**Transcript of Cyberseminar**

**VIReC Clinical Informatics Seminar**

**After Visit Summary Tool**

**Presenter: John M. Byrne, D.O**

**November 19, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact the VIReC Help Desk at virec@va.gov.*

Moderator:At this time I would like to introduce our speaker for today, Dr. John Byrne. Dr. Byrne is the Associate Chief of Staff for Education, Chief of the Clinical Informatics Section, and the Designated Officer at the VA Loma Linda Healthcare System in Loma Linda, California. As a practicing General Internist, Dr. Byrne has been involved with graduate medical education for the past twenty years as Clinical Educator, Associate Program Director, the ACLS for Education, and Associate Professor of Medicine at Loma Linda University School of Medicine. Dr. Byrne has also served as General Internal Medicine Section Chief at Loma Linda. Without further ado, I would like to present Dr. Byrne.

Dr. John Byrne:Thank you and good afternoon to everyone. Thank you for the opportunity to present The After Visit Summary. I have had the privilege to work with our great innovation team here on a number of great projects, and we’re particularly proud of The After Visit Summary. In fact I’ve included on the flyer the number of the people on our Innovations Team. Particularly I want to point out Dr. Rob Durkin who is a Programmer. He’s the genius behind the programming of The After Visit Summary, and he’ll be available at the end as well for some questions, particularly those of a more technical nature. Here’s the outline for today’s talk. You may notice that there are a number of slides; I don’t know if you can see that. 

I’ll move through the software features and the screen captures of the software relatively quickly, but will give you some background on how we developed the AVS, we’ll go through the features and an initial evaluation plan, some lessons learned, and then we’ll take your questions at the end.  I want to get a sense of who our audience is today. Please answer the question, “Which areas of expertise do you work, Clinical, Information Technology, Administrative, Research, or Other?” It looks like we have a pretty good mix, but almost a third are in the Clinical area and another forty percent divides between Information Technology, Administration, and then some Research people as well. It’s a good mix of people and hopefully you’ll find this information useful no matter what area you are in. 

I think the purpose for an after-visit-summary is relatively obvious and intuitive. And if you’ve either been a patient or you’re on the clinical side of patient care, you realize that patients don’t remember most of what they hear during an office visit. They tend to forget it, and what they think they remember they don’t remember correctly. I’m always amazed at what patients will say that I said that I told them, which turns out to be not exactly true. What’s more frustrating is that they don’t remember instructions correctly and come in for their subsequent visits and not follow through on particular aspects of the advice that’s been given. Our VA patients are particularly complex and receive a lot of information from their providers. The more information patients receive, the less they tend to remember. So the outcomes of this kind of problem are pretty clear. There’s poor adherence, medication errors, missed appointments, and perceptions of poor communication with their provider. 

Patients actually want to be more engaged. They desire more information about their care; particularly they want to know about their illness and the treatment plan. Studies have shown that actually combining both oral and written information is better than either one alone. I think that’s true when anybody’s trying to remember something. If you see it in writing it’s certainly easier. In recent years has been the advent of Personal Health Records in which patients can go and view their entire record online. It’s wonderful. There is some evidence that patients are more engaged in their care when they’re able to see that. But of course it expands their entire care at the particular facility and it’s not written or directed towards patients in a patient-friendly way. It’s just more of a view of their medical record, which is really written for other healthcare providers.

One of the questions that comes up is, “Why provide after-visit-summaries when patients can simply go look at a personal health record?” After Visit Summaries printed version of them have actually been shown to enhance patient trust and confidence in their physician in a period before personal health records came into being. And for our veterans, while we have a wonderful tool in MyHealtheVet with lots of opportunities for patients to be engaged in their care there, most veterans have not actually registered for MyHealtheVet, or more importantly, gone through the in-person authentication that allows them to look at their medical record. Furthermore, in other places that have actually implemented both personal health records and after-visit-summaries, After Visit Summaries are still very popular. At Group Health in Seattle our study showed that the AVS was the third most frequently viewed information on the personal health record. And I think that’s because patients want to see what happened with that particular episode, what did they need to take away from that, and they want to see it in a patient-friendly manner. Kaiser Permanente is another system that’s implemented an after-visit-summary and also makes it available through their personal health record. They’ve shown that while there are many other things that are probably more important in patient satisfaction with their care, certainly the after-visit-summary, or the clinical summary, contributes to their overall satisfaction. 

Let me ask you this, “When you or your family have seen a physician, did you receive an after-visit-summary, Always, Most of the time, Sometimes, Rarely, Never?” A third of the people said Always, but another third actually said Never with the distribution of responses in between that. That’s very interesting. In fact this was the reason that prompted me to explore this when we were trying to decide on innovations to do at our site. Because when I went to my own private physician, but I would always receive an after-visit-summary with clear instructions and a diagnosis. And at the VA we certainly have all the data available to do that, but we really don’t have a patient-friendly format to put that in. The government has recognized the importance of this as well. As you may be aware, the government is providing incentives to both physicians and hospitals for implementing Electronic Health Records through the Centers for Medicare and Medicaid Services {CMS). And they developed a number of meaningful use criteria. In other words, criteria to show that you’re using an electronic health record in a meaningful way that warrants reimbursement for that implementation. And without going through all of those details on the slide, there are a number of stages of some things. I’ve just sort of listed some of the core components. But notice that one of those is to provide clinical summaries for patients at each office visit.

More specifically, this particular measure, the objective for after-visit-summaries is to provide one for each out-patient visit. But the measure that they’re using is that clinical summaries are provided to patients for more than fifty percent of office visits within three days. Those can be provided in a number of ways. It could be printed out. It could be through a personal health record, secure messaging, or on a website. They also specify the CMS criteria for meaningful use with the content of the after-visit-summary, or clinical summary. As we go through the presentation you’ll see that we’ve addressed most, if not all of these, on our version of the AVS. 

VA is also committed to seeking meaningful use certification through the Open Source Electronic Health Record Agent, or OSEHRA. This is a public and private effort to modernize VistA for Open Source, and with a goal of achieving meaningful use in 2014. So last year about this time officials from VA came out and stated that they were seeking this goal. Interestingly, the Indian Health Service, who has an electronic health record that’s also based on VistA, has already achieved meaningful use criteria. So the VA is heading in that direction as well. The purpose when we developed the after-visit-summary was to promote patient-centered care, to have a summary of the medications, appointments, tests, and educational material within one document that we could hand to the patient. We were trying to enhance communication, engage patients in their care, help them to recall their instructions and meet the meaningful use criteria. Our goals were to provide a very patient-centered user-friendly clinical summary in a language that they could understand. We also though wanted to minimize the work for the provider. Since most of the data that needed to go into the AVS is available in VistA, we wanted to automate it as much as possible and to reduce any manual work for the providers who are already inputting and retrieving a lot of data out of CPRS. We also wanted to make it flexible for providers so that there were some options that they could turn on and off, depending upon their particular needs for their patients. And then we also wanted to have a record of this in the CPRS, as well as be able to give the patient a copy. So we had to have safe, print, and upload into this imaging. Eventually we’d like to have upload into MyHealtheVet, although we haven’t explored that just yet.

The AVS Development began with the VHA Innovations Grant in 2009. At that point is was known as Greenfield. VA Loma Linda actually received five grants in 2009 and another in 2010. Those are all in various stages of development. This and our clinical supervision index are probably the most advanced, as well as our bedside monitoring system. It’s probably the most advanced of the six. For the AVS we did requirements gathering through patient and clinician focus groups, just to get an idea of what kind of content they would see in this. We used the Innovations Grant to hire a contractor who developed the basic framework. What I think propelled this project forward is that Dr. Rob Durkin, who’s a Programmer and actually still works with us here locally, and he really took it to the next level refining the software with the input from our Innovations Team and our clinical staff here at the VA. So I think that close collaboration with our own programmer and with the Informatics Team was what really made this work and made it successful.

In the AVS Development we kind of don’t follow any particular development plan. I would say if anything you might call it agile. I’m not sure that quite describes it, but we do have a lot of flexibility in terms of getting input and developing the software. A part of the problem with that is we might not always include some of the stakeholders. But in the process of developing this, word got out, people started to see it, and we got some very good input from some stakeholders that probably we should have engaged from the beginning. For example, the National Medication Reconciliation Workgroup has been working with us and has given us marvelous input on this for remote medications and medication descriptions. I’ll show you those shortly. We also engaged our Region 1 Development Team and they helped us with technical issues that actually will allow the AVS to go to other sites with less complications as we avoided using some things that might have been perceived as somewhat of an issue with security, that those have been resolved. So involving these stakeholders has also helped to develop the project.

Some of the main features of the AVS are that it’s web-based and is launched from the CPRS toolbar. It imports CPRS/VistA data through remote procedure calls and it uses CCOW. So it moves in the context of the patient. If a new patient is selected in CPRS, the AVS moves to that patient as well. It auto refreshes, but also has a manual refresh. We can print and store images as a PDF in VistA Imaging, and we can create a stub note in CPRS. It’s integrated with Krames-On-Demand, which is a patient educational sheet that we have a contract with here locally in our network. And there’s an option to save and lock changes between users, which helps with workflow and makes it more flexible depending on who’s going to actually give the patient the printed AVS. Some of the technical features are that the web-based front end is written in Java, the RPC’s are used through the national software VistALink. There are no custom RPC’s or MUMPS code here. So as good as this tool is and as much information as it supplies for the patient, there was really nothing custom here. The setup is remarkably easy. There is a small Delphi client for the CCOW, and it’s hosted at the Denver Regional Data Center using servers that we purchased with the funds that we received from VHA Innovations. We don’t want to prescribe the AVS workflow. In other words, how people actually deploy this in their clinic is really up to their discretion. However, in order to take advantage of all of the features of the AVS, the provider really needs to complete the orders and complete the encounter before producing the AVS. All that data then can be uploaded and refreshed. Also, the provider really should add in any free text instructions and any additional educational sheets at that time after completion of the encounter. Then the completed AVS is printed off, the note is created, and it’s uploaded automatically into VistA Imaging. 

Just to review some of the features of the AVS, as I mentioned it’s actually invoked from the CPRS tools menu. Once it’s opened during a particular clinic session, it does not have to be reopened. It moves from patient to patient. This is a view of what the AVS looks like. The provider would actually see that framework there that sort of looks like a web-browser with the PDF contained within it. That’s exactly what you’re seeing once you’ve initiated the AVS. The AVS actually defaults to the current visit, but other visits can be selected through this drop-down menu to view AVS from a previous encounter. At the very top of the AVS the header display shows the patients name, the visit date, when the AVS was generated, and the facility name and location. We actually can also identify the other divisions, because as you may know you have your main facility, but your CBOC’s may be at different divisions or other facilities that you have so we specify that as well. Under Today’s Visit you’ll note that it shows the visits and provider information for that particular day, which provider is involved in this encounter and printing off the AVS. The diagnoses are populated from the CPR’s Encounter Form. So again, this is why it’s important to actually complete the Encounter Form prior to producing the AVS. It does potentially have some impact on workflow. And some providers like to do some of these things after the fact, but again to take full advantage of it, these would need to be completed ahead of time. It shows the vitals associated with the same visit and CPRS from that day. It also displays the immunizations that were given during the particular visit and it also includes all of the orders from that visit. What I don’t have displayed here in this particular example is that we’ll also show consults and imaging tests, as well as other types of tests that come through clinical procedures like treadmills and echocardiograms. 

You’ll notice with the lab orders it shows the date of the order. So if you order in CPRS a lab for today will default to today, but if you order labs for the future and specify that date, then that will display as well. So the instructions there tell the patient to report to the lab on the following days for those blood tests. The first part of the medication section shows any new orders, any changes, or any discontinuations. You’ll see later that we have an updated medication list, but this part merely shows the changes to their medications. They are referred to My Ongoing Care, which is a section later on to see the full list of the medications. For the free text orders, as an example the immunization order, return to clinic orders, for any other nursing orders that might be answered, those are displayed as well under Other Orders. The AVS also displays upcoming appointments in the next three months. This now actually also includes recall appointments. For those who might not be familiar with that, a part of our advanced access is to use recalls so that patients get a notice to schedule an appointment within the timeframe that they are asked to return so that they can schedule the appointment at the time that they would like. Our old system would have been that we schedule patients when they were leaving and they might not get a time that they prefer. So recall appointments will show on here now. Also appointments at other VA facilities display in this section.

In the section of My Ongoing Care, the primary provider is displayed. Remember back at the top of the AVS it shows who the provider was for the particular day of the encounter. But this is displaying the primary provider for that patient and their PACT Team. We also show allergies and adverse reactions as well with the particular reactions that the patient might have had. And then we have a list of My Current Medications. You’ll note that there’s a little bit of a disclaimer there reminding the patient to update any changes that they make. You’ll also note here that the medications also include the number of refills that remain, when it was last refilled and when the prescription expires. This was a really important addition because patients, who aren’t particularly accessing MyHealtheVet, don’t often track that information very well. We also added a description of the medications. So you’ll notice for example under the Gabapentin 300mg Cap, it says it’s a capsule, yellow/white, and imprinted with APO;113. So this would help patients to identify it. As many of you know who are clinicians, many patients don’t know the names of their medications. They often try to describe them as the “little yellow pill.” So this is an effort to help them to identify the pills correctly. We have also looked at the possibility of using actual images of the pills. It is possible. Just as we’re getting the description it comes through the VA’s Medical Image Library. We’re still working on that and exploring it, but it’s something that could potentially be done.

This next feature brings in remote medications. This was with input from the Medication Reconciliation Work Group. This will provide a popup to the provider, telling them that there are remote medications for this particular patient. Obviously not all patients have remote medications, so we didn’t want to have a default section, but in this way it brings it to the provider’s attention so they’ll not have the tendency to ignore it as well. Then we asked the provider to confirm which medications are taken, because often patients who are receiving remote medications may still be listed as active at the other facility, but the patient isn’t taking them. So the provider would select which medication the patient is actually taking. And when it prints out on the AVS you’ll notice the section there of My Medications From Other VA’s. It’ll also state Medications You Are Taking and in this case it’s Lipitor. But it also says Medications You Are not Taking and it asks the patient to check with their provider at the other VA facility to see what the status is and whether they should continue those particular medications. 

At the bottom of the AVS is a footer that is customizable in our administration interface, which I’ll show you shortly. But this provides contact information, instructions to the patients, and it’s modifiable to the local site. There is also an Instruction section. This is the free text instruction that the provider can type in any type of an instruction that they would want. In this case I’m instructing the patient to check their blood sugar three times a week and to record it. This is invoked with simply pressing the edit instructions button at the top of the AVS. And as you can see here, it then prints out on the AVS. The AVS itself can also be edited. So while we do a number of things, and I’ll also show you shortly that we have a translator in this as well, not all information and phrases might come across in a way that a particular provider prefers. So the content of the AVS itself can be edited. That’s invoked by clicking on the button at the top of the AVS called Edit AVS. And then a warning comes up telling the user that they don’t want to manually refresh after editing it, because that would actually wipe out those changes. And the auto refresh is automatically turned off. So once this process is underway, then you don’t want to do any more refreshing in order to save those edits to the AVS. Any part of the AVS can be edited if you use PDF editing software. You can see that some verbage was added to do labs prior to an appointment in four months. 

We also have Clinical Services Information. So while most of our patients are familiar with our facilities and know where to go, they might not know of every service, or they may be new to the facility. So we thought it important to include information about the service itself, where it’s located, the phone number, what the hours of operation are. So the user can actually go in and select which services they’d like to display on the AVS. In this case Behavioral Medicine, Cardiology, and Dermatology were selected with a check box. Or you could default and display all of them. Then it prints out and it shows you that information for those particular critical services. The font size can also be changed for the visually impaired patients. This display is actually the Large, but there’s also a Very Large version. Lab Results can also be included in the AVS. They display very similar to how they display in the Lab’s tab in CPRS. It defaults to Do Not Display, but we have a range of one week, one month, and the last three months. Then that display looks like this. And for those of you familiar with CPRS, you’ll recognize that format. 

Certain clinical data can also be included in Charts. We selected data that we thought would lend itself best to charting. They are things like body mass index, weight, cholesterol values, and hemoglobin A1C. Again this defaults to Do Not Display, but the provider can select particular items that they want to display on the Clinical Chart. This shows the LDL and HDL Cholesterol. We thought that this was important to include. I know that when I see my patient in the clinic, I often use the charting function to show them their progress on their blood pressure, cholesterol, and diabetes. We also receive feedback from our users that they didn’t necessarily want to display all parts of the AVS. Most of the sections are listed as optional and they default to “On.” But for example, we had providers that didn’t want to provide the diagnosis on their AVS or didn’t want to display allergies or that type of thing. So there is an option to toggle those on and off. 

We integrated the AVS with Krames-On-Demand which is educational material. From an outside company that we’ve contracted with, we realized that not every site has access to Krames-On-Demand. It may be modifiable to other ones as well, but it works particularly well with Krames-On-Demand. This is invoked by selecting that button at the top of the AVS. You’ll notice on the left-hand side there, there’s a list of educational sheets. This is actually generated from the ITD9 codes from the encounter form. The AVS and Krames-On-Demand uses the encounter form and actually generates a suggestive list of topics that may be useful for this particular patient. Then education sheets can be selected with a checkbox. And then in the red circle there you can print those particular selections. So this will print out the Krames Education Sheets separately from the AVS, but it will actually include some instructions for each one of the ones that are selected in the instructions part of the AVS. You’ll see there it says, Please read Krames-On-Demand articles: “Diabetes and Heart Disease.” And that’s automatically uploaded into the instructions. 

An education sheet can be viewed within the AVS by selecting the single article. It then can be printed or inserted in the AVS itself. You see the options here that you can select a part of the article by highlighting, or insert the entire article into the AVS. In this case you see the Krames sheet actually incorporated right within the instructions of the after-visit-summary. We’re not limited to just those education sheets that are generated from the ICD9 codes. You can actually search the entire Krames library and include any education sheets that are available. There are a number of options for printing. The AVS can print to the default Windows printer that’s set up to that particular computer. Or, it can use a network printer that is selected as the default printer. We also provided an option, and this was from the feedback from our users, to select the printers through VistA. As many of our clinical people are not familiar with selecting a network printer, but they were familiar with the process of selecting a printer through VistA. So you see in this slide I’m actually selecting the printer in my clinic. This was more intuitive to our users. You’ll note at the bottom of that screen that you can then select that particular printer as the default for the AVS. You can also go through the process of selecting a printer through the Windows option. Most of you have seen this type of thing. As we mentioned, the AVS has no creation feature. There are a couple of different options. One is to if a default printer is selected to print and create the note with one click, or just create the note and then do the printing separately. The note is then uploaded into VistA Imaging. 

On the slide that you see here on the left, there’s a CPRS stub note created that states that there’s an after-visit-summary uploaded to VistA Imaging, and it explains the content of that. And then the actual PDF can be viewed through VistA Imaging. The AVS can also be viewed as a PDF for printing or saving in another location. The Administrative Function of the AVS is Clinical Services, and this can be edited by a local administrator. We actually are able to give the Administrative Function to people through a designated user class in VistA. So the site can decide who has Administrative Function and update this list of Clinical Services. We also have a translator built into it, because I’m sure as you know, much of the information that is automatically uploaded out of VistA comes out in a format that isn’t very user-friendly. So this is a translation tool in which that information can be translated into something more patient-friendly. Once it’s translated one time, then in subsequent AVS generations it will show the translated version. There is also a custom disclaimer so a particular VA facility can put in disclaimer’s that apply to them. There’s also a header and footer that can be edited for the local site as well. Out of my own curiosity and having seen the AVS, what information on the AVS would you think would be most important to you? Select your top three. I realize this list is kind of long, so we’re going to get responses for each one. But it looks like the Updated Medication List is the most important thing with almost three quarters of the people. Procedures and Instructions and Upcoming Appointments also got a very high number of responses as well. I think it’s kind of what we anticipated that in part that the medication list would be most desirable to patients. Patients want to know the treatment plan and what’s coming next, and we think that the AVS provides that. 

Some Lessons Learned as I mentioned is our Software Development Plan. We kind of have this, it’s not really agile, but we have this kind of rapid development cycle. There are a lot of advantages to it. We have a small development team. We’ve been very, very fortunate to have a local programmer with tremendous expertise so we can develop things very, very rapidly and get feedback directly from our users. It’s sort of informal, and not very bureaucratic. So it’s very flexible. We’ve had a lot of success with this kind of approach. It does create some challenges as well. There’s feature creep and scope bloats, so as you turn this out to users and ask them to test this they come back with, “Why can’t it do this? Why can’t it do that?” And most of the suggestions that we’ve received on the AVS have been very good suggestions. We’ve incorporated a lot of them. But a piece of software can’t do everything that people want. Of course by actually using our users as testers, software bugs get out there. We do have some bugs now and then, but again since we have a local programmer we’re able to fix those relatively quickly. The other thing that’s challenging is the path from Class III to Class I is not entirely clear in what kind of things you need to meet to make the software Class I ready is somewhat unclear. We didn’t have a formal requirements analysis, so we could have missed some of the features. For example, the medication reconciliation and maybe not reaching out to stakeholders as much, although fortunately we have as word got out about this tool. We want to make sure it’s consistent with other patient-facing software. For example, how things are displayed or named in the AVS should be consistent with MyHealtheVet and other patient-facing software. 

Where are we currently? The AVS has been presented to the VHA Innovation Selection Board for possible funding for Class I development in October of 2013. We have not heard a final decision on that. That’s pending. We’ve also been approached by the Veterans Points of Service, which is a group under the business office. They’re also interested in helping us fund the AVS to get it towards Class I. We’ve also worked with VA OI&T Region 1 for approval for testing in San Diego beginning in September and it went out to Long Beach, West LA, and Las Vegas to test in October and November. They’re in various stages of deploying it. It also went out to Cleveland which isn’t actually in Region 1, but they do have it and they’ve embraced it there in Cleveland. They’ve given us some good feedback as well. We do plan to evaluate the AVS. The VAIL, Veterans Assessment and Innovation Laboratory, is a PACT Demonstration Lab out of Greater Los Angeles. They gave us a ten thousand dollar grant in September to do some evaluation on the AVS. The plan on this point is to randomly select about a hundred and fifty patients out of the primary care clinics and do a patient satisfaction survey as well as a survey of their self-assessed knowledge of their treatment plan. We also want to collect usage statistics from the primary care modules. What kinds of things? The number of providers using the AVS. How they use it. What optional features they do. Whether they save and print it. What percentage of patients are actually receiving the AVS. Are we meeting the meaningful use criteria? And then we also plan to do focus groups to get an idea of the provider preferences for using the AVS. What patients do they choose to use it on? We’ve noted in our preliminary use of the AVS that not all providers use them with every single patient. 

That’s the end of my presentation. I have some contact information there. There are also following this slide some references, and then an appendix that shows an entire AVS printed out from beginning to end. 

Moderator:Thank you Dr. Byrne. We’re just starting to get some questions in and I want to read you a comment that someone else wrote in when you began your talk, indicating that you might want to ask how many of us who have been in private practice gave a summary to our patients or clinics. That’s for future reference. A question that just came in is, “What do you think is the best way to encourage providers to enter free text instructions in the flow of care? It seems this could be a critical piece, but hard to get providers to spend the time on it.

Dr. John Byrne:I think that’s a really challenging aspect of this and in any software that we deploy in the VA. This is my opinion, but I think the burden of clinical computing if you will in the VA is actually quite high. I don’t know how well that’s recognized, but as a primary care provider I can tell you that we spend an enormous amount of time retrieving and inputting data into CPRS. It can get somewhat overwhelming. So I think there are real challenges to adding additional software like Secure Messaging, which is an incredible tool, but I think many of our providers feel overwhelmed by that. So that concerns me a bit with this. That’s why we don’t want to be too prescriptive about the workflow at the AVS, because it could be that each team works out some process for entering information in the instruction section. For example, maybe the provider just verbally tells the LDN that he or she is working to add this Krames Education Sheet or add these instructions in there. I found myself I personally like to put those things in. I type the instructions into my CPRS note and then just copy and paste them out of my CPRS note into the AVS. So I do think that there are a lot of different ways that it could be done, but I do think it’s challenging to add more software for our providers to deal with.

Moderator:Thanks. The next is a comment and then a question. First of all there is a comment of “wonderful work.” How long was the development period before the AVS was implemented?

Dr. John Byrne:We received the grant I want to say around mid 2009. I would say it took eight to ten months for a contractor to dissolve the initial framework. We had a number of projects going so I think it slowed some of the development. We started to get some provider input. It was interesting that initially it looked like some of the provider input would make this almost impossible to do. But then we picked it up again so it was probably late 2010, early 2011 that we started making some changes to it. It’s probably been in testing now for six to eight months that I think we’ve had it in the clinics. That includes some real preliminary testing with me and a couple of other providers. But it’s been available to everybody for probably the last four or five months now.

Moderator:Thanks. The next question is, “What are the next steps for national implementation?”

Dr. John Byrne:That’s a good question. We’re learning a lot about the path from developing a VHA Innovation to a potential Class I. I’ll tell you, it’s not entirely clear how that takes place. As I mentioned, we had the opportunity to present this to the Innovation Selection Board, the ISD. I believe that it’s one of the few that is going to go forward potentially to the Secretary for selection. But from that point forward I don’t know, because what I understand the process to be is that then VA OI&T would get involved and they’d have to run through all of the code. There would be a lot involved to try and get it to Class I.

Moderator:Thanks. The next question is, “Is there a explanation of the term ‘expire’ for patients?” They may think that the drug itself shouldn’t be used anymore.

Dr. John Byrne:No. That raises a good point. We could I suppose provide some dictionary explanation of some of those things. I think you’re right. In clinical practice patients don’t necessarily understand “expired.” I encounter that all the time. They’ll say, “I don’t have any refills of this medication. Why did you discontinue it?” Actually, “It expired because you didn’t renew it.” That’s a good point. That may be something that we need to look into. 

Moderator:Thanks. The next question first states, “This looks like a great tool. How long does it take to complete? Is it completed totally by the provider? Or is there a role for assistance from other PACT staff?

Dr. John Byrne:The workflow around this is obviously critical to its implementation. In terms of generating the AVS, it doesn’t take a lot of time because as you select the patient in CPRS, the AVS moves to that patient as well. The data is automatically uploaded into the AVS and it auto refreshes every couple of minutes. So as you write orders, change medications, complete your encounter form, the AVS is automatically updating all of that data. So by the time you finish your encounter, the AVS is already populated. So then the parts that require some manual work from a team member would be entering something into the instructions, printing the AVS, and saving it if you choose to do that as a PDF in VistA Imaging. That process in itself is a few clicks in a minute or two I would say. We haven’t done a time study to determine how long that takes. I’ll tell you what I do. I personally like to edit the instructions myself. As I mentioned, I’ll copy and paste right out of my CPRS note. And I like to print it off myself. So when I finish with the patient, I finish the note, the encounter form, and all of the orders. I print off the AVS as the patient and I are walking down the hallway I grab it off the printer and I point out some highlights like, “Remember we talked about this? I changed that medication. I renewed that one. Don’t forget you have an appointment coming up?” And then I hand them the AVS. But you could deploy your PACT team as well. I know that providers in my clinic for example don’t do that. They have the LVN actually print off the AVS and review it with the patient.

Moderator:Thanks. The next question asks, “Is there a mechanism for attaching the PDF to secure messaging?”

Dr. John Byrne:Yeah. That’s a really good question and an important one. We don’t have that in place as of yet. Given that technically it’s still Class III software, we didn’t feel like we could approach MyHealtheVet on this. But obviously as this continues to move forward and there’s a move towards national deployment, I think that would be a very important priority to get it uploaded to MyHealtheVet.

Moderator:Okay thanks. The next question asks, “Is there any place on the document where you could put a health promotion question such as ‘What are you doing to improve your health’?”

Dr. John Byrne:This question has been raised by others. It’s certainly something that can be added. And again I think that’s the advantage of where we are right now in the development of this. The approach that we take with our local programmer, those are changes that can be easily made.

Moderator:Okay. Thank you. The next question is, “If AVS is a lot of refreshes, is there a way to turn it off so your manual comments aren’t lost?”

Dr. John Byrne:The instructions that you put in the edit instructions will not be lost with auto refresh. The only time this comes into play is if you are going to edit information that was automatically pulled into the AVS from VistA. For example, if you saw some information that came in from VistA automatically and you didn’t like the way it worded, you could say “Edit AVS.” That will turn off the auto refresh. You could edit that piece and then complete the AVS at that point. But if you were to refresh it, it is going to override any changes you make. But that doesn’t affect the edit instructions. You can put in edit instructions and the AVS can continue to refresh and it won’t change things.

Moderator:Okay. Thanks. This attendee indicates that they’re not sure if they missed it but, “Does anyone review the AVS before the patient leaves?”

Dr. John Byrne:Certainly that would be the ideal. That would be my expectation. We again haven’t been prescriptive about the workflow. My preference is to personally review with the patient. And I don’t go through every single detail. I just try to point out some highlights to kind of orient them to the AVS so they know what they’re looking at. But yes, I think that’s a critical feature that needs to be deployed in the workflow.

Moderator:Thank you. That appears to be our last question at the moment. If people are thinking about maybe another question or so, or they’re still contemplating, send their questions to you directly. You’ve provided your e-mail address. Thank you. We would be happy to forward those as well. Heidi I think at this time we can post the evaluation.

Heidi:Fantastic. So as I close out the meeting here you will have a feedback form that pops up on your screen. As Joanne said earlier, we would very much appreciate it if you would take a moment to fill it out. We really do read through all of it and we will pass that on to today’s presenter. I want to thank everyone for joining us for today’s HSR&D Cyber-Seminar, and we hope to see you at a future session. Thank you.

Page 1 of 11