all of the results were at the VISN level for all the measures because didn’t have enough numbers to do facility level results and I also want to point out that this is a mistaken non-guideline based metric because it really should have been 12 or more lymph nodes.  So I imagine the scores would have been even lower if we had specified the metric correctly.  Overall, for all the metrics in this study, we tend to do as well as the private sector but in this particular indicator, there was a national of 46% and you can see the huge variation across VISNs which means that there’s probably even a greater variation across medical centers.  On one of the other measures that was also problematic, nationally and also had great inter-VISN variation, was the rate of documented colonoscopy follow ups.  The national rate was 49%. And this is a follow-up colonoscopy 7 to 18 months after curative intent reception.  And again all of the measures, even when the national average was high and showed considerable variation across VISNs.  

So, in the past few years many VISNs and medical centers have worked pretty hard to improve the quality and timeliness of colorectal cancer diagnosis and treatment. There have local medical center efforts, there have been VISN collaboratives, and there has also been two national collaboratives conducted by the VISN 11 VERC, or VA Engineering Resource Center, and its sponsoring organization, office to office assistance redesign.  And in these collaboratives some of the teams focused on colorectal cancer .  And to spread their and other learning and accelerate improvement throughout VHA, OQP and the QUERI program funded one of the QUERI centers, CIPRS, or the Center for Implementation Practice and Research Support, to create a colorectal cancer improvement toolkit.  And that is what you're going to hear about today.   So Dr. Malin, I think you’re next.

>> Yes, I am on the call here.  Thank you for having me.  I am Jennifer Malin and I’m in collaboration with Steve Asch and our team here at West LA.  We have been very excited to help put together this colorectal cancer quality improvement toolkit.  The idea we had with this in collaboration with Dede and the folks at  QUERI was that the VA facilities receive their performance on quality measures consistently over time, and sometimes they find they need to improve but there is not always information out there about how to improve. We thought it was somewhat like being at a school where you are getting grades but then no one told you what you needed to do to learn the material and improve your grades. So that was the impetus for the quality improvement toolkit series.  We’ve launched our lung cancer one in December and now have been launching the colorectal cancer one over the last couple of weeks.  Next slide. 

So, it was launched officially in March, the colorectal cancer toolkit.  It was, the tools that you will hear about in the toolkit -- someone is calling them we really encourage you to go onto the website and explore the tools -- were developed by your colleagues in the VA.  A number of them were developed through the QUERI colorectal cancer collaborative.  Both the C4 collaborative that worked very hard on a number of quality improvement tools over the last few years, as well as a number of collaboratives, as Dede mentioned.  Each tool is linked to either a quality, a performance measure or one of these other quality monitors that Dede mentioned.  And you can search the website either by tool or by indicator, so if there's a particular indicator that you want to improve, you can search under the indicator and then find the tools that have been developed throughout the VA to improve performance on that indicator. We certainly know that we have not exhaustively identified every tool that’s out there.  Folks are working on this all the time and we are sure there are new tools.  So we really encourage you to not only go on the website to see what’s out there, but please if you have a tool that you have developed please use the discussion forum, use the suggest a tool button that you’ll be hearing about, and let us know about your tools so we can add those to the website.  And without much further ado, I am going to turn it over to Joya, who is going to give you a tour of the website. 

>> Hi, thank you so much, Dr. Malin.  This is Joya Golden.

[pause]

Thank you for your patience.  

[pause]

>> Joya, can you hold on just one moment we are having some technical difficulties. 

>> Sure. 

>> I apologize.

[pause]

>> Okay, terrific. It looks like we are ready to go. 

>> Correct, sorry about that. 

>> No problem, thank you so much.  As Dr. Malin introduced me, I am Joya Golden.  I am going to give you a guided tour of the colorectal cancer toolkit.  We will make three stops on our tour.  I will start with a preview of the user's guide to quality improvement, and then show you how to use the site to locate tools that you might want to adopt at your facility. Last, I will demonstrate how you can share your feedback, experiences, and even the tools you’ve created with other VA toolkit users.  So this is the quality improvement toolkit series home page.  At the top of the screen you'll find links to frequently asked questions and an overview of the toolkit series.  As you scroll further down our home page, access to our site is divided into two parts.  If you're new to quality improvement projects, you'll want to start by reviewing the user’s guide to quality improvement.  If you already have quality improvement experience, you’ll want to start by exploring the CRC toolkit, as shown on the right.  Future toolkits will also be housed on this page.  

Let's begin by taking a look at the user’s guide to quality improvement.  The user’s guide is a tutorial for conducting a quality improvement project.  It takes you step-by-step through the VA Tamix framework with information on processes like team building, setting names, choosing a project, and measuring impact.  You can click on the name of a step in the diagram to read about the step. For example, let's take a look at the tutorial on the vision analyze step by clicking its name. A new page opens that explains the vision analyze step and the VA Tamix framework.  Furthermore, we see detailed examples and visual illustrations matched to these concepts in our toolkit user’s guide.  And you can see examples here. 

Now again we will return to the homepage and click on the colorectal cancer link in the toolkit box to the right.  We are linked to the toolkit series menu selection page.  Let's take a closer look at the colorectal cancer menu selection page.  Here we have provided five links to guide you through the colorectal cancer care toolkit.  The top link, “How Can Colorectal Cancer Quality Metrics Help Me?” describes the colorectal cancer quality metrics.  It also shows how the CRC toolkit was designed to help you focus your improvement efforts by recommending innovative tools that have been used in a VA facility, or in current use elsewhere.  Returning now to the CRC toolkit menu selection page, let's click on the second link to see an entire listing of our CRC quality improvement tools. This page offers a simple list with a link to each tool description page within the CRC toolkit. We have created two ways for you to find specific tools that are matched to specific quality metrics. The first way is to review the Quality Metric by Tool table.  This is a partial view of the colorectal cancer quality metric tool table.  This table lists the VA colorectal cancer quality metrics beside each matched tool recommended for improving facility performance on that metric.  The second way to identify specific tools is to review the Tool by Quality Metric table.  Again here is a partial view of the colorectal cancer tool by quality metric table.  The table shows each tool in the first column and lists the quality metrics associated with that tool in the second column.  It is important to note that there are two types of tools in the CRC toolkit.  First, there are CPRS based tools such as order sets and consult templates.  To adopt these tools you will need to get assistance from your local clinical applications coordinator or IRM staff.  Second, there are tools such as Word documents, Excel spreadsheets, and Powerpoint slides that you can easily download from the toolkit site.  

Now let’s take a look at a sample tool.  Let's say your facility has shown poor performance on CR6, time from diagnosis to initiation of treatment.  You can scroll down the table to find CR6 and take a look at the list of tools that might help you improve performance on that measure. We can see that there are eight tools matched to CR6.  Let's say you want to know more about tool 29, the CPRS surgery consult  template.  You simply click on the tool’s name and you are taken directly to the tool 29 description page where you can read more about tool 29 and how to acquire it. Each tool in the CRC toolkit is described in its own page in the same format. At the very top of the tool 29 description page you'll see the full name of the tool and all five quality metrics that it has been matched to.  Below that you will see some text labeled issue, solution, and what you should know.  This section describes performance challenges the tool may help you address, and offers helpful guidelines to consider before adopting this tool.  

At the bottom of tool 29 description page, there are four important links to take note of.  [pause] When you select the View this Tool link, a short PowerPoint presentation opens with screenshots of the CPRS surgical consult template.  You can review the screenshots, save the presentation on your server, and email it to your colleagues.  Once you've refinished reviewing this tool you can close the presentation and return to the tool 29 description page. Let's say you want to decide to adopt tool 29.  It’s a CPRS based tool, so you'll need to ask your local clinical applications coordinator or IRM department for assistance in getting this tool installed.  To start the process, simply click on the blue Request Tool link at the bottom of this page.  This opens up a request form. You will see that this request form asks for your name and contact information. When you complete and click the Submit This Request form you'll receive an email with further instructions on how to get tool 29 installed. 

Now let's return to the tool 29 description page.  There are two other interactive links at the bottom of this and every tool description page.  Also there are two other interactive links at the very bottom.  Let's take a look at the Join The Discussion for this Tool.  When you click on this link, you will see a list of recent discussion posts created by other site users.  Click on any of these posts to read and share your own comment or post your own new post by selecting the Create A Post button located at the top left-hand side of this page. The toolkit was designed to be a collaborative and ongoing project, a virtual community if you will. We encourage your interaction on the quality improvement toolkit site as part of cancer care improvement within the VA.  

So returning once more to the tool 29 description page, there is one more link called Suggest A Tool. This feature allows you to upload a tool or quality improvement idea which has been used at your facility. When you click here, you can enter your contact information along with a brief description of the tool you wish to share.  If you have -- if you would like to upload a file, go ahead and click on Attach File before clicking OK to submit your innovation to the toolkit team. Your tool will be reviewed, matched to one or more quality metrics, and posted to the website for others to use.  

So that concludes our tour of the CRC toolkit website.  We certainly hope that you find the website and its tools helpful as you plan your improvement efforts.  Moreover we encourage you to visit the site often, as we add new material. We also appreciate any feedback you may have on how to make this website more helpful.  Thank you so much. 

>> Dr. Adam Powell, I will turn it over to you at this time. 

>> OK, thanks.  I also want to thank the toolkit development team for inviting me to present one of the tools on this call.  I am going to be talking about a tool that we developed during the C4 collaborative which is used to track positive FOBT’s.  Let’s go ahead and advance to the next slide.

So Dede mentioned that the improvement that we have seen in the VA on tracking on timeliness of follow up of positive FOBT’s.  What she didn’t mention was prior to a lot of the quality improvement work, this was a pretty big problem.  Back in 2004 around 70% of positive FOBT’s had no documentation of follow up within that year.  We know that number is not a completely accurate reflection of what was going on because some patients were going outside of the VA for follow up, or chose not to get follow up.  But it is still representative of a problem that needed to be addressed and so the C4 base one collaborative was put together which involved 21 sites working on this issue. Very early on in that project, we realized that many of these facilities did not have any mechanisms to track the positive FOBT’s and as anyone with quality improvement experience  knows you cannot improve what you cannot measure.  So one of the first tasks of the project was to create something to help facilities track their positive FOBT’s.  Let’s go on to the next slide please. 

Let’s go back one please. So the positive FOBT tool was developed fairly early on in this project by Jeff Morasky who is a member of the planning committee, and then Dede Ordin and I sort of took over the tool and it went through multiple iterations and evolved to meet the needs of the C14’s and we tried to incorporate as much feedback as we could from them.  And then after the C-4 project expanded and this became a national effort, we did some further tweaks to this tool to make it as user-friendly as possible for facilities who needed to report their timeliness of follow up as part of the national FOBT monitor that all facilities are required to report.  Now let's go on to the next slide.  

So this tool is an Excel spreadsheet, or an Excel workbook with actual several spreadsheets contained within it.  The first spreadsheet is a set of instructions, and I’m not going to show you that. The second tab or spreadsheet is really the heart and soul of the tool, which is what we're looking at right now, and that is the data entry spreadsheet.  To use this tool there are four pieces of information that are essential or required to get this to work really for anything. You need the patient ID number so you can track -- go back into the patient medical record and track what is going on with the patient after their positive FOBT , that’s column A.  Column B is the date of the positive FOBT, that is necessary to enter.   And then skipping over to column E, there is a place to indicate whether or not a VA colonoscopy is appropriate for that patient. The way this is set up, you can either enter just a Y or N, yes or no, or you can get more specific and document why a colonoscopy is not indicated using one of five categories.  So some of the reasons a colonoscopy might not be indicated on a positive FOBT patient are: could be clinically contra-indicated because of age or comorbidities, a patient might refuse a colonoscopy, or a patient might decide to go outside of the VA for their colonoscopy, in which case you’d want to make some indication here that the VA is not following up on this patient.  Then, column H is the last column that is needed to make this tool work and that is the date of the colonoscopy.  So we set this up to highlight the cases were colonoscopy is indicated but no colonoscopy date has been put in.  You can see there’s a couple of cells in column H that are yellow so that makes it fairly easy to kind of just scroll down this and see where patient follow-up is needed.  We have also tried to make this fairly bomb-proof by protecting the spreadsheet so that you cannot enter data into fields other than the data entry fields, you cannot enter colonoscopy date before the positive FOBT date.  There are still ways to break this tool, but we have tried to make it so that mistakes are kept to a minimum.  And I should note that the code to unprotect it is right at the top of the tool, and if facilities want to modify this for their own needs they are welcome to do that.  It does involve some complex programming using arrays and some hidden fields, so make sure that the person who does try to adapt this is someone who knows Excel fairly well. And definitely beta test whatever you do before putting it into production.  A few of the optional things that you can enter in here that were requested by some of the teams... One is column C which is whether or not the FOBT was indicated.  There are some cases where the colonoscopy may be indicated but an FOBT wasn’t.  For example, if the patient is high risk or had symptoms they should have gotten an FOBT but they definitely need a colonoscopy.  Column G is the place to put in initial provider response.  Some of our sites really wanted to be able to look at what proportion of delay was  being caused by the provider versus G.I.  and if you put in the date that a provider places a consult in column G, you can track that.  Pretty much everything that gets entered in here, is also -- statistics are created for it in some of the later tabs in this document. The other thing that you can enter into this is in column I which is the patient’s desired colonoscopy date.  So if a facility has the capacity to get patients in within their targeted date but the patient chooses a later date you can enter it in there.  Let’s go on to the next slide. 

So this is a tab of one of the tables that is created and it takes pretty much all of the fields from the previous slide and aggregates them on a monthly basis. The target for the FOBT monitor was getting  patients in within 60 days, so you can see, sort of down the middle there is the percent each month of patients who received their colonoscopy within 60 days in red.  I am not going to go through all these columns but I just went to give you a sense that you can see percentages based on things that were entered in and you can also see the numerators and denominators to get a sense each month for whether you’re looking at a large sample or small sample.  This provides a lot of information, it is not necessarily the easiest thing to visually quickly assimilate, so we also included a set of run charts.  Let’s go to the next slide please. 

So here's an example of a couple of the run charts. The top run chart is sort of a key measure chart and it allows you to see fairly quickly what is going on with this facility. The bold red measure is the 60 day measure – what we considered at least at the time, the key measure.  You can kind of see where they started out at around 30% in 2008.  They had a nice bump, maybe figured some things out about their processes, and somewhat sustained that and then later on in 2009 they got another bump. You can also see that in 2009 they started getting some of these patients in within 30 days which is in the yellow line on this graph. And then the second one is just an example of one of the other graphs that is created from this.  This is the percent of patients who had a positive FOBT where the colonoscopy was indicated.  Let's go on to the next slide. 

So most of the facilities within the VA were using this tool to report data for the FOBT monitor.  So it may already be still in use and implemented in many of your facilities but if you're considering using this and you are not currently using it or if you are considering re-implementing it I think they're a couple of things that facilities pointed out to us to think about.  One is who is going to complete the tool? Are you going to assign one person to do this, or give it to multiple people and whoever has time?  If you do choose to use multiple people, keep in mind there are some fuzzy areas where it is a matter of interpretation of things like what counts as a patient refusal, some of those things.  So you're going to want to make sure everybody is using it in the same way and inputting the data. Second is to think about how you're going to get the input data. My impression is that most facilities are entering all positive FOBT’s and getting that data straight from their lab. But I know some facilities are just entering in GI consults so depending on the resources you have and what kind of quality improvement you might be interested in doing, that could affect these things.  And then finally, it is important I think to think about who is going to review and use this data. We know that there is a lot of data collected that gets sort of underutilized and if you're going to go through the time and effort to collect it I think it is good to think about how you're going to incorporate it into the bigger quality improvement effort.  So that is all I've got on the FOBT tool. 

>>  Adam, this is Dede, can I just add one quick comment?

>> Please.

>>  That Dushon monitor has been discontinued but hopefully the tool is still here and there is a forum for the discussion around the tool and improvement of the tool.  And I know that there are a lot of facilities that plan to keep on using this tool even though there will not be -- it is not required reporting anymore. 

>> And if anybody has any questions about the programming of it or wants to modify it and is having some trouble please fill free to contact me. 

>> Thank you very much, Dr. Powell.  And Dr. Leaf do I have you on the call?

>> Yes I am here.  Can you hear me?  

>> Yes, you’re coming through fine.  Thank you.

>> Thank you.  OK.  So I am going to discuss the order set for rectal cancer, for the workup of rectal cancer. The problem we realized that, in our facility and in many facilities, the work up for rectal cancer was really taking a very long time. It is a type of tumor that has so much interdisciplinary involvement that it is a real setup for having delays at each decision point and the issue was that no one was really taking ownership over any of the steps. And what would end up happening is that there were steps that were frequently omitted. You can go to the next slide, please.

You can see that we had patients who were in some cases taking 49 days from diagnosis to start treatment and in the work up there were issues, certain lab tests, the CEA’s, were often omitted because no one knew for sure how often or who exactly was going to order it. There was a problem with the patient being placed on tumor board, no one knew who was the person in charge of putting the patient on tumor board and often the patient was not placed on tumor board.  Often radiation oncology wasn't notified in a timely fashion and they take several days to work up the patient and simulate the patient.  So again, and then often because of this several patients ended up being – missed their pportunity to participate in clinical trials because often the NCI clinical trials require, for rectal cancers, are required to have the work up and be put on the trial within 42 days. 

So, these were really the issues. Getting the lab tests, who was going to order the scans, who was going to order when the transrectal ultrasound was going to be done, who was going to let oncology know, who's going to let radiation/oncology know, who’s going to let the surgeon know, because these patients need continuous infusion chemotherapy, so they need to know up front for the port insertion and so on.  So this was our issue. Next slide please. 

You can see this is kind of the before schema where different people were contacting, again nobody had ownership and nobody knew who was going to inform radiation/oncology or surgery, or oncology, or place the orders for the scans or lab tests. Next slide. 

So, what this order set we actually had the cooperation of, at least in our facility, of our GI people.  And we felt that the best way is since the GI service is the first service to see the patient, they make the diagnosis, they’re the first ones seeing the patient, and if they can initially implement the -- and activate the order set they would be the best ones to really do it. So that as soon as the order set is activated then everyone immediately gets notified. Oncology is immediately notified, radiation/oncology is notified, surgery is notified, the appropriate labs and scans are ordered.  And this really ended up making everyone more organized and allowing the work up to proceed in a much more organized fashion. And allowing all of them, radiology/oncology and so on, to be notified in a timely fashion.  Next slide. 

And this is just what the order set includes.  All of the labs and the CT scans and even things that are sometimes forgotten like getting the creatnine prior to obtaining the CT scans, and putting in all of the consults.  Next slide. 

So when you go into the orders set all you have to do is click on each thing and then you are in CPRS so that will order the comprehensive and all the labs you need.  Next slide. 

And then it will order the imaging studies just like we normally do.  Next slide. 

And then put you into the consult page so you can quickly order the consults that are needed. Next slide. 

And then this is the, all of the orders so this could be done really rather quickly and signed off on. Next slide. 

So when we repeated this after we implemented this tool, we were able to work up a patient within 15 days, everything really went very smoothly. The issue is going to be sustainability.  We have not really been able to test that, given that we’ve not had many other rectal patients. We've had other rectal patients with metastatic disease and so on but none that really fit this tool, but I think that sustainability shouldn’t really be an option because this is really such an easy tool to work with.  And with this simple order set everything fell into place rather quickly.  Next slide please. 

The issues though, in implementing this for us.  We two different sites for our VA in New York.  It’s the Brooklyn site and Manhattan site. So it is always a little bit of an issue for having buy-in from everyone especially when there's two different sites. It’s the same computer system but two different sites.  And working with two different sets of physicians, and there are always going to be little quirks and little things that apply to really one facility and not to another.  For example, in our facility with the order set the transrectal ultrasound was ordered immediately.  Of course along with the CT scans. The patient was then not given a date for the transrectal ultrasound until the CT scans came back to make sure they didn’t have metastatic disease. But as soon as those CT scans came back, the patient had a temporary order for that transrectal ultrasound, and didn't have to then start waiting several weeks to get that transrectal ultrasound.  So with some facilities, such as our New York facility, the GI doctors there do not do transrectal ultrasounds and they have to call in someone from an outside facility so they do not really want to have that placed immediately because they did not want to have to cancel it. So again there's going to be different idiosyncrasies at each place.  I think for the most part it is an easy tool to use and I think it really will help facilitate the work up. 

>> Thank you very much, Dr. Leaf.  Dede did you want to make any more comments before we begin the Q&A? 

>> I don't think so.  It’s really great to see these tools.

>> OK, excellent.  Thank you everybody for presenting the individual tools and I want to thank the audience for your patience while we had some technical difficulties at the beginning of the session.  I want to remind everyone that if you have a question or comment to submit, please open your Q&A at this time located in the upper left-hand corner of your screen and simply type into the top box and press Ask.  We do have a couple of questions to begin with.  While we start the Q&A I will also put up our feedback form and I would like to solicit a response for today's presentation.  The first question, while we begin is: “you may be discussing this eventually but will the value of multi-disciplinary tumor boards be presented at all?” 

>> We have completed the formal discussion of the toolkit but if you go to the website you will see a number of tools regarding multi-disciplinary tumor boards, including how to set one up at your site, and tools that have been developed to improve the communication and outcomes of tumor boards. 

>> Thank you for that answer. The next question is: “For FOBT, plus tracking and entering data, presumably data is all entered manually. Who has been entering this data? What level of personnel was used for data entry? Was it RN, MD, other?  How about using ICD-9 codes, SNO-MED codes, consults and downloading this data into a database?” 

>> Adam, do you want to answer that?

>> Sure.  To my knowledge no one has figured out a way to automate this yet. So it is all manually entered at the facilities at least that I know of, and typically it is someone in GI who is doing it and usually a nurse.  I think there may be a large handful of exceptions to that pattern but that is my understanding.  Dede I don't know if you know anything else about that.   

>> No, I agree with you. 

>> Great, thank you both for those responses.  The next question we have is for Dede Ordin.  “Regarding the discontinuation of the CRC diagnosis monitor for FOBT plus being discontinued,  I am curious when this change was made and how facilities were informed.  It recently came to my attention that some GI chiefs were not aware of this change.” 

>> Well, this had been sent out to CMO’s, TMO’s and QM’s at each facility. Actually this afternoon at 2 o’clock was really the first call explaining everything but it was disseminated to all the program offices and through the QMO, CMO system.  We know that that does not filter well and hopefully after the call today things will be filtered. It really is hard to get things down to the departmental level when there is no national coordinator.  For example, in GI.  It is pretty easy for oncology because we have a chief consultant and Dr. Mike Kelly who disseminates these things to all the chiefs. There is no chief consultant for G.I. here, so if any of you have a suggestion on how to get this out to GI, we send it to primary care, we send it to nursing, we send it to everyone we can think of, so if anyone has suggestions on how to get this out to G.I. you can email them to me.  It’s diana.ordin.  O-R-D-I-N. 

>> Thank you for that response.  The next question is: “were timeframes communicated and agreed upon regarding the need to schedule CT scans, lab tests, consults, etc?”  

>> I'm sorry what was that question again? 

>> It looks like it wasn’t completed, but it starts out: “were timeframes communicated and agreed upon regarding the need to schedule CT scans, lab tests, consults, etc?”  

>> I think what they are probably asking, say in some facilities when you put in a request for a CT scan it might take three weeks from the request before they're able to schedule the CT scan so if there’s some service agreement that -- if the request for the CT scan came in on the template, that radiology would schedule it within a certain timeframe, and similarly for the consults with radiation/oncology and oncology. 

>> Yeah , I mean we didn’t have a formal service agreement.  But certainly because we were all aware, everyone was made aware of this consult at the same time, radiation/oncology, medical oncology, and so on would, and the GI people would you know expedite this work up.  And we would, you know – again, it would probably be a good idea to, depending on the type of facility that you have, if CT scans take a long time, to have a service agreement with radiology.  That wasn’t really an issue in our institution.  And we didn’t put that in as part of the toolkit but we again had no problem in expediting radiation/oncology consults but I think that’s a good point because I think in many facilities that may be an issue.  

>> Thank you for that response.  We do have several more questions coming in. I do want to take a moment to, somebody typed in a clarifying comment, and it is: “Actually at the Pittsburgh site we hired an advanced practice nurse. She reviewed the FOBT’s, screened the patients,  wrote orders if they were direct GI lab procedure, or she scheduled a patient to our medical specialty clinic to be evaluated if they had significant comorbidities.”  So thank you to the Pittsburgh colleague who had that additional information.  

>> I could just jump in that this is a great way to use the discussion forum and we really encourage everyone to go online and post comments and questions so that we can get this kind of cross talk across the facilities and really our goal is to not have the toolkit be a repository but be a living, active tool that gets continuousl used and updated so that we can get the various refinements and different approaches to tools that have been developed.  The discussion forum button is accessible directly on our homepage. There’s a Join the Discussion button that you can push.  The other thing, just while I have the floor, so to speak, or the phone, is I want to knowledge our colleagues at the Indianapolis VERC who were really our partners in crime in this and we couldn’t have done it without them.  As Joya presented, the first half of the tool goes through the principles of systems redesign and a number of different suggestions of ways you can evaluate the process and look at what is happening in your facility regarding your processes of care and how things are working. And in the VERC team actually did all the programming for the toolkit website and is maintaining the website as well as serving as a repository for any of the CPRS-based tools. So they have been instrumental in this process and we couldn’t have done it without them. 

>> Thank you very much for that additional information.  We have had a few requests for the toolkit URL to go back up so I am going to replace that on the screen at this time, if I can locate it real quick.  One second.  We will move onto the next question while I scroll through and look for that.  “How were the services notified?  Just by the consult, or was there physician to physician communication as well?” 

>> Well again, once there was a consult put out the patient was also put on tumor board, so they were discussed in tumor board so there was always that physician to physician communication throughout the whole process. And they ended up being put on tumor board in a timely fashion and it was put on in an organized way.  Prior to the toolkit there were always delays in remembering to put the patient on tumor board and so on. So this really helped facilitate the interdisciplinary aspect of the whole thing because the tumor board placement happened right away. 

>> Thank you for that reply.  The next question is: “how about quality of care and patient with metastatic disease? Is there any work being done on that, that people know about?”  Thanks.  So I believe, diseases that have been metasticized.

>> I do not believe that any of the quality indicators or measures for CRC specifically address patients with metastatic disease.  Although there are quality indicators regarding supportive care and palliative care for lung cancer and there are number of tools to improve those aspects of care in the lung cancer toolkit that would be directly applicable to CRC or any other cancer for that matter. 

>> Thank you for that reply, and for correcting the pronunciation of the word.  The next question is: “is the toolkit available ‘off-line’? Like if I'm not on the VA system but at my university affiliate?” 

>> Not yet. Currently it is only available on the VA intranet because it resides on a VA server.  We’re exploring options to attempt to eventually create a mirror site that would allow it to be accessible off-campus.  Although, also if you do connect to the VA through VPN when you're at your university affiliate you should be able to access it that way. 

>> Great.  Thank you for that response.  We have reached the end of our questions that have been submitted.  There is one additional comment that “not all metastatic diseases are considered incurable.  Single liver or lung lesions can be refected with curative intent”.  That was a comment from one of our attendees, thank you for that.  And unless there are further questions I would like to open up the forum to any of our presenters if you'd like to give some concluding thoughts on this topic. 

>> I would just like to thank everyone for participating.  Both Adam Powell and Dr. Leaf for their presentations and Dede of course for sponsoring the development of the toolkit along with QUERI and VERC.  This is really a collaborative effort and we really hope that you participate in our ongoing effort to keep the toolkit under development as we go forward and keep adding to it and post additional questions to the discussion forum and respond with your different experiences and how you've tweaked tools, or new tools that you have, so that we can all learn from your experiences and continue to improve the quality of colorectal cancer care at the VA.  Dede do you have any last thoughts? 

>> It's hard to do any better than you just put it, Jen. 

>> Thanks.

>> Thank you all very much for taking the time to present today’s HSR&D cyber seminar.  And without further ado, this will conclude today’s session.  Please do check your email in the next few days for the archive link which will lead you to the archived presentation of this seminar as well as the PDF slides and the audio.  So think you again to everyone and this does formally conclude today’s HSR&D cyber seminar. 

>> Thank you.