**Transcript of Cyberseminar**

**VIReC Clinical Informatics Seminar**

**Care Assessment Need (CAN) Score and the Patient Care Assessment System (PCAS): Tools for Care Management**

**Presenters: Stephan Fihn, MD, MPH; Tami Box, PhD**

**June 27, 2013**

**Care Assessment Need (CAN) Score and the Patient Care Assessment System (PCAS): Tools for Care Management**

**June 27, 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:**virec@va.gov**.*

Moderator:Good afternoon, and welcome to 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&A portion of GoToWebinar. It will be presented to the speakers at the end of this session. A brief evaluation questionnaire will appear when you close GoToWebinar. Please take a few moments to complete it. Let us know if there is a specific topic area or a suggested speaker that you would like us to consider for future...

[Crosstalk] 

Moderator: Fine. I would like to introduce our speakers for today, Dr. Stephan Fihn and Dr. Tamara Box. Dr. Fihn is the Director of the Office of Analytics and Business Intelligence in the VHA Office of Informatics and Analytics; and is a general internist at the VA Puget Sound Healthcare System. Dr. Box is a clinical...

[Audio gap]

Moderator:... VHA office of Informatics and Analytics. The Health IT Lead for the VA Clinical Assessment Reporting and Tracking Program, CART; the national clinical quality program for VA Cardiology. Without further ado, may I present Dr. Fihn and Dr. Box.

Stephan Fihn:Good morning, this is Steve Fihn. I again apologize to everyone for rudely being late here. Okay, so we will go with the first slide here. Thank you and apologies for starting late. Today Tami and I are going to talk about two related programs within the Office of Informatics and Analytics, the Care Assessment Need Score and PCAS. 

The second slide; so this is based upon the VA’s overarching healthcare delivery model; which as you are familiar with the VA’s strategic plan. It is based on personalized, proactive, and patient-driven care. That is team based. It involves continuous improvement, data-driven. It produces value and focuses on population, health and prevention. It is highly coordinated. In some ways, the way I sort of look at - that one of the big goals is to – if you think about the triple aim. 

One way to view that then is to both enhance quality and eliminate unnecessary and unplanned care. Sort of its background, if we think about this. I am sorry. I am on slide 4. At background, if we think about one way to sort of approach this is to think about what are the reasons that patients are admitted to VA Medical Centers. Listed on slide 4 here are the top ten discharge diagnoses for VHA. These are 2008. But I they have not changed in recent years.

You can see that they are respiratory, cardiac, and mental health. Many of these are diagnoses for which we know or believe that outpatient care, good outpatient care, and coordination could help prevent some of these admissions. Moving slide 5, VA has a broad range of clinical programs that are intended to improve care and coordination for Veterans who have chronic illnesses. You are familiar with many of these. The home-based primary care, case management services, all sorts of specialty clinics; telehealth, palliative care; you can probably name many others. 

One, the problem with these is making sure that there is a good match between patient need and programmatic capabilities and requirements. We know from the health services  literature. It has been shown repeatedly that providers, including attendings, nurses, students, you name it – cannot accurately predict which Veterans are at highest risk of deterioration. In fact, accuracy of predictions in many cases are no better than 0.5 or the equivalent of a coin flipped.

At the same time, we have created thousands of PACT teams; which, each of which has an RN care manager. 

[Crosstalk] 

Moderator:Okay. We seem to have lost Dr. Fihn’s audio. We do appreciate everybody’s patience.

Tamara Box:Okay. Do you want me to go ahead and run with this?  We will pick Steve up when he is able to join?

Moderator:That sounds like a good plan.

Tamara Box:Okay. Alright, and I apologize to everyone who is listening. Steve and I have done a  number of these presentations together. We have not had a lot of problems. But I think that it is a challenging morning. I know I am having trouble with our network here in Denver when I was trying to get on as well. Thanks for bearing with me and also accepting that the  Care Assessment Need Score is something that I have been involved with. But I am not one of the two people on it. Steve, Dr. Fihn is really the expert in this. I will do my best to bridge that gap. 

But so what the...  The scope of what Dr. Fihn was talking about before he lost his audio was that we know in the VA that there are a lot of different programs and services available to Veterans with complex chronic illness. Many of you who are working on this on a day to day basis know how many different things that you can use to help care for your patients. 

However, we often know through research and other methods that providers always – they cannot always accurately predict which Veterans are of the highest risk for things like mortality or having to be readmitted; and needing additional care. It is hard to pinpoint which Veterans are at the highest risk. 

In addition to that, the PACT model embraces the use of care managers to coordinate the care of these Veterans. What Steve Fihn, Dr. Fihn and others within Primary Care Services  and the Office of Analytics and Business Intelligence acknowledged is that there was not a systematic way for us to target those Veterans that need specific care at a specific time given all the Veterans that we have that we care for and just I think close to eight million, 6.5 actively in primary care. Then also, let us build some predictive analytic tools to access all of the wealth of data that we have available to us through our electronic health record; also through other systems in the VA. Include all that data to be able to deliver the right care at the right time to each – and these Veterans at the highest risk. If you want to flip through the next slide.

Okay, so using, and some of this you will bear with me. I am going to go over a little faster than probably Dr. Fihn would be able to. It is just I am going to go over it faster. Because he can give you more granular detail about this; but in general, in developing predictive tools to assess the risk for patients, for Veterans in our care. 

The group of people who developed these models incorporated I believe over 160 different variables to include I the models. They were the usual suspects. Things like demographics, co-existing conditions, the Charlson comorbidity score; and some of the other things that we look at day in and day out in our electronic health records system. They look specifically at the outcomes of readmissions or death at 30, 60, 90 and one year intervals. Then they used part of this, or a multinomial logistic regression model to be able to do conjoint modeling of admission and death. 

You can flip to the next slide. Okay, so this gives you some perspective on the various covariates that were used in these predictive models. I should also say that by I believe, and Steve can correct me later. But the – this modeling strategy has been published recently in Medical Care, I think. If you have additional questions about it, we would be able to point you to more specific information. Here is an example of the wealth of model terms that were used. Then at the bottom you can see that there is a  color coded chart to give you an idea of the relative risk ratios to the models that were included I the term. 

The next slide, please. Okay. I  have not seen all of these slides. I am going to – I suspect that there is another one that will be a little easier to read that incorporates what you are seeing in this particular output. But this gives you a good estimate visually at least when you think about the color coding here of the distribution of terms along the relative risk ratio scales. What you are looking at right here is the one year death among primary care patients, figures. 

Okay, next slide; okay, so the CAN score really reflects. It is an estimated probability of admission. It expresses a percentile. That ranges from a score, a CAN score of a zero to a 99. That is given for an individual patient  or an individual Veteran, even though this is a population risk assessment. I think there will be an opportunity for me to explain a  little more about that in a second. 

But essentially this score from the lowest risk of coming back in for an admission. Or having additional problems that require that in those time intervals. The lowest risk is zero. The highest risk is 99. It gives you a perspective on how the patient relates to their – to other Veterans in terms of targeting the highest risk Veterans or care. 

The next slide, please. This is the slide that I am a bit more familiar with and have seen Dr. Fihn present on this. The past, methods generally show; and some of the details may be hard to view on your screen. But essentially, this is – showing that when the predictive models that were developed for the CAN scores.

[Crosstalk] 

Moderator:We can hear you.

Tamara Box:When the predictive models that were developed for the CAN scores...

Moderator:Sorry, to interrupt Dr. Box.

Tamara Box:That is okay. When these were compared to other models that were in the published literature, we found that the models. Dr. Fihn and his team found that the models that were published for CAN and it derived for CAN actually had a great level of validity and accuracy for the Veteran populations. What you can see for those of us who are not as intervweaved in this data. 

You are looking at the predicted versus observed rates; or death without admission, admission and death score admissions. For each of those outcomes, the alignment of the blue bars and the orange bars is very tight. That we know that these models apply as closely as possible for our Veteran populations; therefore, a good model to use to apply to this to understand our highest risk Veterans.

By the way, I believe that is the, on the left side where you see Wang, et al. I believe that is the reference for the Medical Care article that describes the predictive modeling strategy in much greater detail than I am able to go into. Go ahead, to use the next slide, then?  But again, this again shows the, sort of the scope of what we see with the Veterans in applying these models to different risk categories. 

The next slide; okay. What I would like to explain here is that when you look at the different risk deciles... There is a practical example of how we would relate this to an individual Veterans’ care. For example, a Veteran that is in the highest risk score perhaps received a 99. Kind of up there by that blue bar or that blue arrow. If a Veteran receives a score of a 99 as their CAN score, for example, for risk of admission or death. That is going to approach a risk of returning. I am sorry. Let me say that differently. The score of 99 shows that the Veteran has  a risk of returning to the hospital for readmission or death depending on the model we are looking at. That approaches 72 percent whatever time period we are looking at. 

For example, at one year, a Veteran with a score of 99 would have a risk which approaches about 72 percent of coming back into the hospital or having a mortality event. Similarly, if you look at patients with a low score like a five. Do you want to click again?  There we go. Our patient  with a lower score like a five. Their risk of returning  depending on the model. But their risk would be about three percent for the event that we are looking at. Or the outcome that we are modeling. Again, go ahead and click to the next slide. Okay, and I am going to have you skip through this. I know that we do not want to run out of time for questions. I am going to have you skip a couple of these slides so we can make sure to cover all of the materials. Some of this is new information that Dr. Fihn has added to his slides. I am not. You can hold right there. I am not going to describe all of this. Because I do not believe I would do it justice. 

We will have to get more of Dr. Fihn’s input on a few of these that are new and he has added. But to access the CAN Score Report if you are wondering how to use it. It is a – it is a tool available or providers. You can find it in the tools menu within CPRS if you go to the primary care almanac. When you go to the primary care almanac, you will see this page. You will be able to click on the – you will be able to get right to the CAN score from this page. 

Go to the next slide. Yes, okay. This is just a cut out of what is a little on the page and how to get to the CAN score. It is available to the primary care almanac. The risk data are updated weekly. Right now, I know that they have seen about a thousand users monthly. That is a lot of use. Those of you who work in web analytics and [inaud.], you know that is a lot of people using this particular dashboard on a regular basis. 

However, I believe and Dr. Fihn can correct me. We are hoping that this gains more momentum and is used more and more throughout the VA. Because a thousand users monthly probably represent I believe about a tenth of the target population of providers who could be using this tool to help them understand risks for their patients. 

The next slide, please. Okay, when you go into the CAN score, what you basically find is a dashboard format. You can quickly look at each of your individual patients. The follow up, which is not showing here, but it was on the last little view of this is their CAN score based on whichever model you happened to be looking at, at the time. This dashboard format allows you to quickly see the list of – in this popup view. You can the different care management resources the Veteran might be actively using. You can look at some of their healthcare utilization over a two year period. 

You see that on the top right. Then there, obviously on the bottom you see a quick visual of which clinical category this Veteran is actually dealing with right now. In this example, you can...  Each row represents one patient. You can see that for example, the second row. This patient has a list of a lot of different illnesses that he or she is dealing with such as anemia and congestive heart failure, and diabetes, and hyper tension. It is a quick visual what is – what is the overall health of this individual patient?  What are their care management and healthcare utilization over the last two years?  

The next slide, please. Alright, so the CAN score was rolled out in December, 2011. It was a very soft rollout. I believe and again, Dr. Fihn can correct this later. But I am pretty sure that they just released it. Told a few people about it and launched it to see how people were using it. There was active roll-outs in two whole VISNs, 4 and 17. 

Then Dr. Fihn has been doing a lot of different presentations and different conference calls with stakeholder groups and different organizational groups in the VA, including  a couple of VeHU presentations. If you would much rather prefer to hear his voice and have his explanation of all this, which I am sure is the case. I encourage you to perhaps check out My VeHU campus. There is a presentation that he has done that is quite excellent. He will give you greater detail on all of this. 

First I have the feedback for the CAN score. Using it has been terrific. As you know, when you look at information, sometimes you have more information that you can readily process at one time. Some concerns have been expressed. All of that feedback goes directly to Steve Fihn. He gets those e-mails. He reads them. It helps to begin that cycle of improving and considering the dashboard itself. The next slide, please.

There are a couple of different ways that the CAN scores are being used among – around the VA. Again, this is not something that I can necessarily speak to on a detailed level. But I will mention it in broad strokes here. That a couple of the ways we hope the CAN score, or the CAN scores are being used are to encourage care and coordination; so, and in care management. 

For example, the working as teams in the PACT teams; and a lot of different clinical providers and non-clinical folks working together to take care of Veterans. A good use of the CAN score for example, would be to as a team, look at the CAN scores. Be able to triage your highest Veterans and your highest risk patients to understand if they are receiving services that are available to them to help them with their current problem. Sharing that responsibility amongst your team to use it as a tool daily, weekly, and in team meetings. Whatever is most appropriate. 

I know that Dr. Fihn and others are very interested in how different PACT teams are using the CAN scores. He also; I know. I have heard him say this many times. There are ways that the score should probably not be used. The score is not a performance measure. That is written out in one of these bullets. It is not a performance measure to try to improve care. There is no reason to...  It may be very possible that you have a Veteran that you are caring for on your panel who is very sick. You are using all of the services  that are appropriate. 

It does not mean that because of a Veteran has a score of a 99. It does not mean the patient is not receiving high quality care. But it does indicate that this is a patient that needs close monitoring, making sure that all of the possible are is being provided. It, in the same aspect, the low score is not an indication to ignore a patient. There could be something that occurs acutely with the patient. Again, it is – the scores are run on a weekly basis. There is some care that needs to be taken in interpreting those scores. 

The next slide. I think you can all read this. I will just read it out loud. But it is an example of how you can have the CAN score health. After adjusting for age, sex, co-morbidity, and mental health  diagnoses, patients with CAN scores in the highest ten percent who saw their primary care provider for over 60 percent of their visits were ten percent less likely to die or be hospitalized than some of our risk patients who did not see their primary care provider during the year before PACT’s implementation. Similar but less pronounced association for high risk patients who saw their assigned primary care provider up to 60 percent of the time. 

This slide and a few others that I know will follow. I am skimming through these because these are the results of some analysis that Dr. Fihn and his team have been doing based on the roll-out of the CAN scores. The impact that we have seen so far in assessing high risk Veterans. I did want to mention that before we jump to the next slide; because I am not sure that this is highlighted in a different place. But another caution; so this ties into the last slide. Another caution in interpreting the CAN score is that the CAN score really represents probability. 

I think many in this particular audience will be  receptive to that kind of an interpretation. These are  probabilities. They are accurate for large programs of patients. But as we were talking about on the last slide, their interpretation on individual patients may be – may, of course, require individual clinical expertise to making sure that the care is guided correctly. They are used as a guide and not as performance measures.

The next slide. Okay so again this is – some of the next few slides I think are going to deal with some of the analysis of the impact of the use of the CAN score. I am not going to go over these in specific detail. Because I am not qualified to do so. Also, because I know Dr. Fihn has addressed these on his MyVeHU presentations. We can certainly try to make sure everyone has a link to that. Or we get Dr. Fihn back on to give this particular presentation when we are not having so many network problems. 

I am going to skip through these. Also, leave time to talk about PCAS towards the end. Okay, go ahead. As you can tell as we are flipping through these. These slides will be available to you. You are welcome to browse through them. Many of you will readily understand the interpretation of these slides. But in essence, Dr. Fihn and his team have been working on looking at the outcomes related to CAN. The types of people who are using the CAN score. Trying to think through systematically how the CAN score are being used, and, or may relate to patient care. 

I will walk through this very quickly. How the CAN score are intended to be used are really through care managers or providers. As I mentioned earlier, the ways that you might use this might be to each week get together as a team. Run your CAN scores and look at the dashboards. Identify those patients that might be at highest risk; so in that top ten percentile. That will give you an idea of the patients that are at risk perhaps for readmission or death at different time intervals. That way you are keeping close tabs on those particular patients to deliver the right care at the right time for them. 

Now, ways that you can work with those patients might be to call them if they have an appointment coming up. The dashboard will let you know. But it is to make sure they are following the requirements prior to their appointments. Taking medications as prescribed or maybe there is a test that is going to be run at their next appointment . You can give them a heads up on particular instructions you need for that test. 

Then also, you want to make sure that some of these high risk patients. Making sure that they have visits in the near future. That they are not falling off the radar so to speak. Making sure that they are on appropriate medical therapy or doing that periodically. Then looking at the resources that they are using such as their total health; total health services or specialty care. 

The next slide...  Okay and I do know what this is. This is – we, as I said at the beginning, Dr. Fihn and his team have received a lot of terrific compliments and  great feedback related to the CAN score. I feel a little bit  like I am steeling his thunder sharing this. But recently there was a very interesting feedback that was provided. I think it is very emblematic of the way that people are using the CAN score. I will just read this out loud. 

You can also feel the feedback. Attached is the PowerPoint created for local executive leadership to gain their buy in and support, which we have fully received. I am beginning to educate frontline staff on this structured framework so they can better understand the importance of risk stratification. This education allows them to begin connecting the dots of the different settings. How they impact the  continuum of care. How we can better serve our Veterans together. Especially those suffering from chronic diseases. So far I have received positive feedback from the frontline staff and leadership. 

Our home telehealth program has begun utilizing  the CAN to pull their Veterans into the program rather than waiting for Veterans to be pushed into the program. The PACT teams utilized the CAN for specifically, for patient selection for shared medical appointments. Several PACT teams also cross referenced the CAN with the Datamark database for patient selection of chronic disease management protocols. 

This  is an example of how one specific group has been using the CAN score to improve their overall care delivery. I will stop there with reading out loud. But I think that this was a really tremendous feedback to let us know how they are implementing it. Across not just a PACT team, but also across the other care providers in this particular setting. 

Go ahead and do the next slide. I will say that I also like how that segways into our conversation about the patient care assessment system. Obviously with any – you can read through the problems and limitations. I think I will skip through this. Because I do want to make sure we have a little bit of time to talk about PCAS.

The next slide, please. Okay, alright, so again, with many apologies that we did not have Dr. Fihn on this call. That you had to suffer through listening to me. I think we can switch over to my screen I will go ahead and move forward. Talk about PCAS., and make sure to weave in a little more of how we have been able to incorporate the CAN score into PCAS. 

Again, apologies that I  know I did a significantly insufficient job in giving you a really good explanation of the CAN development and use and how to use it. But hopefully, it gives you just a peak into this incredibly valuable tool. I will come back to it a little bit in a second. I am also looking at time. I am going to flip through my slides fairly quickly. I just wanted to verify with the organizers. We do – this call does end at the top of the hour. Is that correct?  

Moderator:Yes, it is.

Tamara Box:Okay. Alright, I am going to try my best to – with all the different technical difficulties. I will walk you through PCAS and do that rather quickly. I am concerned that we will be limited on time for questions. But I will say that I hope you will be able to direct your questions through the VIReC folks. We will make sure all of the questions that you have are answered and responses returned to you as well.

Okay, so let us talk about PCAS briefly. The patient care assessment system is really, it is an extension of the CAN score. The CAN score are used as [inaud.] for this system. Most of you on this call know that we have and I mentioned this earlier, about 6.5 million Veterans who are actively receiving care in our system. With so many Veterans in our system, we need tools to help providers and those who care for all these Veterans understand who might be at the highest risk for adverse events, to be able to properly identify them. Understanding where to  most effectively target that care is the first step toward better care management. Understanding the services that, as I said in the last piece, the services we are able to provide to those Veterans. 

Then ultimately be able to coordinate care for them across both the patient panels and across the system itself through a large variety of healthcare providers . I am really talking about inside the VA, but also outside the VA. Before Steve was disconnected, he was talking a bit about the organizational structure of the VA. As most of you probably know or have some awareness of, the VA has convened patient aligned care teams. That, the PACT model is really embodied by the mission to identify, manage, and coordinate the right care at the right time to those Veterans  who need it most. 

The Patient Aligned Care Team were initiated to the office of Patient Care Services. The PACT model was really designed to increase care and access to care  for those Veterans. But to also improve their coordination of the providers and provide a better continuity of care for the patient  across the scope of their care. Now specifically, the model embraces a patient centered structure in which the care of the Veterans managed by a team of providers and along with the active involvement of other clinical and non-clinical staff. 

Most importantly, giving the patients the central  piece so that they can have an active role in driving their care. As we tried to describe it in the CAN talk, the – in 2010,the Office of Patient Care Services charged PACT to develop those type of risk prediction models for the CAN score. For the population using the risk factors that were described in the last presentation. Now those risk models help us to target the Veterans at highest risk, of course, so they – as we showed you on the slides. That way to provide specific care delivery to them. Then so that we can evaluate the effectiveness of the case management  model of high risk patient in preventing adverse outcomes. 

Taking CAN really as the midas. CAN score give the providers the direction in targeting care. Extending that, we have developed the patient care assessment system. The patient care assessment system as you can see on this slide is a web based application to provide the PACT team with tools. Then to identify, manage, and coordinate are for their paneled patients with special emphasis given to high risk patients. 

In developing PCAS, we have tried to pull in a huge variety of data sources throughout the VA. Because PACT members stated that they needed to be able to look at a lot of different patient information and in order to assist in managing these patients. You can see a few of them listed on this slide. There were a large group of Pact focus groups including providers. A core group of PACT care managers and other stakeholders who met over a year and determined what core functionality were desired. I am not going to go through this list because I am going to show you some practical examples from screenshots.

In brief, the differences between the CAN score and PCAS. The CAN score is really a dashboard because you have a quick view and an overview of the patient’s care. It allows you to stratify those patients based on risk. It is targeted towards providers. PCAS is a full featured web based application really for PACT care managers to help coordinate the full panel amongst the team. It incorporates a lot of the information that is in that bottom right. I will give you some examples of screens. Alright, I wanted to take a quick poll here. I hope – do we have time to do this?  Or should I just charge ahead?

Moderator:Well, it is really up to you. We have about 12 minutes remaining. It will take about one minute to do the poll.

Tamara Box:I am going to charge ahead. Hopefully, you have all read this slide. I am very interested in the response to this poll. Through your questions and your feedback on this presentation, I would  – I would like to hear your specific thoughts on what the most challenging aspect of patient care is for the patient aligned care team. Something that we are evaluating in an ongoing fashion through the release of PCAS and the implementation. 

I wanted to jump into some screenshots so you get a real flavor for the scope of the patient care assessments within the PCAS. You will be able to access PCAS through the tools menu similarly to how you get the CAN score. When you enter PCAS it will know who you are and the role that you have in the VA. You will not have to log in again. As a provider, it will pull up your entire patient panel. Then it will give you some tools, which I have circled here and then blown up; to manage your patient panel and search through them. 

What is not shown on the search that came about through one of our pilot sites was we have also added the ability to filter your lists based on upcoming appointments. Also at the top of this patient panel overview. Each of these columns is sortable. You will be able to sort by risk, which  I will come back to in a second. Or their upcoming appointments. When you click on a patient and drill down to the individual patient level, on the left-hand side circled in red, you see that there are a  list of patient specific menu items that you will be able to browse through in the final release of PCAS. 

In the first release, we are releasing PCAS in about five releases. Each of these different areas will be released subsequently. We are not throwing it all at you in one big shot. But this first release is really focused on risk characteristic data to align with the CAN score for individual patients. If you look at this page, this is an example of our risk characteristics page. 

At the very...  This is a blow up of what I just showed you on the left, in case it is hard to read coming through the network. At the very top of the risk characteristics page, you will be able to chart to the CAN score over time. You will be able to look at all the different CAN score models for your individual patients. Then you will be able to assign clinical priorities  and manual high risk flags for patients. We added this in because we feel that it is very important. I have said this earlier. While the CAN score are very strong and valid predictive models for our Veterans population, we also know that the individual patient levels. 

All of you have a lot of, more expertise in understanding what is happening on a day to day basis. You will be able to assign your own clinical priorities to effectively triage your own panel and assign risk types. If you change a patient’s clinical priority score as for example, if your patient is a five; meaning that sort of middle ground for risk off readmission. Or needing active care. You change that to a ten. It might be because one of the reasons in the orange box on the right. Perhaps they became homeless or at their suicide risk recently. You want to elevate their individual risk levels so you can continue to monitor those patients. 

We are including in the middle part of this risk page; also, key clinical and risk factors, including ER visits, discharges; and then some of the administration  – administrative and operational data from other areas of the VA including VERA classifications. Polypharmacy, for example, over ten medications by a Veteran in use in pain scales. Then the bottom of this page, we will show you an overview of their care and case management. 

A big aspect of this first release is also to help you coordinate teams. PCAS is a national application. You will be able to view team information, both in your local VA. If one of your patients is a snowbird and lives somewhere else in the winter, you will be able to see teams that are helping that patient in other parts of the country as well. You will also be able to add team members as appropriate. So that and also include home and community providers. Because we know that a lot of our Veterans receive care outside the VA. 

This is just an overview of many of the things that we are putting into this team information page as well. You will be able to look through the last ten months or the ten most recent. Or the last 24 months or two years of their last diagnoses. You will also receive an overview of some of their clinical data including their immunization for the last two years; lab values. You will be able to input community labs. Again, to coordinate all of the spectrum of their care. We will also include  the ten most recent encounters. 

Then another major component which is coming out in release two. We will start to be evaluating next month is a care planning component related to task and notifications for the care team. You will be able to schedule team and patient related tasks, set you reminder. Prioritize those and look at the historical tracking per patient of tasks and notification that are related to the team and patient over time. For the first release, we are including patient consult tracking as well. This is an area of specific interest  to a lot of people in the VA . 

We know that there are a lot of different ways people use the consult. But in general in this first release we will be getting you a full panel overview. Then you will be able to look at individual patients and the consults that they have. The status of those consults, whether open, closed access. Then some basic details per consult. In our care planning component, which will be coming in release three. I am sorry, release four and five of PCAS. This is an area that I am showing you right now are – these are basic mock ups of the screen. 

There are a lot of things going into care planning for individual patients. Some of the things that we will be including are there – the patient situations. Their care background. Their learning preferences. The types of goals they have for their individual care. Then working with the team and the patient to plan and implement a care plan effectively. Then construction of a couple of different care plan notes and interdisciplinary team notes that will go back into CPRS from PCAS to document the  care plan.

These are examples of some of the things we were looking at first off, assessment and  goals. This is an example of the planning and implementing component of our care plan section as well. Then the different ways that we will be able to dynamically create care plan notes that go back into CPRS. You can include things that have only changed recently. Or, if you want to include a full care plan with all of the different areas, you will be able to check those boxes off. Dynamically create that note, edit it and then send it back to the CPRS. 

In PCAS, of course, we are also including ways for you to query and filter into your patient panels. Understand different things like querying them against the appointment range. Or looking at the risk types and risk categories of your patients. We are also including nationally standardized reports. These are reports that were constructed by the group of subject matter experts, stakeholders, and people how helped with the business development for the requirements for this particular application. 

Some of those are listed on this page. But if you look at the bottom, we also want to make sure that you have the ability to create your own standardized ad hoc reports. Save those PCAS. If there are things that you run over and over to understand your panel better, we want you to be able to save those as well. This is a brief overview of our release schedule. Release one is undergoing ongoing evaluation right now. We had our first pilot site begin reviewing some of it in September of last year. We will be releasing this nationally in the next few weeks. 

I will continue to do individual training on a much deeper scale with different facilities and also groups. The goal of this first release though is really as I said. To identify, incorporate the CAN scores to identify our highest risk patients. Understand what types of care they are receiving. Manage our PACT teams and track consults. Release two is going to be under evaluation as we release the first one nationally. It will be in the next few weeks. That really includes the ability to manage tasks and notifications for the full care team. 

We will be adding an additional critical component to PCAS as we move into release two and three. Things like the discharges and the encounters medications, problem lists, and some of the additional clinical data so that you can better manage the full spectrum of your patient care. Then release four and five as I mentioned earlier are really focused on care planning. We are interested in the feedback throughout the full release schedule of PCAS to understand the right components to put into care planning. We have had this evaluated by a lot of people and a lot of groups that are involved in developing PCAS like the Primary Care Services Office and the Office of Nursing Services who are working with us on both implementation, looking at standards of care. 

Then evaluating the best ways to use tools like – and PCAS. Our pilot sites are also invested in that exact same process. We are also interested from them in understanding this paradigm shift between team based care and episodic care. Most of us are used to treating one patient at a time individually. Team based care presents a different paradigm. We are interested in understanding how that occurs and workflow patterns around it. Then, of course, our pilot sites are helping us with the typical software type things; bugs, and issues, and suggestions for improvements. This is very similar to the slide you saw in Steve’s slide set. I would like to make sure that you have my e-mail address. 

Again, I want to extend a sincere apology for all the network challenges that both Dr. Fihn and I had this morning. I would encourage you to please send us your questions. We would love to address those and speak with each of you. In addition there is a MyVeHU presentation that covers much of the same material. It has the live version of Dr. Fihn, which is much better than the canned version of me trying to present the CAN score. I will conclude there and hand it back to the organizers.

Moderator:Thank you, Dr. Box. Did you want to take a few questions?  Or should we have attendees send questions to the VIReC help desk?

Tamara Box:I think that is up to you. I am happy to take questions if you have a couple that I can answer quickly.

Moderator:Okay.

[Crosstalk] 

Tamara Box:But I also wanted to make sure people know that  we will – we will answer questions that come in and send it back personal e-mail.

Moderator:Sounds good. Let us do a couple. Here is one. How are risk categories determined?

Tamara Box:I am going to guess that this relates to the slide I had that had the orange box in different risk categories. Risk, so if it does not; and it relates to the CAN score, then I would encourage you to either...  We will send that to Dr. Fihn or the Medical Care article might have more information for a more detailed statistical analysis of how risk categories are determined. In PCAS, we leave a lot of that to the team. We have come up with the areas that we are able to track effectively. Or ways that we can understand a patient’s care. 

For example, we are able to provide you the VERA classification or the  pain scale, or polypharmacy, and things like that. Risk categories and the assessment of high risk to patient on PCAS. We want you to couple that with an understanding to the CAN score  and a patient’s CAN score over time. But cover that also with your clinical judgment. If you want to assign a risk, a higher risk level to a  patient, based on specific things, you can check off the ones that we are able to provide to you. You can check off suicide risk or something like that. You can also edit that with your own comments of a risk category that may not be in that. 

We will be watching to see the types of comments that people provide. Whether we are covering enough specific risk categorical information. Whether we need to add additional ones to that list. Or create some sort of flexibility by facility for you to create our own list. 

Moderator:Thank you. We are past the top of the hour. How about one more question. 

Tamara Box:Go ahead.

[Crosstalk] 

Moderator:Can you provide information on measured use for functional assessment?  When are these collected and by whom?

Tamara Box:That is a great question. Unfortunately in the time that we have. My level of knowledge about functional assessments, I cannot answer that right now. That is one that I would encourage to shoot us via e-mail. We will address in a better way through that.

Moderator:It sounds great. Thank you so much.

Tamara Box:Sure.

Moderator:Thank you both to Dr. Fihn and Dr. Box for taking the time to develop and present this talk. Please forward any remaining questions to VIReC help desk at VIReC at VA dot gov. our next session is scheduled for Tuesday, July 15th, Knowing and Doing, Automating Performance Measures and Clinical Decision Support. The speakers will be Mary Goldstein, Tammy Hwang, Kaeli  Yuen. We hope you can join us. Thank you to everyone  and everyone have a great afternoon. 

Thank you, Dr. Box, Erica and Margaret. This does conclude today’s HSR&D Cyber Seminar. 

[END OF TAPE]  

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