**Transcript of Cyberseminar**

**Patient Aligned Care Teams (PACT) Demonstration Labs**

**The Patient Care Assessment System (PCAS): A New Tool to Support PACT and High Risk Patient Management**

**Presented by Tamara L. Box, PhD**

**January 29, 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 tamara.box@va.gov.*

Moderator:     We are at the top of the hour now, so I would like to introduce our speaker today. We have Dr. Tamara Box presenting for us. She is a clinical scientist and health informatacist with the VA Office of Informatics and Analytics, and the health IT lead for the VA Clinical Assessment Reporting and Tracking program, known as CART, for the National Clinical Quality program for VA Cardiology. She is also the national project manager for the Patient Care Assessment System for the VHA Office of Informatics and Analytics. We are very pleased for her to be joining us today. Let me pull up your slides Dr. Box. I will turn it over to you. 

Dr. Box:     Thank you. Are you able to hear me okay? 

Moderator:     Yes, you are coming through just fine. Thank you. 

Dr. Box:     Perfect. All right. Good morning everyone. I think that for some of you it is the start of the afternoon, so good afternoon as well, on the East Coast. My name is Tammy Box. I am thrilled to present the walkthrough today, of our first release of the VA Patient Care Assessment System, or PCAS. Today I am going to briefly walk you through the how and the why of PCAS, and then I will talk a little bit about risk assessment, including statistical models. Then I am going to give you a hands on view of Release One. 

Before we get started, I can see that we have a lot of people on the call. I wanted to ask you a quick poll question so that I can know something about all of you. You will see the options for entering your information right there on the screen. We will give you a few seconds to put in some information there. 

Moderator:     Great. Thank you. It looks like the responses are streaming in. We are getting a good response rate from our audience. Thank you, we do appreciate your feedback. The question is what your primary role in the VA is, PACT physician, PACT nurse, other primary care role, for example dietician or pharmacist, investigator or research staff, or other. It looks like most of the answers that we are going to get have streamed in. I am going to go ahead and close the poll now. It looks like we have about 4% that are PACT physicians, about 33% PACT nurses, 12% other primary care roles, 10% investigator or research staff and about 39% reporting as other. Thank you for those replies. 

Dr. Box:     Okay. Here is your first piece of information that you are getting on this talk. When you design a poll question, make sure that you have enough response options so that 50% do not end up in other. That is my fault. I am really happy that you are all on the call. I am very pleased to see that we do have a number of PACT nurses. PCAS is intended for you and your use. I am interested in who the others are. If you have a question or want to reach out, I will have my email at the end of the talk and you can feel free to get in touch with me. 

As I said, I wanted to give you a little context up front. PCAS is a tool to help support our VA Patient-Aligned Care Teams, or PACT. I am certain that based on your responses, everyone knows this already. This is just a review. PACT was initiated through the VHA Office of Patient Care Services. It is designed as a model to increase access for veterans, to improve communication between veterans and their providers, and to also enable better overall continuity of their care. In particular, this approach moves us strategically away from what we used to be familiar with in the single provider episodic care, to a real focus on team based care. 

A team is comprised of a provider, a care manager and an administrator. A team can also include, as you all probably know, many other clinical staff such as dieticians or pharmacists, really anyone who is involved in the care of that patient. Most importantly, the PACT model embraces coordination not just amongst the team, but also for the patient. Patients have a key role in the PACT model, as active participants in their overall and longitudinal management of their care. 

When we start to shift this paradigm from single provider episodic care to a more team based model, there are some challenges that can arise. First, I have learned from many of you over the course of the last year, reaching out to PACT teams and talking with care managers, that a lot of our PACT panels are caring for well over 1,000 patients. How do we appropriately target the right care to the right patient at the right time? 

As a quick example, the list that is shown here shows the top ten VA discharge diagnoses in 2008. As you quickly scan through this list, it should become apparent that for things like cardiac issues and mental health, many of the admissions might be avoidable, if we were able to better coordinate care and be able to predict which patients needed care at a specific moment. To help sort this out, the Office of Primary Care Services charged PACT with developing statistical models for veterans, to be able to predict where improved or enhanced care and case management might be the most efficacious. 

The result was the development of the Care Assessment Needs Score, or the CAN score. You can find more information on the development of CAN score. I am not going to go into all of that. There is a link to a reference article in medical care at the bottom of this slide, down on the left. It will give you all the details on how the CAN scores were developed. In general, I want to point out that these models incorporate well over 100 co-variants from many different VA data sources, some of them in the EHR and some of them external to the EHR. The CAN scores provide us with an estimate of the probability of an adverse event occurring within a specific period of time. In our case, it would be 90 days or one year. CAN scores range all the way from a zero to a score of 99. That 99 represents the 99th percentile of risk, or the highest risk to a patient. 

I want to give you a practical interpretation of the CAN score as well. I know that a lot of you are already using CAN scores to help triage your patient panels and target care. Some of you may still be trying to work through the interpretation. Here is an example for you. These graphs show you the adverse event rates by the risk categories that you can see along the bottom, or X-axis of this figure. These are calculated by the CAN models. As a practical example for interpretation, you can see that the farthest right bars represent the highest risk percentiles. For a one-year model that looks at risk of admission or death, a patient in the highest percentile, the 99th percentile, has a 62% probability of admission, a 30% probability of death and a 72% probability of either event. The nutshell is that when you see these high CAN scores, 95 and above, these patients are at a very high risk for having an adverse event in the specified period of time. 

Once we are able to identify patients that are high risk, it helps us to sort of look through these big panels and get a better grasp on who needs care at any given moment. Once we are able to identify those patients who are high risk for events through tools like the CAN score, we have a start to being able to overcome the challenges of knowing where to target care and resources. However, once high risk patients are identified, the challenge becomes coordinating their care, and that of the full panel amongst all sorts of folks, primary care providers, specialty care providers and community care providers outside of the VA, and coordinating their services, all of this while we are also longitudinally coordinating care for the patient and incorporating their preferences. 

PCAS, the Patient Care Assessment System, has been designed as a national Web based application to provide PACT with tools to identify, manage and coordinate care for their panel patients. It also provides the ability to interpret the universe of risk for a given patient. I will give some examples of that when we get into the demo. To create PCAS, we have incorporated a wide variety of data sources and during the demonstration; I am going to point out some of these key operational and strategic data partners. 

We have five releases planned for PCAS. Today I am going to walk you through the first release. It came out at the very end of December of last year. Over the next few weeks, we are working with Champion sites to evaluate and get them trained, to learn from their use of PCAS so we can start to develop some standard practices. As I said, there are five planned releases. Each release satisfies a specific goal related to high risk patient identification, team based care or patient centered coordination and management. Each release also layers in additional functionality. We have taken great care to make sure that there is a balance in each release, between the clinical and administrative data items that we will provide you to support your care, and the overall impact to PACT workflow. We do not want to throw a huge application at you all at once. 

The first release, which I am going to show you in a moment, focuses on being able to view your panel in several ways, being able to assess patients who might be at risk, and to be able to target care at the right time. The second release, which we are going to send off to pilot very soon, adds in some additional clinical information, as you can see here. It also provides tools to create team based tasks and notifications. For example, you as a team member in a PACT may need to assign someone to follow up on a test result or to call a patient before a visit. This release continues the goal of the first release, to embrace team based care. It provides tools for teams to coordinate care better. 

Our third release of PCAS, which will also come out this year, will include some additional clinical components like meds and labs. There is a possibility that we will be releasing some of that before the third release. I apologize. My screen just went blank. I will keep talking. 

Moderator:     You do not have the Adobe session in front of you at all? 

Dr. Box:     I do now. However, I do not appear to be logged in, or not a presenter. 

Moderator:     Let me look for you really quickly. There you are. Let me get you back in as a presenter. 

Dr. Box:     I will keep chatting while everyone else is looking at it. In the third release, which acts as kind of a stability with release, to go through all the information our Champion sites have given us back, and make tweaks and improvements. The third release is coming out this year as well. What we are trying to do here is to continue to reinforce the use of care planning components in Release Two. In Release Three, we will also pave the way for full robust care management modules in 2015. 

Beginning early this year, we are going to have both members from Champion sites and also PACT and nursing leadership. We are going to ask them to participate in a clinical advisory committee to review the original PCAS care management requirements. The reason we are doing that is because PCAS was actually conceived right at the time when PACT was still in its infancy. Our business requirements are over a year old, probably 18 months old at this point. What we want to do is have the clinical advisory committee review the original requirements, and just make sure that the intent still fits with what has become the current model and practice, and the workflows established for the adoption of team based care. We will make sure it still fits in with how PACT has evolved. 

In brief, the PCAS care management modules really are the centerpiece to the application. That is why we are taking such great care in developing them. These will provide templates and tools to document patient preferences, create notes to track care over time, and then notes created by PCAS will be inserted back to CPRS to provide a narrative of care management. It is now time for me to give you the demo, but before I do that, I have one more quick question for you. I will try to make sure I stay on the talk as well. Please let me know if you use any of these other tools, outside of CPRS to help you in your work. 

Moderator:     Thank you. We have lots of answers streaming in, a very vocal audience. We very much appreciate that. As you can see, you can check all that apply. Feel free to check more if you would like. 

Dr. Box:     I am really glad to see these numbers. It seems like people are fairly aware of these other important tools. Obviously, they know how to get to them. 

Moderator:     Great. We have some great response rates. It looks like about 44% of respondents do use CAN scores, about 75% use primary care almanac and PACT compass, about 63% use VSSC and 25% use other tools. Thank you. 

Dr. Box:     Terrific. I want to mention going into our demo that PCAS will be able to be accessed through a variety of different mechanisms. First, you can get direct URL from me. I will have support teams and facilities if you need training. It will also be available as a link off of the primary care almanac. I am glad to see that a lot of you use the almanac. You will see PCAS on there very soon. Eventually we are going to be having PCAS be available directly from the CPRS tools menu. 

Importantly, as we walk into this demo, I want to mention that PCAS will know who you are based on how you are entering the application. You are not going to need a secondary log-in. That has been a pretty high goal of ours throughout development. We know that you guys always have to log into different things and have different screens up. Our security model brings you in a little different way, so you do not have that burden. 

Once you are into the application, you will see this initial view. As I said, I know that a lot of you have a tremendous number of patients and more than one panel you are following. In order to give you some tools to drill down the panel list so you are not looking at all 10,000 at one time, we enter on this screen. On the left hand side, and let me click here, we have some traditional tools by which you can sort through your panel. The last name, last four of the SSN or portion of the name. That works as well. You can search by an exact appointment day or a date range. 

On the right hand side, because PCAS is a tool that is really focused on allowing you to consider your patients based on their risk, we have given you some initial risk based filters. There will be other things that you will see on the risk side as your versions come out. For now, there are three. I am not going to really mention the first and the third, because we will talk about them on another page. For right now, I am going to show you the CAN score filter. Very quickly in your panel, you can click on the CAN score filter and get a good idea of your top patients with top CAN scores. I want to mention that I have scrubbed this presentation so that we do not have PHI. It does appear in this list that all of these are the same patient. They are not. Each row represents a unique patient. 

When you get your panel view returned based on however you filtered – Molly, I got kicked off again. I am going to keep talking while you make me presenter. I want you to note that at the top of each column, you are able to sort by anything that is underlined. Moving from left to right, we have last four of the SSN, the patient name and the CAN score. Let me highlight that for you. I got kicked off again. 

Moderator:     I cannot understand. I have never seen that happen before. I will make you presenter again. I apologize. 

Dr. Box:     Let’s try it one more time. I am not sure what is going on. Let’s try it one more time. If we have a problem, I can always do the old-fashioned click here thing. As highlighted in the red box, there is the CAN score. You can click on that top column and sort by your CAN scores as well. You also see that you will have last appointment date, next appointment date for that patient, care plan things that are going to come in another version, and tasks and notifications as well. You can also track which team this patient is assigned to. That is especially helpful if you are managing patients from several different panels. 

Let me get out of that. I am still presenter. Once you select a patient, you are drilled down into the patient view. Once you are into the inside, and I am looking at an individual patient because I want to orient you quickly, at the very top circled in the red box are some tabs. Those tabs along the top are panel based tabs. They are universal for your panel. Manage Patients is how you find your patient. I will come back to the Consult. None of you will have an Administrative tab. That is my special tab. There will be a new tab for you as well. On the left hand side is the Individual Patient menu. All of the things related to the patient you are working on are along the left hand side. 

The risk characteristics page is the first page you come to, once you select a patient. It is really the central focus of this first release. We want to give you as many tools and resources as possible, for you to start looking at your patients in terms of their risk. At the very top of this page, and I am going to blow this up, you will see our risk indicators. First, at the top we have all four CAN scores, the 90 day and one year scores for admission or combined death or admission. You are then able to click on any one of those. We track these longitudinally. You may click on any of them and see a graph of that CAN score over time. I have shown you the 90 day admission over time CAN score for this particular patient. You can see there is quite a bit of variation in the patient’s score over time. 

Going back to this, underneath the CAN scores there are three different fields. I am going to walk you through how to use these. I think they are pretty special. We understand that the CAN scores are statistical predictive models that have performed very well in our VA population, and certainly much better in predicting these types of events than any other published models we have looked at or developed. However, we also know that at the point of care, your clinical knowledge is every bit as important as the statistical model. We have given you some tools so that you can manually assess your patients. 

You do this by clicking on the button at the top, Assign Clinical Priority and High Risk Flag. This tracks over time, so that little View History link will allow you to look at every single person that has changed clinical priority or high risk over time, why and what they were doing. Let me show you the page where you do this. The picture I have taken here has everything showing. First, the Clinical Priority Score is intended to be used as a way for you to triage and fine tune your panel. I cannot tell you exactly how you are going to use this. I am hoping that through our work with our Champion sites and all of you, and the feedback we get, you will tell me the best practices that you are using for this particular field. 

What we have done initially is default this field to be the patient’s CAN score divided by ten. The Clinical Priority Score runs from one to ten, with ten being your highest priority. You are able to really fine tune on your patients and if you have a select group that you are monitoring on a regular basis, that Clinical Priority Score will help you keep close tabs on those patients. You can indicate a reason when you change the Clinical Priority Score. In the next box, I have recent cancer diagnosis. You may elevate a patient’s clinical priority because something happened to them. 

For Manual High Risk Flag, I cannot tell you how exactly you should use this. The intent is to give you a way to flag patients that you are following very closely, or someone you need to follow up on. We have given you some text information. When you check off the boxes at the bottom, those automatically pre-populate that text box. You can quickly check off some things. For this patient, I have said the patient may have medication management issues and a recent cancer diagnosis. If that does not cover the extent of your tracking for that patient in the High Risk Flag, you can go back up into that text box and edit it however you wish to edit it. Those are three tools that we wanted to give you to be able to augment your CAN scores and augment the statistical predictive values for your patients, but then also add in your own clinical judgment and track those over time. 

When we come back to the Risk Characteristics page, the second section of this page provides some key clinical risk factors for the last 12 months. You will see in our example patient here, and this is a real patient because I have just jumbled up a bunch of patients together, so maybe all the data does not clinically make sense in different sections. This particular patient had been to the ER five times in the last year. He had one hospital discharge in the last year. He had four national days of of care. He was zero for polypharmacy count. We are adding in a couple of other pharmacy data items that you will see eventually in this list. Their pain scale is listed as a six. They do not have a record of any recent combat areas. They are not listed as a-risk for suicide and that is based on health factors. They are, however, noted in red. These items, if they are above a certain value, will light up as red so you can quickly see anything that might be a risk indicator. This patient has received homeless services in the last 12 months. 

You are probably often noticing these little question marks in brackets next to each of these. They are scattered throughout the application. Those are tool tips. Any time you click on them, they are going to give you information about that field. For example, for the homeless item, we get that data from the PCP panel queue, which is a tool in VSSC. The data that is shown right here was last updated at the end of December. They will be updated nightly, actually. This field indicates if a patient has received any VA homeless service in the last 12 months. Clicking on those tool tips will give you extra information to help you understand the fields, how often they are updated and the definitions and sources for those. 

In many cases, those sources have additional information that you can get from those sources. We will link up if we possibly can, if there is another dashboard somewhere to help you. Those sources are really the gold standard. You can go to their sites or their dashboards and understand more about that information. 

The next section in the Risk Characteristics is Cost Risk Factors for the last 12 months. We have brought in DSS costs, beneficiary travel costs, the third and fourth line are a screen taken off a slightly older version of this Release One so the third and fourth rows are fee costs. We have the disbursed amount and the fee payment amount. We have VERA classification for the last fiscal year and the current fiscal year. For that particular patient, we do not have any records on him. 

When you move away from the Risk Characteristics page and you look on the left hand side where the grey menu is, you can now select their patient demographics. I have scrubbed this page so it is not quite as helpful. However, we bring in as much information as we possibly can. In most cases, we have a phone number and an address. In many cases, we have an email address, their age and some of the other things you would see in CPRS. We do give you the ability to edit some fields. The fields that are in blue are fields that you are able to edit. That data will be stored in PCAS and is not at this time being sent back to CPRS. In many cases, there is no place to house that data. It does give you the ability, if there is a caregiver at home; you are certainly able to enter that person’s information and preferred methods of contact, things like that. 

In addition, you can enter secondary contacts. If you remember our sample patient, he had received homeless services. Maybe this is a patient that is homeless, but has a sister or family member that you have traditionally been able to keep in touch with. You can enter secondary contacts, as many as you would like, for that patient. They will be added to the table. 

Moving through, the other focus of Release One is team based care. On the Team Information page, we give you all the team members that are on the panel to whom this patient is assigned. I am going to blow that up. PCAS is a national application. One of the great things about it is that if your patient is a snowbird and winters somewhere else, or lives in a rural part of the state where they visit various VA facilities and are being tracked by more than one VA or PACT panel, you will be able to see everyone in this view. For this list, and I do not know if we have anyone from Omaha on this call, I have picked some of your views to demonstrate here. 

In this view, we see that this patient is assigned to a single PACT panel that is located in Omaha. Again, we are pulling in as much information as you guys have entered into CPRS and other areas in the VA. We have office phone numbers and digital pagers. We have assignment dates and their roles on the team. This data, as it is recorded in CPRS, is a little bit messy. You can help us out when you interact with PCAS. Just know that a lot of this is coming from you. We are able to pull that information based on what you are entering. 

I also want to point this out. Let’s take the case of this patient being in Omaha, Nebraska. Maybe Omaha is just their referring facility. Maybe they get their care in a smaller community in rural Nebraska. You are able to enter their community providers’ information, and you can enter as many community providers as necessary. You will be able to put in phone numbers, their roles and where they are located, and that type of information. When you look to team information, you are really getting a good view of everyone involved in the care of that patient, and not just a single provider. 

Finally, in Release One, we have included the ability to view consults. What you are seeing right now is the per-patient consult screen. It is as if I clicked Patient Consults on the left hand side of this, the vertical menu. This patient only has a dozen consults. Some patients have a lot more, so we have given you the filter tools again, at the top, to help you filter through the consult requests. If you click on an individual consult, you will see additional information about that consult. 

We elevated this because of a request from leadership to put consults in Release One. We are working on some more detailed views of consults. Are really hopeful that we will be able to eventually give you a view that lets you track the sequence of consults, or given consults, and know who has touched it and how it traveled throughout our system. I also want to point out that we do have, at the top in the horizontal panel based menu tab, a Consults tab. That is for your whole panel. When you click on that for example, the view I have given you here is a filtered list by active CPRS status. These consults are active. These lists represent individual consults. You might have some patients repeated per row. It will show you all of your active patient consults. You can select them on the left and go back to that per-patient consult view. 

Finally, we also have a News tab for you. This will be updated regularly. Right now, we are giving you information about the intent of Release One and some basic Q&A. There are a couple of links at the bottom for additional information. We will update this periodically with help tips and some support for all of you, as we learn the ways you use PCAS. Keep an eye on the News tab. This will take on a blog-type format. Eventually, when we have Release Two come out; we are going to release a full informational website. There will be a link to that as well. 

Lastly, I want to point this out in the top right hand corner. You can see that there is a Help link. I am going to get the little pointer here and show you where that is. It is right here on the top right hand corner. There is a link for Help. When you click on that, it will send an email directly to me. I will work with our development team to check on anything you are reporting. 

That is your first view of Release One. As I said, we are working with Champion sites right now to go through Release One. The Champion sites are three at the moment. We are adding three more. There will be six total. These are sites where we have had clinical folks who have helped shape this application through participation in the original business requirements team. Our Champion sites have also helped pilot various aspects of this application. Initially, we were not aware that different providers could be on multiple panels. Working with some key folks in Portland, they helped us refine the Manage Patients and how we are drilling down into your patient panel. We are also working on specific filters with some of our Champion sites. 

With our Champion sites, we are giving them extra training and we are checking back in with them regularly to understand how they are using PCAS and what their best standards of care and implementing PCAS in a practice might be. We do not know. We know that software comes out and it has a certain intent. People tend to find ways to use applications to suit the needs that they have. We have tried to cover all our bases, but understandably, there may be other things that we did not quite get right. We are always interested in hearing feedback and responding to that. 

I wanted to briefly mention that our Champion sites are also special because they have some specific clinical goals. There are a couple of examples here. We are working with one site in particular to create a panel filter. This will allow you to see high CAN scores and look at potential 30 day readmissions for patients with congestive heart failure. That is a specific panel filter that we are working on with Champion sites. In addition, in Release Two, for some of our facilities up in the Northeast we are going to be implementing integration of a cancer registry. Through PCAS and that Risk Characteristics page, you will be able to link up to additional information related to a patient’s cancer diagnosis. That registry is available for the Northeast and we hope that someday it will be national. That is a tremendous body of work. 

PCAS can therefore help these Champion sites to evaluate specific clinical goals, so we can understand how they are integrating the use of PCAS, and hopefully at the end of the day we will have some evidence of health informatics that can improve patient outcomes. We will be tracking carefully with our Champion sites, their specific clinical goals and the ways they are using PCAS, CAN and other tools to target those goals. 

As we go through evaluation and roll-out, we are really looking at the ways people will use PCAS for team based care versus episodic care. How are you and your team working in PCAS? Do you have it set up so that only your nurse manager really has the reins? Is every member of the team logging in, checking and sending each other tasks and notifications, that sort of thing? We want to know what your workflow patterns are, through the PACT team model. That way, we can understand how to better integrate the application and make it as efficient as possible. Of course, we are always interested when you find bugs, issues or have suggestions. Suggestions will go to a clinical advisory team. I will talk about that in a moment. Bugs and issues are jumped on right away. We have a small but mighty development team and some analysts. I am proud to say that we have been very responsive so far, in sorting out any issues that people have had. 

Finally, I want to walk you through the roadmap for this application. As you know, our first release is out right now. We are doing Champion site training right now, so some of you are either hearing about PCAS for the first time right now, or looking and wanting to get on it. Toward the end of February, we will send Release Two out to one of our Champion sites to pilot. We have a Champion site that has quite a bit of experience and expertise in balancing team based care and tasks and notifications. We really want to see if our tasks and notifications national model holds up under their use at an individual facility and team basis. 

In August, we will send our third release out to pilot. We will have our first three releases out this year. In 2015, our big care management modules will be coming out. [Inaud.] and other important things. Throughout January and February, we are going to be working with PCS, PACT and nursing services to go over our implementation and communication plans. If you are a PACT member, you will be hearing about PCAS through a variety of different groups. We are going to coordinate that with the offices that you are most familiar with. 

In late spring and early summer, we are going to convene a clinical advisory committee. I mentioned this earlier. This is comprised of select members from our Champion sites, and also from some of the PACT leadership. That clinical advisory committee is to assess the care management PCAS requirements. I talked about that earlier. We just want to do the gut-check on the original requirements and make sure that we are in line with everything that is happening in the VA right now, in PACT. That team will be reviewing that in late spring and early summer, so that our development team can then take any changes and incorporate those into the two big care management modules that are coming out in Releases Four and Five. 

Additional clinical suggestions will be reviewed as well, by members of that clinical advisory team. We have also been working with some specialty care groups, and speaking with them, to understand how PCAS can be a platform to link out to those specialty care groups. There are groups that have developed other Web applications or other tools that we can link to. Much like we are piloting with the cancer registry in the Northeast, we want to be able to be a uniform platform to coordinate those other tools and help with other scoring, things like that. 

I want to especially thank the team that has been developing this. We are a small and mighty team. We have had the support of many people. Those that are mentioned in black are supporting folks who have been tremendous in helping us identify data and providing ways for us to incorporate those key data elements. The folks in blue are the development team and analysts. I cannot thank those guys enough. In case you are wondering, not a single one of us works on PCAS full-time. These people all do other things as well. This is really a cross-collaborative effort, across all Office of Analytics and Business Intelligence. I am very grateful to them for the attention and detail they give this application. 

I am going to stop there. I want to point out that my email address is at the bottom. If you would like to begin using PCAS or you want to coordinate some training for your facility or your team, please send me an email. I will be off-site this afternoon. I wanted to mention that up front, if you are missing an email from me tonight. Tomorrow I will make sure that I have a reply sent out to everyone who sends me an email. Molly, that is the conclusion. I think that I have left plenty of time to answer some questions. 

Moderator:     Yes, that was great. Thank you. We do have plenty of good questions that have come in. For those of you who joined us after the top of the hour, I know it was a large number of you. To submit a question or comment, simply use the Q&A box located in the upper right hand corner of your screen. We will get that asked in a timely manner. Is PCAS an open source tool? Could it be used outside the VA? 

Dr. Box:     I just went over to presenter view Molly. It looks like I can see who is sending some of these questions. That is nice. Hello Denise. I would say no. I think that the concept of PCAS would be tremendous as an open source tool outside the VA. The reason I say no outright on that one is simply because our data sources are very specific to VA. I definitely think that if you take out the Risk Characteristics page and you were able to plug this model into other EHRs, I think you could absolutely use PCAS or a tool like it. All of our code is being developed in a way that is very thoughtful and fairly modular. It is flexible, basically. To the question of open source tool and it being used outside the VA, I think that components of PCAS can be openly available in the VA as far as source things go. The tool itself, the model for PCAS, is certainly very applicable to other electronic health records, but not the data model because that is so specific to the VA. 

Moderator:     Thank you for that reply. The next question that came in is this. How can you get the CAN score without having to go through PCAS? 

Dr. Box:     Good question. You can get to the CAN score by going to the primary care almanac. The way to do that if you do not have the link, and I do not have it on me right now and I apologize, is if you are in CPRS, go to the Tools menu. You will find a link in there to the primary care almanac. Then you can navigate your way to the CAN scores from there. 

I will say that the CAN score dashboard, and this is a good point to make here, does give a view of a number of clinical pieces of information. The dashboard is intended to be viewed mostly by providers. It is a tool for quick access to CAN information. On the dashboard, you are not going to see historical scores, per se. You are able to access those. There are a couple of links to help you do that. For the most part, you are not going to see those reported. You will just see a snapshot view. Through PCAS, which is intended to care managers and other staff, you do have the ability to look at your panel based CAN scores and do some filtering in that way. You can also look at patient scores over time. Those are a couple differences between CAN and PCAS. 

However, I want to say this. This is not specifically related to this question, but it is important. Our security model for a lot of our data follows the same security model as the CAN scores follow. That is, and I see that we have the CAN score link up at the top of this slide, if you want to access the CAN scores or if you want to access PCAS, the key here is that you need to be registered on a PACT team through CPRS, through the PCMN module and CPRS. There has been some discussion about that over the last year. I want to tell all of you that the model for PACT, for the workload model or staffing model, is based on a three to one model. A provider, a nurse and an administrator per patient. 

In PCMN, you can enter more than three people. If you have somebody like a pharmacist or a dietician, someone like that covering multiple panels, you can add those people to your patient panels in PCMN, and within about 24 to 48 hours that person will automatically have access to PCAS and their panels will automatically load. That is unrelated, but important. 

Moderator:     Thank you for that reply. Let me get that back up there. We had several people send in that link to us. I thought I would put it up there for you. Somebody did mention that they tried to get to it and it is limited. I tried to access the almanac via CPRS Tools, but got a message that it is limited to PCPS. Thank you for letting us know. 

Dr. Box:    There should be a link on the CAN dashboard, if you want access. You can send a note to their team and they will walk you through. 

Moderator:     Okay, great. 

Dr. Box:     Theirs is a little more restrictive than our access. They only pull in certain members of the team. We allow anyone who is listed on a PACT team through PCMN to get access to PCAS. 

Moderator:     Great. The next question is this. Can the risk characteristics take into account any non-VA care? 

Dr. Box:     That is an excellent question. In terms of statistical model, I do not believe that they do. In terms of what we are going to pull into PCAS, there are plans and things already in the works. For example, we will be bringing in non-VA medications, where we are able to access those. Another example is certainly in our care management module, the risk information related to that. I think that is going to overlap into non-VA care as well. Those are two examples. Wherever possible, we want to take into account and pull in non-VA care. As a matter of fact, we have had some preliminary conversations with some of the locations where the VA is doing data sharing across the EHRs. We are really hopeful that this will take off and if and when it does, we would like to be able to bring those community resources into PCAS as well. We will sort that out when we have a chance to. 

Moderator:    Thank you for that reply. We have several great questions coming in. When a nurse enters information, can it be viewed by new teams if the veteran moves or changes teamlets? 

Dr. Box:     Okay. The answer is going to be yes. I think that will be very important. It may not be something that is in the first release. It depends on the data and it depends on the information. Let’s say that a nurse enters information about a veteran related to their risk, sets a clinical priority or updates their demographics with secondary contacts, those sorts of things. Those data will all be available, no matter what panel that patient is on. They are unique to the patient. 

When we talk about the tasks and notifications that are coming into the second release, I think that is an excellent question. I can tell you the original requirements and original conversations we had did not really look at that particular scenario. I think that is probably just because PACT was still rolling out when the requirements were specified. With tasks and notifications, if a patient goes to a different panel I think it may be very important if their remaining tasks and notifications from the previous team. My answer to that is that we are going to work with the pilot testing of the tasks and notifications with our Champion site that is going to be focusing on that. We will let them give us some feedback on that. If that is something that happens regularly, that patients switch panels regularly, then we definitely need to take that into account with tasks and notifications. We will sort that out. 

Moderator:     Thank you for that reply. The next question is this. In the Consult section, is the high priority pulled from patient high priority or is it set for the specific consult? 

Dr. Box:     I believe it is set for the specific consult. It is definitely set for the consult. It is not the patient’s high priority; however, I did not even mention this. On our panel consult overview, where you can drill down into the consults for your whole panel, there is a way. We have one filter on the right, just like we do on managed patients already, for high risk. If you wanted to look at consults for just your patients in high risk, you click on that filter. If there are other filters that you need on that page, just let us know. 

Moderator:    Thank you. You have piqued the interest of several people. Everyone is dying to know what the current Champion sites are and who is being added. 

Dr. Box:     Okay. The current Champion sites are Long Beach, California, Portland, Oregon and Wichita, Kansas. That is going to be a Champion site as well. We have Eastern Connecticut as a Champion site. There are two more that I will mention at a later date. 

Moderator:     Great. That got about ten questions off the pending list. The next question is this. Will care from another VA, say in another state, flow right into the PCAS site to their new state? 

Dr. Box:     Yes, absolutely. It is a national application. That is one of the hallmarks. Wherever that care is, because we are using a lot of data from CDW related to patient care, we are taking in management of that national data source and bringing it in. Yes. 

Moderator:     Thank you. This is the next question. It looks like PCAS is geared toward PACT members. Are there benefits for researchers or admins wanting to get PACT level numbers? For example, PACT Three has 12 suicides, an average pain score of four and 65 gastro referrals, etc.

Dr. Box:     I think that is an exceptional question. At the moment, it is true. PCAS is 100% geared for PACT members. It is to support daily care for patients at the point of care. That said, we know that we are collecting data through PCAS and we are combining data sources that are important to researchers and things that they would want to be able to do. The examples given, in large part, can be tackled through downloading the CAN exports that are available on the CAN dashboard. 

For peer research, there are two ways to go with this. As I said, our clinical Champion sites have clinical goals in mind in their use of PCAS in general. Those clinical goals could also be looked at as research questions. For example, how can we best target care to patients with heart failure, and reduce our 30 day readmissions? To answer that clinical goal, we are working with that site to create a specific panel filter for them, and have them test that. Then we will make that available nationally. There will also be other very specific and very flexible query and recording tools available in PCAS in later releases. 

All of those things, if you are working with a PACT team, you would be able to query and drill out some reports. You can do some really nice standardized types of things with your panel information. Not everything under the sun will be provided in those queries, but we will put in as much as we possibly can and be flexible, so that you can use that information. Things that go beyond what we pull in or record would have to be coordinated through CDW, _____ [00:55:29] or other mechanisms. 

Moderator:     Thank you for that reply. The next question we have is this. Can the CAN scores be used in the huddles to make care transition better? 

Dr. Box:     I think that is a wonderful question. I will remind you that I am a Ph.D. and not an MD, so I am not the best person to answer that. I am also not an RN. Those folks are better equipped to handle these questions. What I can say is that I know they are being used in huddles. They are being used very effectively in huddles. I would encourage you to go to my Vehu Campus and look this up in the RN boot camp series. I helped present with Cathy Beatty and I cannot remember the other name. I am sorry. I am sure I will get an email saying I did not remember her name. 

If you look in the RN boot camp series, you will see one of the presentations I was on, talking about CAN and talking about PCAS. Those parts are fine. The other two parts that the other ladies did are really tremendous in terms of walking you through practical ways to use CAN scores and other tools to support care delivery and care transition. 

Moderator:      Great. Thank you. It looks like we are down to about a dozen pending questions or so. What is meant by call handling in the demographics page? 

Dr. Box:     That is a great question. I cannot answer that. I do not have the application up in front of me. I cannot tell you what is in that drill down. I apologize, but that is not a field I look at often. If you send me a separate email, I will send you a better response to that. Off the top of my head, I cannot tell you what is in the list of things you can select. 

Moderator:     No problem. The next question is this. I think you have covered this. We will go over it. Is the release for the entire VA community, or just Champion sites as of today? ‘

Dr. Box:     PCAS is actually available to everyone at the moment. We are not shielding it from anyone, so if you are interested in getting hold of the tools, just send me an email. We really are focusing on the Champion sites. I want you to know that we had one [inaud.] research last week related to our Champion sites. I would say you are going to see a number of different things advertising PCAS with the link and how to get to it. You can either email me now if you would like to coordinate some training or a conversation, or even have a clinical goal or something like that to discuss, or you can wait and you will see a lot of other blurbs about PCAS and links to it in the next few weeks. I wanted to make sure that our Champion sites had a good chance to give us some feedback and have a headstart on it first. We really focused on them. 

Moderator:     Great. Thank you. This is the next question. How can one find out if their site is using the application or plans to use the application? 

Dr. Box:     I think the best way to do that is to talk with your coordinators at your facility and see if they are using it or are planning to use it. Downstream, of course we are tracking and keeping tabs on who is using it. We will be able to report back on use as well. I do not think that is something we are going to necessarily make available directly through the application. We will certainly have that available to anyone who wants to know. I can imagine that in the next year or two something we would do regularly is report back to sites and let you know that you have ten people using PCAS, give you a link and ways that people have used PCAS strategically. It is something to consider. I could see us returning some reporting, but it will be much later, I think. 

Moderator:     Thank you. The next question is this. How do you intend to populate with data from community sources, especially when you need to coordinate with the local resources when they do not use VA payment status? 

Dr. Box:     The community resources right now that you can enter into PCAS are all done manually. You can enter in a local community provider. You will be able to enter in community hospitalizations eventually, and that sort of thing. It is all manual at this time. Until we have bidirectional communication with VA and some of the local community sources available, it will have to be manual. However, I have seen initial information about that bidirectional communication, the nationwide health information network and some of the different pilots. They are excited about that. We have talked to a number of people. As soon as that is a reality and something they are able to devote some development time to, we definitely want to jump on that as well. 

Moderator:     Thank you for that reply. We have about eight pending questions. Are you available to stay on for a few minutes and answer them? 

Dr. Box:     Sure. 

Moderator:     Great. This is the next one. I was excited to see the ability to look up consult listings and their statuses for each patient. Is there a way to search for those open past 30 days? Can we drill the panels down into female and male listings? 

Dr. Box:     Those are great ideas. First, you can certainly look for open status. You can do a date range on that. However, the other special drill downs, I was not aware of those requirements or needs, even uses I guess. Male, female and the 30 day, I think those are great ideas. The 30 day one I am going to write down right now and send that back to our team. That is something I think we can put in very quickly. We can probably get that out for you in the second release, I would imagine. 

Just as a universal thing, if you are in PCAS, you are using it and you have a good idea, send it to us. We will try to make it happen. The male/female seems a little more specialized. I am not sure about that one. If you want to shoot me an email, we can talk about that more. I am definitely interested in how to improve anything that will help you get your job done better. 

Moderator:     Excellent. Thank you. I passed along an email to that person. The next question is this. If a local medical center uses registries already, can PCAS interact with those registries? 

Dr. Box:     That is a broad question, I think. It depends on what registries they are, I think. We set PCAS up to be as flexible as possible, but particularly within the VA firewall. I guess there are several caveats. One great example of us interacting and working with a registry is the cancer tracker that I mentioned, with one of our Champion sites in the Northeast. They have developed a terrific tool. You saw how small our development team is. We are not going to build those tools. If you have a terrific tool that serves a great number of facilities and provides an important bridge to other care or another registry, we absolutely want to integrate with those things. 

The cancer tracker is one that we are using as a demonstration of that. We already have most of that machinery built. They have been kind enough to provide some Web services for us to consume. If you have people in a registry, something that is helpful in your region and especially has potential import nationally, we would definitely want to be able to integrate with that. It may be that working with the cancer folks in the Northeast, we might be able to build a construction kit and guidelines on how to get your registry set up, so that it can be consumed within PCAS, so some of the data can be bridged. That is an important question. I think that it depends on where the data are, what kind of data they are and whether they have national implications as well. 

Moderator:     Great. We do have just four remaining questions. We will get through these. Will staff be able to use this if they do not have SSN drill down access? To see CAN scores, you need drill down access. 

Dr. Box:     The answer I have for you is that if you are registered on a PACT team and PCMN through CPRS, you have access to those patients through PCAS. We have adopted security models further up the stream. That is how access to PCAS is granted. 

Moderator:     Excellent. I think you have touched on this before, but we will go through it again. Is PCAS already available and you just have to sign up for it? Will it be deployed facility-wide? 

Dr. Box:     It is both. We are focusing on Champion sites right now. It is not hidden from the world. It is on a VA website. It is a Web based application. You are welcome to email me. We are focusing on the Champion sites. In a short amount of time after we have convened with our PACT leadership and nursing services leadership, we will be distributing the link and pushing it out through all different kinds of channels. You will hear about it in many different ways. 

Moderator:     Great. We do have somebody that has suggested this. I would suggest adding the hepatitis C registry, especially with new treatments on the horizon. Thank you for that comment. 

Dr. Box:     What is the question? 

Moderator:     This is the final question we have. 

Dr. Box:     Molly, My best suggestion is that if they are still on the call. If you shoot me an email, I would love to talk with you about that. 

Moderator:     Great. I can also pass along the Q&A log to you after the session, so you will have their name. This is the final question. Many have access to VSSC without being on a PACT team. Will there be a way to apply for PCAS access for administrators, etc., that are not on PACT team members? 

Dr. Box:     At the moment, we are restricting access to PACT teams. That is just because the application is designed for them and we want their feedback and input on how they are using it and improving it moving forward. I do imagine that we will have a way to enable specific administrators to be able to also view it. The key here is that when you go to access PCAS, you have to be assigned to a team in order to see patients. If you do not have any teams assigned to you, there is nothing to look at. It will just depend on how the model moves forward. That is something we are going to have to work with. Our Champion sites are on it, also with the PACT leadership in particular. 

At the moment, the answer is if you are on a team in PCMN and CPRS, you have access to PCAS. If you are not but you are an administrator, it may be possible that you put yourself on those teams or downstream, I am sure we will work with PACT leadership to figure out a way that other people can at least get into the application. Those who are working directly with the patients are those who should be in the act and editing things. 

Moderator:     Thank you. We did have somebody write in saying they would like to talk to you about the hepatitis C database. Their RN care manager is managing the statewide hepatitis C database. I gave them your email and asked them to touch base. 

Dr. Box:     I would be very interested in hearing more about that. 

Moderator:      Great. I cannot thank you enough Dr. Box, for your presentation and sharing your expertise in the field. It has been a highly attended and very interesting session. I also want to thank our attendees for joining us. I am going to ask our attendees to hold on for just a few seconds. I am going to put up the feedback survey. We would like your feedback as it helps to guide which sessions we have presented. Thank you again Dr. Box, and to all of our attendees. Have a great day. 

Dr. Box:     Thanks so much. 

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