Introduction to VistA Applications

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Introduction to VistA Applications

• Class 806

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Faculty

• Claudette Murch
• Clinical Product Support Specialist Enterprise
  Product Support
• Marianne Myers
• Information Technology Supervisor Tennessee
  Valley Healthcare System
• Anne Rega
• Clinical Product Support Specialist Enterprise
  Product Support
• Kay Willis
• Chief, Pharmacy/SPD Service VAMC North Chicago

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Objectives

• Brief overview of VistA history.
• Understanding that CPRS is VistA
• Overview of Behind the Scenes of CPRS
• Review of service level applications such as
  Registration, Patient Care Encounter (PCE),
  Inpatient Pharmacy, Outpatient Pharmacy,
  Radiology and Laboratory

4
Questions

• Question/Answer period will be at the end of the
  entire panels presentations.
• Please jot down any questions you may have on the
  available question cards.

5
BEGINNING

• Began in 1977 with the American National Standard
  Institute (ANSI) standardization of Massachusetts
  General Hospital Utility Multi-Programming System
  (MUMPS), now known as M.
• The Computer Assisted System Staff (CASS) was
  started within the VA Department of Medicine and
  Surgery.
• This group became known as the Underground
  Railroad by moving forward with their development
  plan which opposed the Department of Computers in
  the VA development plan.

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EARLY HISTORY

• Late 1978, set of generalized routines (input,
  output, lookup, etc.) was developed by George
  Timson. This was the beginning of FileMan.
• 1979 1981 Development of tools (Kernel) and
  FileMan based applications took place in various
  pockets of MUMPS development.

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DHCP

• MUMPS modules made their way into hospitals 1981
  1982.
• Demonstration of applications presented to VA
  physicians at the Symposium on Computer
  Applications in Medical Care.
• End result, February 1982, Executive Order that
  set into motion what became the Decentralized
  Hospital Computer Program (DHCP).

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Next Decade

• 1980s Development and deployment of service
  applications to all medical centers. (i.e.
  Scheduling, Pharmacy, Laboratory as well as
  Fiscal and Management applications)
• Unique feature of DHCP was that is was an
  integrated hospital information system.

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1990s

• Development of provider focused software became
  primary.
• 1996 DHCP was changed to VistA Veterans
  Health Information Systems and Technology
  Architecture.
• VistA is built on a client-server architecture
  and graphic user interfaces (GUI) were
  introduced.
• 1997 Release of Order Entry/ Result Reporting,
  version 3 was released known as CPRS (Computer
  Patient Record System).

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CONTINUED GROWTH

• Incorporation of commercial off the shelf
  software (COTS)
• Imaging System
• Bar-Code Medication Administration
• Master Patient Index
• My HealtheVet
• HealtheVet applications

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HealtheVet VistA (HVV)

• The next generation of VistA
• Some of key characteristics of HVV
• Relevant clinical demographic patient available
  point of care in standardized format (VA Non-VA
  data)
• Shifts from facility centric to patient centric
• Improved clinical decision support
• VA DOD data exchange
• New technical architecture

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Technology Shifts to

• N-Tier Platform
• Presentation Tier
• Web Based interface or Client Based
• Java
• Business Logic Tier
• Application Server
• BEA Web logic for several ongoing projects
• Request for Procurement for National solution
• Data Tier
• Oracle Database for Enterprise systems
• Cache Database for RDPCs

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Applications

• Scheduling
• Patient Care Encounter (PCE)
• Pharmacy
• Radiology
• Laboratory

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Behind the Scenes - Administrative Processes

• Marianne Myers,
• Supervisory IT Specialist, Applications
• Tennessee Valley Healthcare System

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DEMOGRAPHICS

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Select ADT Manager Menu Option
Disposition an Application Patient
Enrollment Purple Heart Request
History Purple Heart Status Report
Add/Edit/Delete Catastrophic Disability
Collateral Patient Register Combat
Vet Status Report Edit Inconsistent
Data for a Patient Eligibility Inquiry
for Patient Billing Eligibility
Verification Load/Edit Patient Data
Means Test User Menu ... Patient
Inquiry Preregistration Menu ...
Register a Patient View Patient
Address View Registration Data
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PATIENT DEMOGRAPHIC DATA, SCREEN
CPRSPATIENT,ONE 000-00-0001
NSC VETERAN

Name CPRSPATIENT,ONE
SS 000-00-0001 DOB 1945 Family
CPRSPATIENT Sex MALE MBI
UNANSWERED Given ONE
Alias file Middle
Prefix
Suffix
Degree
Remarks NO REMARKS ENTERED FOR THIS
PATIENT Permanent Address
Temporary Address 10 SOMEPLACE
ROAD NO TEMPORARY ADDRESS
ANYWHERE, USA County UNANSWERED
County NOT APPLICABLE Phone
000-000-0000 Phone NOT
APPLICABLE Office 000-000-0000
From/To NOT APPLICABLE Bad Addr
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EMERGENCY CONTACT DATA, SCREEN CPRSPATIENT,ONE
000-00-0001
NSC VETERAN

NOK CPRSPATIENT, MRS NOK-2
CPRSPATIENT,KID Relation WIFE
Relation
DAUGHTER 10 SOMEPLACE ROAD
15 WHOKNOWSWHERE AVE.
ANYWHERE,USA
SOMEPLACE,USA Phone [phone]
Phone [phone]
Work Phone UNANSWERED
Work Phone UNANSWERED E-Cont.
CPRSPATIENT, MRS E2-Cont.
UNANSWERED Relation WIFE
Relation
UNANSWERED 10 SOMEPLACE ROAD
Phone UNANSWERED
ANYWHERE,USA Phone [phone]
Designee CPRSPATIENT, MRS
Relation WIFE 10
SOMEPLACE ROAD ANYWHERE, USA
Phone [phone]
Work Phone UNANSWERED
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MILITARY SERVICE DATA, SCREEN CPRSPATIENT,ONE
000-00-0001
NSC VETERAN
Service
Branch/Component Service Entered
Separated Discharge ------------------------
--------- ------- ---------
--------- NAVY
000000001 1965 1969
HONORABLE 2 Conflict Locations Vietnam(1966)
3 Environment Factors A/O Exp. YES
(VIET) Reg Exam 00/00/2005 A/O
ION Rad. NO Reg
Method Env Contam NO Reg
Exam N/T Radium
NO POW NO From To
War Combat NO From
To Loc Mil
Disab Retirement NO Dischrg Due to
Disab NO Dent Inj NO
Teeth Extracted YES Purple
Heart NO PH Remarks VAMC
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ELIGIBILITY STATUS DATA, SCREEN
CPRSPATIENT,ONE 000-00-0001
NSC VETERAN

Patient Type NSC VETERAN
Veteran YES Svc Connected NO
SC
Percent N/A Rated Incomp. NO
Claim Number SS Folder Loc.
HOUSTON-RO Aid Attendance NO
Housebound NO VA
Pension NO
VA Disability NO Total Check Amount NOT
APPLICABLE GI Insurance NO
Amount UNANSWERED
Primary Elig Code NSC Other Elig Code(s) NO
ADDITIONAL ELIGIBILITIES IDENTIFIED
Period of Service VIETNAM ERA Service
Connected Conditions as stated by applicant
--------------------------------------------------
- NONE STATED
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PATIENT APPOINTMENTS

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Select Scheduling Manager's Menu Option
Appointment Management Appointment
Check-in/Check-out Add/Edit Stop Codes
Append Ancillary Test to Appt.
Cancel Appointment Chart Request
Check-in/Unsched. Visit Computer
Generated Menu ... Delete Ancillary
Test for Appt. Discharge from Clinic
Display Appointments Edit Clinic
Enrollment Data Enrollment Review Date
Entry Find Next Available Appointment
Make Appointment Multiple
Appointment Booking Multiple Clinic
Display/Book No-Shows
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Select Appointment Menu Option Appointment
Management Appt Mgt Module Jun 28,
2007 _at_ 1130am Page 1 of 1
Patient CPRSPATIENT, ONE MT
REQ Outpatient Total Appointment
Profile - New GAF Required 07/09/07
thru 05/03/09 Clinic
Appt Date/Time Status

1 Mu-pcc/XXXXX/
Firm A 10/02/2007_at_1300 Inpatient/Future
______________________________________
____________________________ CI Check In
CD Change Date Range DX
Diagnosis Update UN Unscheduled Visit EP
Expand Entry DL Wait List
Display MA Make Appointment AE Add/Edit
DE Delete Check Out CA Cancel
Appointment RT Record Tracking WD
Wait List Disposition NS No Show
PD Patient Demographics CP Procedure
Update DC Discharge Clinic CO Check Out
PC PC Assign or Unassign AL
Appointment Lists EC Edit Classification
TI Display Team Information PT Change
Patient PR Provider Update CL Change
Clinic WE Wait List Entry Select
Action Quit// ma Make Appointment Patient
Patient CPRSPATIENT,ONE (0001) MT
REQ Outpatient CLINIC General
Medicine
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PATIENT'S SERVICE CONNECTION AND RATED
DISABILITIES Service Connected No Primary
Eligibility Code NSC No Service Connected
Disabilities Listed APPOINTMENT TYPE REGULAR//
NO PENDING APPOINTMENTS Select ETHNICITY
INFORMATION D Choose from DECLINED TO
ANSWER D HISPANIC OR LATINO H
NOT HISPANIC OR LATINO N UNKNOWN BY
PATIENT U Select RACE INFORMATION D
Choose from AMERICAN INDIAN OR ALASKA
NATI 3 ASIAN A BLACK OR
AFRICAN AMERICAN B DECLINED TO ANSWER
D NATIVE HAWAIIAN OR OTHER PACIF
H UNKNOWN BY PATIENT U WHITE
W IS THIS A 'NEXT AVAILABLE' APPOINTMENT
REQUEST? Y/N Answer 'yes' if scheduling to
the next available appointment is desired.
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IS THIS A 'NEXT AVAILABLE' APPOINTMENT REQUEST?
NO Calculating follow-up status Select one of
the following 'F' for First
available following a specified date Date
(or date computation such as 'T2M') for a
desired date Date/time to schedule a
specific appointment ENTER THE DATE DESIRED FOR
THIS APPOINTMENT T2M
GENERAL MEDICINE
Oct 2007 TIME 8 9 10 11
12 1 2 3 4 DATE

SU 07 1 1 1 11 1 1 11 1 1 11
1 1 11 1 1 11 1 1 11 1 1 11 1 1 1 MO 08 z
z z zz z z zz z z zz z z zz z z zz z z zz z
z zz z z z TU 09 z z z zz z z zz z z zz z
z zz z z zz z z zz z z zz z z z WE 10 z z
z zz z z zz z z zz z z zz z z zz z z zz z z
zz z z z TH 11 z z z zz z z zz z z zy z z
zz z z zz z z zz z z zz z z z FR 12 z z z
zz z z zz z z zz z z zz z z zz z z zz z z
zz z z z SU 14 1 1 1 11 1 1 11 1 1 11 1 1
11 1 1 11 1 1 11 1 1 11 1 1 1 15 MINUTE
APPOINTMENTS (VARIABLE LENGTH) DATE/TIME
10/2/2007_at_100pm LENGTH OF APPOINTMENT (IN
MINUTES) 15// 15-MINUTE APPOINTMENT MADE THIS
APPOINTMENT IS MARKED AS 'NOT NEXT AVAILABLE', IS
THIS CORRECT? YES// WANT PATIENT NOTIFIED OF
LAB,X-RAY, OR EKG STOPS? No// (No) OTHER INFO
Lab and X-ray Also
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Creating Progress Notes

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• Notes can be created through multiple options
• Free-text typing
• Personal template
• Shared template
• Reminder dialog
• Voice Recognition software

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Free-text typing
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Templates
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Complete Encounter Forms

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Patient Care Encounter (PCE)

• Collection and management of outpatient encounter
  data
• Presentation of outpatient encounter data through
  Health Summary components and Clinical Reports.
• Capture of outpatient encounter data through
  interactive and non-interactive interfaces.
• Recording of workload

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• PCE Encounter List Jun 25,
  2007_at_104757 Page 1 of 1
• CPRSPATIENT,ONE 000-00-0001 Clinic
  All
• Date range 6/25/2007 to 7/26/2007
• - New GAF Score
  Required
• ------Encounter----------Clinic-------------------
  ---Appointment Status---------
• 1 7/3/2007 1100 MU-PCC/XXXX/FIRM A
  INPATIENT APPOINTMENT
• ---------- Next Screen - Prev Screen ?? More
  Actions-----------------------
• UE Update Encounter CD Change Date
  Range VC View by Clinic
• LI List by Appointment CC Change Clinic
  DD Display Detail
• AD Add Standalone Enc. IN Check Out
  Interview GF GAF Score
• HI Make Historical Enc. PC PC Assign or
  Unassign
• TI Display Team Info QU Quit
• SP Select New Patient

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• Encounter Profile Jul 06,
  2007_at_104850 Page 1 of 2
• CPRSPATIENT,ONE 000-00-0001 Clinic
  MU-PCC/xxx/FIRM A
• Encounter Date 7/3/2007 1100 Clinic
  Stop 323 PRIMARY CARE/MEDICINE
• --------------------------------------------------
  ------------------------------
• 1 Encounter Date and Time JUL 03, 2007_at_1100
  
• Patient Name CPRSPATIENT,ONE
  
• Hospital Location MU-PCC/XXXXX/FIRM A
  
• Clinic Stop 323 PRIMARY CARE/MEDICINE
  
• Agent Orange Exposure NO
  
• 2 Provider XXXX, XXXXX PRIMARY
  Physicians/Physician/Osteopath/Labor
• 3 ICD9 Code or Diagnosis 202.80 LYMPHOMA
  NEC UNSPEC SITE
• Provider Narrative Lymphoma, Non-Hodgkin's
  (ICD-9-CM 202.80)
• Primary/Secondary Diagnosis for the
  Encounter PRIMARY
• Provider Narrative Category Problem List
  Items
• 4 CPT Code 99202 OFFICE/OUTPATIENT VISIT,
  NEW
• CPT Modifier 51 MULTIPLE PROCEDURES

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Rules for Workload Credit

• If it is NOT documented
• It has NOT been done
• Therefore, credit is NOT received
• And money is NOT disbursed!

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Pharmacy Outpatient Inpatient Medications

• Kay Willis
• Chief, Pharmacy/SPD
• North Chicago, IL

45
Different Views

• The views are different for the provider ordering
  outpatient medications than for the pharmacist
  finishing
• Biggest difference is that providers work with
  orderable items and the associated dosages
• Pharmacists work with a dispense drug which
  only has one strength
• Pharmacists are also stuck with the blue screen
  scroll and roll

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Prescription Status Clarified

• Active-valid prescription within date may or may
  not have remaining refills
• Suspended-active prescription which has been
  processed for filling date in future indicates
  date it will be mailed
• Expired-prescription is unable to be filled
  because it is too old (one year rule)
• Discontinued-provider, pharmacist or admission
  has discontinued the prescription
• Hold-prescription on hold by provider, pharmacist
  or patient request

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How to Document Clinic Administered Medications

• IMO (Inpatient Meds for Outpatients)
• Outpatient Medications-Administered in Clinic
• Issues with Both

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IMO Settings

• Sample Settings and more information may be found
  at
• http//vista.med.va.gov/cprs/html/IMO.html

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Remote Data Interoperability

• New functionality which provides information
  about medications/allergies from other VA/DOD
  sites
• Provides real time information about same/similar
  medications
• Uses the Health Data Repository as the source for
  information

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Notice if HDR is Unavailable
Order checking dialog when the HDR is
unreachable. Note This display may be included
within a list of local order checks.
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Order Check Dialog
Order checking dialog with the name of the
originating site for the data displayed.
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Inpatient Meds Order Check Display

• --------------------------------------------------
  --------------------------
• This patient is already receiving an order for
  the following drug in the same
• class as the drug selected
• Rx 0000000000
  WARFARIN NA 10MG TAB
• Status ACTIVE
  Issued 00/00/05
• SIG TAKE ONE-HALF
  TABLET BY MOUTH BEFORE
• BREAKFAST --TO THIN
  BLOOD--
• QTY 4
• Provider PSOPROVIDER,TWO
  Refills remaining 2
• 
  Last filled on
  00/00/05
• 
  Days Supply 1
• --------------------------------------------------
  ------------------------------------
• In the Remote Outpatient Order Display
  example above, notice the name of the remote
  location has been added. In addition, the total
  number of refills is not returned from the HDR.

DAYTON
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Inpatient Medications

• Principal difference between inpatient and
  outpatient medications is that multiple orders
  for the same drug are allowed in inpatient
• Outpatient only allows one active/suspended order
  per drug item

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Inpatient Med Screen Scrape
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Pharmacist View
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Radiology/Nuclear Medicine

• Anne Rega
• Enterprise Product Support, Clin 3
• Hines OI

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Radiology/Nuclear Medicine

• Patient Registration for exams, automatic
  printing of flash cards and jacket labels and
  transcription of reports.
• Supports Health Level 7 (HL7) messaging used in
  voice-to-text and Imaging systems.
• On-line physician verification of reports.
• Supports entry of multiple diagnostic codes.
• Provides the ability to enter/edit information
  specific to radiopharmaceuticals for Nuclear
  Medicine

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Placing an order
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Placing an Order
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Order is signed
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Rad/Nuc Med Main Menu

• Select Rad/Nuc Med Total System Menu Option
• Exam Entry/Edit Menu ...
• Films Reporting Menu ...
• Management Reports Menu ...
• Outside Films Registry Menu ...
• Patient Profile Menu ...
• Radiology/Nuclear Med Order Entry Menu
  ...
• Supervisor Menu ...
• Switch Locations
• Update Patient Record
• User Utility Menu ...

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Register Patient for Exam

• Select Rad/Nuc Med Total System Menu Option Exam
  Entry/Edit Menu
• Add Exams to Last Visit
• Cancel an Exam
• Case No. Exam Edit
• Diagnostic Code and Interpreter Edit by
  Case No.
• Edit Exam by Patient
• Enter Last Past Visit Before VISTA
• Exam Status Display
• Indicate No Purging of an Exam/report
• Register Patient for Exams
• Status Tracking of Exams
• Switch Locations
• View Exam by Case No.

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Registering Exam
Patient Demographics
Name ZERO,PATIENT Pt ID
666-00-0000 Date of Birth 1935 (72)
Veteran Yes Eligibility
Unknown Sex MALE Other
Allergies 'V' denotes verified allergy
'N' denotes non-verified allergy
PENICILLIN(V) Case Last 5 Procedures/New
Orders Exam Date Status of Exam Imaging
Loc. ------ ----------------------------
--------- --------------
------------ ECHO EXAM OF HEART
Ord 6/28/07
No registered exams filed for this
patient. Imaging Exam Date/Time NOW// (JUN
28, 2007_at_1758)
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Registering Exam
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Case No. Exam

• Select Rad/Nuc Med Total System Menu Option Exam
  Entry/Edit Menu
• Add Exams to Last Visit
• Cancel an Exam
• Case No. Exam Edit
• Diagnostic Code and Interpreter Edit by
  Case No.
• Edit Exam by Patient
• Enter Last Past Visit Before VISTA
• Exam Status Display
• Indicate No Purging of an Exam/report
• Register Patient for Exams
• Status Tracking of Exams
• Switch Locations
• View Exam by Case No.

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Case No. Exam Edit

• Select Exam Entry/Edit Menu Option Case No. Exam
  Edit
• Enter Case Number 41
• Choice Case No. Procedure
  Name Pt
  ID
• ------ -------- ---------
  -----------------
  ------
• 1 062807-41 ECHO EXAM OF HEART
  ZERO,PATIENT 0000
• (US Detailed) CPT93307
• PROCEDURE ECHO EXAM OF HEART//
• CONTRAST MEDIA USED NO//
• Select PROCEDURE MODIFIERS
• Select CPT MODIFIERS
• CATEGORY OF EXAM OUTPATIENT//
• PRINCIPAL CLINIC 20 MINUTE//
• REQUESTING PHYSICIAN VEHU,TIUEXPERT//
• Select TECHNOLOGIST PROVIDER,SEVENTYTWO//
• TECHNOLOGIST COMMENT
• COMPLICATION NO COMPLICATION//

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FILMS REPORTING MENU

• Batch Reports Menu ...
• Display a Rad/Nuc Med Report
• Distribution Queue Menu ...
• Draft Report (Reprint)
• On-line Verifying of Reports
• Report Entry/Edit
• Resident On-Line Pre-Verification
• Select Report to Print by Patient
• Switch Locations
• Verify Report Only

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Films Reporting

• Select Films Reporting Menu Option REPORT
  Entry/Edit
• Select Imaging Type All// ULTRASOUND
• Another one (Select/De-Select)
• Enter your Current Signature Code SIGNATURE
  VERIFIED
• Do you want to batch print reports? Yes// N ...no
  batch selected
• Enter Case Number 41

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Report Entry

• Enter Case Number 41
• --------------------------------------------------
  -----------------------------
• Name ZERO,PATIENT Pt ID
  666-00-0000
• Case No. 41 Exm. St EXAMINED Procedure
  ECHO EXAM OF HEART
• Exam Date JUN 28,2007 1806
  Technologist PROVIDER,SEVENTYTWO
• Req Phys
  VEHU,TIUEXPERT
• --------------------------------------------------
  -----------------------------
• ...report not entered for this exam...
• ...will now initialize report entry...
• Select Report to Copy
• --------------------------------------------------
  -----------------------------
• PRIMARY INTERPRETING RESIDENT VEHU,TIUEXPERT
  
• Select SECONDARY INTERPRET'G RESIDENT
• PRIMARY INTERPRETING STAFF PROVIDER,FORTYTWO
• Select SECONDARY INTERPRETING STAFF
• INTERPRETING IMAGING LOCATION SBK ULTRASOUND//
  (ULTRASOUND-500)

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Report Entry

• --------------------------------------------------
  ----------------------------
• CLINICAL HISTORY
• Rapid Heart Beat
• ADDITIONAL CLINICAL HISTORY
• No existing text
• Edit? NO//
• --------------------------------------------------
  ----------------------------
• REPORT TEXT
• No existing text
• Edit? NO// YES
• WRAP INSERT
• REPORT TEST IS ENTERED HERE.
• IMPRESSION TEXT
• No existing text
• Edit? NO// YES

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Verification/Coding

• Select one of the following
• V VERIFIED
• R RELEASED/NOT VERIFIED
• PD PROBLEM DRAFT
• D DRAFT
• REPORT STATUS D// VERIFIED
• PRIMARY DIAGNOSTIC CODE ?
• Choose from
• 1 NORMAL
• 2 MINOR ABNORMALITY
• 3 MAJOR ABNORMALITY, NO ATTN.
  NEEDED
• 4 ABNORMALITY, ATTN. NEEDED
• 5 MAJOR ABNORMALITY, PHYSICIAN
  AWARE
• 6 UNDICTATED FILMS NOT RETURNED, 3
  DAYS
• 7 UNSATISFACTORY/INCOMPLETE EXAM
• 8 PATIENT REFUSED EXAM
• 9 POSSIBLE MALIGNANCY, FOLLOW-UP
  NEEDED
• 10 THIS A TEST DIAG CODE

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Notifications
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Application Parameters

• Multiple parameters allow customization to a
  certain degree.
• Allow standard reports, copy reports
• Requirements to complete a case
• Who can verify a report
• Released/Not Verified
• Auto E-Mail to Requesting Physician
• Impression Required
• Submit to prompt on order

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VistA Imaging System

• Provides a multimedia, on-line patient record
  that integrates traditional medical chart
  information with medical images including x-rays,
  CAT scans, MRIs, dental images as well as
  pathology slides, EKGs and scanned documents.
• Components of VistA Imaging
• VistA Rad
• VistA Display
• VistA Capture

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VistA Imaging

• Interfaces with the Radiology/Nuclear Medicine
  application and the Computerized Patient Record
  System (CPRS).
• Provides an interface between VistA and
  commercial PACs (Picture Archiving and
  Communication systems)

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Imaging Icon
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DICOM Modality (ie CT)
Workstation
4. DICOM Image file
Imaging Gateway
2. Worklist query/response
Text Gateway
6. Images moved
5. Match order with study
1. Register Exam
Server
Server
VistA
7.Transfer files between RAID and JB
2A.Patient info
3A. Files moved
Imaging Cluster
Display Capture Client
Background Processor
1A. Digital Capture file
RAID
JBox
Non-DICOM - Scanner, Camera, MUSE
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Imaging Capture

• Scanned documents from other sources
• Advance Directives
• Means Test
• Automatically transmitted to the Health
  Eligibility Center via capture
• Annotation Tool

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Continued Development

• Interfacility Teleretinal
• Remote Images
• VA/DoD
• Passing of Images on returning veterans from DoD
  hospitals to VA.

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A Day (or more) in the Life of a Surgical
Pathology Specimen

• or
• What happens after I send that container to the
  lab?
• Claudette Murch
• Health Data Systems Clin2 Team
• Togus, Maine

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Difference in how orders created

• CPRS used to order labs such as Chem 1
• CPRS is NOT used for Pathology specimen
  processing, such as Surg Path, EM, Cytology or
  Autopsy
• No CPRS or Lab order number generated
• Surgery package initiates Surgical Pathology
  specimen processing
• Surgery pkg generates SF 515 to accompany
  specimen to lab
• Lab manually enters and creates accession for
  Surgical Pathology specimen from SF 515 info

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Case Study
Our patient is a 52 year old female, a veteran
who served two tours in Operation Desert
Storm The veteran has presented with multiple
atypical skin lesions. Surgery was scheduled to
remove a sample of the lesions for anatomic
pathology testing. 3 skin lesions removed. Three
specimens in three separate containers of
formalin arrive in lab
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Steps in Surgery

• Surgery package used to document procedure
• Computer generated SF 515 printed
• Information from SF 515 should be complete as it
  is later used by the lab pkg.
• SF 515 and specimens delivered to the lab
• Multiple specimens can be included in a single
  case (our example has 3)

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--------------------------------------------------
------------------------------ MEDICAL
RECORD TISSUE
EXAMINATION --------------------------------------
------------------------------------------ Specime
n Submitted By
Obtained JUL 11, 2007 OR2, SURGERY CASE
10121 --------------------------------------------
------------------------------------ Specimen(s)
-------------------------------------------------
------------------------------- Brief Clinical
History Patient is veteran of Operation
Desert Storm, presenting with multiple
atypical skin lesions. ---------------------------
--------------------------------------------------
--- Operative Procedure(s) REMOVE SKIN
LESIONS ------------------------------------------
-------------------------------------- Preoperativ
e Diagnosis Atypical Skin Lesions -----------
--------------------------------------------------
------------------- Operative Findings
-------------------------------------------------
------------------------------- Postoperative
Diagnosis Signature and
Title Atypical Skin Lesions
PROVIDER,ONE -------------------------------
-------------------------------------------------
Attending Surgeon PROVIDER,TWO ------------------
--------------------------------------------------
------------
PATHOLOGY REPORT ---------------------------------
----------------------------------------------- Na
me of Laboratory
Accession Number(s) ------------------------------
--------------------------------------------------
Gross Description, Histologic Examination and
Diagnosis (Continue
on reverse side) ---------------------------------
----------------------------------------------- PA
THOLOGIST'S SIGNATURE
DATE -------------------------------------
------------------------------------------- PATIEN
T,ONE AGE 52 SEX FEMALE ID
000-00-0000 ETHNICITY UNANSWERED
REGISTER NO. RACE
UNANSWERED WARD
ROOM-BED ---------------------------------------
----------------------------------------- VAMC
VEHU
REPLACEMENT FORM 515
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Initial Lab Processing

• Specimen logged into Lab Package
• Case is numbered
• Lab package searches and displays all surgeries
  performed w/in past 7 days
• Clerk can select the specific surgery that
  applies to the case
• Information from the computer generated SF 515 is
  transferred from the surgery pkg into the lab pkg

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Select ANATOMIC PATHOLOGY SECTION SURGICAL
PATHOLOGY Log-In for 2007 ? YES//
(YES) Select Patient Name PATIENT,ONE
ONE,PATIENT 1955 000000000 YES
SC VETERAN PATIENT,ONE ID
000-00-0000 Physician PROVIDER,ONE AGE 52 DATE
OF BIRTH 1955 PATIENT LOCATION 3N SR// 3
NORTH SURG Accession number assigned for
Jul 09, 2007 is SP 07 16 Checking surgical
record for this patient... 1. 07-11-07 Case
10121 REMOVE SKIN LESIONS (COMPLETED) Only
one operation on record in the past 7 days. Is
this the correct operation for the specimen(s)
(Y/N)? YES Assign SURGICAL PATHOLOGY (SP)
accession 17 ? YES// (YES) Date/time
Specimen taken NOW// (JUL 11,
2007_at_0814) SURGEON/PHYSICIAN PROVIDER,ONE//
PROVIDER,ONE SPECIMEN SUBMITTED BY
PROVIDER,ONE Select SPECIMEN LESION UNDER LEFT
ARM Select SPECIMEN LESION, RIGHT CHEEK Select
SPECIMEN LESION, LEFT TEMPLE Select SPECIMEN
DATE/TIME SPECIMEN RECEIVED NOW// (JUL 11,
2007_at_0816) PATHOLOGIST PROVIDER,TWO
PROVIDER,TWO troy NEW YORK PT
112G Select COMMENT FROZEN SECTION No
existing text Edit? NO// Select Patient Name
102
Additional Initial Processing

• Clerk numbers and labels specimens prior to hand
  off to Pathologist
• Specimen and Pathologist move into the lab for
  Grossing.

103
GROSSING

• Pathologist dictates description
• of specimen, any cutting to create additional
  cassettes, any stains ordered etc.
• All cassettes have at minimum an HE Stain
• (Hematoxylin Eosin)

104
Get the info to VistA

• Lab option GD Clinical Hx/Gross Description/FS
  is used by a transcriptionist to enter
  information recorded during the GROSSING step

105
Select Data entry, anat path Option Clinical
Hx/Gross Description/FS Select ANATOMIC PATHOLOGY
SECTION SURGICAL PATHOLOGY
SURGICAL PATHOLOGY (SP) Data entry for 2007 ?
YES// (YES) Select Accession Number/Pt name 17
for 2007 PATIENT,ONE ID 000-00-0000 Specimen(s)
LESION, UNDER LEFT ARM LESION, RIGHT
CHEEK LESION, LEFT TEMPLE Select SPECIMEN
LESION, RIGHT CHEEK// SPECIMEN LESION, RIGHT
CHEEK Replace Select SPECIMEN BRIEF CLINICAL
HISTORY Patient is veteran of Operation Desert
Storm, presenting with multiple atypical skin
lesions. Edit? NO// PREOPERATIVE
DIAGNOSIS Atypical Skin Lesions Edit? NO//
OPERATIVE FINDINGS No existing text Edit?
NO// POSTOPERATIVE DIAGNOSIS Atypical Skin
Lesions Edit? NO//
106
RESIDENT PATHOLOGIST PROVIDER,TWO PROVIDER,TWO
CM CO PHYSICIAN GROSS
DESCRIPTION No existing text Edit? NO//
YES WRAP INSERT DESCRIPTION HHelp Specimen
I. labeled 'lesion under left arm". consists of
an ellipse of skin measuring 0.8 cms long by
about 0.5 cm wide and about 0.3 cm deep. It is
trisected and submitted with inked
base. Specimen II. Labeled lesion right cheek
". Consists of a small specimen measuring 0.4
cms in circumference roughly. This is bisected
and submitted in toto. Specimen III. labeled
"lesion left temple ". consists of a flag piece
of tissue measuring approximately 0.3 to 0.4 cms
square. It is divided and submitted in
toto. TTTT FROZEN
SECTION No existing text Edit? NO// Select
Accession Number/Pt name
107
How lab stays organized

• Lab has a report called a Histopathology
  Worksheet that can be used to document numbers of
  cassettes and stains performed

108
Jul 11, 2007 0850 VEHU HOSPITAL
Pg 1 SURGICAL PATHOLOGY
(SP) SHEET ACCESSION DATE Jul 11,
2007 ---------------------------------------------
--------------------------------------------------
---------------------------- Accession
SPECIMEN CASSETTE BLOCKS
SLIDES STAINS ---------------------------------
--------------------------------------------------
---------------------------------------- SP 07 17
LESION UNDER LEFT ARM
----------------------------
--------------------------------------------------
--------------------------------------------- SP
07 17 LESION, RIGHT CHEEK
------------------------
--------------------------------------------------
------------------------------------------------ S
P 07 17 LESION, LEFT TEMPLE
--------------------
--------------------------------------------------
--------------------------------------------------
---
109
Preliminary Pathology Report

• Generated after initial data entry from Grossing
  step
• Report includes past surgical and cytology
  history
• SNOMED codes from past surgical specimens
  processed included also

110
--------------------------------------------------
----------------------------- MEDICAL RECORD
SURGICAL PATHOLOGY
Pg 1 ------------------------------------------
------------------------------------- Submitted
by PROVIDER,ONE Date
obtained Jul 11, 2007 0814 ---------------------
--------------------------------------------------
-------- Specimen (Received Jul 11, 2007
0816) LESION, UNDER LEFT ARM LESION, RIGHT
CHEEK LESION, LEFT TEMPLE -----------------------
--------------------------------------------------
------ Brief Clinical History Patient is
veteran of Operation Desert Storm, presenting
with multiple atypical skin lesions.
-------------------------------------------------
------------------------------ Preoperative
Diagnosis Atypical Skin Lesions
-------------------------------------------------
------------------------------ Operative
Findings ----------------------------------------
--------------------------------------- Postoperat
ive Diagnosis Atypical Skin Lesions
Surgeon/physician
PROVIDER,ONE

PATHOLOGY
REPORT Laboratory VEHU HOSPITAL
Accession No. SP 07
17 -----------------------------------------------
--------------------------------
REPORT INCOMPLETE
Pathology Resident PROVIDER,TWO
111
Gross description Specimen I. labeled
'lesion under left arm". consists of an ellipse
of skin measuring 0.8 cms long by about 0.5 cm
wide and about 0.3 cm deep. It is trisected and
submitted with inked base. Specimen II. Labeled
lesion right cheek ". Consists of a small
specimen measuring 0.4 cms in circumference
roughly. This is bisected and submitted in
toto. Specimen III. labeled "lesion left temple
". consists of a flag piece of tissue measuring
approximately 0.3 to 0.4 cms square. It is
divided and submitted in toto. SURGICAL
PATHOLOGY Organ/tissue Date rec'd 05/14/2007
Acc SP 07 4 PROVIDER UTERUS 22 gm
NORMAL CELLULAR MORPHOLOGY
FALLOPIAN TUBES, OVARIES AND BROAD LIGAMENT, CS
NORMAL CELLULAR MORPHOLOGY
Organ/tissue Date rec'd 11/07/2006 Acc SP
06 23 PROVIDER NAIL OF TOE
ABNORMAL APPEARANCE IMMUNOFLUORESCENCE 1
Date Nov 08, 2006 IMMUNOPEROXIDASE 2 Date
Nov 08, 2006
112
CYTOPATHOLOGY
Organ/tissue Date rec'd 03/06/2007 Acc CY
07 5 PROVIDER SPUTUM
POSITIVE FOR MALIGNANT CELLS CARCINOMA,
SQ CELL Organ/tissue Date rec'd 02/14/2006
Acc CY 06 1 PROVIDER URINE
NORMAL CELLULAR MORPHOLOGY Organ/tissue Date
rec'd 04/26/2005 Acc CY 05 1
PROVIDER -----------------------------------------
--------------------------------------

(End of report) TWO PROVIDER
cm Date -----------------------------
--------------------------------------------------
PATIENT,ONE STANDARD FORM
515 ID000-00-0000 SEXF DOB1955 AGE 52
LOC3N SR
PCP
113
Tissue processing

• Tissue cassettes are placed in a tissue
  processing machine overnight
• Removes water from specimens, preparing for
  further processing
• Histotechnologist embeds specimens into paraffin
• Specimens are then ready for slide preparation
  and staining

114
Slide Preparation

• Histotechnologist uses a microtome to thinly
  slice specimens from cassettes and creates slides
• Each cassette has at minimum have an H E stain
• Additional stains may be ordered on some of the
  slides
• Some slides may need to be sent to a reference lab

115
Example of slide labelingEach cassette with 4
slides
S-07 17 I 1            
S-07 17 I 2             S-07 17 I
3             S-07 17 I 4            
            S-07 17 II 1            
S-07 17 II 2             S-07 17 II
3 S-07 17 II 4     
S-07 17 III 1 S-07 17 III 2
S-07 17 III 3 S-07 17
III 4
116
Slides Examined

• Pathologist examines slides
• May dictate, scribble, type or otherwise
  communicate slide findings for transcription into
  the report

117
Lab option GS FS/Gross/Micro/Dx/SNOMED Coding

• Allows editing of info previously entered from GD
  option
• May include CPT codes directly into rpt
• Based on local policies
• Surgical Diagnosis is entered here
• Must document where testing is performed
• Tissue Committee codes can be entered

118
SNOMED Codes

• Entered in the Organ/Tissue section of the report
• Codes mainly used for internal QA
• Not diagnostic
• Do NOT print out on final report
• Allows for easy searching of case types

119
Select Data entry, anat path Option
FS/Gross/Micro/Dx/SNOMED Coding Select ANATOMIC
PATHOLOGY SECTION SURGICAL PATHOLOGY
SURGICAL PATHOLOGY (SP) Enter
Etiology, Function, Procedure Disease ? NO//
(NO) Data entry for 2007 ? YES// (YES) Select
Accession Number/Pt name 17 for
2007 PATIENT,ONE ID 000-00-0000 Specimen(s) LES
ION, UNDER LEFT ARM LESION, RIGHT CHEEK LESION,
LEFT TEMPLE FROZEN SECTION No existing text
Edit? NO// GROSS DESCRIPTION. . . . .
. It is trisected and submitted with inked base.
Specimen II. Labeled "lesion right cheek".
Consists of a small specimen measuring 0.4 cms
in circumference roughly. This is bisected and
submitted in toto. Specimen III. labeled
"lesion left temple". consists of a flag piece
of tissue measuring approximately 0.3 to 0.4 cms
square. It is divided and submitted in toto.
Edit? NO//
120
MICROSCOPIC DESCRIPTION No existing text
Edit? NO// SURGICAL PATH DIAGNOSIS Edit? NO//
YES WRAP INSERT DIAGNOSIS HHelp I. LESION,
UNDER LEFT ARM Melanotic lesion. This
case will be sent to another VA for
consultation. final report to follow II. LESION
RIGHT CHEEK Seborrheic keratosis III.
LESION, LEFT TEMPLE Intradermal nevus.
Present in deep margins. This case will be
sent to another VA for consultation. Report to
follow. Testing at SOMEWHERE VAMC, SOMEPLACE,
USA TTTT PATHOLOGIST
PROVIDER,TWO// DATE REPORT COMPLETED T (JUL
11, 2007) Select ORGAN/TISSUE Enter CPT coding?
NO//
121
CPT Coding

• Based on the complexity of the case
• Lab software allows menus to be created as a pick
  list
• Example
• List or range e.g, 1,3,5-7,88300.
  
• Select from the following or enter CPT
  separated by a comma
• 1 88300 LEVEL I - SURGICAL PATHOLOGY,
  GROSS EXAMINATION ONLY
• Surgical Pathology Level I NLT
  88551.0000
• 2 88302 LEVEL II - SURGICAL PATHOLOGY,
  GROSS AND MICROSCOPIC EX
• Surgical Pathology Level II NLT
  88518.0000
• 3 88304 LEVEL III - SURGICAL PATHOLOGY,
  GROSS AND MICROSCOPIC E
• Surgical Pathology Level III NLT
  88553.0000
• 4 88305 LEVEL IV - SURGICAL PATHOLOGY,
  GROSS AND MICROSCOPIC EX
• Surgical Pathology Level IV NLT
  88555.0000
• 5 88307 LEVEL V - SURGICAL PATHOLOGY,
  GROSS AND MICROSCOPIC EXA

122
Print Final Office Copy

• This copy includes the SNOMED codes on a separate
  page
• Copy can be used for review prior to electronic
  signature or manual release
• Electronic signature capability with LR5.2259
• Pathologist can also review on line prior to
  electronic signature
• Electronic Signature use is not mandatory

123
Pathologist Electronic Signature

• Currently provides an information only view alert
  to the PCP
• Pathologist can request additional alerts be sent
• Action alerts currently under development
• OR3243 (CPRS GUI 27), LR5.2365, WV123

124
LR5.2317

• Released June 18, 2007
• Fixes PSI-04-025
• Previously signed/CPRS available Pathology
  reports had to be un-released to add a
  supplementary report no longer viewable in CPRS
• When creating a supplemental report, all
  previously verified fields available for editing

125
LR5.2368

• Fast-Tracked lab patch
• Restores ability for Pathologist to edit the
  diagnosis on a released pathology report

126
Select Data entry, anat path Option SR
Supplementary Report, Anat Path Select ANATOMIC
PATHOLOGY SECTION SURGICAL PATHOLOGY
SURGICAL PATHOLOGY (SP) Enter
Etiology, Function, Procedure Disease ? NO//
(NO) Data entry for 2007 ? YES// (YES) Select
Accession Number/Pt name 17 for
2007 PATIENT,ONE ID 000-00-0000 Specimen(s) LES
ION, UNDER LEFT ARM LESION, RIGHT CHEEK LESION,
LEFT TEMPLE Select ORGAN/TISSUE This SURGICAL
PATHOLOGY report has been released. Supplementary
report additions/modifications will create an
audit trail.
127
Select SUPPLEMENTARY REPORT DATE T JUL 11,
2007 SUPPLEMENTARY REPORT DATE/TIME JUL
11,2007// DESCRIPTION No existing text
Edit? NO// YES WRAP INSERT

HHelp SUPPLEMENTAL REPORT RECEIVED
FROM ANOTHER VA ON JULY 11, 2007
DERMATOPATHOLOGY CONSULTATION I.
LESION, UNDER LEFT ARM Compound
melanocytic nevus, papillomatous congenital
type, with mild-to-focally moderate
atypia/dysplasia focally irritated the
lesion extends to the edges of the
specimen (but appears largely removed).
II. LESION, RIGHT CHEEK
Compound melanocytic nevus, papillomatous
congenital type, with mild-to-focally
moderate atypia/dysplasia focally
irritated the lesion extends to the edges of
the specimen (but appears largely removed).
a/k/a A. PROVIDER,THREE TTTTTT
TT
128
---- SURGICAL PATHOLOGY
---- - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - MEDICAL
RECORD SURGICAL PATHOLOGY - -
- - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - -
PATHOLOGY REPORT Laboratory VEHU HOSPITAL
Accession No. SP 07
17 - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - Submitted by
PROVIDER,ONE Date obtained
Jul 11, 2007 0814 - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - -
- Specimen (Received Jul 11, 2007 0816) LESION,
UNDER LEFT ARM LESION, RIGHT CHEEK LESION, LEFT
TEMPLE SUPPLEMENTARY REPORT
HAS BEEN ADDED
REFER TO BOTTOM OF REPORT
- - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - -
- BRIEF CLINICAL HISTORY Patient is veteran
of Operation Desert Storm, presenting with
multiple atypical skin lesions. - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - PREOPERATIVE DIAGNOSIS
Atypical Skin Lesions - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - -
- - OPERATIVE FINDINGS - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - -
- - POSTOPERATIVE DIAGNOSIS Atypical Skin
Lesions
Surgeon/physician PROVIDER,ONE ---------
-------------------------
----- -
129
- - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - -
PATHOLOGY REPORT Laboratory VEHU
HOSPITAL Accession No.
SP 07 17 - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - -
Pathology Resident
PROVIDER,TWO Gross description Specimen I.
labeled 'lesion under left arm". consists of an
ellipse of skin measuring 0.8 cms long by
about 0.5 cm wide and about 0.3 cm deep. It
is trisected and submitted with inked base.
Specimen II. Labeled "lesion right
cheek". Consists of a small specimen
measuring 0.4 cms in circumference roughly. This
is bisected and submitted in toto.
Specimen III. labeled "lesion left temple".
consists of a flag piece of tissue measuring
approximately 0.3 to 0.4 cms square. It is
divided and submitted in toto. DIAGNOSIS
I. LESION, UNDER LEFT ARM
Melanotic lesion. This case will be sent to
ANOTHER VA for consultation. final report
to follow II. LESION RIGHT CHEEK
Seborrheic keratosis III.
LESION, LEFT TEMPLE Intradermal
nevus. Present in deep margins. This case will
be sent to ANOTHER VA for consultation.
Report to follow. Testing at SOMEWHERE VAMC,
SOMEPLACE, USA
130
SUPPLEMENTARY REPORT(S) Supplementary Report
Date JUL 11, 2007
SUPPLEMENTARY REPORT HAS BEEN ADDED/MODIFIED
(Added/Last released Jul 11, 2007
1012 Signed by PROVIDER,TWO)
SUPPLEMENTAL REPORT RECEIVED FROM ANOTHER VA ON
JULY 11,2007 DERMATOPATHOLOGY
CONSULTATION I. LESION
UNDER LEFT ARM Compound
melanocytic nevus, papillomatous congenital
type, with mild-to-focally moderate
atypia/dysplasia focally irritated
the lesion extends to the edges of
the specimen (but appears largely removed).
III. LESION, LEFT TEMPLE
Compound melanocytic nevus,
papillomatous congenital type, with
mild-to-focally moderate atypia/dysplasia
focally irritated the lesion extends to the
edges of the specimen (but appears
largely removed). a/k/a
A. PROVIDER,THREE /es/ PROVIDER,TWO MD Signed
JUL 11, 2007_at_101234 - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - -
-
(End of report) PROVIDER,ONE
cm Date Jul 11, 2007
131
Questions?