**Transcript of Cyberseminar**

**VIReC Clinical Informatics Seminars**

**Better Mental Health Scheduling**

**Presenter:  Peter F. Fore, M.D., MPH**

**February 18, 2014**

*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 virec@va.gov.*

*Moderator:*Welcome, everyone.  This session is part of the VA Information Resource Center’s ongoing Clinical Informatics Cyber Seminar Series.  The series’ aims are to provide information about research and quality improvement applications in clinical informatics and also information about approaches for evaluating clinical informatics applications.  Thank you to CIDER for providing technical and promotional support for this series. 

Questions will be monitored during the talk in the Q and A portion of Adobe Connect and will be presented to the speaker at the end of this session.  A brief evaluation questionnaire will pop up when we close the session.  If possible, please stay until the very end, and take a few moments to complete it.  Let us know if there is a specific topic area or suggested speaker that you would like for us to consider for future sessions.  

At this time I would like to introduce our speaker for today, Dr. Peter Fore.  Dr. Fore is the director of the Mental Health Service Line at the Jesse Brown VA Medical Center in Chicago and is a clinical associate professor of psychiatry at the University of Illinois.  Dr. Fore’s clinical work has been with the post-traumatic stress disorder team.  Dr. Fore is also the immediate past president of the Illinois Psychiatric Society and has been an active member of the American Psychiatrist Association in various capacities for many years. 

Without further ado, may I present Dr. Fore. 

*Dr. Fore:*Thank you, Erica.  Thank you, Heidi.  Welcome to all from snowy Chicago.  We had about eight inches of snow yesterday evening, so weather’s been pretty bad here.  I am a service line chief at the Jesse Brown VA in Chicago.  This project is something that we did.  It is of a very practical nature.  It’s designed to address the problem with scheduling.  Those of you who work in mental health programs have, I’m sure, encountered some of the limitations of our current scheduling system. 

The main scheduling system in the VA, as you know, is VISTA scheduling.  It’s antiquated.  It’s probably at least 30 years old.  It’s a roll-and-scroll program.  It has no graphical user interface.  It’s somewhat rigid.  It has things in it like clinic grids that are difficult to change, and it’s difficult to maintain clinic grids.  We were having problems here with using VISTA scheduling in the way that we wanted to schedule to see mental health patients.  We developed a team that looked at this problem.   

Some of the principles that we were looking at was we felt that scheduling really should be oriented around the clinician, not the clinic.  You’ll know that in VISTA scheduling, they have individual clinics set up.  We have several hundred here at Jesse Brown in mental health alone.  You have to have one clinic for individual, a different clinic for group and sometimes special clinics for evening or weekend hours.  It’s not designed around the clinician; it’s designed around clinics. 

We thought that scheduling in this day and age really should have a modern interface.  The calendar should be able to be shared between the clinicians and the clerical staff.  It should have a graphical user interface, and it should be a single system so that the same calendar is used by the clinician and by the clerk.  It has to be accessible by both clinician and clerk.  We wanted it to include both patient and non-patient appointments.  VISTA scheduling really has only patient appointments in it.  There’s no way, or it’s not easy, to block out time for other things like department meetings, having to meet with interns, different things that clinicians need to do but non-patient items. 

We wanted it to be able to easily handle mental health group appointments.  This is a particular problem in mental health.  How do you schedule a group and do it easily?  

We wanted to eliminate paper appointment books because we can’t have anything with confidential information, patient information.  Since we’re still using VISTA in the VA, that’s the official scheduling system, anything we did really has to ultimately wind up with the appointments in the VISTA scheduling package.   

Some of the history on this:  Our clinicians traditionally, over the years, used paper appointment books.  I think that was widely used in the VA.  Then we were told we really can’t do that anymore, but we didn’t want to lose the control where clinicians are directly in charge of their schedule.  We wanted to maintain the one thing that we thought was very positive here at Jesse Brown, is the interaction between patient and clinician over appointment date.  The other way to do this, of course, is to have all clerk scheduling, which works well.  Some places may want to do that.  We just felt that it’s better, especially in mental health, to have those negotiations between patient and clinician.  It’s part of therapy in some cases. 

At Jesse Brown, we started working on this.  Originally, we got rid of the appointment books.  We put the appointment times on pieces of paper, and those were delivered to the clerks at the end of the day, and then they entered the appointments.  As you can imagine, there are a lot of problems with that system.  The clerks couldn’t always read the handwriting.  Sometimes the slips got lost.  We were creating a lot of extra paper with confidential information on it, so it was less than ideal. 

We got this idea of moving to an electronic system that would be faster.  It would instantly give the information to the clerical staff.  It would be legible and much more secure.  We wrote software here.  The idea is that it uses existing VA programs, one being a Microsoft Outlook calendar which everybody has and VISTA which everybody has.  What this software does is sit in between those two other programs and allows for better integration of both programs. 

This application is designed to sit on top of the Outlook calendar, and the clerk puts in the appointment information.  Then the application transfers a patient identifier number onto the appropriate place in the clinician’s Outlook calendar.  Outlook then becomes the main calendar for the clinic for each clinician.  We then share the clinician’s Outlook calendar with the supporting clerks.  Both can schedule patients from their own computers.  The security/privacy issues with Outlook are avoided by using random numerical placeholders.  

We were concerned; we’ve been told that we cannot put patient names, even initials, in Outlook because it’s not secure.  We learned that we could put these random numbers in that no one knows what they are other than this program so that it’s not a security problem.  Then, once the clinician puts the appointment into the system, it places a placeholder in Outlook.  Then the appointment information is saved in the database.  Later in the day, the clerks use a separate application, a different one, to auto load the appointment into VISTA.  

Now I’m going to show you all this.  That was the overview.  Now we’ll get into the some of the nitty-gritty and screen shots of how this works.  What you see now is the program that we wrote here.  It’s a fairly small box designed to be small so it doesn’t take up the clinician’s whole screen.  It’s designed to sit on top of Outlook so you can see Outlook and this program at the same time.  

The next slide I’m going to show you is a little bit complicated, so I wanted to say a few words about it before I show you.  This is actually an Outlook calendar.  It has appointments in it.  It has a blank spot where there’s no appointment.  It has the application we wrote here also on the same screen.  Let me get my pointer.  This part is the Outlook calendar, and up here is Outlook.  This over here is the application. What you’re seeing is how it looks to the clinician as they’re working.  They have their Outlook calendar here, and they can switch easily from day to day, and they have the application open at the same time right on top of it.  You don’t have to do it this way, but that’s really how it’s designed. 

What you can see here is a bunch of numbers, and the numbers each represent a patient, but notice there’s other things other than patient appointments in the same calendar.  For example, on this day I have an executive council meeting for an hour.  I blocked out my lunchtime.  I have an appointment with somebody nonclinical.  I have a group down here.  This time I blocked out because I need to do some treatment plans.  The clinicians can have control over their time still and block out time if they need to do something other than patient care. 

Some people may say, “How do you make sure that the clinicians get all their RVUs and see as many patients as they need to see?”  The answer is simple.  We run reports.  We hold people accountable for meeting their standards, but we don’t micromanage exactly how they use their time day to day. 

Next slide.  This is the beginning of the scheduling process.  The clinician clicked this button here.  It dropped down the patient names.  Actually, that’s not quite right.  I started typing in ZZ and this name popped up.  The clinicians can either type in the name or drop down and select the patient on the next slide here.  You’ll see now this test patient has been selected, Mr. ZZ Test.  It then automatically filled in the last four of Social Security.  That’s to help make sure you get the right patient.  Also, this number here is the patient code.  Each patient has their own number that this program associates with them.  That’s the number that’s going to go into Outlook when everything gets going. 

Then, in this next box here, we dropped it down and started typing in the clinics.  I’m looking for my PTSD clinic, JB PTSD 4.  Then, on this, the next step is that you indicate what date the appointment is going to be.  You highlight the date in the calendar.  In this case, I’m looking at February 21, so I make this February 21 down here.  Then you push desired date.  When that’s selected, the date pops into this box.  Then you push appointment date, and it goes into this box.  

Why two dates?  Originally, we had one, but then there was some concern.  Those of you that work in clinical areas in the VA, there was a whole big issue about making sure we’re accurately capturing the desired date and the appointment date.  The appointment date is the actual date of the appointment.  The desired date is the date that the patient and the clinician agree that the patient really should be seen.  

That can sometimes be two different dates.  If, for example, the clinician has no capacity, really should see the patient next week but can’t see the patient for three weeks, then the desired date is in one week and the appointment date is in three weeks.  This system allows accurate capture of both the desired date and the appointment date. 

On the next slide, we’re going to be indicating whether this patient is service connected or not.  If you click this button once, it switches to yes; if you click it again, it goes back to no.  Here, you can see who clicked it and it’s yes.  We’re putting in the time.  It’s a drop-down box; you can also type it in.  In this case, we want 11:00 so that it goes into this spot, so 11:00.  Then the duration is 30-minute appointment.  

All that, it took me longer to go over that than it actually takes for the clinician to go through the process.  That takes really just a few seconds to enter that information.  It’s all drop-down.  You can start typing, and it fills it out, so it goes very quickly for the clinicians.  Also, once you set this clinic, you can just leave it all day.  You don’t have to keep changing it. You can just change the patients and change the time and duration. 

Then, when all the information is ready, the clinician pushes this all-important scheduled appointment box.  What happens is this number from here—what is it?  I can hardly see it.  It’s probably too small on yours, too.  I think it’s 20, 888 or 88.  Two eights.  Goes from the scheduling application right into Outlook.  That’s done through the magic of computer code.  There’s really no connection between these two programs.  We were just able to program it so that it actually creates an Outlook appointment and puts it onto the Outlook calendar.  

By the way, it puts it on the Outlook calendar of whoever is creating this system.  If the clerk is entering the appointments, the appointments go onto the clerk’s outlook calendar.  We haven’t gotten around that yet but it works well.  There’s also a pop-up box that tells the clinician that the appointment has been scheduled.  Now the appointment is listed on the clinician’s calendar and they’re done.  Behind the scenes, the appointment has also gone into a scheduling queue.  I’m going to show you in a moment. 

Before I do that, though, I wanted to point out another feature of the program.  One thing we found is the clinicians get a little crazy after a while with all these numbers in their calendar.  They want to know, who are these actual patients?  The application has a reverse lookup feature.  You clear all the information, and then you type the number into this box.  This drop-down comes up.  You select that number, and then it gives you the name of the patient.  If you have somebody that has a number in there and you want to see the actual name, you can do that using this program.  

We can’t put names in Outlook.  In practice, though, the appointments are all in VISTA so that the clinicians have their VISTA CPRS set to show their appointments for that day.  That’s where they usually see who’s scheduled to see them.  If they want to look up from Outlook from the numbers, they can use this application. 

We found that this wasn’t really enough.  Originally, we didn’t let the clinicians see the scheduling queue.  As I said, the data for each appointment goes into a database.  We found that we really had to let the clinicians see the queue as to what patients had been scheduled, which ones were waiting in this queue to go into VISTA and what their status was.  The main reason is that there’s a fair number of errors.  I’ve done this several times myself.  You get going quickly, and you just click the wrong time or you’re off on the date or something you do wrong.  There’s no way to get it out of the queue other than—I’m going to show you.  

We had to let them have this other feature.  They click on this button here at the bottom that says “View Scheduling Queue.”  What happens is the whole queue comes up.  What this is now is what the clinician sees.  I’ve blocked out this big box here so you can’t see the actual patients that are in this system.  At the bottom here is Mr. ZZ Test, the one we just entered.  It shows that he’s scheduled for my clinic at the time and date we indicated, 30-minute appointment.  

The clinician sees this.  If this were an error, what I would do is I would go over to this “Modify Status” button and click on that button.  Then I get a little box.  I didn’t get a screen shot of this, but it allows you to change this last column here, which is the status of the appointment.  What I would change the status to is “Error” or “Do Not Schedule” or something else.  You can type in whatever you want, but it’s really a message to the clerk to not schedule that appointment.  If it was an error, I’d go back in and schedule it correctly, and that time I wouldn’t indicate that there was an error. 

A couple of other features to demonstrate from this slide is that you can see these appointments up here, just really maybe ten appointments earlier, have already been scheduled by the clerk.  There’s a clerk working elsewhere that is using a different application to schedule these appointments into VISTA.  When that clerk schedules, then these appointments start showing as being scheduled.  This is important feedback for the clinicians.  They like to confirm that the appointments they entered have been scheduled.  If there are errors, as I said, they can indicate there’s an error. 

A couple of other things to point out here.  You’ll see this later.  Over here, you’ll see this is all the same clinic.  What’s that?  That’s a group that got entered all at the same time by the group application.  The clinician pushed one button and scheduled all those patients and put them all in the queue at the same time for scheduling a group.  

Also, I wanted to point out that you’ll see most of these—I don’t know if you can see this; it’s kind of small.  They’re all JB; but there’s a few that are like this one down here, Crown Point, our Adam Benjamin Clinic.  We use this system at our main site and all of our CBOCs and it works fine.  Usually, they’re all scheduled from Jesse Brown.  The clinicians at all sites can use these, use the system, and the appointments all go through and get scheduled.  It doesn’t have to be limited just to your main site. 

I mentioned that there’s another application that the clerical staff use to enter the appointment into VISTA.  This is key.  In the VA, you have to have everything in VISTA.  This is a completely separate program from the clinician program that you saw first.  A clerk operates this program and really has to be operating VISTA at the same time.  Two screens is ideal for this.  We actually were able to get some money.  This project was a 2011 VA Innovation Project winner, and we got some money and bought some second monitors to use for this.  Our clerks all have two screens.  You need that because they have the application on one screen and VISTA open on the other. 

What happens is that the application interacts with VISTA, and it schedules the appointment using automation.  The clerks don’t retype it.  The application drives the VISTA system.  It actually reads the prompts and puts the information at the right time and automatically schedules the appointments.  It takes about *[inaudible 23:53]* for each appointment.  We’ve been able to get to the point where we have mostly a single clerk entering all these prescheduled appointments for all of our sites. 

This screen is now really a double screen.  Here’s one screen, and here’s the other screen.  This is what it looks like to the clerk operating the system.  I know this is going to be small on your screens, but you’ll get the idea.  This clerk application looks a lot like the view scheduling queue feature that the clinicians have, but it’s got several additional buttons on there that I’ll go over in a minute.  To the right is a second screen.  This is VISTA.  The clerk has to log on to VISTA and, on the other screen, open the scheduling application.  That’s where we are.  

Some of the other buttons on here—I need to just find my place.  This button here, it may be too small to see, but it’s a “Modify Status” button.  It’s the same kind of button that the clinicians have.  It allows the clerk to change the status of the appointment manually if they need to for some reason.  There are times when this doesn’t work perfectly.  The clerks have to watch to see the appointment gets in properly.  There are other things that can happen.  If the patient has another appointment at the same time, it won’t be able to schedule for that time, and the status will be “Conflict.”  Then the clerk may need to call the clinician and talk with them, get another time, enter that time, and then the clerk can use this “Modify Status” button to change the appointment to “Scheduled” from “Conflict.” 

We also had a problem a few times with bad Social Security numbers.  This won’t be a problem in the future, we hope.  Our current system, the Social Security numbers are all entered in using a clerk.  They’re supposed to copy and paste, but sometimes the Social Security number gets entered incorrectly.  When that happens, there’s been a problem.  The clerks need to be able to view the actual Social Security number for the Veteran to correct any errors.  We had problems with that in the beginning.  It’s mostly not an issue anymore; we’ve corrected them all.  We have a plan for better data pulling in the future where we won’t actually enter any of the numbers, so it’ll avoid all of that. 

Okay, next screen.  The clerk pushes this button here, which is “Connect to VISTA.”  They push that one time.  Then they highlight the line of the patient that they want to schedule, so the clerk has now highlighted the appointment for Mr. ZZ Test that we entered earlier.  Then they push this button, which is “Schedule in Vista.”  

That went awfully fast *[chuckle]*, but if you look carefully, you’ll see that this screen changed.  It was very hard to show this on screen capture.  Without doing anything, this program interacted with VISTA, entered all the appointment information, and the patient now is scheduled in VISTA.  You may not be able to see this, but it also changed the status for that appointment in the clerk’s scheduler program to schedule.  Now everybody knows that that appointment is scheduled. 

We have a clerk and backups that are running this program all day long.  They are typically an hour, sometimes two hours behind the clinicians.  Normally, by the end of the day, most of the appointments that were entered that day have already gotten into VISTA.  They show up very quickly in VISTA. 

There’s another application that we came up with to solve the problem of group scheduling.  This is a particular problem for mental health programs.  Those of you who have done this know that VISTA does pretty well with having a group every week or once a month.  There’s ways to auto schedule those.  If you try to have a second and third or a second and fourth or a first and third group, it’s very difficult to handle.  Also, patients are always changing.  The clinician usually knows who’s coming into group but clerks don’t, and so we were overscheduling our appointments.  

This application looks like this. This is the group scheduler.  We have all the groups entered in here.  It’s actually turned out to be a lot more than I ever thought we have.  We have over 110 groups in here now.  The clinician begins by selecting the group, pushing that down with that arrow.  This is the actual screen shot.  This is just the beginning of the groups in our system here.  I put in a test group down here at the bottom.  They’re selecting this test group.  Once that’s selected, it auto populates with the patients that have been put into that group.  I’ll show you in a minute how the clinician enters those in the first place and then maintains that list as the patients change. 

These five patients are members of this test group.  When you select a group, the names come automatically into this box.  Over here is who you’re actually going to schedule.  You may know that one or two of these patients is not coming to the next group.  First, though, you can click this button to move them all or you can move them one by one.  In this case, we’ll move them all.  Now the names are all over here in the box to be scheduled.  I know that Minnie Mouse is not going to make it this week, so I highlight her and then click this button.  It moves her back over to the other side so she’s not going to be scheduled.  Just these patients are going to be scheduled for the next group. 

Then you go through the same kind of process that is used on the individual application.  First, the date is selected.  When this is clicked on here, that’s automatically filled in there.  For a while, we let the clinicians type in their own dates.  They made so many errors that it was impossible, so we made it real simple.  When you click on here, it puts the date in the date box in the correct format, then time and duration.  

Now these are filled out.  This is a 1:00 group.  It’s 60 minutes long.  Then you’d push the “Scheduled” button to schedule the group.  What that would do is put these four patients for that time and date into the queue and also indicate on the clinician’s Outlook calendar that Test Group has been scheduled for that time and date.  It also is connected to the clinician’s Outlook calendar. 

How are these lists maintained?  The way that this is done is there’s another screen.  You click up here on the “Create/Modify Patient List” box.  That takes you to this other screen.  You again select your group.  In this case, it’s Test Group.  Then I’m adding a patient.  I scroll through here and select a patient.  I’ve got it on ZZ Test.  Now you can see Mr. ZZ Test has been added to this group.  If I’m done with that, then I would do “Save List and Exit,” but I want to show you one more thing. 

Let’s say Minnie Mouse, she’s not coming to group, and she’s also no longer even in the group.  She went to Hines.  You can delete this patient from the group by highlighting the name, and then click on the “Delete” button.  Now you’ll see we have the new list that has Mr. ZZ Test added and Minnie Mouse gone.  You click the “Save and Exit” button.  That takes you back to the first group screen.  You select your Test Group.  Now, in this screen, the names of the patients have been revised.  

Groups don’t change that much.  With my group, I have to change them only every few months.  It’s very convenient for the clinician to just go in and select the name of their group.  Then, if the computer knows the names of the patients, you just put the time and date in, and then it schedules the whole group for you. 

That makes more work for the clerks.  I should have mentioned, I don’t know if I did, but the clerks have figured out how to schedule these very quickly.  It turns out, in that scheduling app, you can click it ten times and it will go through the scheduling routine ten times and schedule all ten patients.  It takes about five seconds per patient, so in a minute you can schedule ten appointments.  They still have to watch to make sure they all go in correctly, but it is working quite well. 

To finish up, I just wanted to talk about where we are with this system.  We started this in 2011.  In one test clinic, we did it about six months there and then slowly expanded.  Now, since mid-2012, it’s been used throughout our system at the main site and CBOCs.  We use it only in mental health.  This theoretically could be used for primary care or some other area, but it may not work as well for primary care.  They may prefer to—primary care clinics are more set times, 1:00 to 4:00 every Tuesday afternoon, and the VISTA scheduling might work fine for that.  Mental health people are typically full time and have other things to do other than patients throughout their week, so this system handles that situation much better. 

One thing we learned as we implemented this is that there was a huge variety of levels of training in Outlook.  Some staff were very computer savvy and knew Outlook well.  Others really didn’t use the calendar much and had no idea how it worked.  We provided special training in how you use Outlook, and that seemed to be essential to getting this whole system to work properly. 

Since we started this, there’s been requests about how it can be used elsewhere.  We’re trying to find a way to do that.  The problem is that this system relies on a database that we have at Jesse Brown that was developed really to keep track of what patients belonged to what clinicians.  We had that all in place, and that’s what we used to pull the patient names.  Other sites don’t have that, so it can’t easily be moved to other sites.  

We have a potential solution in sight.  We’ve got some testing going on, and it looks very promising.  We’ll probably start it in VISN 12 first, but we may well have a solution to allow piloting of the system at other sites within the next month or two, I’m hoping.  

Here’s my contact information if there’s any questions or people want to write and find out about piloting the system. 

With that, that’s the end of the slides, so I’ll open it up for any questions that people have. 

*Moderator:*We do have a few questions.  Here’s the first, Dr. Fore.  Do you have patients who share or move to other providers?  It appears as though it works best with the same Veteran or provider duo.  

*Dr. Fore:*We do have patients that move to other providers.  For scheduling, you can schedule really any clinic and any patient, so it doesn’t really matter if a patient were to move to other providers.  We have patients that also move between programs.  They may start out in mental health clinic and then also enroll in our addiction treatment program.  You can schedule for mental health clinic appointments and addiction appointments and PTSD program appointments.  It’s very flexible.  It’s as flexible as VISTA is in terms of which different clinics you can schedule in. 

*Moderator:*Is the patient code the random number that is generated? 

*Dr. Fore:*Yes, it is.  It’s not rocket science.  In our system, we just use the number that the patient was entered into the database.  The first person entered into the database is number one and on up through 12,000 or so patients that we have in there. 

*Moderator:*Another question:  Does the scheduling queue show just the clinician’s appointments, or are other clinicians’ appointments shown? 

*Dr. Fore:*You can see all appointments.  Yes, you can see other clinicians’ appointments. 

*Moderator:*Okay.  Around slide 10, you discussed desired date versus appointment date.  If another Veteran cancels, can the Veteran who wanted that space be called and allowed to see a provider earlier than the three-weeks-out appointment date? 

*Dr. Fore:*Absolutely.  This would really be no different than how it would work in VISTA.  Truthfully, at our site, we haven’t had for followup appointments.  We have enough capacity that usually the appointment date and the desired date are the same thing.  There are some times when they aren’t, and VA was very interested in making sure that we capture this correctly as it is in VISTA.  That feature is there.  It might be especially important for new appointments where often there is capacity problems. 

*Moderator:*Thank you for that.  How has this impacted your clinic utilization data?  Someone wants to know. 

*Dr. Fore:*I think the question there is in VISTA—I might not have this right, but we get a clinic utilization report that shows what percent of the available space in each clinic is actually being utilized.  I think that’s probably the report that they’re talking about.  This system hasn’t had any direct impact on that.  You still have to maintain your grids, and you have to maintain them in ways that you make sure that you’re putting patients into the grids using reasonably high utilization rates.  It hasn’t been a really help or hindrance to that whole issue. 

*Moderator:*Thank you for that.  Another question:  I saw in the presentation how Outlook can talk to VISTA, but would changes made to an appointment in VISTA be translated back to Outlook? 

*Dr. Fore:*No.  It doesn’t do that.  VISTA is still the final official location for an appointment.  It really has to be.  If a patient cancels and reschedules and does that through a clerk, the clerk has to pull up the clinician’s Outlook calendar and manually take that appointment out and move it to the correct location.  The software doesn’t do that. 

*Moderator:*How are you interacting with the call center?  Do they have access?  

*Dr. Fore:*Right now, our call center doesn’t.  They certainly could, but we haven’t done that so far.  The call center here is mostly focused on primary care.  We actually have our own mental health appointment scheduling line that’s analogous to the call center, but it’s not the real call center.  We haven’t done that yet.  We haven’t given the call center staff access to the system, but certainly we could do that. 

*Moderator:*Does each Veteran keep the same code?  

*Dr. Fore:*Yes. 

*Moderator:*Here’s another one:  What kinds of staff work on the project, and what offices do they come from? Who provides the programming expertise? 

*Dr. Fore:[Chuckle]*I made this sound like it’s a huge number of people.  We have a team.  It’s a system redesign team that has a number of different mental health, mostly clinical people but a clinical staff, our administrative officer.  That team meets twice a month.  They’ve been involved in this project over the years.  We also had a lot of help from the PTSD clinical team.  They were the original site that did the testing for this when it was brand new and ironed out a lot of the bugs.  

In terms of the programming, that’s me.  I am an amateur programmer.  I learned just enough to figure out how to do this so far.  When people ask about expanding it to other sites and I say, “Well, that’s easier to say than do,” the problem is, to a large extent, my limited programming ability.  This is very much an amateur project and dependent what I can do.  I have gotten some help recently from more sophisticated programmers in VISN 12 and helped me with some of the next steps.  This is an example of clinicians getting involved in doing some software that has direct help in our day-to-day lives.  It’s been fun.  It’s getting a little bigger than I initially anticipated.  

*Moderator:*Sounds good.  Here’s another question:  Could there be an option to notate the appointment as in CPRS orders?  For example, noting for clerks where the patient should meet the provider if the provider has more than one office or to ask the clerk to reserve time in advance of the meeting for the Veteran to fill out paperwork or symptom checklist. 

*Dr. Fore:*We absolutely could do that.  It would be relatively simple.  It would be along the same lines as that part where I was trying to show how you modify the status bar; the clinician can enter “Error,” “Do Not Schedule,” that kind of thing.  We could create another field like that and basically allow the clinicians to write notes, more extensive notes, to the clerical staff.  That would not be difficult. 

*Moderator:*This is a followup to a previous question:  Does this mean that all clerks would need to have access to the Outlook calendar of all of the providers? 

*Dr. Fore:*That’s a really good question.  In our main mental health clinic at Jesse Brown, we have three support clerks.  They have access to all the clinicians at Jesse Brown.  At other sites, for example addictions program, the clerk there has access to the addiction.  We have two different addiction programs, so we have two different clerks with different sets of providers.  Basically, the clerks have the access to the calendars of the clinical staff that they support.  Same thing down in Crown Point. 

*Moderator:*The Veteran number is the same for each appointment scheduled in the future as well.  Is that correct? 

*Dr. Fore:*Yes. 

*Moderator:*What processes need to be done to pilot this program? 

*Dr. Fore:*That’s a *[chuckle]*great question.  I’ll talk a little bit about what we’re trying to do for making it available to be used elsewhere.  The biggest problem is getting away from this local database.  The plan is to link to the VISN Data Warehouse, which is essentially a gigantic database.  Every VISN has one.  I’ve been in touch with the VISN Data Warehouse people there.  We have some code already done that will link to the database.  It involves getting some permissions and setting up some new data fields there.  That really seems to be the way to go. 

The other problem with that approach was that all the clinicians will have to get access to the VISN Data Warehouse in order for it to work, but I don’t think that would be difficult.  Once we have that, then there’s no reason why this couldn’t be used at any site in a VISN where it’s been set up.  

That’s really the goal.  We’re not entirely sure that it’s going to work.  Some of the possible problems could be right now the script that’s written to enter the programs into VISTA works great at Jesse Brown.  I’ve never actually tried it at another site.  If there’s any changes in the scheduling routine at another site, which I don’t think there are but there well could be, things won’t go as smoothly.  It won’t work as well.  

We have a lot of things to try out and test, but at least we have an idea now of how to do it.  I think that it could be fairly soon that we’ll be able to start looking for other pilot sites.  We’d want to test it in VISN 12 first because that’s where we’re going to have the first link with the VISN database. 

The other real advantage of doing that is that then we get all accurate data as opposed to data that’s being entered by clerks at Jesse Brown.  If you enter enough data, there’s errors that get introduced. 

*Moderator:*Do you use a recall system at your clinic? 

*Dr. Fore:*We don’t for mental health.  Primary care has a recall system.  We’ve had reasonable capacity here at Jesse Brown, and so we’re usually able to see patients without having to use a recall system. 

*Moderator:*Is the programming exportable to other sites? 

*Dr. Fore:*Well, the program itself could certainly be run anywhere.  The problem is that it won’t work because you need the database piece of it.  The database that we use all has Jesse Brown patients in it, so the answer is no.  Right now, it only works here, but we’re trying to expand and make it possible so it could be used at other sites. 

*Moderator:*We have just a couple of more questions.  Do clerks need to switch between clinicians’ Outlook calendars for each new appointment?  Does this switching take a lot of time? 

*Dr. Fore:*The clerks, when they’re scheduling the appointments, they don’t actually use Outlook at all.  They’re just really using the scheduling application for clerks in VISTA.  They’re very rapidly transferring the appointments from the database scheduling queue into VISTA.  They don’t need to look at Outlook at all during that whole process.  It goes very, very quickly.  If a patient calls, though, and they want to schedule with a clerk, then the clerk would need to call up that clinician’s Outlook calendar and see when the next opening is.  That would involve looking at the clinician’s Outlook appointment.  

However, because the vast majority of appointments are made at the end of the current session, the clerk’s scheduling is relatively much less frequent than it might be at other places. 

*Moderator:*Does this method of scheduling prevent scheduling clinic wait-time errors? 

*Dr. Fore:*I’m not sure if I understand.  Scheduling clinic wait-time errors?  

*Moderator:*Prevent scheduling clinic wait-time errors. 

*Dr. Fore:*I think the answer to that would be no.  This does not really offer anything other than what’s already in VISTA; it just makes it easier.  If there’s not enough capacity in the system and there’s wait times, the system will not solve that.  It’s more convenient for clinicians and for patients.  One thing it does do is save a fair amount of clerical time because the clerks don’t have to enter appointments manually all day.  It’s mostly done through automation. 

*Moderator:*One last question:  Does this program work for offsite clinic scheduling—that is, remote telehealth clinics—or does it only work onsite? 

*Dr. Fore:*That is a really good question.  *[Chuckle]*I think it depends on how you connect remotely.  If you connected to your own computer and basically are running your own computer remotely, your own office computer, then it certainly would work just as if you were in the office.  If you connect through a VIN client, then I don’t know.  It actually does work with the VIN clients, so the answer is probably yes, but I’d have to try that. 

*Moderator:*Thank you so much to Dr. Fore for taking the time to develop and present this talk.  Please forward any remaining questions or comments to Dr. Fore or to VIReC’s help desk at VIReC@va.gov.  Our next session is scheduled for April 8 and is entitled VA Kidney Disease Dashboard.  The speakers will be Karen Sovern and Susan Crowley.  We hope that you can join us.  Everyone, have a great afternoon.  

*Moderator:*I’ve just put up a feedback form.  If you guys could take just a moment to put some feedback in, we’d definitely look through it and try to respond to as much feedback as we receive in here.  Thank you, everyone, for joining us today.  We hope to see you at a future HSR&D Cyber Seminar.  Thank you. 

*[End of Audio]*

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