**Transcript of Cyberseminar**

**VIReC Clinical Informatics Seminar**

**Web-based Patient Portal to Directly Elicit a Comprehensive Medical History**

**Presenter: Ann Walia, MD**

**7/23/2012**

Moderator:Welcome, everybody. This session is part of the V.A. 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. 

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At this time, I would like to introduce our speaker, Ann Walia, MD. Doctor Walia is Chief of Anesthesiology and Peri-operative Care at the Tennessee Valley Healthcare System and Professor of Anesthesiology at Vanderbilt University Medical Center in Nashville, Tennessee.

Without further ado, may I present Doctor Walia.

Doctor Walia:Thank you, Margaret and Heidi. And good morning, everyone. Thank you for giving me the opportunity to share this new web-based pre-operative assessment software and its applications with you today.

Before we proceed, I have some disclosures. I would like to take the next 40 minutes or so to define the challenge and the opportunity we faced within the V.A., briefly describe how we have used the innovative approach to deal with this challenge and also share our results and results from some other academic institutions and programs that have used this innovative solution. 

We received one of the first Greenfield Innovation IT Grants for this back in 2009. And over the last three years, we have worked to where this application is now scheduled to be incorporated into the National V.A. Surgical Quality Workflow Management Initiative. 

As we all know, a timely medical history serves as a cornerstone for delivering quality care. Unfortunately, there have been no patient-friendly methods for collection of this medical information. Current methods include generic paper based forms, which we all get handed when we go to a doctor's office. Or, we have the clinicians who are serving as expensive scribes. Or, primitive electronic medical record systems which are unable to provide the required information at the point of care.

All of the above mentioned approaches are collecting medical history but share one major problem. They apply homogenous profits...[missing audio]...exogenous patient population and fail to meet the patient's individual needs collected. Collectively these approaches result in a subset of patients who are either not appropriately evaluated or a subset of patients who are unnecessarily subjected to exhaustive evaluations and diagnostic tests and consults that are not indicated.

Therefore, a smart triage platform that can be customized in real time to the needs of each and every patient is absolutely required. This would allow for evaluation of the patient far enough in advance of their medical encounters and allow for ample opportunity for necessary intervention prior to their appointment.

That we feel that there is a need for a patient-driven, web-based system that is comprehensive in its assessment and patient specific and smart. That is it provides checks and balances to help eliminate many of the errors that occur from patient misunderstanding or forgetfulness or from inadvertent mis-interpretation of certain components of their medical history.

If you work within a V.A., you would agree that if you’ve seen one V.A., you’ve seen one V.A. Each facility has its own system for evaluating preoperative patients. Most V.A.s that have a pre-op clinic require a separate scheduled visit for a pre-anesthetic evaluation once the patient is identified as a surgical candidate. 

A pre-anesthetic evaluation is required by the Joint Commission as well as V.A. regulations. Several V.A.s do not have a pre-op clinic and see the patients on the day of surgery resulting in a very high day-of-surgery cancellation rate, and wasted resources, increased patient dissatisfaction as well as provider dissatisfaction.

I recently had a call from a colleague in New York who said that their on-the-day-of-surgery cancellation rate was as high as 20 percent. That is excessive. This lack of triage process also means that every time the same patient is scheduled for -- sorry about that. 

This lack of triage process also means that every time the patient is scheduled for surgery, he goes through the pre-op operative process all over again. For example, if we have a patient who is evaluated for monitored anesthesia care topical cataract in May and has the second eye scheduled for the same procedure in July, under the current system, he would indiscriminately go through the full process of assessment, lab work, et cetera all over again.

This means additional co-pays for the patient, travel reimbursement for the V.A. and unnecessary work load for the pre-op clinic, the lab, the heart patient and the consulting. Additionally, with a pre-set number of appointments available in the pre-operative clinic per day, there may actually be a wait list for the patients in the pre-op clinic. This great list would then lead to delays in evaluation, further workup if some is required and then this all adds up to surgical scheduling delays adding to a surgical backlog and increasing wait lists.

I have to get this minimized somehow.

Just as an example, Tennessee Valley Healthcare System has two major campuses. Nashville Campus is a 1-A facility. We have another campus about 40 miles away which is a 1-C facility.

If you are not familiar with that, a 1-A facility is usually the one -- the designation depends on the type of surgeries done. We do transplants at the Nashville Campus so it is the highest acuity facility; 1-C is a lower acuity facility and most of the patients we see there are monitored anesthesia care with very limited general anesthesia.

At the Nashville campus, we perform about 4,500 O.R. surgical procedures per year. In keeping with the changing VA population, 60 percent of our patients are outpatients and each of these is evaluated by a nurse practitioner or a certified registered nurse anesthetist in the pre-op clinic.

Each of these evaluations is then reviewed by an anesthesiologist who determines if further investigations are required in order to perform risk stratification. This whole process, I know it appears cumbersome but it probably explains our almost non-existent day of surgery cancellation rate. Our cancellation rate is under 10 cases per year due to anesthesia reasons. 

This does stress our resources as well as the patients who can end up spending several hours in the hospital after their surgical clinic appointment. This could lead to patient dissatisfaction but comparing our two campuses that have such different pre-op clinic protocols, the natural pre-op clinic is an open clinic where patients just walk in after their surgical appointment and there is not a separate clinic appointment. We see anywhere from 18 to 25 patients in that clinic every day.

The Murfreesboro or the 1-C facility has pre-op clinic appointments so the patients have to come in on a separate appointment to be seen there. This requires additional travel so we actually had patients complain about both systems. Especially the younger veterans which have to take time off from work and the very old veterans that require relatives to take time off from work to bring them for yet another appointment to the V.A.

So, how did we get started on this grant? We identified the problem very easily because we have been dealing with it for several years. When, in 2009, the Central Office rolled out their first round of innovative IT grant idea solicitation in order to improve processes at the V.A., we defined our pre-op assessment clinic as a problem area in need of improvement. This was recognized by the Central Office as an overwhelming issue within the V.A.

Just to tell you how competitive this grant process were, there were 60 V.A.s that applied for the grant from 20 VISNs and a total of 178 letters of content were submitted. Of these, 30 were granted funding. After rigorous marketplace scanning, MedSleuth, Incorporated and their BREEZE preoperative software was identified as a good fit and was awarded a sole source contract through this grant.

The objective of the project was to demonstrate novel use of the software in intense environment that could triage pre-surgical patients based on anesthetic risk. As we envision it, the surgical clinic would identify a patient requiring surgery. A consult would be entered into CPRS which would activate the brief access for the patient in a secure location like My Healthy Vet. 

Patients would then be able to access this website from a kiosk in the surgery clinic, a CBOC or from a home computer or a mobile device. The patient would complete the questionnaire which is entered as a view alert to the preoperative nurse practitioner or CRNA. The data is reviewed by the Nurse Prac or the MD and a decision is made to whether the patient can be fast-tracked to the day of surgery or not. And if routine pre-op labs were needed, they could be obtained at the local CBOC or a decision can be made to get them on the day of surgery if it can be done in a timely manner.

For more complex patients, an appointment would be arranged in the pre-op clinic and on the same day other anticipated testing would be scheduled as well, like chest X-rays or EKGs or a cardiology consult or other testing like ECHO or stress test if one is quite sure that a repeat one is required. This would save the patient multiple trips to the hospital.

The additional benefit for this software is that as this data is fed into this software and the computer learns, over time, it will also be able to produce recommendations based on the guidelines that we provide and the data that it analyzes. Just one more step in the V.A. IT development.

How does BREEZE work? It employs a patented machine-learning computer algorithm to generate a unique survey for each user of the system. There are three features that make this triage process truly unique. 

It employs an expert system and machine learning to decide a patient's medical history from their medication profile, which I will show you in just a minute. 

It elicits and formulates a comprehensive medical history that not only allows for patient triage based on risk factors of relevance but can also be completed without healthcare provider intervention. That is saving manpower for the providers. 

It offers the product via a software as a service, thus eliminating up-front and ongoing maintenance costs and allowing for easy customizations. 

This is a screenshot of what the survey would look like. The demographics for the patient would be automatically entered into the software through the HL7 interface with CPRS. The software is designed to elicit a comprehensive medical history in a patient specific manner starting with medication.

Through the HL7 interface you can get a pre-population of the medication list and the patient goes down that list and answers the relevant questions. The interface is designed as a two-tier dropdown menu.

The first tier is linked to the most commonly used medications. The system can learn as it goes with use such that the most common medications are listed up top. Or they can be pre-programmed to list all most common medications and the names that are used such that the patient can use that more easily.

The second tier is an alphabetical listing of all medications. 

The first tier makes it simple for anyone to use as it also uses a type of head methodology so that you don’t need to type in an entire name of the medication. If you entered A S it would give you a list of drugs. The next screen would then be a complete listing of every single condition with on and off label indications for each drug. 

If the patient selected aspirin on the previous screen, the next screen would ask him the indication for taking aspirin. Is it for a history of angina? Has he had angioplasty? Does he have a stent and so on?

This process is repeated for each medication. At the end there is a separate section, which allows them to enter medications or conditions, which they could not place or link to any medications presented during the survey.

The final output can actually be modified to fit any desired format. We decided to go with this look. The caution sign here actually alerts the provider that the patient has conditions that need to be reviewed. Like this patient is on Plavix. This alerts the provider that they need to initiate bridge therapy in the peri-operative period.

This can also be linked to a hyper link that leads to healthcare providers who, through an educational screen that the healthcare provider can review or to clinical pathways that can be initiated when the patient is identified as seen on this clinical pathway.

This view alert also has another alert. The patient has known difficult intubation. This would alert the provider that additional preoperative preparation is required before the patient presents to the OR. Specialized equipment is required. This alerts the support staff, the health technicians and the anesthesia technicians that they would have to have a difficult airway in the O.R. The O.R. nurses can be alerted to have a tracheostomy set handy if this is seen as an alert on the surgical schedule. 

Another important application would be the ability to provide clinical reminders with such things as smoking cessation and to comply with requirements such as med reconciliation.

All of this information is entered by the patient and can be printed by the patient for their record and will appear in layman's language where it would have presented to the healthcare provider will be translated into appropriate medical terminology presented in the format that is useful to the healthcare providers.

Moving forward as this gets incorporated into SQUIM, the dataset that the patient puts in will be incorporated not only into the anesthesia history and physical and preoperative assessment. The same dataset, the relevant dataset will be transported into the surgical H&P thus cutting down on their time to go through the patient's CPRS chart and data mine relevant information.

The three project deliverables for the grant included customization of the BREEZE software to VA specification. A patient list consisting of 30 V.A. patients, employees or volunteers where we would evaluate the suitability of the software for our patients as well as compare the accuracy of BREEZE output with the gold standard, traditional preoperative evaluation utilizing two uninvolved independent anesthesiologists.

And last but not the least, to develop the bi-directional HL7 interface with CPRS. All of the deliverables were completed within the timeframe of the grant. At the conclusion of the grant we continued to test this software with our local IRB approval for an additional 75 patients in a similar manner to ensure that our results would hold true in this tough, V.A. population.

For the purpose of the grant, 31 patients or employee, veteran volunteer completed the web-based questionnaire and also underwent the traditional preoperative evaluation by me. The volunteer mix was a standard V.A. patient mix where 75 percent of our patients were ASA 3s and 4s with a multitude of medications. 

Two uninvolved anesthesiologists compared the two preoperative evaluations for all 31 patients and found the results to be very accurate. In fact, I have to say I missed a couple of these things during the traditional preop. I later found out that one of the patients had a history of PTSD along with other standard V.A. chronic conditions of which he had a list of over 20 medications.

In the rush to do the number of patients that come through the preop clinic every day, I mistook a lot of the uncommon medications to be his PTSD meds and missed the fact that he had multiple sclerosis which was obviously very well controlled as he was completely functional.

BREEZE, however, picked this up from his medication history. During this review of BREEZE versus the gold standard, it was found that BREEZE did not miss anything of significance and had very good accuracy where 75 percent of the evaluations were more than 85 percent accurate.

BREEZE also looked at our cumulated results from the 106 patients and found that 100 percent of the volunteers were able to complete the web-based evaluations with minimal help. Our oldest patient was an 89-year-old Veteran with very little computer exposure. Average time to completion was about 20 minutes with ASA 2 patients completing this in less than five minutes.

The most complex station had a list of 27 medications and we still had 97 percent accuracy. Patient satisfaction was not required by the grant but we did an unofficial exit questionnaire showing that 75 percent of patients were either very satisfied or satisfied with the process. This is also very comparative to the results for this software from other centers like UCSF. 

This software has been implemented in the UCSF preoperative clinic. Their data from 670 patients shows that 95 percent of the patients were either satisfied or very satisfied. Their average time to completion of the survey was 16 minutes, a little less than ours but then, our patients have longer medication lists and this software is medication driven.

The UCSF group also showed federal resource utilization and were able to show that their nurse practitioners in the pre-op clinic had improved productivity by almost 45 percent, ultimately resulting in FTE savings.

The savings continued into the travel costs. The group also found that just over two thirds of their patients were eligible for remote triage and did not need to be seen in person by the pre-op clinic prior to their day of surgery.

Average distance traveled in that big city was about 160 miles. We also found that the distance traveled correlated inversely with the median income of the patient. That may account partly for the improved satisfaction. 

Looking at the same thing from our V.A. data the average cost of travel reimbursement by our patients was about $60 round trip. That is to the Nashville campus. Seventy five percent of our veterans were eligible for travel pay. In our conservative estimate at least 30 percent of our veterans presenting to the national pre-op center were eligible for remote triage for a total savings of about $270,000 a year just at the Nashville campus.

Murfreesboro campus applying the same principal I would think that over 90 percent of those patients would be eligible for remote triage and could be seen on the morning of surgery, thus saving at less acute hospitals would be extensive.

BREEZE has also been utilized by the United Network for Organ Sharing Kidney Donor Program in an effort to increase their donor pool in an efficient manner. Using this template they showed that their patient satisfaction was very high and the ease of use was equally high; 97 percent of the 1,000 potential donors completed the survey and the median time to completion was less than 10 minutes.

Of note, this software identified 25 percent of the potential donors as ineligible on remote triage. While increasing the donor pool by 41 percent during the same period resulting in a projected 30 percent increase in living donor kidney transplants for that time frame.

They were also able to increase the transplant nurse coordinator's productivity similar to the nurse practitioner productivity by the UCSF group and the entire patient dataset was available for review immediately rather than weeks later. That is allowing for timely decision making and potential cost savings for the ineligible donor work up.

There is a lot of information on this slide and a lot of IT information which I'm going to leave alone but just say that the purpose of the grant was to show that this project is customizable and could interface bi-directionally with CPRS. 

We took the off-the-shelf product and worked with BREEZE IT people to customize to our needs and then their IT people worked with the V.A. IT at TDHS and Central Office to develop this bi-directional interface in a sandbox environment.

This will be further worked on by the SQUIM team as natural implementation for the surgical quality work flow manager process rolls out in Phase II.

This essentially demonstrates the actual HL7 capability showing that the message went out from CPRS and one was sent back thus confirming a functional interface. Based on discussions with the medical IT just as we were able to connect with CPRS, they are confident that they can do the same with the available electronic anesthesia record keeping systems like the [XXXX] Innovian and Centricity. 

This is important from a perioperative standpoint because it is important to have the entire perioperative dataset in one location especially going forward as we start to develop the quality improvement initiative for anesthesia. There is a site for the surgical quality improvement and data mining already but the anesthesia piece still needs to be developed.

This software will allow us to optimize perioperative management for our patients by allowing us to review and risk stratify early, implement clinical pathways and optimize pre-op work group management while at the same time decreasing day of surgery delays and cancellations. 

We see over 6,000 patients in our pre-op clinic in Nashville. Sadly, a third of these do not present for surgery for some reason or another. We also have quite a few repeat offenders like the cataract patient I mentioned earlier or patients who are having bronchoscopy, medianoscopy and then present for lung surgery a week later.

All this adds up to a lot of wasted resources because these patients would indiscriminately present for re-workup two weeks later. A lot of our surgical clinics are staffed by residents and when they fill out the pre-surgical forms they automatically click on every single lab and workup that is in there instead of you know, taking the time to see what actually is required.

Once an order is entered, you cannot retract it without the ordering physician actually retracting it and that’s just too time consuming. I think we could easily fast track over a third of our patients, especially these days as we are starting to see more of the younger veterans returning from the ongoing wars.

This would eliminate unnecessary travel and other basic resources like labs, consults, radiology which, in turn, would lead to the true patient and staff satisfaction while at the same time decompressing our preoperative clinics.

This set based patient portal application would extend well beyond the procedure areas and could be effectively utilized to triage consults in all specialty clinics with a positive impact on electronic basis and appointment prioritization.

The same process could be used in other procedure clinics like the GI clinic or the cath lab or radiology where this would initiate a patient-generated history and physical and meet other performance measures for patient centered care like medication reconciliation. 

ICU and rapid response teams is another area where this could prove very useful. In fact, this could be used as a platform for all medical history needs starting in the surgical area and importing the pre-anesthesia evaluation information into the surgical history.

This could also be used as initial medical history for all new patients including patients presenting for comp and pen exams. It would be an efficient tool to populate CPRS patient records. Scheduling triage for all outpatient appointments could be an important triaging tool for all specialty consults especially high volume clinics like orthopaedics, urology, pain and cardiology where this patient-entered information could be utilized to not only triage the patients to the suitability for the consult but also whether they need to be seen sooner as compared to the other patients.

This type of opportunity to create a truly patient friendly interface within the V.A. system would just enhance the telemedicine opportunities within the V.A. 

In summary, you think this software would allow the patient to provide their medical history on their own fear of -- [audio static 00:33:59 -00:34:11]

...and timely medical history, the full benefit of remote triage can be realized for patients and their caregivers.

We recognize the pre-op evaluation process as the problem area within the V.A. and BREEZE has now been recognized as a very viable solution to this issue. This will now be rolled into the surgical quality workflow manager project, which is a $40 million national initiative and is intended to streamline the entire V.A. surgical process.

We hope to have this completed in Phase II of SQUIM. But for now, a contract has been approved at Tennessee Valley Healthcare System for local implementation. BREEZE can also be incorporated as the primary portal for all history within the V.A. system. 

Any questions?

Margaret:There are some questions. This is Margaret. Questions have been typed in and probably more will be typed in now. 

You have kind of addressed this but can we use the software for other clinics?

Ann Walia: Absolutely. In fact, orthopaedics has actually already started working with the software to develop a range of motion stick figure in their template. This is something that they do not have right now. They have looked at this -- our orthopaedic surgeons have looked at this. They like the idea of not going through every single medication for medication reconciliation. 

Letting the patients enter their problems at the same time and then, being able to document the range of motion so that when they see the patient again in a month, two months, three months, they can actually refer back to what they had seen three months ago instead of a subjective range of motion.

So yes, I think it would be a great tool to use as a triage tool in all clinics.

Margaret:Could the software be used for other medical disorders or modified for other medical disorders?

Ann Walia:You mean for in clinics or -- I'm sorry -- what medical disorders?

Margaret:It's not clear from the question. Just medical disorders. So maybe you have already answered this in terms of you can use it in other clinics beyond preoperative surgical clinics.

Ann Walia:The questionnaire can be modified to fit if it is a C&P exam, they can modify the questionnaire to fit the C&P exam. Specific questions or if it’s a psychiatry clinic that wants it they can modify the questions to fit their needs. 

We started to work on a pain clinic questionnaire. So, the questionnaire and the output can be modified to suit the needs of the clinic.

Margaret:Okay. What percent of patients were not able to complete the forms due to lack of access to a computer or inability to use a computer?

Ann Walia:For our 106 patients, the patients actually completed it in the hospital. We provided the computers. Going forward, the patients would have kiosks in the CBOC clinic or in the surgical clinics that they visit and are identified as surgical candidates. 

Even if they do not have a computer at home they can access one at a CBOC or at a library or use a smart phone. Lack of computer availability, I do not think will be an issue because the V.A. is rolling out a whole bunch of kiosks as well in different areas.

The inability to use the computer per se was not really an issue. We had an 89-year-old who had never used an e-mail account. He was able to do it once we got him access to the website.

Margaret:Okay. How do we tailor the software for other specialty clinics? Will it require further funding?

Ann Walia:It is off the shelf software so you would have to work with the company to develop clinic-specific questionnaire. At this time, it is going to develop a medication based history and physical. If you want to incorporate other specific questions, they can definitely do that but it would require further development.

Margaret:Okay. A related question -- how do we get the software and get approval from our internal privacy officers and ISOs?

Ann Walia:We went through the grant and received the okay through the grant when we went and asked for a contract for the specific clinics. The ISO and the COS all signed off on it. Once it gets incorporated into SQWIM and has been converted from a Class III to a Class I software, it is going to become a lot easier to implement it into other clinics because then it would actually be on the V.A. servers. 

The best thing to do is to -- we hope to have this going forward in April to be part of this going Phase II. I think it is going to become a lot easier once it gets converted to a V.A. checked off software.

Margaret:Okay. Next question. Other than SQWIM, where is the funding for getting the proof of concept out of the sandbox? You would be the first, since there are security issues writing back to CPRS.

Ann Walia:Right. After the grant was completed we worked for two years with the Central Office IT and the Greenfield Innovation team to continue to develop a model for converting this into a Class III software. Once the SQWIM project was initiated, this became part of that contract. 

Where, exactly, would the funding come from outside SQWIM, I do not know. It would be the Central Office IT that would have to pair the need with another project, I would think.

Margaret:Okay. Can you explain what Class III software is?

Ann Walia:It is the off-the-shelf software that has not been vetted by the V.A. IT. It has not been approved by the V.A. IT to be installed on V.A. computers and servers.

Margaret:Okay. Another question. Was there any difficulty with the HL7 connectivity?

Ann Walia:Absolutely not. They did that in less than an hour.

Margaret:Great.

Ann Walia:...part of the grant.

Margaret:Okay. I am at the end of questions here. There may be a few more typed in. Let me just say to the audience that I want to thank you, Doctor Walia, very much for taking the time to present this talk. 

Our next VIReC Clinical Informatics Session is scheduled for Tuesday, August 21st. Our speaker will be Laura Bonner, PhD and her title is Qualitative Analysis of V.A. Personnel Experiences with the Electronic Medical Record.

Let me see. I do not see any more questions coming in. If anybody does have a question following this talk, you can certainly send it to VIReC at V.A. dot GOV. The VIReC help desk and we will forward it to Doctor Walia. 

I think that we have finished with this. Thank you very much. Thank you, audience. Thank you, CIDER. 

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